Dizziness and Imbalance in Kids

Dizziness is not the easiest thing to figure out in adults. It is even more difficult to figure out in kids who may not have the vocabulary to explain what they feel. Regardless of adult or child, a good history is required to help narrow down possibilities. A flowchart of questions to help come up with a diagnosis can be found here.

Given that, a review article published in 2014 went over the most likely diagnosis of a child who is dizzy.

Based on 724 subjects over 10 studies, benign paroxysmal vertigo of childhood (18.7%) and migraine-associated vertigo (17.6%) were the two main etiologies causing vertigo and dizziness in children. Head trauma (14%) was the third most common cause of vertigo. The mean (95% CI) rate of every vertiginous form was also calculated in relation to the nine studies analyzed with vestibular migraine (27.82%), benign paroxysmal vertigo (15.68%) and vestibular neuritis (9.81%) being the three most common forms.

Benign paroxysmal vertigo of childhood is not clearly understood with some researchers feeling it is a form of adult BPPV (benign paroxysmal positional vertigo) given similar symptoms whereas others feel it is more related to a neurologic vascular basis. With this particular condition, there is no established treatment protocol.

True BPPV occurred in 1.8%. Meniere's disease accounted for only 1.5%. Othostatic hypotension only 1.2%. Middle ear problems surprisingly only occurred in 3% which was felt by the researchers to be highly under-estimated.

Given the top 3 causes of vertigo in children all have a neurologic basis, an evaluation by a good pediatric neurologist is warranted.

Reference:
Prevalence and diagnosis of vestibular disorders in children: A review. Int J Pediatr Otorhinolaryngol. 2014 May;78(5):718-724. doi: 10.1016/j.ijporl.2014.02.009. Epub 2014 Feb 15.

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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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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

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Sinus Headache [video]

I could describe it... but I think it's better if you just watch the video...

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Dr. Chang Mentioned on NBC News Regarding Sound of One's Voice

Dr. Chang was mentioned today in a NBC News article on their popular Body Odds section. The article entitled "why you hate the sound of your own voice" describes why people sound and often dislike the way their voice sounds on a recording.

What we hear when we speak, however, is air- and bone-conducted sounds. Vibrations from our vocal cords directly reach the cochlea. Our skulls deceive us by, in fact, lowering the frequency of these vibrations along the way, which is why we often perceive ourselves as higher-pitched when we listen to a recording.  

“When [someone] listens to a recording of their voice speaking, the bone-conducted pathway that they consider part of their ‘normal’ voice is eliminated, and they hear only the air-conducted component in unfamiliar isolation—what everybody else actually hears,” says Dr. Chris Chang, an otolaryngologist at Fauquier Ear, Nose & Throat Consultants in Warrenton, Virginia. [link]

I wrote a more comprehensive blog article on this phenomenon here.

In any case, very cool I got quoted!!!

Source:
Why you hate the sound of your own voice. NBC News 4/2/13

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Coffee Reduces Risk of Death from Oral Cancer

In a prior blog, I mentioned that researchers found that regular coffee drinkers who drank more than four cups of coffee a day had a 39 percent decreased risk of two types of head and neck cancer: oral cavity and pharynx cancers. In the study published in the Journal of Cancer Epidemiology, Biomarkers & Prevention, they found however, that coffee did not decrease the risk of laryngeal cancer. Read a CNN report on this here.

In a more recent study (Dec 2012), researchers have found that not only does coffee reduce risk of cancer, but that consuming more than four cups of caffeinated coffee per day was associated with a 49 percent lower risk of oral/pharyngeal cancer death relative to no/occasional coffee intake.

Coffee contains over 1,000 different chemical compounds, including cancer-fighting antioxidants, and it’s those antioxidants that may provide a “plausible explanation” for reducing the cancer risk as well as cancer death.

However, patients should not take this study as an excuse to increase their coffee intake specifically to counteract known cancer-causing behaviors including smoking, drinking alcohol, and chewing tobacco.

Reference:
Coffee and Tea Intake and Risk of Head and Neck Cancer: Pooled Analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiol Biomarkers Prev. 2010 Jul;19(7):1723-36. doi: 10.1158/1055-9965.EPI-10-0191. Epub 2010 Jun 22.

Coffee, Tea, and Fatal Oral/Pharyngeal Cancer in a Large Prospective US Cohort. American Journal of Epidemiology, 2012 DOI: 10.1093/aje/kws222

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ENT Surgeons Who Use daVinci Robot

Readers know my skepticism on the practicality of the daVinci robot in ENT head and neck surgeries.

However, that does not mean that I do not doubt its effectiveness in certain unique situations... as well as market forces that use such high (and expensive) technology to market a given hospital's services.

In any case, plenty of patients have asked me if there's any ENT surgeons who use the daVinci robot in the region.

There are... and here are two that I am aware of.

Dr. David Shonka at UVA
Dr. Stan Chia at Georgetown

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ENT as Comic Book Hero (or Villain)

I had no idea that ENTs with our head mirrors are relatively common in the comic book world alternately portrayed as heroes or villains. (Most of us have upgraded to a headlight powered by battery, but some of us ENTs still use a head mirror.)

There is a Family Practice physician who has compiled all the situations where ENTs were portrayed in comic book settings in his blog Polite Dissent.

