Why is Allergy Present More Now than in Past? Hygiene vs Hapten Hypothesis

It is pretty much well-established fact that there are more people with food and inhalant allergy now than in the past. Two main theories have been proposed to try and explain this unfortunate phenomenon that is affecting more kids with each new generation.

Keep in mind the explanations provided below are significantly simplified for lay public understanding. One can go into cytokines, Th1 and Th2 responses, and other techno-jargon, but not here.

Perhaps the most popular explanation is the "Hygiene Hypothesis" which mainly states that major improvements in public health and medical technology have led to a cleaner home environment with less infectious and parasitic disease burden, resulting in less stimulation of the immune system and a consequent predisposition to allergic disease.

This hypothesis helps to explain why 3rd world nations which have poor sanitation and greater microbial/parasitic diseases do not suffer nearly as much allergic problems as well-developed nations. Basically, the dirtier and more disease ridden people grow up in, the less allergies they have because the immune system is preoccupied with fighting "real" infectious problems. In the absence of such immune stimulation, the immune system essentially gets "bored" and starts treating normal things like pollen as an infection that needs to be eliminated.

The alternative explanation is the "Hapten Hypothesis." Before explaining further how this theory works, first a little immunology instruction. Haptens are very small molecules which are able to easily pass through skin and mucus membranes with ease and by themselves cause absolutely no problems whether immune or allergy. However, when such haptens attach to a carrier protein, it may elicit a profound allergic immune response. Keep in mind that the carrier protein itself may also not elicit an immune response. It is the combination of hapten and carrier protein together that causes the problem.

According to the Hapten Hypothesis, persistent low-grade exposure to environmental haptens via the skin and oral routes at key times during human development – namely, pregnancy and the first year of life – can lead to allergy development. Dietary hapten intake may interfere with oral immune tolerance mechanisms while repeated skin exposure to haptens may promote elevated allergy responses.

What are some of these oral and skin haptens?

• Preservatives
• Nickel
• Cobalt
• Vanillin
• Pesticides
• Drugs (antibiotics and others)
• Industrial chemicals
• Food emulsifiers
• Food colorants
• Flavour enhancers
• Antioxidants
etc etc

Arguments promoting the Hapten Hypothesis over the Hygiene Hypothesis goes as follows:

#1. The biggest reduction in infections came at the end of the 19th century with improvements in sanitation and nutrition – not in the second half of the 20th century, when the greatest increase in allergic disease began – so why didn't they occur together??? However, significant exposure of haptens to the human population on a recurrent basis occurred on a major scale during the 20th century.

#2. The Hygiene Hypothesis states that our immune system does not get stimulated enough by infections. But technically, that's not true... Vaccination programs are the deliberate exposure of our immune system to a whole host of diseases including polio, tetanus, diphtheria, and measles, all by the age of 1 year. Disease burden is not a factor according to the Hapten Hypothesis.

#3. Studies have repeatedly shown that respiratory infections are associated with the development of allergic disease... but according to the Hygiene Hypothesis, the opposite should occur. According to the Hapten Hypothesis, drugs like antibiotics are haptens and can actually promote allergy development.

So is there a definitive answer here?

Unfortunately not, though there are very smart people working on this.

My hunch is that the final answer may be a combination of both hypothesis.

At the very least, there really may be something to the organic movement which promotes eating/drinking foods that contain no pesticides, preservatives, or chemicals and the use of skin products which also contain only "organic" ingredients.

However, keep in mind that the BIGGEST impact towards the prevention of allergy development are actions taken while a woman is pregnant through the infant's first year of life. After that, interventions may be too little, too late according to the Hapten Hypothesis.

I personally like the Environmental Working Group website to check if certain products are "organic" or not because I certainly don't have the time to check every consumer product myself.

When it comes to food, try to make all baby food from scratch. Next best would be to purchase baby food that is sold refrigerated (avoid baby food sold on regular shelves).

References:
Does hapten exposure predispose to atopic disease? The hapten-atopy hypothesis. Trends Immunol. 2009 Feb;30(2):67-74. doi: 10.1016/j.it.2008.11.006. Epub 2009 Jan 8.

