Man Files $15 million Lawsuit Against NYC Citi Bike Claiming Smell Loss From Bike Crash

Image by Pharos of Wikipedia

In 2013, a man rented a bicycle from New York City's Citi Bike program. Apparently while riding this rental bike, the front wheel struck a wheelstop installed near a bicycle docking station which the man did not notice, flipping him resulting in head trauma. This head trauma resulted in permanent smell and taste loss. [link]

The wheelstop is meant to prevent cars from from backing into bike stations, but the lawsuit alleges "no cones or colored warnings to alert a bicyclist of its existence... constituted a trap for the unwary."

Regardless of the legal merits of the case, how does head trauma like this cause smell and taste loss?

The smell nerve is located right between the eyes and is analogous to the roots of a plant where the plant is the nerve next to the brain and the roots are the nerve endings that go through the skull bone (cribiform plate) and into the nose where "smell" is detected (the yellow in pic below). With significant head trauma, the brain suddenly moves and "bounces" around in the skull when struck. When this happens, the delicate smell nerve endings which are going through the bone "tear" when the brain moves relative to the bone.

With such nerve damage, smell can be permanently lost. With complete smell loss, taste can be adversely affected given so much of flavor is attributable to smell. As such, the man can technically probably still taste (salt, sweet, sour, bitter, etc), but not smell.

BTW... Did you know that the tongue taste map we all learn in school is incorrect?


Source:
Conn. man files $15 million lawsuit against NYC, Citi Bike, claiming nerve damage from bike crash. Daily News 2/27/14

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Infant Sound Machines for Sleep May Cause Hearing Loss

As a father of two young kids who still use a sound machine to help them sleep, I was quite curious about a recent paper that warned that such devices may cause permanent hearing loss. Researchers compared a total of 65 sounds produced by 14 machines and measured the maximum sound level at a distance of 30 cm (crib-rail placement), 100 cm (beside crib placement), and 200 cm (across room placement).

Why is placement important?

When it comes to risk of hearing loss due to loud noise exposure, there are three factors that come into play: 1) how loud is it; 2) how close is it; 3) how long are you exposed to it. Clearly, a person is at a higher risk for permanent hearing loss the louder a sound is, the closer the sound is, and the longer one is exposed to the loud sound.

When it comes to infant sound machines, two of the three risk factors are typically present given such machines are usually placed in or on the crib (close) and is typically played all night (duration).

Alarmingly, 3 machines produced sound levels 85+dBA which exceeds current occupational limits (if exposed for 8+ hours) for adults in the workplace which would mandate use of hearing protection. All 14 machines were capable of producing noise 50+dBA at distances of 30 and 100cm. 13 machines were capable of 50+dBA at 200 cm.

Which machines were tested? Beyond stating "procured from major online and brick-and-mortar infant-accessory stores," the machines were not identified. I wonder if the authors were fearful of lawsuits from sound machine manufacturers and as such, kept it anonymous.

Of course, one can always try contacting the ENT department at University of Toronto where this research was done and get an off-the-record answer.

Given lack of identification, the main steps a parent can take to minimize noise-induced hearing loss is to:

1) place sound machines as far away from infants as possible
2) set volume as low as possible
3) limit duration of sound machine usage


Reference:
Infant Sleep Machines and Hazardous Sound Pressure Levels. Published online March 3, 2014 (doi: 10.1542/peds.2013-3617)

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Lisa Marie Presley Throat Cancer Scare

Image from Wikipedia

The National Enquirer reported 1/20/14 that Lisa Marie Presley suffered a throat cancer scare when she was told by a medical expert that "the 45-year-old singer’s throat is so severely ravaged that ... the damage could lead to deadly esophageal cancer!" [link]

The National Enquirer, which is not know for stellar journalism, goes on to report that she has been pushing her voice hard in order to succeed as a singer like her more famous father Elvis.

In spite of what the story implies, although singing can lead to vocal cord damage (i.e., nodules)... singing in and of itself does not cause or lead to increased risk of cancer.

However, uncontrolled reflux which can cause throat and vocal cord damage CAN lead to throat cancer. In one report, reflux can increase the risk of throat cancer by 78% (this risk is separate from esophageal cancer).

Source:
WORLD EXCLUSIVE: LISA MARIE THROAT CANCER NIGHTMARE. National Enquirer 1/20/14.

