Diagnostic Test for Laryngeal Sensory Neuropathy (Chronic Cough)?

Patients who suffer from a persistent chronic cough undergo a tremendous amount of testing, trials of medications, and seeing numerous specialists to try and make the cough go away. Ultimately, the cough may be found due to a rare condition called laryngeal sensory neuropathy which is treated with anti-depressant and even seizure medications. This nerve also may contribute to swallowing problems as well.

Because laryngeal sensory neuropathy is a diagnosis of exclusion, an extensive workup is required to rule out all other causes of cough including tests for reflux, reactive airway disease, allergy, etc. Given the time-consuming nature of evaluating a chronic cough, very smart researchers have been trying to develop a test that checks for laryngeal sensory neuropathy (LSN).

One such test called SELSAP (Surface Evoked Laryngeal Sensory Action Potential) is a non-invasive, surface evoked, sensory nerve function testing of the superior laryngeal nerve. Why the superior laryngeal nerve? It's because that's the nerve that is responsible for causing the sensation/urge to cough in affected patients. It's also the primary nerve that suffers from the neuropathy. [see references below]

The test basically involves placing an electrode to the side of the voicebox and another under the chin. A mild electric stimulus is than performed behind the ear.

Because this test is so new, it is unproven and unclear whether this test will ultimately provide valuable assistance in the evaluation of a patient suffering from chronic cough. Normative values have yet to be rigorously determined.

BUT... it is something that can be considered especially if the history is consistent with LSN and the SELSAP is "clearly" abnormal (HYPERfunctional). In such cases, appropriate treatment can be immediately started without going through the entire chronic cough workup first.

Of course, even though LSN treatment is started, it still behooves to still do the workup to ensure a person does not have more than one cause for persistent cough that would still need to be addressed for true cough resolution. Read more about LSN treatment failures here.

When it comes to swallowing difficulties, if SELSAP does come back abnormal (HYPOfunctional), it may suggest that there is "numbness" of the voicebox region preventing a proper swallow as the body does not "know" where the food is when it passes by leading to aspiration.

Be aware that not all places will offer such testing. Contacting a good neurologist is really one's best bet to see if they are willing to learn and perform SELSAP.

However, Dr. Kristin Williams in Warrenton, VA does perform this test.
Office Phone: 540-316-5980
384 Hospital Drive
Warrenton, VA 20186


References:
Surface-Evoked Laryngeal Sensory Action Potential Evaluation in Neurogenic Chronic Cough. Journal of Voicw, May 28, 2014.

A new noninvasive method for determination of laryngeal sensory function. Laryngoscope. 2011 Jan;121(1):158-63. doi: 10.1002/lary.21182.

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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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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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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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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

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Can Melatonin Stop Ringing in the Ears (Tinnitus)?

In a rigorous study, researchers have found that taking melatonin 3mg nightly for 1 month did significantly help with patients suffering from chronic tinnitus (ringing in the ears).

Of course, the caveats are that melatonin significantly helped in patients with these specific characteristics:

• Male
• No history of depression
• Tinnitus has been present for a long time
• History of loud noise exposure
• Tinnitus is severe and on both sides

Given melatonin is a relatively benign supplement that can be purchased over-the-counter, it can't hurt to give it a try!

BTW... what did I mean by rigorous study above? It means that it was a prospective, randomized, double-blind, crossover clinical trial. That's pretty much as good a study as one reasonably achieve!

Reference:
Melatonin: can it stop the ringing? Ann Otol Rhinol Laryngol. 2011 Jul;120(7):433-40.

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Def Leppard's Guitarist Vivian Campbell's Chronic Cough Due to Lung Cancer

Image from Wikipedia

A chronic cough that's been going on for months to years is an extremely tough problem to figure out due to the many possible triggers including reflux, reactive airway disease, post-nasal drip, allergies, etc.

For Def Leppard's guitarist Vivian Campbell, his chronic cough was ultimately found to be due to Hodgkin's Lymphoma in his chest around his windpipe. In his own word's that he posted on the band's Facebook page (June 10, 2013 post):

“I feel fortunate that my cancer sent me an alarm call in the form of ‘the cough that wouldn’t quit’. Otherwise, how would I have known? After several months of trying every inhaler known to man, my doctor finally had me X-rayed. A further CAT scan revealed that enlarged lymph nodes were doing wrestling manoeuvres on my windpipe – hence the cough. What was causing the enlarged lymph nodes, however, was yet to be determined, so I underwent a surgical biopsy on March 11th, the first day of Leppard rehearsals for our Viva Las Vegas shows. Obviously, I didn’t make it to rehearsal that day, but it’s okay; I know the songs by now…"

Fortunately, compared to other types of lung cancer, Hodgkin's Lymphoma is more indolent leading to vague symptoms like a chronic cough that goes on for months if not years. It is also highly curable.