Food-provoked eczema: A hypothesis on the possible role of systemic contact allergy to haptens present in both cosmetics and foods. Estetol Med Kosmetol 2011; 1(1): 35-40. DOI: http://dx.doi.org/10.14320/EMK.2011.006

The importance of hapten-protein complex formation in the development of drug allergy. Current Opinion in Allergy and Clinical Immunology 2014 Jun 17;

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Acupuncture Helps with Ear Surgery Pain

Researchers at Boston Children's Hospital has found that acupuncture may be effective in diminishing both pain and post-anesthesia agitation in children after ear tube placement determined thru a prospective randomized controlled trial.

Typically, children are placed under general anesthesia in order to have this procedure performed and upon waking, are often tearful and agitated. In this study, acupuncture needles were placed at LI-4 and HT-7 immediately after anesthesia, but prior to ear tube placement.

A blinded assessor than determined that pain and agitation were significantly lower in the acupuncture group compared with controls during the 30 minutes after surgery. Furthermore, the number of patients who required analgesia was considerably lower in the acupuncture group than that in the control group.

Although promising, in order to be fully convinced of the effectiveness of acupuncture, further research by other groups in larger number of kids need to be performed.

BUT... because the risks and side effects are so nominal, it can't hurt to give it a try for those patients and families interested in doing so.

For full disclosure, I personally have no experience in providing acupuncture and I would suggest taking these research findings to a reputable and licensed acupuncturist to get this done in those who are interested.

Reference:
Acupuncture management of pain and emergence agitation in children after bilateral myringotomy and tympanostomy tube insertion. Pediatric Anesthesia. Volume 19, Issue 11, pages 1096–1101, November 2009

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The Nose is a Jungle of Germs (even in Normal Healthy People)!

A fascinating study was conducted by Stanford researchers on the amount and types of germs found inside the nose in normal healthy individuals, whether they are staph carriers or not.

In a typical nose in a healthy individual without any symptoms, the following "germs" can be found. Keep in mind that ALL these germs have the potential to cause a pathological sinus infection:

• Corynebacterium
• Propionibacterium
• Escherichia-Shigella
• Staphylococcus aureus (including MRSA)
• Staphylococcus (other species)
• Dolosigranulum
• Tomitella
• Moraxella
• Actinobacteria
• beta-Proteobacteria
• Prevotella
• Anaerococcus
• Streptococcus
• Peptoniphilus
• Variovorax

These germs were found not just in the nostril, but also on the middle turbinate located about 1-2 inches into the nose and the sphenoid recess located in the very back upper part of the nose (about 3+ inches into the nose).

The top 2 most common germs found in healthy individuals were corynebacterium and propionibacterium. When these bacterial populations decrease, the presence of staphylococcus increases.

Staphylococcus was also found not just at the nostril where cultures are most commonly obtained, but in both much deeper locations within the nose.

This may explain why in spite of aggressive whole body MRSA body hygiene management and use of bactroban ointment to the nares not uncommonly fails to eradicate staph/MRSA in susceptible patients.

Clearly, more research is needed, especially in how to minimize/eradiacate staph colonization beyond the nostril (but allow for normal, healthy bacteria to remain).

Source:
Staph Germs Hide Out In The Hidden Recesses Of Your Nose. NPR 12/11/13

Reference:
Nasal Microenvironments and Interspecific Interactions Influence Nasal Microbiota Complexity and S. aureus Carriage. Cell Host & Microbe, Volume 14, Issue 6, 631-640, 11 December 2013

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Nasal Spray Cure for the Common Cold?

Well maybe not cure per se, but at least effective treatment to reduce the duration and severity of the viral cold at least. Austrian researchers have reported on the results of a randomized, double-blind, placebo-controlled trial involving 211 patients suffering from early symptoms of the common cold. [link]

Treatment of the non-placebo group involved using a nasal spray containing carrageenan (a sulphated polysaccharide found in red seaweed/algae) three times per day for 7 days. Cold symptoms were found to resolve 2.1 days faster and viral loads in the nasal washings were significantly decreased compared to placebo group. At day 21 of observation, one sixth of patients given the placebo were still ill, while only one twentieth were in the treatment group.

Personally, I would like to see larger studies conducted by other independent groups to verify the findings.

So how does this nasal spray work?

The problem with the common cold is that there are SO many viruses that manifest the same disease including rhinovirus, coronavirus, parainfluenza, influenza, respiratory syncytial virus, adenovirus, enterovirus, and metapneumovirus. As such, an effective treatment should be able to disable all these virus types and not just one.

