How Long Do Swallowing and Voice Problems Last After C-Spine Surgery ACDF?

I often see patients for swallowing and/or voice difficulties after cervical spine surgery (ACDF). In the vast majority of cases, reassurance that such "side effects" are not uncommon is the only thing I need to provide after a complete exam.

After all, both the voice box and swallowing tube are manipulated and pushed over to one side in order to perform cervical spine surgery from an anterior approach. Check out the video below that illustrates how this happens.

Beyond reassurance, the next question patients have is how long before things go back to normal. Until now, that was a hard question to answer.

A recent report was able to provide some numbers I can now use to help explain to patients. After anterior approaches to cervical spine surgery:

• 60% had a postoperative issue, including 27% with postoperative voice complaint and 48% with postoperative swallowing complaint
• Swallowing complaints that lasted beyond 1 year occurred in 28%
• Voice complaints that lasted over 1 year occurred in 9%
• Approaching spinal levels above C4 and exposing more than 3 spinal levels were 2 factors that significantly resulted in voice and swallowing problems

In certain patients with more extreme swallowing difficulties, barium swallow studies may be ordered. Swallow therapy can be helpful as well.

Should vocal cord paralysis be seen on endoscopy, voice therapy and even vocal cord medialization injections can be performed to alleviate voice problems.

Reference:
Factors Predictive of Voice and Swallowing Outcomes after Anterior Approaches to the Cervical Spine. Otolaryngol Head Neck Surg. 2013 Dec 23. [Epub ahead of print]

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Beatboxing Protective of the Vocal Cords?

Beatboxing is a popular vocal percussion technique that incorporates use of the entire vocal tract. Recently, research by Dr. Steven Simms (who I had the pleasure of working with briefly when we were both at Yale University in the 1990s) suggested that beatboxing techniques may actually protect against vocal cord injury.

Unlike singing where most of the sustained energy is directed at the vocal cord level, beatboxing makes extensive use of the entire vocal tract, especially the muscles of the throat.

Although more research is needed, it is not inconceivable that beatboxing techniques may potentially be helpful to patients who have suffered from vocal cord injury. The question is what techniques specifically and how it can be incorporated into voice therapy sessions. Furthermore, such vocal techniques may be more "acceptable" to teenagers who may scoff at more traditional strategies.

Check out this fiberoptic laryngoscopy video of a beatboxing artist.

Reference:
Functional Endoscopic Analysis of Beatbox Performers. Journal of Voice. Published Online 12/23/13. PII: S0892-1997(13)00243-9 doi:10.1016/j.jvoice.2013.11.007

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Acupuncture Helps with Ear Surgery Pain

Researchers at Boston Children's Hospital has found that acupuncture may be effective in diminishing both pain and post-anesthesia agitation in children after ear tube placement determined thru a prospective randomized controlled trial.

Typically, children are placed under general anesthesia in order to have this procedure performed and upon waking, are often tearful and agitated. In this study, acupuncture needles were placed at LI-4 and HT-7 immediately after anesthesia, but prior to ear tube placement.

A blinded assessor than determined that pain and agitation were significantly lower in the acupuncture group compared with controls during the 30 minutes after surgery. Furthermore, the number of patients who required analgesia was considerably lower in the acupuncture group than that in the control group.

Although promising, in order to be fully convinced of the effectiveness of acupuncture, further research by other groups in larger number of kids need to be performed.

BUT... because the risks and side effects are so nominal, it can't hurt to give it a try for those patients and families interested in doing so.

For full disclosure, I personally have no experience in providing acupuncture and I would suggest taking these research findings to a reputable and licensed acupuncturist to get this done in those who are interested.

Reference:
Acupuncture management of pain and emergence agitation in children after bilateral myringotomy and tympanostomy tube insertion. Pediatric Anesthesia. Volume 19, Issue 11, pages 1096–1101, November 2009

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Bengals Punter Kevin Huber Suffers Jaw Fracture During Game

Courtesy of Jeffrey Beall from Wikipedia

This past weekend, Cincinnati Bengals punter Mark Huber suffered a broken jaw when he was viciously knocked to the ground by Steelers Terence Gavin who lead the tackle with his helmet. [link]

Given bleeding from the mouth, there is the possibility of an open fracture extending into the mouth, though it could also be from a self-inflected bite when Huber got hit.

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.

Also, it is easier to precisely place the metal plates after the jaw is wired shut. In Huber's case, metal plates will almost certainly be utilized as it allows for faster healing, sooner removal of jaw wiring, and quicker return to normalcy.

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

With this type of facial fracture, it will be unclear when exactly he will be able to return play.

