Allergy Sufferers also Have More Severe Migraines

Many people suffer from migraines. Many people also suffer from allergies. What may have been suspected but is now clarified is that those individuals who suffer from BOTH allergies and migraines have much more frequent and severe headaches than those who do not have allergies. [link]

Based on a survey response from 5,849 patients who suffer from migraines, over two-thirds also suffered from allergies. From this group, researchers found that the odds of experiencing more frequent headaches for individuals with allergies and migraines were 33 percent greater than those suffering from migraines without allergies.

When patients were further subdivided based on the type of allergy they had (allergic, non-allergic, or both), those who suffered from both allergic and non-allergic had the most frequent and severe headaches.

Although there appears to be an association between allergies and migraine severity, the question now becomes whether the migraines themselves increase sino-nasal symptoms OR does the sino-nasal symptoms of allergies aggravate or trigger the migraine.

Based on a prior study, it is known that migraine patients under 45 years with allergies who received allergy shots had 52% less frequent and severe headaches than those who did not receive allergy shots. As such, it may be worthwhile to aggressively treat any sino-nasal symptoms in patients who suffer from migraine headaches. Such treatment may involve not just medications, but even surgery if anatomic trigger points are seen.

References:
Chronic rhinitis and its association with headache frequency and disability in persons with migraine: Results of the American Migraine Prevalence and Prevention (AMPP) Study. Cephalalgia. Published online before print November 25, 2013, doi: 10.1177/0333102413512031

Allergy and immunotherapy: are they related to migraine headache? Headache. 2011 Jan;51(1):8-20. doi: 10.1111/j.1526-4610.2010.01792.x. Epub 2010 Nov 4.

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Hearing Protection and NRR (Noise Reduction Rating)

For all hearing protection devices from ear plugs to ear muffs, there is a NRR (Noise Reduction Rating) score that informs consumers how much of a decrease in noise exposure to expect with use. For example, if an ear plug has a NRR score of 30, use of the device would be expected to reduce a 90 decibel sound by 30 decibels resulting in a noise exposure of 60 decibels.

If two hearing protection devices are used, an ear plug inside the ear canal followed by ear muffs over the ear, the ultimate noise exposure would be an additional 5 to 10 decibels greater than the higher rated NRR of the two devices.

How is NRR determined anyways? This single number rating is determined by the Environmental Protection Agency as specified under 40 CFR (Code of Federal Regulations) Part 211, Product Noise Labeling, Subpart B - Hearing Protective Devices. The raw data compiled from test subjects is than plugged into a formula which than produces the NRR:

Given that, there are MANY different types of hearing protection devices on the market. Regardless of style, most devices offer a NRR between 20-30. However, as a general rule, ear plugs typically offer a higher NRR than ear muffs. Among high NRR earplugs, disposables offer higher NRR than reusables. BUT... ear muffs typically block sound more consistently than ear plugs which require some degree of molding and fit for optimal effectiveness. Using both obviously is better than using just one.

Also, keep in mind that unless hearing protection devices are correctly fit and used properly, the attenuation suggested by NRR may not over-estimated. Indeed, lay-use of such devices without training typically result in sound attenuation far below what NRR may suggest.

The highest rated NRR disposable ear plugs are around 33:


The highest rated NRR ear muffs are around 30:

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How to Describe Hoarseness?

At heart, physicians are science geeks. And when it comes to a raspy voice, one can go truly bananas in how exactly to describe how a raspy voice sounds.

For the layperson, when asked to describe a hoarse voice, one often gets imprecise answers to a question most feel ridiculous... I often get a blank look with an answer that goes something like "You know... raspy... it's not clear." Unfortunately, such a description is inadequate. Even when using more descriptors like deeper/higher than normal, onset delays, pitch breaks, breathy, click, tight, etc, more information is needed.

There are 2 fundamental ways to more precisely convey the characteristics of how a raspy voice sounds and to document change (better/worse) over time.

Method #1 - Perceptual Tests

Developed by Dr. Robert Bastian, I personal prefer this method as it is more intuitive and replicable by anybody including the patient.