Just goes to show you that for patients suffering from chronic cough, more needs to be done than just a chest x-ray, breathing tests, and trying out different inhalers.

Sometimes, a CT scan of the chest and even bronchoscopy may need to be performed to fully evaluate pulmonary etiologies for a chronic cough.

And if nothing is found wrong with the lungs... further testing to check out other disease processes that may lead to a chronic cough is required and may include barium swallow, allergy testing, methacholine testing, 24 hour impedance testing, etc, etc, etc.


Media Report:
Def Leppard's Vivian Campbell battling Hodgkin's. USAToday 6/10/13

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What is the BEST Way to Disinfect a Toothbrush?

In my previous blog article, I discussed the debate over whether a toothbrush becomes "contaminated" leading to the practice of throwing them out after a strep throat infection. Although the answer is still ambiguous whether it helps or not, the fact that even NEW toothbrushes contain harmful bacteria brings even more confusion on what to do.

Going on the assumption that bacteria on a toothbrush is harmful and if a new or old toothbrush contain such bacteria, perhaps the best practice would be to disinfect toothbrushes on a regular basis.

Would toothbrush disinfection work best by...

• Microwave
• Ultraviolet light (examples in this list from Amazon)
• Dishwasher
• Listerine
• Crest Pro-Health
• Air dry
• 3% Hydrogen Peroxide

Although the ultraviolet sanitization method is perhaps getting the most attention due to the high-tech nature, researchers have found that though this method did significantly decrease bacteria load, they also have found this method to be the least effective compared to other measures.

Rather, the best way to disinfect a toothbrush is by rinsing the toothbrush with Crest Pro-Health mouthwash for 20 minutes OR having it go through a normal dishwasher cleaning cycle.  3% Hydrogen Peroxide was also found helpful.

Interestingly, Listerine didn't work much better than air-dry alone and ultraviolet light didn't do much better.

Bottom line?

Don't waste your money on ultraviolet light toothbrush treatments.

Rather, if you already use a dishwasher regularly, stick the toothbrush in there. If you already like gargling with mouthwash, get Crest Pro-Health which can also disinfect toothbrushes effectively.


References:
Disinfection of toothbrushes contaminated with Streptococcus mutans. Am J Dent. 2011 Jun;24(3):155-8.

Germicidal activity of antimicrobials and VIOlight Personal Travel Toothbrush sanitizer: an in vitro study. J Dent. 2010 Aug;38(8):621-5. doi: 10.1016/j.jdent.2009.08.011. Epub 2009 Sep 23.

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Top 3 Reasons Why Your Child Can't Shake that Cough

Guest Blog Post by Dr. Julie Wei

Any parent who has lived with a toddler or preschooler knows the pain of hearing a child’s endless cough, daytime, nighttime, all the time... It seems as if the cough never clears up in a day or two, or after a cold, but may last for weeks. Even if it does clear up, it always seems to return without much warning, and can be more stubborn than your 4 year old about eating vegetables! If you are wondering why cough medications can't stop your child's cough, or for that matter, why inhalers for "asthma", another 10 days of antibiotics, and/or allergy medications are all not working, then continue reading. Have you dragged your child all over town to see yet another specialist to find out why they just keep coughing?

Here is what I explain to all families who come to see me about cough. Cough is an involuntary reflex, or protective mechanism the body has to get unwanted particles or irritants out of our airway. So if dust got into our windpipe, or a droplet of liquid goes into the airway accidentally while your child was drinking and trying to talk at the same time, or the phlegm that he/she gets with a viral illness... all of these things can make our children cough. While most children are thankfully not intermittently or continuously inhaling dust, or running around drinking with their head tilted while talking at the same time, the one frustrating thing about young children is the fact that they get 7-10 viral upper respiratory track illnesses, or colds every year. Each one of these “colds” last 7-10 days, and so pretty quickly, you can have a child with cold symptoms for a third of the year!

So... without further ado... the top 3 reasons why the cough is still hanging on...

NUMBER 3: Post-viral neurogenic cough or habitual throat-clearing. Whatever the reason was, your child started out having a bad cold and coughed due to being sick. Even after the fever and acute illness goes away after 7-10 days, their throat and voice box somehow stays irritated and they continue to cough. At some point, your child may not even realize that he/she is "coughing". Often these are children who are throat-clearing and not really coughing (more often in short annoying bursts, as often as every few minutes). If you no longer hear them "coughing" during sleep, but only when they are awake, then this is likely what your child has. These children often show no other signs of illness or discomfort. It's a difficult diagnosis to make and usually after all other reasons have been rules out. I often offer strategies to families to help break these habits such as creating a game (older than 3 or 4 years of age can do this) whereby a kitchen timer is used to help suppress the urge to "cough" starting from 30 seconds and working up to 5 minute intervals. School aged children who do not appear ill but have a “dry” throat clearing do very well with this exercise. Another option is when they get into a coughing fit, to distract them with chewing gum, having them count backwards from 20, hopefully distracting them from this habit.