Source:
SEE IT: Bengals punter Kevin Huber fractures jaw after taking hit from Steelers' Terence Gavin. NY Daily News 12/15/13

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Acupuncture Alleviates Pain After Tonsillectomy in Children

The study showed that acupuncture significantly decreased pain after tonsillectomy in children (2-17 years of age) with reported pain levels before acupuncture of 5.52 (SD=2.28) out of 10 which fell to 1.92 (SD=2.43) after acupuncture.

This retrospective research was conducted in 31 patients who underwent a tonsillectomy within a 3 month period of time by Dr. James Ochi, one of only a handful of dual board-certified ENT and medical acupuncture in the United States. No study patients received any narcotics for pain control beyond tylenol, ibuprofen, and a single dose of intra-operative dexamethasone. The tonsillectomy itself was performed using electrocautery set at 24W.

The acupuncture points used for pain control are shown below and was performed bilaterally:

Image taken from the Research Paper

All patients received acupuncture at LI4 (between thumb and index finger). Additional points were found effective in relieving tonsillectomy pain and provided on an as needed basis at (in decreasing frequency) CV23, GV24.5 and GV20. Acupuncture points LI20, LI11, and LI10 were utilized in only a few patients.

LI4 point is hypothesized to work so well because:

"Stimulation at LI4 increases activity in the somatosensory cortex and a region of the brainstem known as the periaqueductal gray area, as revealed by functional magnetic resonance imaging, that are involved in processing pain signals." [link]

Although promising, in order to be fully convinced of the effectiveness of acupuncture for post-tonsillectomy pain, further research that is prospective, randomized, and controlled is required.

BUT... because the risks and side effects are so nominal, it can't hurt to give it a try for those patients and families interested in doing so.

For full disclosure, I personally have no experience in providing acupuncture and I would suggest taking these research findings to a reputable and licensed acupuncturist to get this done in those who are interested.


Reference:
Acupuncture instead of codeine for tonsillectomy pain in children. International Journal of Pediatric Otorhinolaryngology Volume 77, Issue 12 , Pages 2058-2062, December 2013

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Two New Sublingual Allergy Tablets Approved by FDA Advisory Committee

This week, the FDA Allergenic Products Advisory Committee unanimously supported approval for two new sublingual allergy tablets (Oralair and Grastek) that work the same way allergy shots do... but instead is dissolved under the tongue at home instead of a shot in the arm in a medical office. Although both tablets have been available in Europe for some time, final "official" FDA approval may not occur until end of 2014 (or later) for sale/distribution under prescription in the United States.

Oralair is made by a French pharmaceutical company Stallergenes and treats patients aged 10-65 years who are allergic to 5 different grasses: Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass. Treatment is composed of a buildup and maintenance phase. Starting 4 months prior to the grass pollen season, a 100 IR tablet is administered under the tongue in a medical office to ensure no significant side effects. At home on day 2, two 100 IR tablets are administered. On day three and daily thereafter, a 300 IR tablet is placed under the tongue until the end of the grass pollen season. The tablets take about 1 minute to dissolve.

Grastek (aka Grazax in Europe) is made by ALK-Abello and Merck and treats patients aged 5-65 years who are allergic to only Timothy Grass. Grastek has a simpler regimen of 1 sublingual tablet daily starting 12 weeks before and continued until the end of the grass pollen season. As with Oralair, the first dose is given in a medical office to ensure safety with all other doses are taken at home. The tablet dissolves in less than 10 seconds.

For both tablets, epipen needs to be available at home due to possible risk of anaphylaxis. As with allergy shots, patients on beta-blockers for high blood pressure are not eligible to undergo this treatment.

Sources:
Grastek Recommended by FDA Panel for Timothy Grass Allergy. Medscape 12/12/13

Sublingual Oralair Recommended for Grass Pollen Allergy. Medscape 12/11/13

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The Nose is a Jungle of Germs (even in Normal Healthy People)!

A fascinating study was conducted by Stanford researchers on the amount and types of germs found inside the nose in normal healthy individuals, whether they are staph carriers or not.

In a typical nose in a healthy individual without any symptoms, the following "germs" can be found. Keep in mind that ALL these germs have the potential to cause a pathological sinus infection:

• Corynebacterium
• Propionibacterium
• Escherichia-Shigella
• Staphylococcus aureus (including MRSA)
• Staphylococcus (other species)
• Dolosigranulum
• Tomitella
• Moraxella
• Actinobacteria
• beta-Proteobacteria
• Prevotella
• Anaerococcus
• Streptococcus
• Peptoniphilus
• Variovorax

These germs were found not just in the nostril, but also on the middle turbinate located about 1-2 inches into the nose and the sphenoid recess located in the very back upper part of the nose (about 3+ inches into the nose).