1) Maximum Phonation Time (MPT) - How many seconds can a single note be sustained for with a single breath? This test provides a rough measure of lung capacity and how "breathy" a voice is. The more breathy a voice is, the lower the MPT.
2) Pitch Range - What is the lowest and highest note a person can say/sing (I use a piano keyboard). Provides information on how much vocal cord swelling and length is present (the more swollen the vocal cords are, the deeper the pitch just like a violin string). I also typically like the patient to glide up and down from their lowest and highest note as it provides some additional information on neurological/muscular control of their voice depending on how smoothly it is performed.
3) Swell Tests - Essentially, the test involves singing a song (I use Happy Birthday) very quietly an octave higher than your normal pitch. If onset delays or pitch breaks are heard, does suggest the presence of a small bump (nodule, cyst, polyp, etc) on the vocal cords.

One can also add documentation of yell, cough, throat-clearing, and speaking voice.

Method #2 - Objective Tests

This type of testing can only be performed with the help of instruments and provides "numbers" that can be documented. It is more difficult to "hear" the voice looking at just these numbers, but does provide a more rigorous way to actually "measure" the voice quality. There are now even iPhone apps that can obtain such data.

The basic measures include:
1) Shimmer - Measures how much variation in loudness is present. Think of a volume knob being turned up and down slightly. Normal is less than 3%.
2) Jitter - Measures how much variation in pitch is present. Think of going up and down on the equalizer slightly. Normal is less than 1%.
3) MPT is also measured.
4) Fundamental frequency (f0) - Measure of how high/low a person's voice sounds (pitch).

One can go crazy and also add intensity, glottal noise, ratio, tremor, spectrum, EGG-pitch, EGG-intensity, EGG-jitter, EGG-shimmer, EGG-noise, CQ, CQ perturbation, CI, CI perturbation, opening rate, etc.

Regardless of the method, with this type of information, the actual degree and characterization of the vocal quality can be measured, documented, and tracked over time. Also, when communicating with other health professionals, such measures provide for an efficient and understandable way to describe a patent's voice with a colleague.

Of course, from the patent's perspective, they "just want to sound better," but this is how professionals do it.

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At-Home Rapid Strep Testing

Rapid strep test kits can be purchased by anybody to be done at home which may save parents/patients a lot of money in doctor visits for those prone to strep infections. Indeed, should a rapid strep test be positive, than you know that a doctor's visit is definitely worthwhile. (A doctor visit may still be worthwhile since a sore throat may be due to something else like cancer, aphthous ulcer, sinus infection, reflux, etc).

Such home kits (which in fact are the same kits used in medical offices) can be purchased online through Amazon. The price is surprisingly affordable at around the cost of a single copay $30 to do 25 tests.

However, with the purchase of such DIY kits, there are some pitfalls patients should be aware of if they decide to proceed.

1) Perform the internal controls that come with the kit!!! The kit may be a dud and needs to be tested against itself to ensure accurate results whether negative or positive. If the controls do not work, throw the whole test kit out and buy another.
2) You must follow the directions precisely, otherwise the test results will be unreliable. In other words, if the directions call for 4 drops, than it MUST be 4 drops (not 3 drops or 5). If directions state to wait 4 minutes... you must wait exactly 4 minutes. This literally is like precision baking.
3) The test strips need to be kept in protected, sealed bag and used immediately after taking one out, otherwise the test results will be unreliable.
4) When swabbing the throat, you MUST get the cotton tip on the tonsil and/or back wall of the mouth which than must be rubbed around a couple times. Getting the tongue or cheek will increase the risk of a false negative. As such, it may be worthwhile to invest in some tongue blades to help push the tongue down in order to perform this test properly.

Should patients elect to start performing home strep tests, please be aware that physicians will be obligated to not only REPEAT the testing but also examine the patient to ensure antibiotics are appropriate. An actual throat culture may be performed as well which is the gold standard test.

1) Repeat testing is required because the patient may not have followed the instructions precisely. For example, the test strips must be read at 5 minutes (variable depending on the kit). If test results are read past 5 minutes, it may incorrectly show a positive result.
2) Some patients unfortunately fabricate test results just so they can get an antibiotic without an office visit.
3) Some patients unfortunately also fabricate test results in order to skip work or school for personal reasons not related to an actual medical condition.
4) There are situations that even though the strep test is positive, no treatment may be recommended. The patient may be a strep carrier for which treatment of any kind is not recommended.

