Sinus Infection Leads to Skull Removal in Child

The UK reported a 9 years old boy who had an extremely rare sinusitis complication that ultimately resulted in the left skull being removed temporarily.

Briefly, in Feb 2013, the child developed headaches and a droopy eyelid. Surgeons ultimately had to remove his left skull due to brain swelling and concern the bone itself was infected. Over the next few months, the child had to wear a bike helmet to protect his brain which was no longer protected by his skull. A few weeks ago, he underwent another surgery to cover the hole in his left skull with a custom-shaped ceramic plate.

No mention was made in the media about which sinus cavity led to this horrible problem.

But here's a guess without benefit of more information...

Based on the skull defect shown (see pics here), it appears that the parietal and temporal skull bones were removed. There are actually no sinus cavities in these regions. As such, the only thing that makes sense to me is that the left cerebral dural sinus (large blood vessels of the brain) became clotted off and infected secondary to a sinus infection, probably the ethmoid sinus cavities located between the eyes.

The blood supply from the ethmoid sinus cavities communicates with the cavernous sinus found at the bottom of the brain. This anatomic structure is a major source of venous drainage of the brain.

If the cavernous sinus gets inflamed/infected due to a sinus infection, it could lead to multiple facial abnormalities due to injury of the numerous cranial nerves that go through it including:

• Inability to move the eyeballs (CN3, 4, 6)
• Numbness, pain of the skin over the forehead and cheeks (CNV1, V2)
• Loss of pupillary constriction (CN3)
• Visual loss/changes (CN1)

Ultimately, the cavernous sinus could also become thrombosed.

Cavernous Sinus shown by red arrow. Taken from Sonoworld.

From there, the infection can spread to the rest of the brain via the dural sinus cavities and potentially can even lead to death if not treated promptly and aggressively.

How aggressively? In this particular case, the child had half his skull removed!

Thankfully, the vast, vast, vast majority of sinus infections do not lead anywhere close to this type of complication.

Source:

Boy, 9, has half his skull removed after sinus infection spreads to his brain - but he still manages to attend school thanks to a BICYCLE HELMET. MailOnline 8/26/13

Read More

Possible Blood Test for Oral Cancer Caused by HPV?

There might be a blood test which can possibly predict individuals who may develop oral cancer caused by HPV years before it happens. HPV, an abbreviation for human papilloma virus, encompasses over 100 different strains among which only a few can cause problems in humans. Specifically, HPV 16 can lead to cervical cancer in woman and oral cancer in both genders.

HPV triggered oral cancer is also the most common cause of oral cancer now exceeding even smoking and drinking alcohol.

Unlike HPV that causes cervical cancer which can be screened for by pap smears in women, there's currently no good screening test to look for HPV that might cause oral cancer.

However, that's not to say that researchers aren't busy looking for just such a test...

In June 2013, researchers published a possible blood test that might predict those individuals at risk for developing HPV oral cancer.

By analyzing blood samples taken from 638 patients with head and neck cancers, they discovered that antibodies against HPV16 E6 was present in pre-diagnostic samples for 34.8% of patients with oropharyngeal cancer and 0.6% of controls (healthy patients without cancer). Furthermore, HPV16 E6 was NOT associated with other cancer sites. The increased risk of oropharyngeal cancer among HPV16 E6 seropositive participants was independent of time between blood collection and diagnosis and was observed more than 10 years before diagnosis.

Now I should state that HPV16 E6, which is actually a gene found in the virus, only accounted for 34.8% of patients. It bears repeating... it was positive only 34.8% of the time. In other words, this test predicted oral cancer only one out of every 3 patients who actually developed cancer.

As such, it is not a very specific test... ideally, you want a number as close to 100% as possible, otherwise patients who test negative to this blood test may falsely think they are not at risk.

Now, the other problem is what if a patient DOES test positive to HPV16 E6?

