Is Your Metal Implant MRI Safe? There's a Website for That...

Although one could always contact the manufacturer or surgeon who performed your metal implantation directly to determine whether it is MRI safe or not, there's also a website that contains a comprehensive database of metal implants and how compatible they are with MRI scans.

Who knew that certain metal implants are compatible with MRI scans up to a certain strength?

Who knew a metal implant that may not necessarily be compatible with MRI, but given enough time after implantation (usually 6 weeks), it is still safe to get an MRI scan?

Check this website www.MRIsafety.com out!

The actual searchable list of implants is here.

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Aspirin Allergy and Desensitization Protocols

For patients who suffer from terrible allergies, asthma, nasal polyps, and also suffer an allergy to aspirin, desensitization to aspirin can profoundly improve overall allergies and airway hyper-reactivity through an as yet unknown mechanism. It is hypothesized that aspirin desensitization works by decreasing leukotriene production and downregulating cystienyl leukotriene receptors resulting in a decrease in histamine and tryptase release from mast cells which causes allergy symptoms.

However, there are two problems regarding patients who wish to pursue aspirin desensitization: not many physicians perform it due to risk of life-threatening anaphylaxis and lack of standardized protocols.

Here are some sample published protocols for aspirin desensitization. Keep in mind that regardless of which protocol is administered, the aspirin desensitized state only exists as long as regular aspirin continues to be taken. If the patient forgets to take aspirin for a few days (typically 48 hours), the protocol has to be repeated.

Protocol #1:
Aspirin dissolved in water at 1mg/cc concentration. On day 1, patient is given 10mg, 30mg, 60mg, and 100mg of aspirin spaced 6 hours apart. On day 2, an additional 100mg, 150mg, and 300mg is given spaced 8 hours apart. The patient is discharged home on 300mg or 350mg of aspirin to be taken twice a day as well as zantac 150mg twice a day for GI prophylaxis. If needed, proton pump inhibitors can also be taken.

Protocol #2:
Aspirin is administered at intervals of 10–30 min in the following dosages: 0.1 mg, 0.3 mg, 1 mg, 3 mg, 10 mg, 30 mg, 40 mg, 81 mg, 162 mg, and 325mg. The dilution and dosing may be altered depending on the patient's clinical situation.

Protocol #3:
Aspirin is administered starting at 1 mg and doubling each dose every 30 min up to a final dose of 100 mg (therefore lasting 3.5 hours).

Protocol #4:
Aspirin given in 5 sequential doses of 5, 10, 20, 40, and 75 mg given every 30 minutes (the protocol lasting 2.5 hours).

Depending on the physician, patient's clinical characteristics, and comfort level of all concerned, these protocols may be performed in an office-setting to even in the intensive care unit of a hospital.

Pre-treatment with anti-histamines, singulair, or systemic steroids may or may not be administered. Beta-blockers typically is stopped 24 hours prior to protocol initiation. Monitoring during the protocol include blood pressure, pulse, and peak expiratory flow measurements every 30 min as well as checking for any reactions involving the skin, nose, eye, or breathing. Once the protocol is completed, monitoring is continued for an additional 3-6 hours.

Keep in mind that our office does not perform aspirin desensitization and provides this information for educational purposes. Please contact your local allergist to determine if they perform aspirin desensitization. Your best bet is your closest tertiary care academic medical center as locations where such protocols are performed.

Trivia: When a patient suffers from asthma, nasal polyps, and aspirin allergy, it is known as Samter's triad.

References:
Hypersensitivity to ASA in patients with coronary artery disease: rapid desensitisation is feasible. European Society of Cardiology Council. E-journal of Cardiology Practice 3.

Selection of patients for ASA desensitization treatment. J Allergy Clin Immunol 118: 801–804.

Rapid oral challenge-desensitisation for patients with ASA-related urticariaangioedema. J Allergy Clin Immunol 105: 997–1001.