NUMBER 2: Chronic Rhinosinusitis (CRS). Your child may have developed true chronic rhinosinusitis which means inflammation from thickening of the lining inside their sinus cavities and their sinus "plumbing" is clogged up. Chronic sinus inflammation is NOT a bacterial infection so antibiotics will not make it go away completely, even if it seems to decrease the cough temporarily. This usually occurs in children older than 4, especially if they have underlying test proven allergies to common aero-allergens like trees, pollen, grass, dust-mites, and other environmental allergens. Sometimes this is bad luck and develops after your child has experienced a terrible viral illness, such that the mucous membranes inside the nasal passages were so swollen that the natural drainage points that lead each sinus cavity into the nasal passage are blocked, which then leads to the inflammation inside the sinus. Since there is a built-in mechanism called the "sinopulmonary reflex", children who have inflamed sinus mucous membrane lining will likely continue to cough until the nasal passage and sinus mucous membranes are no longer swollen and healthy again. The only way to truly know if your child has CRS is for him/her to get a CT scan, a special imaging of their sinus cavities which can involve some radiation exposure. These children tend to complain of a stuffy nose all the time along with the cough, and can't blow anything out of their nose even if they try. Mothers always tell me that their child is stuffy and can’t breathe well, leading to snoring, fatigue, sometimes headaches.

NUMBER 1: The Milk and Cookie Disease (MCD). Your child is coughing because day after day, night after night, their larynx (voicebox) is bombarded with stomach content backwash (gastroesophageal reflux and laryngopharyngeal reflux) coming up to and irritating the voicebox. The voicebox which enables humans to talk is also designed to "cough" as a way to keep unwanted materials from entering our airway. If it did not protect itself by coughing, then we would aspirate and possibly get pneumonia. Find out how your child can live and eat in "A Healthier Wei" and fight the Milk and Cookie Disease, by minimizing dairy and sugar in the evenings and then his/her voicebox can rest and not be in "fighting" mode all the time. I have met thousands of children who have chronic cough not because they are sick, but because they were eating a diet or drinking beverages containing too much dairy and sugar, as well as possibly greasy foods and processed foods. All these items increase likelihood of reflux or backwash and assault on the larynx. If the voicebox is always on “alert” and ready to “fight” and protect the body, then it really can’t relax and rest. I believe that when this happens chronically from MCD, and let’s not forget those 7-10 colds and how they also lead to an irritated overreactive cough, then together, this child has no chance and probably will cough, A LOT! By making changes in diet and dietary habits in children, we can decrease the chance of stomach backwash coming up to irritate the voicebox and cause cough, then hopefully your child only coughs when it is truly because of a cold. Don’t take my word for it, try “A Healthier Wei”. You will likely notice at least much less coughing, and coughing ending much sooner after a cold. I also ask parents to stop dairy/milk for up to 1 week during the time their child is sick. This is when digestion is not at its best, and things get sour and gross in the stomach increasing chance for reflux and more cough.

by Julie Wei, MD, FAAP

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When Your Child Has a Draining Ear

Guest Blog Post by Dr. Julie Wei, MD, FAAP

One of the most common and simple procedures that Otolaryngologists (ear, nose, and throat specialists) perform is that of putting “tubes” in children’s ears. General and pediatric otolaryngologists alike perform thousands of these simple and quick procedures every year, often several times in a single hour! Most children who need and get “tubes” in their ears are toddlers and those in preschool age. What continues to surprise me is how often parents and caretakers are not explained to clearly about what to do once a child has ear tubes in and then develop a wet or draining ear. Yes, I am talking about yellow, green, white, brown, stinky (the smell can fill up a room!), sticky, nasty stuff that not only runs out your child’s ear canal, but then crusts around their ears and worse, perhaps down their cute cheeks!