Does that mean such patients need to undergo routine fiberoptic endoscopy screening examinations every few months or years? Are biopsies required or not if visual examination appears normal? If biopsies are required, how often and from where? After all, oral cancer encompasses the tongue, tonsil, pharynx, larynx, supraglottis, palate, buccal mucosa, etc, etc, etc. That's a lot of biopsies...

Coincident with the development of a good blood test is the need for research to develop a protocol of what to do with the results of such test information.

Reference:
Evaluation of Human Papillomavirus Antibodies and Risk of Subsequent Head and Neck Cancer. Journal of Clinical Oncology. Published online before print June 17, 2013, doi: 10.1200/JCO.2012.47.2738

Read More

At Home Allergy Testing

Recently, a new at-home allergy test can be found on store shelves throughout the United States as well as Amazon.com. It is called "MyAllergyTest" produced by ImmuneTech Corporation and it is FDA approved. The way it works is that you place a few drops of blood into the collection kit which is than mailed to a lab in a pre-paid, pre-addressed envelope.

Results are than obtained via internet or by certified mail in about one week.

What's tested? Only ten things (IgE only):

• Timothy Grass
• Bermuda Grass
• Mountain Cedar
• Short Ragweed
• Alternaria Mold
• Cat Dander
• Mite pternoyssinus
• Egg White
• Wheat
• Milk

As such, if testing comes back normal, it does not mean you do not have allergies... It just means that you do not have allergies to these 10 things only... You could be allergic to other non-tested substances.

A report is produced listing what you are allergic to and how badly:

How accurate is the testing? Apparently, it is comparable to Pharmacia CAP system (specific IgE FEIA).

In terms of actual numbers, the test has a sensitivity 88%, specificity 94%, and accuracy 91%.



Source:
FDA.gov

Company Website

Read More

Do Nosebleeds Cause Stool Blood Tests to Become Positive?

As a general rule, an ordinary nosebleed will not cause a screening stool blood test (hemoccult or guaiac) to come back positive.

However, if the nosebleed is bad enough to consider going to the emergency room... and you are swallowing a lot of it... only than will it be likely that such stool tests will come back positive for blood.

To be precise, such stool tests turn positive only if there's at least 2+ teaspoons of blood leaking into the digestive system everyday (or swallowed from a very bad nosebleed).

Of course, there are MUCH more sensitive tests out there to determine if there's blood in the stool including heme-porphyrin or immunochemical tests, but have a high false-positive rate.

From an ENT perspective, immunochemical testing is interesting because this test uses antibodies to detect human globin epitopes which get digested in the stomach... so if there's a question of whether a patient's anemia is due to nosebleed or a lower GI tract bleed (ie, colon), immunochemical stool testing can answer the question.

Just as an FYI, if the nosebleed is severe, it is likely that you will end up getting your nose packed.

Read More

Pop Singer Nathan Sykes Undergoes Vocal Cord Surgery

Nathan Sykes, singer for the boy band The Wanted, underwent vocal cord surgery on April 18, 2013 for a "hemorrhaged nodule" according to media reports.

Rather than a nodule, I am suspecting he actually suffered from a hemorrhagic polyp which makes more medical sense. And along with surgery... he is now on voice rest for an indefinite period of time.

This condition is the same reason Adele underwent vocal cord surgery in 2011 which mandated a several month period of voice rest leading to cancelled concerts.

Typically, a hemorrhagic polyp is treated with strict voice rest followed by extensive voice therapy prior to surgical consideration. However, this (safe) course of action takes time and as such, much more aggressive approaches can be pursued in order to recover the voice as quickly as possible.

For professional singers like Nathan Sykes and Adele, the desire to have a restored voice as soon as possible is understandable. However, there are always downsides.

To explain, a lesson in some basic anatomy first...

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

When there is a hemorrhagic polyp with a blood vessel as in Nathan's case (presumably), the vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to phono-trauma or even hormones especially in females. When a polyp is present, the vocal changes are even more dramatic. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice very unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. There may even be mild pain associated with this occurrence.