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Malpractice Lawsuit for Nerve Damage Sustained After Neck Cyst Excision

Earlier this month, a malpractice lawsuit resulted in a $4 million dollar award to the patient plaintiff who suffered permanent nerve damage after a family practice physician excised a cyst from the neck. [link]

Briefly, the patient visited the family physician in July 2009 for a lump in his left neck. The family physician recommended that the mass be surgically excised which was subsequently performed by the same family physician (not a surgeon) in the office. After the procedure, the patient experienced a weakened left arm and shoulder and had difficulty picking things up with that arm or moving the arm more than 90 degrees. Subsequent evaluation by an orthopedic surgeon and neurosurgeon determined that the spinal accessary nerve was cut at the time of the neck mass excision.

So what probably happened?

The spinal accessory nerve (also known as cranial nerve XI), is a major nerve that comes off the spinal cord and supplies motor function to the shoulder and arm (red arrow below pointing to the nerve which is yellow).

Image Modified from Wikipedia

I suspect that in this case, the mass was located in the same area denoted by the red arrow above. Now assuming that media and court documents were correct that it was truly a cyst that was excised, the cyst must have laid right below the skin, but on top of the nerve.

Careless excision of the cyst would have resulted in this nerve being cut especially during dissection on the mass's deepest aspect, especially if the physician did not hug the mass during dissection. Using an analogy, good surgical technique is like peeling an orange without puncturing the yummy orange underneath. Poor surgical technique would be peeling the rind and taking bits of the edible orange as well... or leaving some nasty rind on the fleshy orange itself.

Often, novice surgeons take large cuts around a mass with the tip of the scissor or scalpel extending beyond visualization. Also, thick layers of tissues are cut rather than thin transparent amounts. Furthermore, when a mass is grasped and pulled, anatomic structures like a nerve can get pulled out of its usual location along with the mass which can lead to unintentional damage. 

As such, experienced surgeons know when to cut big (no important structures are around) and when to cut in tiny microscopic degrees (important nerves and blood vessels are around).

The neck has a large number of important blood vessels and nerves in a highly compacted area making surgery in this part of the body potentially fraught with peril. However, there are certain "safe" areas where no significant important nerves or blood vessels are found. Such a "safe" zone from a nerve perspective is right under the chin extending down over the voicebox. Of course, there are other important structures located in this area that could get damaged even if nerves aren't a concern.

Source:
Montco jury awards Hatboro man $4M for nerve damage. Phillyburbs 8/27/13

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Teens (People) Who Listen to Music Loudly... A Possible Solution

Now parents may not like this, but I do have a possible solution to getting teenagers to turn the music volume down so not to damage their hearing... Get them noise-cancelling headphones.

As an occasional audiophile myself, I understand that when listening to music with headphones, you invariably HAVE to turn the music volume up in order to hear everything clearly, especially when listening to music in noisy environments. Such environments include city sounds while walking, airplane buzz when flying, and car engine/road drone while driving.

Test this out yourself next time you drive a car. First, listen to the car radio with the engine turned off. Note the volume.

Now, see how well you hear the music from the car radio when driving on the highway.

It's the main reason why one may constantly fiddle with the volume knob while driving. It's also why people have to raise their voice in order to be heard in a loud restaurant.

For teens and other people who are audiophiles, the only solution is to turn the music volume up in order to hear the music clearly... which can damage their hearing over time.

So what to do? One can listen to music only when the environment is silent, but that's not going to happen for music-loving individuals who want to hear it all the time.

The other solution is to get a nice pair of noise-cancelling headphones.

A good pair of NC headphones significantly reduces if not eliminates the buzz, drone, white noise of the environment which is a very common cause of requiring a volume increase.

Now, not all NC headphones are created equal. Bose NC headphones are perhaps the best but are pricey at around $300.

However, cheaper brands do not noise-cancel at all or do so poorly even if they are labelled as noise-cancelling.

Generally speaking, Bose is by far the best followed by Panasonic, Sony, and AKG. You can read a Pogue's New York Times review of different noise-cancelling headphones here.

So... perhaps you can make a deal with your teen or adult loved one to turn the music volume down to protect their ears by getting them a Bose NC headphones which come in headphones and earbud models. Available for purchase on Amazon.

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Cicadas Can Cause Permanent Hearing Loss!

Cicadas are pretty darn ugly... But beyond their ugliness and making cars look pretty messed up... the sound they make is not only irritating, but potentially harmful.

Sometime the end of this April 2013, billions of large flying insects called cicadas will make their appearance along with their characteristic stridorous noise. The male cicadas are the ones making this mating noise with "tymbal" soundmakers amplified by large resonance chambers found on body.