I have believed it is critical that every ENT surgeon take the time to explain to parents why and how tubes decrease “ear infection”, which is when there is buildup of pus in the middle ear space, pushing on the eardrum from the “inside”. Every time I recommend ear tubes, I make sure that parents understand the simple “plumbing” logic that is involved once there is a small opening created in the eardrum so that oxygen and air can go from the world into that tiny space behind the eardrum (middle ear space), and of course, when there is “infection” or pus which develops from that space now it can drain out through the tube directly out of the ear canal and be seen by parents. The whole point of tubes is that parents and caretakers can tell when a child actually has an ear “infection”. Instead of pain from pus trapped and pushing on eardrum and fever that results from trapped pus, there should be no pain or fever... just nasty stuff coming out the ear. I realized early in my career that unless I explain in detail how a wet ear should be treated once a tube has been placed and is working, parents go first to an urgent care, or their primary doctor’s office, and then are usually prescribed oral antibiotics (almost always unnecessary as well as ineffective), instead of using antibiotics in the form of ear drops which primary and ENT doctors should prescribe.

You see, the beauty of the ear tubes is that now just as air can go through that tiny 1.2 mm round ‘hole” in your child’s ear drum, so can ear drop which contain antibiotics (and steroid, an important component of ear drop therapy in my experience). The strength of the antibiotics in those few drops from that expensive bottle is likely 300 times stronger than what the human body can safely eat. Since the drops are getting absorbed into our blood stream and system which is what happens when we eat/drink it, it works by simply making contact with the infected surfaces of the middle ear space, the mucosal lining with living cells which produce the pus or mucus in the first place (when it is inflamed by viral and bacterial infection along with the irritation that goes with every infection).

A nasty draining ear is easily treatable – the junk is all removed from the canal, tube is checked to ensure it is still in the eardrum and “working” (hole is open), and then topical ear antibiotic and steroid drops are prescribed. I emphasize the importance of aural toileting, that means taking toilet paper or KleenexTM, twirling it into tiny 1-2 cm “wicks”, and putting that gently into the canal for a few seconds so that the nasty drainage is absorbed onto the tissue. Twirl another area of tissue and repeat, and repeat, until not much nasty wet stuff is coming out. THEN, and ONLY THEN, do they start putting the few ear drops into the ear canal. It is also critical to perform the “tragal pump”, meaning to gently push on the little “nubbin” just in front of the opening of the ear canal to make sure that trapped air bubbles come out and drops make it all the way deep into the canal to where the tube and “hole” is to have a chance to get into the middle ear space where the infection is.

Of course, there may be other problems. Sometimes the child is having this issue because it’s been 2 or 3 years since the tubes were put it, but not one knows if it’s still in the ear drum or has “fallen out”. Often the tube is no longer in the drum, the hole has healed itself, but the tube is “stuck” on the drum or ear canal which is lined by skin. The body gets irritated with this “foreign body” that is stuck there and then angry tissue called granulation tissue forms. This angry reddish mass is full of blood vessels and is most likely cause of blood coming out of any child’s ear if that child has had tubes placed. Thankfully, the treatment is the same. As I tell parents every clinic day, it doesn’t matter what is coming out of the ear canal, using the antibiotic and steroid ear drops is the way to go. The steroid component will calm the anger, reduce inflammation, shrink the angry tissue, stop the drainage and pain associated with this, and then the tube can be removed from the canal in the office most likely.

If families are informed of how tubes work, and techniques for good aural toileting, as well as immediate use of ear drops whenever there is draining ear in a child with tubes, then they can be empowered to stop going to urgent care, their primary physicians, save time from work and school missed, save money on oral antibiotics, and most importantly, spare their child from yet another course of oral antibiotics.

I must mention that while perhaps 95% of draining ears should respond to a solid week of using ear drops containing antibiotics and steroid, currently we do have another cause of persistent draining ears in healthy kids. That is the issue of methicillin-resistant staphylococcus aureus (MRSA) infection, even in the ear. I find that many daycare aged toddlers will show up in the office, after using drops as I have intensely preached, and in these children often the culture will prove they have MRSA as the bacteria causing this problem. Thank goodness MRSA in this setting is almost universally susceptible to a class of antibiotics that are “sulfa” based, like “Bactrim” (trimethoprim/sulfamethoxazole), because we the medical professions have not used this drug much in the past decade or two since we have many “newer” antibiotics, it is actually useful to fight MRSA. If your child’s ears are still draining after a week of the antibiotic and steroid ear drops, you should call the surgeon who put the tubes in, ask to be seen, for a culture to be done of the nasty drainage, and if it is MRSA positive, then the best treatment is to switch to a “sulfa” based drop , 10% sulfacetamide, used 3 times daily for next 7 days, as well as put mupirocin ointment in the child’s nostrils twice a day for 10 days, and finally your child should also be given oral Bactrim for 10 days. The idea is to try to eradicate the MRSA living in their nasopharynx which is connected to the middle ear space through the Eustachian tube – details worthy of a separate blog.