It is unknown what exactly happened in Nathan Syke's case.

But, in Adele's case, she remembers the very moment this occurred during a radio interview when she "felt a pop" and her vocal pitch suddenly dropped into the bass range.

This makes perfect sense... To use the analogy of a violin string, the thicker the violin string the deeper the pitch. When hemorrhage occurs, the vocal cord becomes thicker due to blood pooling resulting in a deeper voice instantly.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially, during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in the development or exacerbation of a vocal cord polyp. With repetitive cycles of healing and trauma, vocal cord scarring may even develop. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel and associated polyp.

For that, surgical intervention is required.

One option is to precisely cut out the polyp and cauterize the feeding blood vessel at the same time. This approach was the course that Adele pursued and probably what happened with Nathan Sykes as well. Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. This latter approach is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision and vessel obliteration with a laser at the same time (though not zero). Furthermore, a smaller polyp also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Adele, that was strict voice rest for nearly two months (Nov and Dec 2011). Why? Because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won't heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

The vocal cord surgical wound MUST heal prior to talking let alone singing for normal recovery. That means strict voice rest. Strict voice rest means no talking, no singing, no whispering, no mouthing words, no throat-clearing, no humming, etc.

Read more about vocal cord polyps here.

Source:
The Wanted's Nathan Sykes Taking 'Unforeseen Hiatus'. MTV News 4/17/13

The Wanted say they 'fear' for Nathan Sykes' voice. BBC News 4/29/13

Read More

Why Do Culture Results Take So Long? [video]

One of the most common questions I get after obtaining a culture of pus whether from the ear or the nose is how long it takes before the culture results are back... especially when MRSA is a concern.

Does it take a few hours? 24 hours? Days?

Disappointingly, it can take up to 5+ days if not longer.

You want to know why?

Well, rather than explaining, watch a 6-minute video that explains the numerous steps that goes into providing a diagnosis after a culture has been obtained... in this particular case, ear drainage though the same steps apply to any culture obtained from anywhere else in the body.

Special thanks to Robin Earl who spent hours hanging out in the microbiology lab video-taping all the relevant video clips as well as Fauquier Health for allowing this video to be made!

Read More

Kim Kardashian Gets Allergy Testing

Celebrity Kim Kardashian of Keeping up with the Kardashians reality TV show underwent allergy testing with Dr. Mirmelli. Allergy testing was accomplished via skin prick (our office performs allergy testing by blood draw instead called immunocap).

She apparently was allergic to her pet cat...

Kim apparently decided to let her pet cat Mercy go... a decision in contrast to what most cat-allergic people do.

Watch the video.

Read More

The Facial Triangle of Danger (Even Death)

Image by SpooSpa from Wikipedia

If you draw a line between the eyebrow to the corners of the lip, a triangle is created which delimits a region esoterically known as the "danger triangle".

Why is this region considered dangerous?

It's because infections within this region can lead to infections of the brain (rarely). Why? The blood supply within this triangular area communicates with the cavernous sinus found at the bottom of the brain. This anatomic structure is a major source of venous drainage of the brain.

If the cavernous sinus gets inflamed/infected due to a rip-roaring pimple of the upper lip, it could lead to multiple facial abnormalities due to injury of the numerous cranial nerves that go through it including:

• Inability to move the eyeballs (CN3, 4, 6)
• Numbness, pain of the skin over the forehead and cheeks (CNV1, V2)
• Loss of pupillary constriction (CN3)
• Visual loss/changes (CN1)

The cavernous sinus could also become thrombosed.

Cavernous Sinus shown by red arrow. Taken from Sonoworld.

From there, the infection can spread to the rest of the brain and potentially can even lead to death if not treated promptly and aggressively.

Of course, tiny infections like a small pimple or a small laceration due to biting a lip is not going to cause problems.