Occurring every 17 years, this year's swarm is known as Brood II and has not been seen since 1996. Expected to cover much of the East Coast, the buzz created by these insects can reach 90 decibels... about as loud as a jackhammer. If one is right next to your ear, the sound can reach 120 decibels are equivalent to sandblasting or a loud rock concert. [see noise chart]

At 90 decibels, possible hearing damage may occur if a human ear is exposed to this level noise for more than 8 hours a day. At 120 decibels, less than 15 minutes of exposure can induce possible permanent hearing loss.

So... keep a pair of ear plugs in your purse or pants pocket and use them if the sound starts to get too loud.... or too irritating.

Sources:
17 years in the making, this spring's cicada invasion generates early buzz. NBC News 4/10/13.

Cicada. Wikipedia

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Dr. Chang Quoted in Washington Post Regarding Hearing Damage from Noise

The Washington Post on April 8, 2013, published a story about how loud noises can lead to hearing loss, even in young teenagers.

Dr. Chang was liberally quoted throughout this informative article.

"...That’s according to Christopher Chang, an ear, nose and throat doctor at Fauquier ENT Consultants in Warrenton, who sees patients every day with hearing-related issues. “What he’s hearing is way too loud, because it’s concentrated directly into the ear itself,” he says of my son, adding that the anatomy of the ear magnifies sound as it travels through the ear canal." 

"And when someone turns the music up louder? Well, in short spurts, that’s okay. Loudness is only one part of the equation. How long you’re exposed to loud noises also affects your risk. “The biggest concern is that teens and 20-somethings are using music players so regularly,” Chang says. 

"Cheap earplugs that you can buy at the drugstore offer some protection, Chang says. In addition, there are specialized ear plugs, such as ones for hunters that amplify low-level sounds and block out gunshots. Musicians’ earplugs reduce noise with higher fidelity than the muffling effect that regular plugs have: You want to hear the music that you and your orchestra mates are playing, after all."

Read the entire article here.

Source:
Hearing loss may be caused by cities’ noises and music that’s played too loud. Washington Post 4/8/2013.

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ER Doc Found Negligent in Bell's Palsy Case

This case is not quite what you might think...

Here's the background... The Wisconsin State Supreme Court  found an ER physician negligent for failing to offer a carotid ultrasound for a patient who presented with an isolated facial paralysis (patient did not exhibit paralysis anywhere else in the body) and upheld a $2 million jury award to the patient in 2008. Not only that, the Wisconsin Medical Board reprimanded the ER physician and fined her $300. [link]

Hmmmm... After all, it is not considered routine nor standard of care to obtain a carotid ultrasound for an isolated facial paralysis known as Bell's palsy. I should also mention that the ER physician was NOT found negligent in the diagnosis of Bell's palsy.

Well, here's the other part of the story... The patient did have a CT scan of the brain in the ER which was normal. A diagnosis of Bell's palsy was appropriately made by the ER physician and the patient sent home. Eleven days later, the patient suffered a stroke with irreversible damage. A stroke workup at that time revealed a carotid artery with 95% obstruction.

For those uninitiated, paralysis due to a blocked carotid artery would cause lack of blood flow to one entire half of the brain resulting in not only facial paralysis, but also paralysis of half the body too. Furthermore, a stroke causing facial paralysis would have forehead sparing (more on this).

The court's feeling was that the patient should have been offered a carotid ultrasound at the time of the initial ER visit for Bell's palsy... in essence, the court was stating a stroke workup should have been offered/done for a Bell's Palsy. I should also mention that most ER's do not have carotid ultrasound capabilities outside of business hours.

To reiterate, a carotid ultrasound is NOT a test that a physician would or should normally order for a Bell's Palsy workup. By the court stating a carotid ultrasound should have been performed, it has turned a medical condition of Bell's palsy which is not a stroke concern into a diagnosis of possible stroke.

Does that now mean that whenever a patient presents with a Bell's palsy, a stroke protocol should also be pursued which would include:

1) Stroke rapid response by the ER
2) Hospital admission
3) Stroke workup which would include:
  • Carotid ultrasound
  • MRI Head
  • Cardiac workup for arrhythmias (atrial fibrillation which can cause embolic stroke)
  • Pulmonary and vascular workup for deep venous thrombosis (can also cause embolic stroke)
etc, etc, etc

Medically speaking, Bell's palsy is NOT a stroke nor a concern for possible stroke nor increased risk of stroke. Bell's palsy is an isolated inflammation of the facial nerve that has nothing to do with the brain.

ER physicians have a hard enough job as it is now, but to be responsible for pursuing workups for totally unrelated diagnosis separate from the main presenting concern should be cause for concern.

Perhaps there is more to this case that was absent from what has been reported in the media...