If the MRSA drainage does not clear up, I will make the tough but proactive and effective decision to take those tubes out and let the ear drum heal. Thankfully, these children do not necessarily go back to having a bunch of ear infections or trap fluid causing mild hearing loss. Thanks to time, sunshine, love, and nourishment, little heads and bodies grow and they often do well without the tubes.

Sometimes I joke with parents that I am just a glorified plumber. There is a great deal of truth in that. If the plumbing is blocked, much goes wrong in the house. You would certainly contact the plumber, and as such, do contact your child’s ENT sooner rather than later if a draining ear does not stop, AFTER you’ve done what I have described. May you and all parents out there whose children have tubes save money and time live better lives as promised by your child’s ENT.

By the way, stop plugging your child’s ears from bath and swimming, unless they complain of pain every time water gets in. Ten years of a handful of studies show that children whose ears are plugged from water are no better than those who plug and there is no difference….but everyone is much happier without those plugs. Yes, even if your child is swimming in a lake (again, another blog worthy topic). I am a mother first, and believe that your child deserves more than opinions, but information based on science.

by Dr. Julie Wei, MD, FAAP

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Dr. Chang Featured in Regional Newspaper Regarding Balloon Sinuplasty

Dr. Chang was recently featured inside a regional quarterly newspaper regarding balloon sinuplasty in the treatment of chronic sinusitis.

Sinus surgery has come a long way compared to even just 5-10 years ago and great patient experiences after this type of surgery is not uncommon now.

A few key features of sinus surgery of the 21st century that is provided at Fauquier ENT include:

• Nasal packing rarely occurs

• Most patients are surprised by how little pain there is

• No facial swelling or bruising... your best friend won't be able to tell you just had sinus surgery

• Fast recovery

• No incisions on the face or in the mouth

• GPS-like image guidance to make sinus surgery even safer is available
• In select patients, can even be performed in the office without sedation using local anesthesia only

Balloon sinuplasty is a relatively new innovation that allows sinus surgery to even be performed even more comfortably in the office without any sedation (not all patients are candidates).

Such advanced sinus surgery techniques have been available at Fauquier ENT since 2005.

Read more about sinus surgery and balloon sinuplasty.

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Pacifier Use Increases Risk of Ear Infections in Infants

There are many reasons why an infant may suffer from ear infections... parental smoking, not breast-feeding, daycare, etc.

However, what many parents may not realize is that pacifier use is also an additional well-known independent risk factor for causing ear infections as well.

Numerous studies have documented this association and depending on what study you look at, the risk can be quite significant.

Furthermore, the longer and more frequently the pacifier is used, the more ear infections a child can have.

As such, it is suggested that pacifiers should be used only during the first 10 months of life and only when need for sucking is strongest.

Of course, pacifier do have benefits including analgesic effects, shorter hospital stays for preterm infants, and a reduction in the risk of sudden infant death syndrome.

References:
A pacifier increases the risk of recurrent acute otitis media in children in day care centers. Pediatrics. 1995 Nov;96(5 Pt 1):884-8.

Pacifier as a risk factor for acute otitis media: A randomized, controlled trial of parental counseling. Pediatrics. 2000 Sep;106(3):483-8.

Is pacifier use a risk factor for acute otitis media? A dynamic cohort study. Fam Pract. 2008 Aug;25(4):233-6. Epub 2008 Jun 17.

Risks and benefits of pacifiers. Am Fam Physician. 2009 Apr 15;79(8):681-5.

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How is Sinusitis Like Diarrhea, Germs and All?

A normal human body is composed of more "bacteria" cells than "human" cells. Indeed, the bacteria collectively living inside a normal healthy person would fill a half-gallon jug; numerically, there are probably 10 times more bacterial cells in the body than human cells.

Though the majority of these bacteria have no known effect on the human body (good or bad), some of these organisms perform tasks that participate in maintaining health and are deemed necessary members of the normal human flora.

When such "good" bacteria is wiped out through medical intervention (most commonly antibiotics), human diseases like clostridium difficile manifested by massive diarrhea occurs. Treatment (gross as it sounds) may include fecal bacteriotherapy which involves transplanting poop from a healthy individual into the patient.

So How is Diarrhea Related to Sinusitis?

Well, it seems when it comes to chronic sinus infections, the same phenomenon may be happening whereby chronic antibiotic usage leads to a situation where all the "good" bacteria has been killed off leading to a situation where "bad" bacteria constantly re-colonizes the sinus cavities causing mayhem.

"Good" bacteria needs to be present to prevent "bad" bacteria from reforming.

It is possible that simply giving more antibiotics may only reinforce the elimination of not only the bad bacteria, but also all the good ones leading to a chronic and repetitive state of sinusitis especially when biofilms develop.