The way carrageenan works is by sticking to the virus regardless of type and preventing it from attaching to the nasal lining. As such, the virus is unable to enter into the body and cause problems. It essentially blocks the virus like the wall of a castle.

The caveat is that in order for this nasal spray to work, you have to start using the medication as soon as cold symptoms appear (within 2 days). Remember... it works by blocking the virus from entering the body. If you wait too long, the virus has already entered the body making any type of blocking medication ineffective.

Where can you buy it?

It is available over-the-counter in most European countries and Canada. But NOT available in the United States.

The nasal spray is made by Marinomed in Europe using their Mavirex technology and also licensed for marketing/distribution by Boehringer. Carragelose is the brand name of the carrageenan ingredient. Depending on the country, the actual name of the nasal spray is sold under is different.

For example, in England, the nasal spray is called "Cold and Flu Defence Nasal Spray".

To make sure you have the right nasal spray, look under ingredients and make sure carragelose is listed.

On another note... Afrin nasal spray has also been shown to have some anti-viral activity in unpublished reports. Just be aware to not use it more than 3 days or else you may get addicted to it.


References:
Efficacy of a Carrageenan nasal spray in patients with common cold: a randomized controlled trial. Respiratory Research 2013, 14:124 doi:10.1186/1465-9921-14-124

Efficacy and safety of an antiviral Iota-Carrageenan nasal spray: a randomized, double-blind, placebo-controlled exploratory study in volunteers with early symptoms of the common cold. Respir Res 2010. doi:10.1186/1465-9921-11-108

Lessons learned from a double-blind randomised placebo-controlled study with a iota-carrageenan nasal spray as medical device in children with acute symptoms of common cold. BMC Complement Altern Med 2012. doi:10.1186/1472-6882-12-147

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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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At-Home Rapid Strep Testing

Rapid strep test kits can be purchased by anybody to be done at home which may save parents/patients a lot of money in doctor visits for those prone to strep infections. Indeed, should a rapid strep test be positive, than you know that a doctor's visit is definitely worthwhile. (A doctor visit may still be worthwhile since a sore throat may be due to something else like cancer, aphthous ulcer, sinus infection, reflux, etc).

Such home kits (which in fact are the same kits used in medical offices) can be purchased online through Amazon. The price is surprisingly affordable at around the cost of a single copay $30 to do 25 tests.

However, with the purchase of such DIY kits, there are some pitfalls patients should be aware of if they decide to proceed.

1) Perform the internal controls that come with the kit!!! The kit may be a dud and needs to be tested against itself to ensure accurate results whether negative or positive. If the controls do not work, throw the whole test kit out and buy another.
2) You must follow the directions precisely, otherwise the test results will be unreliable. In other words, if the directions call for 4 drops, than it MUST be 4 drops (not 3 drops or 5). If directions state to wait 4 minutes... you must wait exactly 4 minutes. This literally is like precision baking.
3) The test strips need to be kept in protected, sealed bag and used immediately after taking one out, otherwise the test results will be unreliable.
4) When swabbing the throat, you MUST get the cotton tip on the tonsil and/or back wall of the mouth which than must be rubbed around a couple times. Getting the tongue or cheek will increase the risk of a false negative. As such, it may be worthwhile to invest in some tongue blades to help push the tongue down in order to perform this test properly.

Should patients elect to start performing home strep tests, please be aware that physicians will be obligated to not only REPEAT the testing but also examine the patient to ensure antibiotics are appropriate. An actual throat culture may be performed as well which is the gold standard test.

1) Repeat testing is required because the patient may not have followed the instructions precisely. For example, the test strips must be read at 5 minutes (variable depending on the kit). If test results are read past 5 minutes, it may incorrectly show a positive result.
2) Some patients unfortunately fabricate test results just so they can get an antibiotic without an office visit.
3) Some patients unfortunately also fabricate test results in order to skip work or school for personal reasons not related to an actual medical condition.
4) There are situations that even though the strep test is positive, no treatment may be recommended. The patient may be a strep carrier for which treatment of any kind is not recommended.

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What is the Best Antibiotic for Strep Throat?

The traditional answer for the best antibiotic to treat strep throat is penicillin. This antibiotic works astoundingly well... until it doesn't. Why is that?