However, rapidly progressive major infections of the skin with abscess formation do need to be treated cautiously.  Typically, such patients are hospitalized on IV antibiotics until definite and significant improvement can be seen at which time patients can be discharged home on oral antibiotics.

At which point a "minor" infection becomes "major" requiring hospitalization is a judgement call.

Read More

Bacteremia IS Present During Tonsillectomy!

@ENTHouse brought to my attention a very interesting research regarding the presence of bacteria in the bloodstream during tonsillectomy, both elective and quinsy. Elective tonsillectomy is when the tonsils are removed in the absence of any significant infection. Quinsy tonsillectomy is when the tonsils are removed in the setting of a peritonsillar abscess.

The research involved obtaining blood cultures, tonsillar swabs, core tissue, and pus aspirates during the operation on 80 patients undergoing elective surgery and 36 undergoing quinsy surgery.

What they found was,

"Bacteremia was detected in 73% of patients during elective tonsillectomy compared to 56% during quinsy tonsillectomy. Significantly more blood culture bottles were positive for each isolate obtained from elective tonsillectomy cases compared to quinsy tonsillectomy cases. In all, 59% and 42% of electively and acutely tonsillectomized patients, respectively, had bacteremia with microorganisms that are predominant in bacterial endocarditis. Ninety-three percent of the isolated strains were sensitive to amoxicillin, and all were sensitive to amoxicillin with clavulanic acid." [link]

Amoxicillin with clavulanic acid is also known as Augmentin.

What is fascinating is the high rate of bacteria presence in the bloodstream during a routine elective tonsillectomy... even higher rates than tonsils which are actively and terribly infected. Perhaps because those with an active infection are already on antibiotics thereby suppressing bacteria in the bloodstream? Also, with an abscess, the pus pocket is already walled off by inflammatory tissue thereby preventing further leaching of bacteria into the bloodstream?

Regardless, these findings are especially interesting in light of the fact that antibiotics are not routinely recommended before, during, or after surgery!

Reference:
Bacteremia during quinsy and elective tonsillectomy: an evaluation of antibiotic prophylaxis recommendations for patients undergoing tonsillectomy. J Cardiovasc Pharmacol Ther. 2012 Sep;17(3):298-302. Epub 2011 Oct 24.

Read More

Stem Cells Restore Toddler's Congenital Hearing Loss

In a potentially revolutionary treatment, a two years old toddler born deaf has had her hearing restored after receiving stem cells from her banked umbilical cord blood. (Reported in ABC News)

Madeline Connor at age 1 year old was completely deaf in the right ear and had severe hearing loss on the left. Normally hearing aids or cochlear implant would have been the only options.

However, in January 2012 at the age of 2 years old, Madeline underwent a "simple" experiment whereby stem cells were infused into her damaged inner ear. The stem cells were derived from umbilical cord blood that was banked at the time of her delivery at the Memorial Hermann-Texas Medical Center.

Over the next 6 months, there has been dramatic improvement in her hearing. She is also now talking for the first time.

Madeline also is not the only child who has undergone this revolutionary stem cell treatment. Apparently, there are ten other children who are being followed after undergoing similar stem cell infusion derived from banked cord blood.

It must be stressed that though Madeline's progress is quite amazing, it is still too early to say if this is a "bona fide" treatment for congenital hearing loss.

• Will the improvement continue and more importantly, last over years to decades?
• Will it work for other children?
• What is the expected hearing improvement with stem cell infusion?
• Will it treat ALL forms of nerve-damaged hearing loss?
• Does it have to be stem cells derived from cord blood or are stem cells derived from other sources possible (i.e., skin)?
• Can adults with non-congential hearing loss also benefit?

I eagerly await the outcome of this FDA approved trial which hopefully will be published at some point in the near future.

I also eagerly await the protocol used to obtain and infuse the stem cells. I suspect the infusion of stem cells is similar to that done when steroids are infused into the ear for sudden hearing loss as shown in this video below. However, this is just a guess of mine.