But... is this true???

Apparently... it's possible!

Researchers have determined that there IS a relationship between sinus bacterial composition (microflora) and chronic sinusitis and that it differs from normal healthy sinuses.

The sinus microflora of chronic sinusitis patients exhibited significantly reduced bacterial diversity compared with that of healthy individuals. At least in the sinusitis population investigated, they found relative abundance of a single species, Corynebacterium tuberculostearicum. When mouse sinuses were populated with this bacteria, sinusitis occurred. Having a normal healthy microflora protected AGAINST this bacteria.

In healthy sinuses, Lactobacillus sakei was identified as a potentially protective species and defended against C. tuberculostearicum sinus infections, even when the sinus cavities were wiped of all bacteria.

This study demonstrated that sinus mucosal health may potentially be highly dependent on the sinus microflora and that "good" bacteria presence is necessary in maintaining healthy sinuses.

Now, I'm not advocating that we take poop from healthy people and fill the sinus cavities of chronic sinusitis patients... but it may influence a fundamental change in the way physicians treat patients suffering from sinus infections that just won't go away no matter what treatment has been pursued whether numerous antibiotics, saline flushes, sinus surgery, etc.

In such sinus cripples, perhaps saline flushes containing "healthy" bacteria would be beneficial??? Hopefully, it won't stink like poop, otherwise I think patient compliance may be an issue.

What about a gel containing good bacteria injected into the sinus cavities???

I should mention that taking probiotics would help the gut, but not the sinus cavities as I can't really see how the elements contained within the probiotic pill can get absorbed into the blood and land in the sinus cavities intact.

Pretty cool area of research which I'm looking forward to hopefully seeing more of in the near future!

Source:
Humans Carry More Bacterial Cells than Human Ones. Scientific American 10/30/07

Reference:
Sinus Microbiome Diversity Depletion and Corynebacterium tuberculostearicum Enrichment Mediates Rhinosinusitis. Sci Transl Med. 2012 Sep 12;4(151):151ra124.

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Yet Another Sinus Dilation Device - AerOS Sinus Dilation System

Sinus dilation has become all the rage in the past few years to treat chronic sinusitis, especially since CPT codes for this procedure has become available as of January 2012.

The first company was Acclarent who coined the balloon sinuplasty term.

Next was Entellus who produced their simpler system (XprESS and FinESS).

Now, there is SinuSys who has produced a new way to dilate the sinus opening without use of a balloon like Acclarent and Entellus. It is currently pending FDA approval, but is used in Europe.

This new system is called AerOs Sinus Dilation System and utilizes an osmotic self-expanding technology. A "simple" two-step insertion and removal of the device is required. Once inserted, the device gradually expands via low-pressure osmotic pressure in about 60 minutes. At that point, it can be removed.

The device itself is 5mm in size and exerts pressure of 2.5 ATM. The diameter is 3mm before dilation that ultimately expands to 5mm.

Compare this with Acclarent and Entellus balloon devices which are inflated to 12 ATM pressure and expands up to 7mm in size (depending on the model).

My personal concern with this device is the small size of 5mm... the surgeon will have to be super-precise for placement, otherwise, it'll fall out or do nothing.

Also, I question whether a 2mm dilation will actually make any difference. Prior studies have established that 4-5mm ostia size really is the minimal efficacious opening size. Larger is better, especially when the uncinate process is still intact as it would be in pure dilation cases. More study is required.

In any case, when (or if) this new device becomes available in the USA is unclear. It's all up to the FDA now.

Reference:
Feasibility of an osmotically driven, self-expanding device for sinus dilation to treat chronic sinusitis. Poster Presentation

Assessment of the short term patency of the maxillary sinus ostium following dilatation with an osmotic device in a sheep model. Jerome E. Hester, MD, David Edgren, BS, Andrea Koreck, MD, PhD, Jason Fox, BS, Janie Mandrusov, PhD, East Palo Alto, CA USA (Annual Meeting of American Rhinologic Society, September 2012, Poster# P-7).

Treatment of Maxillary Sinusitis Using the SinuSys AerOsTM Sinus Dilation System. White Paper 

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Oral Steroids No Help in Sinus Infections?

Media outlets such as Fox News reported yesterday that oral steroids do not help with sinus infections. This claim is based on a small study of 174 patients with clinical symptoms of an acute sinus infection and given either 30 milligrams per day of prednisolone or placebo pills for one week. Of note, antibiotics were not given.

No significant difference in symptom resolution was found.

Now why would one even think to give oral steroids for sinusitis in the first place?

Steroids decrease inflammation and swelling which theoretically would allow for the sinuses to drain more easily and effectively therefore expediting sinusitis resolution.