Source:
State board reprimands doctor who was found negligent by high court. Wisconsin State Journal 3/21/13

Health Sense: How much should doctor tell you? Wisconsin State Journal 7/9/12

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Some Facts About Q-Tips and Ears

In this week's episode of "Girls" (Season 2; Episode 9 "Girls Gets Dark"), Hannah grappling with OCD, inserted a Q-tip deep into her ear canal and "heard air hiss out the hole" due to perforating her eardrum.

Although this scene came out of a TV show, this scenario is not uncommon and results in many ENT office visits every month for not only eardrum perforations, but bleeding due to trauma to the ear canal skin.

Some facts about Q-tips as it relates to the ear...

It should never be used to clean earwax within the ear canal. In fact, on Unilever's website (the maker of Q-tips), the company explicitly states that Q-tips should only be used to "gently around the outer ear, without entering the ear canal." [link]

In fact, the word "ear" appears less than a dozen times on the entire Q-tip website.

Apparently, Q-tips are meant for many other uses beyond ears which play only a very small role in the world of Q-tips.

• Cleaning tiny spaces in ventilator grates
• Applying polishes to silverware
• Dust picture frames
• Clean keyboards and the computer screen
• Applying wood stain
• Clean tracks and grooves of medicine cabinets
• Clean small compartments of washing machines
etc, etc, etc

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Speech Impediment to Great Singing on American Idol

During January 2013 auditions of Season 12 of American Idol, there was Lazaro Arbos who has a terrible stutter when he talks, but sings beautifully. A week later, we encountered Micah Johnson who also suffers from a speech impediment, but rather than a stutter, it was due to "nerve damage" sustained during a tonsillectomy. (Watch videos below)

With stuttering, the problem mainly lies at the brain level. The brain coordinates how a person uses all of their throat muscles to create speech. Talking and language is mainly a LEFT-brain activity (or more precisely, the dominant hemisphere). Singing is mainly a RIGHT-brain activity and as such, uses different pathways than talking. It's also the same reason why patients who have suffered from a stroke may not be able to talk at all, but can sing their words out.

Now, in the case for Micah Johnson, it is reported that his speech impediment was due to "nerve damage" from tonsil removal surgery. As such, his speech impediment is NOT at the brain level (also known as central), but peripheral. Peripheral nerve injury is much more difficult to correct and requires extensive practice (speech therapy) in order to create brand new pathways at the brain level to help it "adapt" and compensate for the loss of function from the nerve injury. The analogy would be walking with a limp to compensate for a leg injury.

However, in Micah's case, it is a bit difficult to explain why he talks with an impediment, but sings wonderfully. It is not a matter of activating previously established brain pathways as what happens with stuttering.

With a tonsillectomy, there is a mouth gag placed to move the tongue out of the way. Typically, this surgery takes about 15 minutes to perform on average. Per Micah, his tonsillectomy took 90 minutes or almost 6 times longer than normal.

I hypothesize that the mouth gag over that time duration slowly crushed the nerve innervating the tongue (cranial nerve 12) causing it to not move as well leading to his speech difficulties. This complication is EXTREMELY rare and if it occurs, almost always temporary. This situation is analogous to a "dead" arm when sleeping on it for too long... but recovering normal function after a few minutes.

Unfortunately in Micah's case, it seems to never have recovered fully.

The puzzling issue for me is how is it that he is able to sing, but not talk well? Peripheral nerve injuries would affect ANY activity involving the affected muscle. For example, if the nerve to a leg muscle is cut, that muscle will not work well whether running or walking. The ability to sing, but not talk well due to a peripheral nerve injury is akin to stating that one can only limp when walking, but can run fantastic.

Anyone have any ideas what may be going on with Micah's amazing singing?

Just as an FYI, another rare complication of tonsillectomy that may lead to speech problems is velopharyngeal insufficiency leading to a hyper-nasal sounding speech. In this situation, there is no nerve damage present. Rather, it is an anatomic problem whereby the soft palate does not 'lift" completely to close off the nasal passage from the mouth. This problem can be surgically fixed.

In any case, best of luck to both men!

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Do Ear Candles Actually Remove Earwax? [video]

About once a week, I have a patient who presents to my clinic with a history of ear candling for earwax removal due to clogged ear sensation.

About once a month, I have a patient with ear canal and/or eardrum damage due to using an ear candle in an attempt to remove earwax.

I even have on occasion patients who I thoroughly remove earwax under the microscope, who than go home, perform an ear candle, and inform me of all the "earwax" that I missed.