Although in the lab, penicillin is probably the most effective antibiotic against Group A beta-hemolytic streptococci (GABHS) or "strep throat" infection, when it comes to human beings, it doesn't always work. A recent paper out of Georgetown elucidates the reasons why that might be the case and also explains why if you took a survey of ENT doctors, clindamycin and augmentin are perhaps the two most popular antibiotics used in our patient population (patients seen in an ENT practice suffering from recurrent and/or severe infections of the head and neck region).

Penicillin may fail to work because:

• presence of beta-lactamase producing bacteria that "protect" strep from penicillins
• absence of bacteria that interfere with the growth of strep
• co-aggregation between strep and Moraxella catarrhalis
• poor penetration of penicillin into the tonsillar tissue cells which allows intra-cellular strep and Staphylococcus aureus to survive

Indeed, in the treatment of recurrent and chronic strep throat, clindamycin or amoxicillin-clavulanic acid (augmentin) can eradicate both aerobic and anaerobic beta-lactamase producing bacteria as well as strep itself. Cephalosporins and clindamycin have superior intracellular penetration which enhances their efficacy as well.

Of course, if a patient has suffered from such severe and recurrent strep infections, it just might be time to remove and tonsils and adenoids surgically.

Reference:
Penicillin failure in the treatment of group A streptococcal pharyngo-tonsillitis: Causes and solutions. Journal of Pediatric Infectious Diseases. Volume 8, Number 2 / 2013 Pages 59-69

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Did a Case of Lemierre's Syndrome Influence Super Bowl XLVII?

Image by Keith Allison from Wikipedia

Lemierre's syndrome is an exceedingly rare complication of tonsillitis characterized by an infected clot of the jugular vein leading to sepsis. It may also have potentially influenced Super Bowl XLVII due to an interesting quirk in history.

Back in 2008, a former Heisman Trophy winner from Ohio State University named Troy Smith was the quarterback for the Baltimore Ravens. Great things were expected of him as he was gearing up to start in the third preseason game of the 2008 season.

Unfortunately... you guessed it... he came down with Lemierre's Syndrome.

Which allowed for a rookie quarterback named Joe Flacco to step in.

Joe Flacco went on to lead the Baltimore Ravens to a Super Bowl win in 2012.

Troy Smith, in the meantime, has never quite recovered professionally since his bout of Lemierre's Syndrome.


Sources:
Troy Smith. Wikipedia

Joe Flacco. Wikipedia

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PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus)

Only in kids, there is a VERY rare (and controversial) disorder where strep throat infections can rapidly lead to involuntary tics including chronic throat clearing, cough, head/neck movements, sneeze, etc as well as OCD behavior. Known as PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus), it is felt to be an autoimmune reaction triggered by antibodies produced by the body when fighting a strep infection. With this disorder, an evaluation with a pediatric neurologist is warranted.

However, what role if any an ENT may play is less certain. Obviously, the main ENT related concern is whether tonsillectomy and adenoidectomy is helpful.

Certainly, this surgery should be pursued if the child meets the guidelines of when T&A should be performed from an infectious standpoint in any child:

• 7 or more tonsil/strep infections within past 12 months OR
• 5 infections in each of the last 2 years OR
• 3 infections in each of the last 3 years

However, it has been demonstrated that T&A does NOT seem to affect the onset nor influence the neuropsychiatric course of a child suffering from PANDAS.

According to one research, no significant differences were found between children who had T&A and those who did not in terms of PANDAS classification, and OCD or tic severity. In fact, most children with PANDAS had surgery before onset of neuropsychiatric symptoms and surgery did not affect symptomology.

More info about PANDAS can be found here.

To find a doctor who is familiar with PANDAS, click here.

References:
Tonsillectomies and Adenoidectomies Do Not Prevent the Onset of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococcus. Pediatr Infect Dis J. 2013 Mar 20. [Epub ahead of print]

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Should Toothbrushes be Thrown Out After Strep Throat?

As with so many things with medicine, this question which sounds so straightforward unfortunately has no straightforward answer.

After all, there have only been a few studies that have specifically looked to answer this question.

And the answer is decidedly ambiguous as the few studies done so far either support or disprove this practice.

Two studies have found no difference in recurrent infections whether one keeps using an old toothbrush or replaces it with a new one after a strep throat. In one study, even NEW toothbrushes contained harmful bacteria.