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iPhone App to Objectively Measure Vocal Quality (f0, shimmer, jitter, etc)

For the inner geek in all singers and other professional voice users, you can now download onto your iPhone an advanced voice analysis program that provides objective measures of vocal quality similar to what is obtained in a professional voice laboratory.

Called OperaVox, preliminary studies have shown good reliability compared to KayPentax Multidimensional Voice Program (f0, shimmer, jitter). Noise to harmonic ratio showed less reliability. Retest reliability was also fairly consistent in all parameters.

Developed by a team of British researchers including an ENT and an audio specialist, there are 3 version of this app including a free "lite" version, a full-featured version meant for one person, and a much more expensive multi-user version meant for professionals.

The free "lite" version provides a recording of pitch f0, jitter, and shimmer as well as a history of your last 3 tests on a graph over time.

The paid full-featured version additionally also records MPT (maximum phonation time), reading measures (pitch range, mean pitch), and singing pitch range. Historical data is presented without any limits.

The multi-user version is really applicable to professionals in order to track more than one patient/student.

For the serious voice user, this app is a worthwhile investment to objectively measure your vocal quality progress (i.e., singers) as well as to provide helpful information to a speech/voice pathologist and physician when things suddenly change or get worse.

Watch video below on how this program works.

References:
Presentation by Dr Marina Mat-Baki et al from University college London and the Royal National Throat Nose and Ear Hospital, London at Cutting Edge Laryngology 2013; “Reliability of OperaVOX as acoustic analysis software: preliminary results”

Presentation by Dr Emily Lin and Jeremy Hornibrook from the University of Canterbury, New Zealand on the suitability of the iPhone microphones for performing acoustic analyses.

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Actor Zac Efron Broke His Jaw

Image by Liam Mendes from Wikipedia

This past weekend, actor Zac Efron slipped in a puddle of water outside his home and fell resulting in a severe facial cut as well as a broken jaw. [link]

Unlike most facial fractures that do NOT require any surgical intervention, most jaw fractures do need to be surgically repaired and typically entail wiring the jaw shut. Often, a metal plate with screws will be utilized to stabilize the fracture as well.

The reason the jaw is wired shut is so that as the broken bone heals, it heals in such a way that the way the teeth comes together is normal (in essence, the teeth act as the cast for the jaw fracture). Of course, eating is limited to liquid diet and dental care is important as brushing the teeth thoroughly will be impossible.

The wires holding the jaw shut can be removed after a few weeks, but exact duration depends on the fracture location and severity.

Source:
Zac Efron broke his jaw this weekend. CNN 11/13/13

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Pediatric Sinus Development and Sinusitis

There is a tendency for any type of nasal drainage to be attributed to "sinusitis" in children. Especially in young children, "sinusitis" is a relatively rare cause for nasal drainage and congestion which is actually more commonly due to viruses and enlarged adenoids.

The reason why sinuses play a relatively minor role in nasal drainage and congestion is because sinuses are not fully developed in children. It probably is not until around the age of 7 years old that "sinusitis" starts playing a more major role in disease manifestations. And even than, viruses and enlarged adenoids still play a major role in sino-nasal discomfort and as such, antibiotics not typically warranted.

Take a look at sinus development from newborn to adulthood below. In newborns, sinuses are mere indentations in the facial bone (light green). Adult sinuses are denoted by the dark green/peach.

It is for these reasons that sinus x-rays (or radiological imaging in general) are not warranted in children under 2 years. First, there is not much there, and secondly, x-rays are notoriously poor at diagnosing true sinus pathology [more info]. From 2 years to adolescence, sinus x-rays provide some guidance as to the presence of possible sinusitis, but CT Sinus scans are the gold standard to evaluate sinus disease presence or absence.

With persistent sino-nasal symptoms in children in spite of medical management, nasal endoscopy can be performed to evaluate the nasal cavity as well as the adenoids. Initial surgical management include adenoidectomy with or without turbinate reduction. While sedated for surgery, allergy testing can also be performed. If symptoms persist after these interventions, a CT Sinus scan can be obtained and consideration for sinus surgery can be made. The reason why CT Sinus scans are not obtained earlier is because whether it comes back normal or not, management does not change unless there are unusual extenuating circumstances present (significant eye or facial swelling).

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