The full list can be found here.

I have reproduced a few of my favorites below:

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Head CT Scans Increase Risk of Cancer in Kids

By how much?

Brain tumor/cancer risk was 3X greater than the general population in children who received two to three CT scans of the head.

And the chance of developing leukemia was three times as great for children who received five to 10 CT scans of the head.

In the study published in Lancet, the researchers examined 176,587 children who had received a CT scan before age 22 and looked at their medical history for an average of 10 years afterward.

Though the risk sounds "high," the overall risk is still relatively small and CT scans should still be performed if medically warranted.

Phrased another way, the risk corresponds to one additional case of leukemia in the 10 years after the first scan for every 10,000 patients younger than 10 who were scanned or an extra case of brain cancer for every 30,000 children scanned.

Even so, the study does illustrate that CT scans should not be ordered unless there's a very good reason to do so, especially in children given they are more radiosensitive compared to adults.

In the ENT world, the most common reason to order a CT scan is to evaluate for sinusitis.

My own personal preference is to obtain one in children if and only if all other sinusitis interventions have already been performed.

Such "sinusitis" interventions include:

• Allergy intervention (steroid and/or anti-histamine nasal sprays)
• Failure to respond to antibiotics
• Adenoidectomy (if large adenoids present which can be determined on endoscopy)
• Turbinate Reduction (if turbinates are enlarged)
• Check for cystic fibrosis and primary ciliary dyskinesia

If above interventions have been performed, only than would I consider a CT scan of the sinuses.

Some (other ENTs) may argue that CT scan of the sinuses should be performed early as a more directed intervention can than be performed.

My argument against that is, EVEN if the CT sinus comes back abnormal, I STILL would perform the above interventions first because often the above interventions will clear up and sinus abnormality seen on a CT scan.

Only when everything else has been tried would I consider sinus surgery in a child and only than would a CT sinus be justified in my mind.

However, there are certain other situations I may consider getting a CT scan relatively quickly...

• If I find a sino-nasal mass on exam concerning for tumor or nasal polyps
• Congenital hearing loss
• Cholesteatoma (tumor of the ear)
• "Significant" Facial Trauma (ie, not just for a simple broken nose)


Reference:
Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet. 7 June 2012. doi:10.1016/S0140-6736(12)60815-0

Source:
Children's CT Scans Pose Cancer Risk. Wall Street Journal 6/6/12

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Strong Sneeze Broke Woman's Neck

Fox News reported yesterday about an Australian woman, Monique Jeffrey, who sneezed SO hard that she broke her neck... literally.

According to the neurosurgeon the patient eventually saw, her C1 and C2 vertebrae had dislocated and were displaced which resulted in her symptoms of excruciating pain with her head locked to her right shoulder and in too much pain to move anything but her right arm. Her left arm was also numb with tingling.

She was placed in a halo traction for three months with weights to gradually move the vertebrae back in alignment.

Source:
Super-strong sneeze puts mom in traction for three months. Fox News 3/27/12

Melbourne mum dislocates neck by sneezing. 9 News Melbourne. 3/27/12

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Head MRI and CT Scans Explained!

@ENTHouse brought to my attention a FANTASTIC website that literally identifies and goes through all anatomic structures on every slice of a CT or MRI scan of the head.

Sinus cavities, blood vessels, nerves, bone, suture lines, etc...

Wish I thought of doing it first...

It may be a bit confusing for a layperson, but if you have a copy of your CT/MRI scan and wonder where the maxillary sinus or optic nerve is located on your scan, check this website out and you probably can figure it out!

headneckbrainspine.com

Check it out!

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Portable CT Scanner

Portable X-ray machines are commonplace... but a portable CT scanner?!!

I saw this article by MedGadget about a portable CT scanner introduced earlier this year that can be wheeled around in the hospital made by NeuroLogica.

When looking up more details, the company makes not just one portable CT scanner, but FOUR different portable machines:

• BodyTom: Portable whole-body CT Scanner
• CereTom: Portable CT Head scanner
• OTOscan: Portable CT Sinus scanner
• inSPira HD SPECT: Portable SPECT scanner

Pretty amazing.

Though the whole-body CT scanner seems a bit big to be easily moved from hospital room to hospital room, it is comparable in size to portable fluoroscopy equipment currently in use. The other models are quite a bit smaller.

Realistically, I think the CereTOM will be the big winner as CT scans of the head is probably the most ordered CT scan in the hospital, often ordered to evaluate for stroke, head injury after a fall, sinusitis, facial fractures, brain tumor, seizures, etc, etc, etc. In many of these situations, the patient is fairly immobile and it just may be easier and faster if the CT scanner is brought to the patient rather than patient wheeled to a stationary CT scanner.

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Woman Survives Live Grenade Lodged in Face

A 32 year old Mexican woman, Karla Flores, survived extraction of a live grenade from between her jawbones. Apparently, she was minding her own business when she was knocked out after something hit her face. Read report here.

In the hospital, it was realized that rather than a stone as initially thought, it was a live grenade!

Due to fear of it going off, 3 volunteer doctors and one nurse surgically removed the live grenade in an open field under direction of two explosive experts from the military.

Due to airway compromise, a trach was first performed prior to extraction.

Bear in mind, that the doctor who removed the grenade did not wear any armor.

Read more on Fox News here.

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