Rational approach to aspirin dosing during oral challenges and desensitization of patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol. 2009 Feb;123(2):406-10. doi: 10.1016/j.jaci.2008.09.048. Epub 2008 Dec 3.

Selection of aspirin dosages for aspirin desensitization treatment in patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol. 2007 Jan;119(1):157-64. Epub 2006 Nov 13.

ASA sensitivity: the role for ASA challenge and desensitisation in postmyocardial infarction patients. Cardiology 91: 8–13.

Rapid desensitisation procedure for patients with ASA hypersensitivity undergoing coronary stenting. Am J Cardiol 95: 509–510.

Aspirin Hypersensitivity and Desensitization Protocols. Ther Adv in Drug Safe. 2011;2(6):263-270.

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Popular Nasal Decongestants Associated with Birth Defects

Researchers have discovered that there is a very small, but significant association between birth defects and use of nasal decongestants in the first trimester of pregnancy. Unfortunately, decongestants (ie sudafed, afrin, etc) are also one of the most popular medications purchased over-the-counter to treat symptoms of nasal congestion, runny nose, and allergies.

In particular, three strong associations were found:

• Phenylephrine and endocardial cushion defects
• Phenylpropanolamine and ear defects
• Phenylpropanolamine and pyloric stenosis

Although these associations were related to ORAL decongestant use and first trimester intake, it was also found that intra-nasal decongestant use during the first trimester was associated with pyloric stenosis and tracheo-esophageal fistula.

Taken in summary, it is perhaps ideal that women in their first trimester of pregnancy avoid decongestant use due to a possible association between birth defects and medication usage. This association accounts for a VERY small percentage increase in birth defects and as such more study is needed.

For example, the baseline prevalence of endocardial cushion defect is 0.34 per 1,000 live births. Phenylephrine exposure increases this risk 8-fold resulting in 2.7 per 1,000 live births. That's an overall increased risk of only 0.27%.

Keep in mind that all these over-the-counter products contain a decongestant ingredient:

• Afrin
• Sudafed
• Tylenol Cold Multi-Symptom Nighttime
• Alka-Seltzer Plus Cold
• Delsym Night Time Multi-Symptom
• Tylenol Cold Multi-Symptom Severe
• Tylenol Cold & Flu Severe
• Vicks Dayquil Cold & Flu Relief
• Benadryl Allergy Plus Sinus Headache
• Theraflu Warming Relief Nighttime Severe Cold & Cough
• Vicks Nyquil Sinus
• Acutrim
• Dexatrim
• Afrin
• Zicam
etc, etc, etc

So what is a pregnant woman to do if her nose gets all stuffed up and wants to avoid decongestant medications to eliminate any possible risk of birth defects? Click here for some suggestions.

Source:
Use of Decongestants During Pregnancy and the Risk of Birth Defects. Am. J. Epidemiol. (2013) doi: 10.1093/aje/kws427

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Cheerleading A Dangerous Sport from an ENT Perspective

The American Academy of Pediatrics (AAP) published its first policy statement regarding cheerleading due to the increasing rate of injuries found in this increasingly competitive sport.

Who knew that although the overall risk of injury is lower than other sports, it has one of the highest rates of catastrophic injuries including closed-head injury, skull fractures, cervical spine injuries, paralysis, and even death.

After all, cheerleaders do not wear protective gear and safety is utterly dependent on external factors such as spotters and floor protection.

From an ENT perspective of a solo private practice, cheerleading is one of the leading causes of facial fractures in a student population.

Such fractures include nasal bone and orbital blow-out fractures sustained from elbows and other flying limbs.

Although AAP made 12 recommendation to make this sport safer, I was going to suggest that all cheerleaders should wear face-guards to minimize risk of facial trauma.

Here's one called Mueller Nose Guard. Available for purchase on Amazon.com.

Reference:
Cheerleading Injuries: Epidemiology and Recommendations for Prevention. Pediatrics 2012;130:966-971.

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