Source:

Cord Blood Stem Cells Restore Toddler's Hearing. ABC News 7/11/12

Read More

Singer Florence Welch Cancels Concerts Due to Vocal Injury

CBS news reported that Florence Welch, the lead singer for British band Florence + The Time Machine, had to cancel two upcoming concerts due to a vocal injury.

Florence Welch (@flo_tweet) herself provided most of the details in a series of tweets today:

July 11, 2012 @ 11:15AM : hello everyone, thankyou so much for all your messages of support, yes its true..it finally happened, I've lost my voice..:(

July 11, 2012 @ 11:18AM : I've sustained a vocal injury and been told i cannot sing for a week.., seriously i felt something snap, it was very frightening.

July 11, 2012 @ 11:20AM : unfortunately this means i will not be able to perform at Benicassim and Optimus alive festival this weekend..i am so so sorry..

Florence used the words "felt something snap" which is pretty classic for a vocal hemorrhage. For those who are Adele fans, something similar happened to her as well in November which mandated a prolonged period of voice rest (months) and even resulted in vocal cord surgery. (read more)

I am guessing that Florence had a blood vessel on her vocal cords that was causing minimal vocal impact. But with the "snap," the blood vessel likely ruptured causing instant vocal decompensation whereby the vocal pitch suddenly becomes much deeper and if bad enough, even complete voice loss as it appears to have happened to Florence.

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this which is what Florence's vocal cords prior to the "snap" might have looked like:

When there is a hemorrhagic polyp with a blood vessel as in Adele's case, her vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. If it is small, the changes may be non-existent. If it is more pronounced, the vocal instability may be noticeable and for a singer, it may make the voice very unpredictable.

When the blood vessel becomes engorged and traumatized (singing forcefully, screaming, coughing), it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle (typically right before period).

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully which increases chance of vocal cord hemorrhage. Rupture (even in the middle of a performance) results in hemorrhage into the vocal lining itself causing a sudden and complete loss of voice (see picture to right). There may even be mild pain associated with this occurrence. This is the "snap" sensation Florence felt.

In Adele's case, she remembers the very moment this occurred during a radio interview when she "felt a pop" and her vocal pitch suddenly dropped into the bass range.

This makes perfect sense... To use the analogy of a violin string, the thicker the violin string the deeper the pitch. When hemorrhage occurs, the vocal cord becomes thicker due to blood pooling resulting in a deeper voice instantly. If significant hemorrhage is present, the vocal cord may not even be able to vibrate causing vocal loss.

How is this treated?

Initially, during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in the development or exacerbation of a vocal cord polyp. With repetitive cycles of healing and trauma, vocal cord scarring may even develop. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel and associated polyp if present.

In Florence's case where she was told to be on strict voice rest for only one week, I suspect no polyp is present. Just hemorrhage.

If polyp is present, surgical intervention may be required.

One option is to precisely cut out the polyp and cauterize the feeding blood vessel at the same time. This approach was the course that Adele pursued. Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. This latter approach is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision and vessel obliteration with a laser at the same time (though not zero). Furthermore, a smaller polyp also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Adele, that was strict voice rest for nearly two months (Nov and Dec 2011). Why? Because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won't heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

Source:
Florence Welch told not to perform "to avoid permanent damage" to voice.  CBS News 7/11/12

Read More

R&B Singer Maxwell with Vocal Cord Hemorrhage

At least that's what the Washington Post reported on June 22, 2012. This has resulted in cancellation of his summer tour.

Per media reports, his vocal cords are swollen with hemorrhage.

Some fans may recall that something similar happened to Adele in winter of 2011 which resulted in her also canceling a number of engagements. She ultimately had surgery to correct her problem.

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. If a voice is present, it is much deeper than normal due to the additional "weight" of blood and edema (just like a violin string where the thicker the string, the deeper the pitch). There may even be mild pain associated with this occurrence.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in a vocal cord polyp or vocal cord scarring. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel.