Of course, there are several studies that support this practice.

In fact, environmental hygiene in general is also disputed with studies supporting for as well as against this practice after an illness.

Check out a few references below to add more mud to the confusion.

Of course, with multiple recurrent episodes of strep throat, tonsillectomy surgery is quite helpful.

Also given the confusion, perhaps the safe course would be to disinfect a toothbrush regularly.


References Against Throwing Toothbrushes Out:
Recurrence rate of streptococcal pharyngitis related to hygienic measures. Scand J Prim Health Care. 1998 Mar;16(1):8-12.

How dirty is your toothbrush? Answer: Not as much as you think. NBC News 5/4/13


References in Support:
Contamination of toothpaste and toothbrush by Streptococcus mutans. Scand J Dent Res. 1978 Sep;86(5):412-4.

Persistence of group A beta-hemolytic streptococci in toothbrushes and removable orthodontic appliances following treatment of pharyngotonsillitis. Arch Otolaryngol Head Neck Surg. 1998 Sep;124(9):993-5.

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Fecal Transplantation Administered Through the NOSE!

Fecal transplant is nothing new as it has been around since the 1950's... It is used to treat multi-drug resistant clostridium dificile infection by replacing the "bad" gut bacteria with normal "good" bacteria. However, what is new is the fact that such fecal transplantation is being administered through the nose using a tube threaded into the small bowel. [Thanks to @GuildfordENT who brought this to my attention!]

Historically, such fecal transplantation (aka fecal bacteriotherapy) was performed via multiple infusions via enema (uncomfortable for both the physician as well as the patient) or via colonoscope. Although first described being done in humans in 1958, it was never really seriously studied until the mid-1980's. Even before humans, it had been performed in animals by veterinarians for centuries.

In any case, there has been new literature supporting the use of nasoduodenal tubes to administer poop via the nose. With nasoduodenal tubes, a tube is threaded through the nose, past the stomach, and into the small bowel.

Now keep in mind that the stool actually NEVER comes into contact with the nose. It is contained within an impermeable tube at all times, so it is not quite as gross as you might think (though mentally, there may still be an emotional ick factor present).

Another approach being considered is encapsulating the poop inside enteric-coated capsules so a patient can theoretically swallow the pill-containing poop.

Media Mention:
Doctors save patient from deadly superbug by transplanting faeces through his NOSE. MailOnline

Reference:
Duodenal infusion of donor feces for recurrent Clostridium difficile. New England Journal of Medicine. 2013 Jan 31;368(5):407-15. doi: 10.1056/NEJMoa1205037. Epub 2013 Jan 16.

Same poop, different gut. The Scientist 11/3/105/2/13

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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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Surgeries on a Weekend Have More Complications

The New York Times published an interesting story regarding how patients with ulcerative colitis suffered significantly more surgical complications when performed on a weekend compared to a weekday. Just how much worse?

The cited research reported that the most common post-operative complication was post-operative infections (Weekend 30% vs. Weekday 20%). However, there was also an increased risk of need for repeat laparotomy, mechanical wound complications, and pulmonary complications. Of note, there was no difference in disease severity between weekend and weekday groups.

Oddly, this increase in complications did not occur with Crohn's disease patients.

Although these findings can not and should not generalize to other surgical procedures, the following logistical issues ARE present when decision for urgent surgery is made after hours or on weekends.

The following issues are probably what prompts this type of research to occur in the first place.

During such off-periods, there are no surgical support staff present in the hospital. They need to be called in from home. As such, there may be a slightly higher time delay before surgery begins. Furthermore, the surgical tech that assists the surgeon may be unfamiliar with the surgery as well as instruments used leading to a surgical procedure that may be "inefficiently" performed.

For example, if I need to take a child back to the OR who is suffering from excessive bleeding after a tonsillectomy, the surgical technician who may be assisting me may be an orthopedic technician unfamiliar with ENT instruments as well as unfamiliar with how the procedure is performed.

Although one may like to select who assists in the surgery, unfortunately, the patient nor the surgeon gets to choose who their surgical support staff is. It is whoever happens to be on-call when the need for urgent surgery arises. You get who you get...

However, during the weekday, the surgical support staff helping with the surgery is the team that does that particular surgery all the time... the "A" team so to speak.

