Vocal Ranges of Famous Singers Past and Present

Concert Hotels has put together a nifty interactive chart documenting the vocal ranges of famous singers past and present. Check it out!

Keep in mind that the chart represents the recorded vocal range of each artist, not necessarily their actual range.

For the "interactive" chart, click here.

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Upper Lip Tie and Posterior Tongue Tie Treatment Without Sedation

It seems that in the past few years, upper lip tie and posterior "hidden" tongue tie has become increasingly recognized as factors affecting breast-feeding which correspondingly has led to higher numbers of referrals for evaluation and treatment.

Prior to 2011, I probably received only one or two consultations a year to evaluate these two conditions. Ever since than, it seems more and more infants are being diagnosed with these two conditions, especially by lactation consultants.

Anterior tongue tie and upper lip tie have historically been easily treated in the clinic under local anesthesia using common tools any ENT has.

Posterior tongue tie, given its relative rarity (at least from a referral basis), has historically been treated under sedation in the operating room given the need for specialized equipment and more aggressive surgical dissection.

However, given the increasing number of referrals for posterior tongue tie evaluation, specialized instruments needed to treat this condition have been purchased in order to address this condition without the need for sedation (assuming an infant). Young children with teeth may still need to be sedated.

Although laser is commonly used to treat this condition in the dental world, ENTs rely more on scissors and fine electro-cautery/coblation instruments which is what I use.

Read more about these conditions:

Anterior Tongue Tie
Posterior Tongue Tie
Upper Lip Tie

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Hearing Test Administered Over the Phone

I was just made aware of this service in a Washington Post article published May 16, 2014. This screening hearing test is taken over the telephone and accomplished by listening to three-digit sequences presented in a background of white noise. The test-taker has to then enter the digits using the telephone keypad. Based on accuracy of the response, the test than adjusts the next query.

Normally, the cost to take this telephone hearing test is $8, but at least for the month of May 2014, it is free in celebration of "Better Hearing and Speech Month."

Here's how to take the test by phone:

1. Find a quiet place to take the test that is free from distractions. 
2. If you hang up in the middle of your test, you will have to start from the beginning. 
3. Use a telephone that plugs into a wall-mounted jack. Please do not use a cell phone. 
4. Dial our toll-free number: 1-866-223-7575 
5. Listen to the recorded instructions. 
6. At the end of the test, write down your test results for each ear and the date. The categories are: 

Within the Normal Range

Slightly Below the Normal Range

Poor

Further details of this test can be found here, but the test essentially is based on the speech-to-noise ratio (SNR) that is adjusted using an adaptive procedure seeking a threshold for 50% correct identification of the digit sequences. A set of 25 sequences provides a reliable SNR threshold in about four minutes of testing per ear. This method of testing is different from most hearing tests in that it uses digits in static noise, rather than pure tones. Because the test measures an SNR threshold rather than one based on the absolute level of tones, a reliable screening measure of hearing, despite the differences in sound levels produced by different telephones, can be achieved.

Of note, this method of testing was validated in Europe by scientists at VU University Medical Center in the Netherlands in 2004. The U.S. version began in 2008 with funding from the National Institute of Health and was validated in two studies performed at the Indiana University Hearing Clinic and the other in collaboration with clinics administered by the VA Health System.

If hearing is assessed to be abnormal, you can contact our office to undergo a more sophisticated hearing test for confirmation and next steps.

Source: 
Take this hearing test right now. I did, and the results were disturbing. Washington Post 5/16/14.

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Top 4 Causes of Dizziness (Table)

Dizziness is an extremely common disorder that afflicts an estimated 10-20% of individuals older than 70 years old. Even for those younger, dizziness is a not uncommon problem.

Several studies have been performed over the years to try and quantitate what are the most common causes of dizziness to help narrow the possibilities given the workup for dizziness can be long, tedious, and time-consuming which often frustrates patients.

Also frustrating is the fact that without a diagnosis, treatment can not be reliably pursued resulting in symptom persistence in spite of attempted treatment.