For that, surgical intervention is required.

Such surgical intervention is much like trying to get rid of varicose veins in the leg.

One option is to precisely cut it out. Watch a video on this approach (video shows a vocal cord mass removal, but just pretend the mass is a blood vessel as the approach is identical).

The other option is use of a laser which is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision (though not zero). Shown below is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser.

Read more about laser treatment of vocal cord pathology here.

Read the Washington Post story here.

Read More

Adele Speaks About her Vocal Cord Surgery on 60 Minutes

When it was first reported that Adele was undergoing vocal cord surgery in October 2011, there was much speculation regarding what exact vocal cord pathology she suffered from (hemorrhage? polyp?) and what type of vocal cord surgery she underwent for correction (laser? cutting?).

During her 60 Minutes interview with Anderson Cooper which aired on February 12, 2012, many details regarding her vocal cord problems have clarified.

She apparently suffered from a vocal cord polyp with hemorrhage.

Typically, this problem is normally treated with strict voice rest followed by extensive voice therapy prior to surgical consideration. However, this (safe) course of action takes time and as such, she pursued a much more aggressive approach in order to recover her voice as quickly as possible.

To explain, a lesson in some basic anatomy first...

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

When there is a hemorrhagic polyp with a blood vessel as in Adele's case, her vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. When a polyp is present, the vocal changes are even more dramatic. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice very unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. There may even be mild pain associated with this occurrence.

In Adele's case, she remembers the very moment this occurred during a radio interview when she "felt a pop" and her vocal pitch suddenly dropped into the bass range.

This makes perfect sense... To use the analogy of a violin string, the thicker the violin string the deeper the pitch. When hemorrhage occurs, the vocal cord becomes thicker due to blood pooling resulting in a deeper voice instantly.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially, during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in the development or exacerbation of a vocal cord polyp. With repetitive cycles of healing and trauma, vocal cord scarring may even develop. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel and associated polyp.

For that, surgical intervention is required.

One option is to precisely cut out the polyp and cauterize the feeding blood vessel at the same time. This approach was the course that Adele pursued. Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. This latter approach is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision and vessel obliteration with a laser at the same time (though not zero). Furthermore, a smaller polyp also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Adele, that was strict voice rest for nearly two months (Nov and Dec 2011). Why? Because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won't heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

The vocal cord surgical wound MUST heal prior to talking let alone singing for normal recovery. That means strict voice rest. Strict voice rest means no talking, no singing, no whispering, no mouthing words, no throat-clearing, no humming, etc.

Read more about vocal cord polyps here.

Read the 60 Minutes interview here.

Of note, she later went on to sing a stellar performance at the Grammy Awards debuting her new voice for the first time after her surgery.

Read More

Singer Adele Has Vocal Cord Hemorrhage and to have Surgery

At least that's what the LA Times reported on Oct 28, 2011. And supposedly will be having surgery to treat it in the near future.

Before going any further, the title to the LA Times story was "Adele to have surgery to treat vocal cord hemorrhage. What is it?"

I sincerely hope that whomever her surgeon is knows not to perform surgery when the vocal cord is in the middle of a hemorrhage. You do the surgery when the hemorrhage is gone and the culprit blood vessel is left behind which likely is the reason for the hemorrhage happening in the first place.

What do I mean?

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. There may even be mild pain associated with this occurrence.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in a vocal cord polyp or vocal cord scarring. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel.

For that, surgical intervention is required.

Such surgical intervention is much like trying to get rid of varicose veins in the leg.

One option is to precisely cut it out. Watch a video on this approach (video shows a vocal cord mass removal, but just pretend the mass is a blood vessel as the approach is identical).

The other option is use of a laser which is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision (though not zero). Shown below is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser.

Read more about laser treatment of vocal cord pathology here.

Read the LA times story here.

Read More