The top 2 most common germs found in healthy individuals were corynebacterium and propionibacterium. When these bacterial populations decrease, the presence of staphylococcus increases.

Staphylococcus was also found not just at the nostril where cultures are most commonly obtained, but in both much deeper locations within the nose.

This may explain why in spite of aggressive whole body MRSA body hygiene management and use of bactroban ointment to the nares not uncommonly fails to eradicate staph/MRSA in susceptible patients.

Clearly, more research is needed, especially in how to minimize/eradiacate staph colonization beyond the nostril (but allow for normal, healthy bacteria to remain).

Source:
Staph Germs Hide Out In The Hidden Recesses Of Your Nose. NPR 12/11/13

Reference:
Nasal Microenvironments and Interspecific Interactions Influence Nasal Microbiota Complexity and S. aureus Carriage. Cell Host & Microbe, Volume 14, Issue 6, 631-640, 11 December 2013

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Lawsuit for Botched Laser Vocal Cord Surgery

In February 2012, an ENT surgeon removed vocal cord polyps using a laser while the patient was asleep with a Medtronic Laser-Shield II endotracheal tube. Unfortunately, the laser perforated the endotracheal tube, ignited the 100% oxygen being used at the time resulting in catastrophic burns to the patient. [link]

Subsequent lawsuit resulted in favor of the patient who received an award totaling $30 million on 12/5/13.

What Happened?

Even though an endotracheal tube meant for use with laser procedures was utilized, if this specially designed tube sustains enough damage from the laser, it will either perforate or heat to a high enough temperature to ignite. Furthermore, 100% oxygen was administered by the anesthesiologist which just added gasoline to the flame.

Ideally, in such laser procedures, meticulous surgical technique is still required and care taken to avoid damaging the endotracheal tube, even if a "laser-safe" tube is used. The "weak" part of any laser-safe tube is the cuff that is inflated to make a tight seal between the trachea and the tube itself. As such, the cuff material is necessarily thin. Saline-soaked pledgets placed immediately above the cuff helps protect the cuff as well as use of a tube with two cuffs (in case one fails). Also, room air should have been administered to the patient in the event the tube fails in order to minimize oxygen in the area... and the patient placed temporarily on apnea whenever the laser is turned on.

The risk of fire among other reasons are why many ENT surgeons (myself included), have stopped using lasers for procedures done in the mouth and airway.

With vocal cord procedures, I still utilize cold steel techniques which has a zero risk of airway fire.

Sources:
Botched surgery will cost hospital. The Wenatchee World. 12/6/13.

Medtronic slips $18M verdict in surgical fire case. MassDevice. 12/10/13

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Tracheostomy Fire During Surgery Burning Patient

Image from Wikipedia

In early 2012, a surgeon was performing a trach (breathing hole in the neck) when the oxygen used during the procedure caught fire severely burning the patient. Apparently, the surgeon used an electrocautery device which most likely emitted a spark igniting the oxygen being given to the patient leading to the fire. [link]

What happened?

Tracheostomy procedures are performed typically in very sick patients who have been intubated for a prolonged period of time. Often, such patients require higher concentrations of oxygen than normal in order to maintain oxygen levels in the body.

Problem in this scenario is that higher concentrations of oxygen also mean a higher risk of accidental fire when using instruments that help stop bleeding like an electrocautery device.

During a tracheostomy, an opening is created in the windpipe (watch video below). This allows oxygen that is being given to the patient to leak out into the surgical field. If electrocautery is used in this oxygen rich environment, any spark from an electrocautery device can lead to ignition and a flash fire.

Typically, in order to minimize this risk of fire, the surgeon should avoid using any electrical instruments in the surgical field that may create a spark after entering into the airway. Cutting into the airway would allow oxygen to escape into the surgical field. That usually means meticulous surgical technique and controlling all bleeding BEFORE cutting into the airway. If possible, reducing the oxygen given to the patient as much as possible is also beneficial.

Nitrous oxide should be avoided as an anesthetic agent as it is also ignitable like oxygen.

If electocautery use is unavoidable after the airway is surgically entered, the endotracheal tube cuff should re-inflated and advanced past the tracheostomy incision. Vacuum suction should be applied to evacuate as much oxygen from the surgical field and if possible, a period of apnea while cautery is applied.


Source:
Revealed: The chief of surgery who set patient on fire when his electronic scalpel caused 'EXPLOSION' Mail Online. 5/6/12

References:
Airway fire during tracheostomy: prevention strategies for surgeons and anesthetists. Ann R Coll Surg Engl. 2001 November; 83(6): 376–380.

Fatal inhalation injury caused by airway fire during tracheostomy. Acta Anaesthesiol Scand. 2007 Apr;51(4):509-13.