In any case, in rank order, the top 4 most common causes of dizziness are:

#1: BPPV

Depending on the study (see table below), accounts for ~25% of all dizziness. The symptoms of BPPV (Benign Paroxysmal Positional Vertigo) are spinning attacks that last no more than a few minutes that occur with positional changes, usually turning the head. Diagnosis is achieved by Dix-Hallpike maneuver. Treatment is positional therapy, usually Epley.

#2: Anxiety

Frequency is around 20% depending on the study (see table below). Fairly self-explanatory. Usually the dizziness is described as light-headed imbalance that lasts hours to days.

#3: Unknown

In spite of exhaustive testing and evaluation by multiple specialties, a diagnosis is never reached and treatment is symptomatic. Sadly, the cause of the dizziness can not be found in approximately 20% of patients.

#4: Orthostatic Hypotension

Orthostatic hypotension is usually described as light-headedness (vision going dark when severe) when going from a laying to standing position. Due to cardiac or blood pressure issues which when corrected, resolves this particular dizziness. Only around 5% is dizziness attributable to this condition.

Below is a table (references at end) that goes over the frequency rates for other causes of dizziness.

Variable	Study #1	Study #2	Study #3	Study #4	Study #5
# of Patients	1194	117	149	731	2556
Age of Subjects	over 70	over 50	over 65	over 70	under 70
Examiner	ENT	Neurology	Geriatrics	ENT/Neurology	ENT/Neurology
Diagnosis
BPPV	47%	26%	4%	27.6%	22.6%
Anxiety	0%	3%	32%	15.3%	33%
No Diagnosis	23%	14%	0%	15.2%	11.4%
Orthostatic Hypotension	2%	3%	1%	7.1%	1.3%
Vascular Disorder	8%	7%	70%	5.2%	0.2%
Cervical Disorder	0%	0%	66%	0%	0%
Meniere's Disease	4.05%	4%	-	5.2%	5.6%
Migraine	0.08%	-	-	1.1%	3.9%
Labyrinthitis	1.77%	3%	-	0.96%	0.51%
Brain Tumor	1.4%	3%	-	0.55%	0.24%
Medication Side Effect	-	2%	-	1.9%	0.2%
Stroke/TIA	6.34%	7%	-	5.2%	0.2%

References:
Dizziness in the elderly: Diagnosing its causes in a multidisciplinary dizziness unit. ENT Journal. 93(4-5):162-167.

Dizziness in elderly men. JAGS 42:1184-1188.

Evaluation of investigations to diagnose the cause of dizziness in elderly people: a community based controlled study. BMJ 313

Dizziness in aging: A retrospective study of 1194 cases. Otolaryngol Head Neck Surg. 1994 Mar;110(3):296-301.

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Whooping Cough Without the Whoop - The Bad Lingering Cough

Although I have been practicing medicine since 2000, the first time I diagnosed whooping cough was in 2011 and ever since, I have been diagnosing more and more cases each year thereafter. However, what makes these cases a little unusual is that for ALL cases of whooping cough I have diagnosed, there was no characteristic whoop for which it is named after.

Rather, the common characteristics for all patients I have diagnosed include:

• "Mystery" cough that has been going on for weeks if not months

• Cough can occur in severe attacks with in-between periods of relative normalcy. Cough could also be just a "bad, lingering" cough.

• Cough attacks can be so severe, patient may get short of breath, faint, turn blue, vomit, etc. However, they could be minor attacks as well.

• Dry cough, though some mucus may be seen
• All studies like lung function tests and chest x-rays (save those described below) come back normal.

• Medications typically do not work except for strong narcotic cough suppressants.

• No whoop after the cough.
• Afflicts ALL ages

Should a person been coughing like this only in the past few weeks, I usually obtain a nasopharyngeal swab tested for bordetella pertussis DNA.

If it has been for longer than a month and antibiotics have been given, I usually obtain blood titres for bordetella pertussis mainly because the infectious agent may have been cleared and culture may come back falsely negative.

My personal observations have also been reported elsewhere.

In fact, a study in 2010 stated that the "classic" symptoms of whooping cough which historically was considered only a childhood disease, is no longer a reliable way of determining whether a patient has whooping cough or not. It is also no longer a childhood disease.

In fact, most teens and adults lack the classic symptoms for whooping cough and their only symptom may be a bad lingering cough. In fact, some estimate that 10% to 30% of prolonged coughs in adults are caused by pertussis.