The other factor is the surgeon himself. During the weekday, the patient will most likely have surgery performed by "their" surgeon who knows and is already familiar with the patient.

After-hours or on the weekend, the patient may or may not get the surgeon who knows the patient personally. It would be whoever the on-call surgeon is.

So now you know...

Now to be fair, there have been studies that both support as well as refute the assertion that weekend surgeries/admissions place patients at elevated risk of complications.

Source:
Weekends Worse for Surgery. New York Times. 3/22/13

Reference:
Weekend hospitalisations and post-operative complications following urgent surgery for ulcerative colitis and Crohn's disease. AP&T Article first published online: 4 MAR 2013. DOI: 10.1111/apt.12272

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Just How Contagious is the Flu (and Other Viral Infections)?

Everybody knows the flu and other viral infections are contagious, but did you wonder just how contagious???

Well, here are some facts gleaned from a few studies:

• In just 4 hours, one sick worker can contaminate 50% of surfaces in a typical office
• After 8 hours, one sick worker can contaminate 70%+ of surfaces
• Non-sick workers have a 40-90% chance of getting infected after spending one day with a sick worker
• A sneeze or cough can hurl virus 6 feet away from the mouth
• A sick person literally "emanates" virus up to 6 feet away... even if they are NOT sneezing or coughing.
• Some sick individuals are super-carriers spreading the virus around them 32 times more than others

The good news is that viruses can not survive on surfaces for long... They usually die off within a day (type of surface, temperature, and humidity affecting duration).

Source:
Flu Virus Can Travel Up to 6 Feet, Infect Up to 90 Percent of People Just from Contaminated Surfaces. Medical Daily News 2/1/13

References:
Exposure to Influenza Virus Aerosols During Routine Patient Care. J Infect Dis. 2013 Jan 30. [Epub ahead of print]

InfluenzaVirus: Here, There, Especially Air? J Infect Dis. (2013) doi: 10.1093/infdis/jis774

Germs Spread Fast at Work, Study Finds. AHSC 1/30/13

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Video of Epiglottitis

The normal epiglottis is a very thin flap of tissue that closes over the windpipe when swallowing preventing food/liquids from going down the wrong way. Shown by the blue arrow in the picture, when the epiglottis becomes infected, it can swell in size to even obstruct the airway leading to death by asphyxiation. Indeed, epiglottitis is what is thought to have killed our first President George Washington.

Fortunately, epiglottitis is quite rare ever since the introduction and regular use of the Hib vaccine in the 1980s. Although rare, it is a problem that still occurs intermittently even today. Each time I've encountered it in the past, I unfortunately was always in a situation whereby video recording of the endoscopic exam was not possible.

Until one day, a patient with epiglottitis did walk into my clinic and I WAS able to video-record the endoscopic exam.

Briefly, this patient developed a severe sore throat with difficulty swallowing that occurred suddenly over a 24 hour period of time. Patient reported the severe sore throat was localized to the base of tongue region.

Without further ado, here's the endoscopic examination both before treatment and than again 1 week later after a course of antibiotics and steroids.

Note the markedly swollen epiglottis before treatment. Even after treatment, the epiglottis is still mildly swollen though much improved. Normal is shown in the picture above.

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How Long Does it Take for a Cough to Clear Up?

Hypothetically speaking, how long would it take for a cough to clear up if a person comes down with an acute respiratory infection?

According to a telephone survey of 493 adults, the lay-public expect the cough to clear up in 7 to 9 days.

Now, is this one week guess actually true?

Not at all... In reality, it takes about 17.8 days on average.

This number was determined on a recent study that reviewed 19 prior studies that determined how long a cough lasts for.

It should also be mentioned that taking antibiotics does little to shorten this duration, especially given most upper respiratory infections are due to viruses.

In any case, the disconnect between patient expectations and reality in cough duration probably leads to some frustration between physicians and their patients.


Reference:
How Long Does a Cough Last? Comparing Patients’ Expectations With Data From a Systematic Review of the Literature. Annals of Family Medicine. doi: 10.1370/afm.1430 Ann Fam Med January/February 2013 vol. 11 no. 1 5-13

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Embedded Earrings and Treatment

A few times a month, I have a patient, usually a young child, who presents with an earring that not only can not be removed, but is embedded within the earlobe (or ear) itself.