Well... I've decided to make a video (see below) illustrating how ineffective ear candling is in removing earwax as well as how it could be even harmful. The other aspect of this educational video is to show how misleading ear candling is when it comes to earwax.

Please note that we are aware that the  "official" way to use an ear candling is small end down into the ear, but for this video, we have elected to use it the way most "lay" public would (small end up).

[SPOILER ALERT!!! A burning ear candle actually creates debris that looks like earwax. As such, an ear candle "works" whether it is in the ear or not.]

References:
Ear candles: Efficacy and safety. Laryngoscope 106 (10): 1226–9.

Ear candling: Should general practitioners recommend it? Can Fam Physician 53 (12): 2121–2. PMC 2231549. PMID 18077749.

Ear candles can be purchased on Amazon.com for you to "experiment" with.

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Sinus Surgery Lawsuit Ruled Against ENT

A patient who had undergone endoscopic sinus surgery suffered detachment of the extraocular muscle resulting in double vision that required further surgical intervention.

A jury found against the ENT and ambulatory surgery center rewarding $2.5 million dollars to not only the patient, but also the wife "for loss of consortium".

Damage to the eye and vision is part of the normal consent process for endoscopic sinus surgery when considering the geographic proximity of the eye and sinus cavities.

Eye muscle injury as in this case is particularly relevant when surgery is performed on the ethmoid sinus cavity which is located between the eyes (purple in illustration). Risk of injury is even higher when powered instruments are used like a diego sinus shaver.

Although informed consent appears to have been present, the jury still found for the patient:

- $1.5 million to Mr. Dias for pain and suffering
- $0.5 million for loss of service
- $0.5 million to his wife for loss of consortium.

This case appears to suggest that informed consent does not really provide any legal protection. A bad outcome regardless of consent implies sufficient cause for lawsuit... and winning.

This case also suggests that any bad outcome can affect a patient's ability to have intimate relations with a spouse which is sufficient cause for lawsuit and winning.

I wonder if I now have to add to the informed consent (which may not afford me any legal protection) the possibility of "loss of consortium" with a spouse.

Source:
Patient Awarded $2.5 Million After Suffering Endoscopic Sinus Errors. Outpatient Surgery Magazine 9/5/12

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Noise Charts as It Relates to Hearing Damage

Fun hearing facts collected from a variety of sources...

Environmental Noise
Weakest sound heard	0dB
Whisper Quiet Library at 6'	30dB
Normal conversation at 3'	60-65dB
Telephone dial tone	80dB
City Traffic (inside car)	85dB
Train whistle at 500', Truck Traffic	90dB
Jackhammer at 50'	95dB
Subway train at 200'	95dB
Level at which sustained exposure may result in hearing loss	90 - 95dB
Hand Drill	98dB
Power mower at 3'	107dB
Snowmobile, Motorcycle	100dB
Power saw at 3'	110dB
Sandblasting, Loud Rock Concert	115dB
Pain begins	125dB
Pneumatic riveter at 4'	125dB
Even short term exposure can cause permanent damage - Loudest recommended exposure WITH hearing protection	140dB
Jet engine at 100'	140dB
12 Gauge Shotgun Blast	165dB
Death of hearing tissue	180dB
Loudest sound possible	194dB

OSHA Daily Permissible Noise Level Exposure
Hours per day	Sound level
8	90dB
6	92dB
4	95dB
3	97dB
2	100dB
1.5	102dB
1	105dB
.5	110dB
.25 or less	115dB

Perceptions of Increases in Decibel Level
Imperceptible Change	1dB
Barely Perceptible Change	3dB
Clearly Noticeable Change	5dB
About Twice as Loud	10dB
About Four Times as Loud	20dB

Sound Levels Found in Music
Normal piano practice	60 -70dB
Fortissimo Singer, 3'	70dB
Chamber music, small auditorium	75 - 85dB
Piano Fortissimo	84 - 103dB
Violin	82 - 92dB
Cello	85 -111dB
Oboe	95-112dB
Flute	92 -103dB
Piccolo	90 -106dB
Clarinet	85 - 114dB
French horn	90 - 106dB
Trombone	85 - 114dB
Tympani and bass drum	106dB
Walkman on 5/10	94dB
Symphonic music peak	120 - 137dB
Amplifier, rock, 4-6'	120dB
Rock music peak	150dB

Sources:
The National Institute for Occupational Safety and Health (NIOSH)

Binge Listening: Is exposure to leisure noise causing hearing loss in young Australians? [pdf] – Australian Hearing, National Acoustic Laboratories

Occupational Noise Exposure. OSHA




   

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