Even if a patient has been vaccinated for whooping cough, you can STILL get it mainly because it is not 100% effective. Furthermore, vaccine protection fades with time. Given incomplete ineffectiveness in combination with more and more parents electing to not vaccinate their kids, it is no surprise there are more cases being diagnosed every year. It's just that physicians may not recognize the cough for what it is.

Here's what the CDC has to say about whooping cough vaccines:

Vaccine protection for pertussis, tetanus, and diphtheria can fade with time. Before 2005, the only booster vaccine available contained tetanus and diphtheria (called Td), and was recommended for adolescents and adults every 10 years. Today there are boosters for adolescents and adults that contain tetanus, diphtheria, and pertussis (called Tdap). Pre-teens going to the doctor for their regular check-up at age 11 or 12 years should get a dose of Tdap. Adults who didn’t get Tdap as a pre-teen or teen should get one dose of Tdap instead of the Td booster. Most pregnant women who were not previously vaccinated with Tdap should get one dose of Tdap postpartum before leaving the hospital or birthing center. Getting vaccinated with Tdap is especially important for families with and caregivers of new infants.

The easiest thing for adults to do is to get Tdap instead of their next regular tetanus booster—that Td shot that they were supposed to get every 10 years. The dose of Tdap can be given earlier than the 10-year mark, so it’s a good idea for adults to talk to a health care provider about what’s best for their specific situation. [link]

Of course, there may be other causes for a chronic lingering cough, but whooping cough should be in the differential.

References:

Does this coughing adolescent or adult patient have pertussis? JAMA. 2010 Aug 25;304(8):890-6. doi: 10.1001/jama.2010.1181.

No big whoop: Adult pertussis may not produce the whooping cough. Harvard Health Blog 9/13/10

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Cure Hiccups by Pulling on the Tongue

There are many different ways to treat hiccups (otherwise known as singultus). Some of the more bizarre ways of treating hiccups include rectal massage and tongue pulling.

Tongue pulling treatment is most commonly attributed to Sir William Osler (1849-1919). However, origins of tongue pulling can be found in much earlier French references including Jean Laborde (1830-1903), Jean Viaud (1862-1946), and Raphaël Lépine (1840-1919).

It is hypothesized to work by stimulating the vagus nerve thereby easing the diaphragmatic spasms.

Reference:
Treatment of singultus by traction on the tongue: an eponym revised. J Hist Neurosci. 2013;22(2):183-90. doi: 10.1080/0964704X.2012.728389.

[Stimulation of the root of the tongue can cure hiccup. 20 years of "unscientific" experience supports the thesis]. Lakartidningen. 1998 Oct 7;95(41):4477-9.

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Anal Massage Cures Hiccups?

So... I came across a few references addressing treatment of hiccups (otherwise known as singultus), but perhaps the most bizarre treatment for hiccups I saw was rectal massage.

Digital rectal massage (see references below) has apparently been reported in the literature to help stop hiccups, mainly by disrupting the vagal afferent limb of the hiccup reflex arc. Name says it all. Essentially, you stick a finger up the bungholio and massage the area firmly until the hiccups stop.

It apparently stops hiccups fairly quickly.


Reference:
Termination of intractable hiccups with digital rectal massage. J Intern Med. 1990 Feb;227(2):145-6.

Termination of intractable hiccups with digital rectal massage. Ann Emerg Med. 1988 Aug;17(8):872.

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How Common is Hoarseness?

At some point, we all have suffered from a hoarse voice whether from illness or from yelling. However, it was unclear exactly how common this malady is until now... and apparently, the answer is "very common"...

According to a study looking to answer this question, hoarseness affected 17.9 million adults in 2012.   The average age was 49 years old and 63% were women. Overall, 10% saw a health care professional for their hoarseness and 40% were given a diagnosis.

Infectious laryngitis was the most common diagnosis mentioned (685±86 thousand cases, 17.8±2.0%). Gastroesophageal reflux disease was mentioned in 308±54 thousand cases (8.0±1.4%).

33% reported their voice problem to be a significant problem. Bad enough that the mean number of days the hoarseness lasted was about 56 days. Because of the hoarseness, patients missed work about one week in the past year.