Tracheostomal fire during an elective tracheostomy. Chang Gung Med J. 2005 Mar;28(3):186-90.

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Nasal Spray Cure for the Common Cold?

Well maybe not cure per se, but at least effective treatment to reduce the duration and severity of the viral cold at least. Austrian researchers have reported on the results of a randomized, double-blind, placebo-controlled trial involving 211 patients suffering from early symptoms of the common cold. [link]

Treatment of the non-placebo group involved using a nasal spray containing carrageenan (a sulphated polysaccharide found in red seaweed/algae) three times per day for 7 days. Cold symptoms were found to resolve 2.1 days faster and viral loads in the nasal washings were significantly decreased compared to placebo group. At day 21 of observation, one sixth of patients given the placebo were still ill, while only one twentieth were in the treatment group.

Personally, I would like to see larger studies conducted by other independent groups to verify the findings.

So how does this nasal spray work?

The problem with the common cold is that there are SO many viruses that manifest the same disease including rhinovirus, coronavirus, parainfluenza, influenza, respiratory syncytial virus, adenovirus, enterovirus, and metapneumovirus. As such, an effective treatment should be able to disable all these virus types and not just one.

The way carrageenan works is by sticking to the virus regardless of type and preventing it from attaching to the nasal lining. As such, the virus is unable to enter into the body and cause problems. It essentially blocks the virus like the wall of a castle.

The caveat is that in order for this nasal spray to work, you have to start using the medication as soon as cold symptoms appear (within 2 days). Remember... it works by blocking the virus from entering the body. If you wait too long, the virus has already entered the body making any type of blocking medication ineffective.

Where can you buy it?

It is available over-the-counter in most European countries and Canada. But NOT available in the United States.

The nasal spray is made by Marinomed in Europe using their Mavirex technology and also licensed for marketing/distribution by Boehringer. Carragelose is the brand name of the carrageenan ingredient. Depending on the country, the actual name of the nasal spray is sold under is different.

For example, in England, the nasal spray is called "Cold and Flu Defence Nasal Spray".

To make sure you have the right nasal spray, look under ingredients and make sure carragelose is listed.

On another note... Afrin nasal spray has also been shown to have some anti-viral activity in unpublished reports. Just be aware to not use it more than 3 days or else you may get addicted to it.


References:
Efficacy of a Carrageenan nasal spray in patients with common cold: a randomized controlled trial. Respiratory Research 2013, 14:124 doi:10.1186/1465-9921-14-124

Efficacy and safety of an antiviral Iota-Carrageenan nasal spray: a randomized, double-blind, placebo-controlled exploratory study in volunteers with early symptoms of the common cold. Respir Res 2010. doi:10.1186/1465-9921-11-108

Lessons learned from a double-blind randomised placebo-controlled study with a iota-carrageenan nasal spray as medical device in children with acute symptoms of common cold. BMC Complement Altern Med 2012. doi:10.1186/1472-6882-12-147

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Does Removing the Adenoids Decrease Risk of Ear Infections? Yes...

A recent meta-analysis has determined that risk of recurrent ear infections is significantly reduced if adenoidectomy is performed in combination with ear tube placement as opposed to ear tube placement alone. When stratified by age, removing the adenoids was found particularly helpful in children older than 4 years of age.

Combining results from over 15 studies containing over 71,000 children, the estimated rate of repeat ear tube placement for recurrent ear infections in children who also had adenoidectomy was only 17.2% vs 31.8% for children undergoing ear tubes alone. However this significance faded under the age of 4 years.

Why would adenoid removal influence ear infections?

First a little anatomy lesson...

In the back of the nose, there is an opening called the eustachian tube that goes up into the ear. That's why one is able to pop the ears when blowing into a pinched nose.

Image by Chittka and Brockmann from Wikipedia

The adenoids are located in the back of the nose immediately behind the eustachian tube opening. The adenoids can potentially lead to ear problems via two mechanisms. First, the adenoids could be very enlarged causing physical obstruction of the eustachian tube which can make it impossible to pop the ears. Second, the adenoids could be a reservoir of germs which can lead to ear infections given proximity to the eustachian tube.

As such, removal of the adenoids would allow the eustachian tube to function better as well as eliminate a potential reservoir of infection.

However, recommendation for adenoid removal typically occurs if a child requires a 2nd set of tubes which usually occurs around age 4. Adenoidectomy may be recommended with the initial set of ear tubes (after taking into consideration age) if other symptoms are present including nasal obstruction and a snotty nose.


Reference:
Adenoidectomy as an Adjuvant to Primary Tympanostomy Tube Placement: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2013 Nov 28. doi: 10.1001/jamaoto.2013.5842. [Epub ahead of print]

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