Also, there have been studies that suggest steroid nasal sprays do help with resolve sinusitis to a certain extent.

Keep in mind that steroids are NOT antibiotics and do not kill the germs that cause an infection. Furthermore, many viral upper respiratory infections are misdiagnosed as sinus infections.

What this study suggests is that at least for acute sinusitis, oral steroids alone do not help resolve an acute sinus infection.

HOWEVER, keep in mind that oral steroids have been shown to help with nasal polyps and chronic sinus infections when given in the setting of antibiotics and sinus surgery.


Source:
Oral steroid doesn't clear up sinus infections. Fox News 8/7/12

References:
Systemic corticosteroid monotherapy for clinically diagnosed acute rhinosinusitis: a randomized controlled trial. CMAJ August 7, 2012 First published August 7, 2012, doi: 10.1503/cmaj.120430

Chronic rhinosinusitis: epidemiology and medical management. J Allergy Clin Immunol. 2011 Oct;128(4):693-707; quiz 708-9. Epub 2011 Sep 3.

Treatment outcomes and predictors for systemic steroids in nasal polyposis. Acta Otolaryngol. 2012 Jun;132 Suppl 1:S82-7.

Intranasal Corticosteroids in Management of Acute Sinusitis: A Systematic Review and Meta-Analysis Ann Fam Med May/June 2012 vol. 10 no. 3 241-249

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Guns n' Roses Rocker Duff McKagan Underwent Sinus Surgery

Duff McKagan, the bassist of Guns n' Roses, apparently underwent sinus surgery back in December 2010.

According to media reports, his sinus cavities developed significant scar tissue due to years of cocaine abuse.

Sinus surgery due to scar tissue is a relatively rare indication for surgery, but required if they block sinus cavities leading to recurrent sinus infections.

Cocaine abuse more typically causes other sino-nasal abnormalities especially septal perforation.

Exactly what type of sinus surgery Duff McKagan underwent is unclear, but for sinus scar tissue, balloon sinuplasty is typically the route taken and can be performed in the office.

Balloon sinuplasty is when the sinus openings are enlarged using a balloon and can potentially be performed in the office assuming no anatomic contraindications (significant deviated septum, nasal polyps, etc).

However, before sinus surgery is considered in a patient who is suffering from recurrent sinus infections whether scar tissue is present or not, a workup is typically required followed by maximal medical management.

A typical workup includes a CT sinus scan, allergy testing, and nasal endoscopy. If allergy testing is significant, aggressive allergy management is required prior to surgical consideration.

Depending on the CT scan and endoscopic findings, there are two "flavors" of sinus surgery: traditional and balloon sinuplasty.

Traditional sinus surgery, otherwise known as functional endoscopic sinus surgery, is when all sinus disease is physically removed endoscopically from the nose and sinus entrances are enlarged.

Source:
Duff McKagan explains sinus surgery. SFGate 12/17/10

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Motley Crue Bassist Facing Sinus Surgery

Dr. Feelgood may be just a song by Motley Crue, but the band's bassist, Nikki Sixx may be facing sinus surgery.

Per his twitter comment on June 27, 2012:

"Spent a lot of the day at the doctors. The 80s and the damage done. Yes the sinuses are a mess. Eventual surgery. The price we pay."

Typically, before sinus surgery is considered in a patient who is suffering from recurrent sinus infections, a workup is required followed by maximal medical management.

A typical workup includes a CT sinus scan, allergy testing, and nasal endoscopy. If allergy testing is significant, aggressive allergy management is required prior to surgical consideration.

Depending on the CT scan and endoscopic findings, there are two "flavors" of sinus surgery: traditional and balloon sinuplasty.

In traditional sinus surgery, otherwise known as functional endoscopic sinus surgery, is when all sinus disease is physically removed endoscopically from the nose and sinus entrances are enlarged.

Balloon sinuplasty is when the sinus openings are enlarged using a balloon and can potentially be performed in the office assuming no anatomic contraindications (significant deviated septum, nasal polyps, etc).

Exactly what type of sinus surgery Nikki Sixx will pursue is not clear, but regardless of what method is selected, there will be a period of recovery afterwards which almost certainly will include saltwater sinus rinses.

Our office provides both sinus surgery options as well as in-office sinus surgery.

Source:
Nikki Sixx needs surgery for sinus problems. SFGate 6/28/12

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Chronic Cough Could be Due to Lung Cancer

BBC News recently reported that chronic cough may be due to lung cancer.

Here are my two cents on this condition in support of this assertion.

I often seen patients for chronic cough... not the kind that has been going on for only a few weeks, but the kind of cough that has gone on for over 1 or more years. Even 10-20 years.