A general rule of thumb is to see your local ENT if the hoarseness lasts more than 1 week. Intervention can be performed to minimize the duration of hoarseness as well as to alleviate the morbidity associated with this problem.

Another general rule of thumb is to minimize using your voice if it becomes unexpectedly hoarse.

Reference:
The prevalence of voice problems among adults in the United States. Laryngoscope. 2014 Apr 29. doi: 10.1002/lary.24740.

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Cricoid Pressure May Minimize Symptoms of Reflux (LPR)

Specifically throat symptoms attributable to reflux such as globus, throat-clearing, phlegmy throat, chronic cough, etc. However, cricoid pressure may not be realistic nor practical even if it does help.

In one of the more unusual studies I have seen, researchers deliberately infused 60 cc of hydrochloric acid into the esophagus of 14 patients who suffered from LPR as well as 12 healthy controls. 9 patients exhibited confirmed LPR (laryngopharyngeal reflux) events, but none in the control group. With moderate sustained cricoid pressure (20-30 mmHg), only one patient had a confirmed LPR event.

Theoretically, why would cricoid pressure work?

The cricoid cartilage is located immediately below the voice box. It is a circular cartilage that is right at the level where the throat connects to the esophagus. By putting pressure on the cricoid cartilage, the top part of the esophagus is manually compressed shut which theoretically would prevent reflux from regurgitating up into the throat.

It is based on this theory that anesthesiologists often perform cricoid pressure to prevent aspiration during intubation for surgery, especially if a patient is suspected of drinking/eating something prior to surgery.

The problem with cricoid pressure is that in order for this to work, it needs to happen continuously which may make it unrealistic and impractical for patients who suffer from LPR. Continuously means 24/7/365. Not just when symptoms are present (because it's too late than).

Reference:
Prevention of esophagopharyngeal reflux by augmenting the upper esophageal sphincter pressure barrier. Laryngoscope. 2014 Apr 29. doi: 10.1002/lary.24735.

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Map of Vaccine-Preventable Outbreaks Over Time

Image by Council of Foreign Relations

The council of foreign relations have produced an interactive map the shows the concentration of vaccine-preventable outbreaks throughout the world over time. Such diseases include measles, mumps, rubella, polio, and whooping cough.

The take-home point of the map is that diseases that were once considered "eradicated" due to near-universal vaccinations have now made a tremendous comeback which is felt almost certainly due to the anti-vaccine movement.

Vaccinate!!!

Reference:
Vaccine Preventable Outbreaks. Council of Foreign Relations.

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Hearing Loss Over Time

It is well-known that professional musicians have a higher risk of hearing loss and tinnitus compared to non-musicians. According to one study, the risk for musicians is 1.5x for hearing loss and nearly 4x for tinnitus.

And although people understand that as you get older, hearing loss increases, what is less clear is how quickly hearing loss occurs over time.

After analyzing over 3 million subjects, here is the graph of hearing loss with age. Intuitively, I thought there would have been a "jump" in hearing loss after a certain age. The graph indicates no such "jump," but rather a continuous increase of hearing loss from the earliest age studied (19-21 years).

This gentle slope does suggest that the vast majority of hearing loss is due to the slow accumulation of noise-induced nerve damage over time and that the vast minority of hearing loss is secondary to an acute event whether from infection or sudden loud noise exposure (i.e., gunshot without hearing plugs).

Source: http://oem.bmj.com/content/early/2014/03/28/oemed-2014-102172.full

Reference:
Incidence and relative risk of hearing disorders in professional musicians. Occup Environ Med doi:10.1136/oemed-2014-102172

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A Single Sneeze Can Spread Throughout Entire Building

MIT researchers using high-speed cameras and applying fluid dynamics have discovered that although ejected droplets from a sneeze typically fall to the ground, the "cloud" of moisture from a single sneeze actually floats and can enter ventilation ducts and can potentially spread throughout an entire building or airplane. Watch video below.

These findings have profound implications as to how infections may travel within buildings and other contained structures like cruise ships and airplanes.

So although most people cover their mouths when sneezing in public, it also needs to happen in private even when there's nobody around. Of course, more study is needed to see if the sneeze "cloud" is even minimized with mouth-covering.

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