There are two common scenarios that lead to this unfortunate situation: infection and fiddling.

Infection is fairly straightforward. For whatever reason, the piercing gets infected and the earlobe skin starts to swell around and eventually even enveloping the earring itself. To prevent an embedded earring, immediately remove the earring!!! If you wait until the swelling is too severe, it may not be possible to remove the earring at all without surgical intervention. This type of infection can occur rapidly from being normal to rip-roaring infected swelling within 24 hours.

Fiddling is basically when the patient keeps tightening the earring backing snug with the skin as tightly as possible so the earring won't loosen and potentially get lost. However, such tightening can actually induce the skin to overgrow the earring with subsequent infection. To prevent this from happening, always make sure there is some “play” that allows the earring to push back and forth through the ear and turn easily.

Now, should the earring become embedded and manual removal not possible, surgical intervention is required.

The steps are as follows:

1) Sterilize the area with betadine.
2) Inject area with lidocaine.
3) After the area becomes anesthetized, a scalpel is used to create an "X" shaped incision over the embedded earring.
4) Toothed forceps and clamps are used to grab and pull the embedded earring out.

Aftercare typically involves oral antibiotics and application of antibiotic ointment several times a day. Once the infection clears, I typically recommend waiting a few months before re-piercing to allow scar activity to completely fade first.

Also, keep in mind that they DO make earrings that are physically impossible to tighten up against the skin to reduce the possibility of embedded earrings.

On that note, we do offer ear-piercing in our office.

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57 Maggots Removed from Woman's Ear

92 years old woman with Alzheimer's was found to have 57 maggots in her ear sparking a lawsuit. Read more from media reports.

Beyond the gross factor and questions regarding how this was allowed to happen, this story does bring up some interesting teaching points and the medicinal properties of "maggot therapy".

Media reported the patient suffered from earwax build-up and had "an enlarged ear canal from surgery performed decades earlier."

This  surgery was most likely a canal-wall-down tympanomastoidectomy often performed for a benign ear tumor called cholesteatoma or a severe chronic draining ear. This surgery essentially removes all the bone from behind the ear (mastoid) and ear canal back wall. Depending on how aggressive the surgery, the eardrum and middle ear bones (malleus, stapes, and incus) may also be removed.

With such surgery, the ear canal now 2-3 times larger than before, is prone to developing earwax impaction and requires surgical debridement or removal every 4-6 months for the rest of the patient's life.

If surgical debridement is not performed regularly in such patients, infection may set in.

With such infection, ear drops can be used as described in the story, but such treatment is bound to fail until ear canal debridement of all earwax is first performed.

What I suspect is that this poor patient did not get her ear cleaned out regularly resulting in infected earwax. A fly noting the foul cesspool located in a dark, humid environment of this enlarged ear canal probably thought this the perfect place to lay eggs and allow a maggot infestation to occur.

Gross, horrid, and astounding I know...

However, medicinal maggot therapy is actually used in hospitals... Why?

Because maggots are apparently WAY better than a surgeon in certain situations at removing dead infected tissue with or without antibiotics.

It is entirely possible that given time, the maggots might have cleaned and removed the infection that was probably present in this patient's ear. However, unlike medical-grade maggots which are "sterilized" prior to use, "natural"maggots probably harbor other microbes that could cause a secondary infection.

Such medicinal maggots can be purchased for wound control with a prescription. Monarch Labs is the exclusive USA supplier of medicinal maggots which the FDA considers a "medical device."

Here is a video produced by National Geographic on maggot therapy.

Source:
92-year-old has 57 maggots removed from ear, family sues nursing home. CBS News 11/30/12

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Dr. Chang Quoted in Voice Council Magazine

Dr. Christopher Chang was quoted in a Nov 4, 2012 article published in Voice Council Magazine.

The Voice Council Magazine is based out of United Kingdom and focuses on "practical insight for the emerging vocalist."

The article by Megan Gloss was focused on why Celine Dion cancelled her concert 2/22/12 in Las Vegas (a viral laryngitis), a subject I already blogged about here.

Read the published Voice Council article here.

Source:
Celine Dion's Viral Voice. Voice Council Magazine 2/22/12.

Viral Infections and Singing — More From Dr. Chang. Voice Council Magazine 2/22/12.

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