It is not unusual for such patients to have seen an ENT, GI, pulmonary, and allergy specialists to try and stop their cough.

In particular, such patients may be informed their cough is not due to the lungs after getting a chest x-ray and pulmonary function tests which all come back normal along with lack of response to inhaler medications.

Unfortunately, some patients' chronic cough is due to lung cancer which is only discovered on additional studies including bronchoscopy and CT scan of the chest. Obtaining only a chest X-ray and breathing tests are not sufficient enough.

Now, it certainly is not necessary to perform these additional specialized studies in every patient who has been coughing for a few weeks... but when somebody has been coughing for over 1 year, a more intensive search for abnormalities is required.

In my clinic, it is not uncommon that a patient who has been coughing for over 1+ years ends up being found to have lung cancer.

Of course, there are other causes of chronic cough including reflux, allergies, post-nasal drip, medication side effect, etc that also needs to be looked into.

For more info on chronic cough.

Source:
Persistent cough 'could be lung cancer warning' BBC News 5/6/12

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Unnecessary Sinus Surgery

A well-respected ENT surgeon, Dr. Salah Salman, recently wrote a book, "Scrubbed Out," critical of the American health system with its links to corporation, powerful lobbies, administrators, and bureaucrats resulting in care driven by money rather than by medical necessity.

In particular, he focuses in one part of his book on endoscopic sinus surgery in the treatment of chronic sinusitis. The excerpt from the book is quite lengthy and I encourage anybody interested to read a lightly edited version here.

In essence, there are a few unscrupulous sinus surgeons who perform sinus surgery for every patient with facial pain and pressure even though there's no evidence for any chronic sinus infection whether on CT, endoscopic exam, and other objective testing.

Indeed, in my practice, perhaps only 10% (if not less) of patients with chronic "sinus" complaints actually have pathology related directly to the sinuses that merits consideration of sinus surgery. More commonly, symptoms suggestive of a chronic sinus infection are more commonly related to allergies and atypical facial pain syndromes (ie, migraines, sluder's neuralgia, contact point headaches, etc).

Unfortunately, in many physicians' minds including patients, if multiple courses of antibiotics do not resolve pan-facial pain/pressure, the sinuses must be horrible and something more aggressive geared towards the sinuses must happen.

And there's a few ENT surgeons willing to do just that... and mistakenly so.

It's not just ENTs, but allergists and infectious disease specialists who also may accommodate what the patient wants for treatment, even if it is incorrect.

If such patients see an allergist in the belief that their symptoms are due to allergies, they will get allergy testing and allergy shots.

If they see an infectious disease specialist, they will get antibiotics.

A much neglected specialist for patients with "sinus" problems are the neurologists given so many of these patients are actually suffering from atypical facial pain syndromes... but nobody (physicians, pharmaceutical companies, hospitals, bureaucrats) gets paid much for this particular problem... and so it gets ignored.

Though sinus surgery has been abused in the past into the present, a more recent, highly reimbursed, and "sexy" sinus procedural development is balloon sinuplasty, also ripe for being abused.

Traditional sinus surgery and now balloon sinuplasty certainly have their place in the treatment of true chronic sinus pathology with astounding success, but only in highly selected patients.

As with everything, the right treatment in the right patient is the right way of doing things.


Source:
Book Excerpt: A Saga Of ‘Fishy’ Surgery For Chronic Sinus Trouble. WBUR.ORG March 2, 2012

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Northern Virginia Balloon Sinuplasty for Chronic Sinusitis

In the past month, local residents of Northern Virginia may have received a magazine newsletter from Prince William Hospital (Manassas, Virginia) that contained a feature story about sinus surgery and about balloon sinuplasty specifically.

It was a great story about how far sinus surgery has come compared to even just 5-10 years ago and great patient experiences after this type of surgery is not uncommon now.

A few key features of sinus surgery of the 21st century that is provided at Fauquier ENT include:

• Nasal packing rarely occurs

• Most patients are surprised by how little pain there is

• No facial swelling or bruising... your best friend won't be able to tell you just had sinus surgery

• Fast recovery

• No incisions on the face or in the mouth

• GPS-like image guidance to make sinus surgery even safer is available
• In select patients, can even be performed in the office without sedation using local anesthesia only

Balloon sinuplasty is a relatively new innovation that allows sinus surgery to even be performed even more comfortably in the office without any sedation (not all patients are candidates).

Such advanced sinus surgery techniques have been available at Fauquier ENT since 2005.

Read more about sinus surgery and balloon sinuplasty.

Source:

Balloon Sinuplasty. Perspectives Winter 2011 Pages 2-3.

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