Ear Injection of AM-101 May Stop Tinnitus

Phantom ringing of the ears also known as tinnitus is an extremely frustrating condition that afflicts many people. Often triggered by hearing nerve damage, there's no good treatment to fix this condition once it sets in.

Until possibly now... 

AM-101 made by Auris Medical is an experimental drug containing esketamine hydrochloride embedded within a hyaluronic acid gel formulation. It works by blocking the NMDA receptors of the cochlear inner hair cell.

Normally, when there is trauma sustained by the cochlea whether it be loud noise or viral infection, excess amount of a neurotransmitter called glutamate gets release. The problem is that too much glutamate also triggers hearing nerve death due to over-excitation via the NMDA receptor. When these hearing nerves die, it leaves the brain cells responsible for hearing in a permanently switch-on state leading to tinnitus, even if there's no sound present.

AM-101 is hypothesized to block the NMDA receptor from being over-stimulated by the glutamate neurotransmitter thereby preventing hearing nerve death.

But, does it work?

According to one small prospective, double-blind, randomized, placebo-controlled study involving 248 patients, it DOES work to a significant degree.  42% reported their tinnitus was half as quiet as before compared with 14% in the placebo group. After 90 days, 57% of those taking the active gel said their tinnitus was 'much improved' or 'very much improved'.

Of course, the trick is to administer the drug before nerve death has set in after which it would be too late. In the study, only patients with onset of ringing within 3 months were eligible to participate.

Patient also need to realize that the drug is administered by injection through the eardrum and into the middle ear space. This injection technique is commonly used in the treatment of sudden nerve hearing loss where steroids are injected. Watch video of this injection method below.

Unfortunately, AM-101 is not available except under research protocols currently and is undergoing FDA clinical trials. The preliminary results are very promising however.

Reference:
Efficacy and Safety of AM-101 in the Treatment of Acute Inner Ear Tinnitus—A Double-Blind, Randomized, Placebo-Controlled Phase II Study. Otology & Neurotology: April 2014 - Volume 35 - Issue 4 - p 589-597

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Nexium is Available Over-The-Counter

Nexium, a medication to treat acid reflux, has gone over-the-counter and joins Prilosec and Prevacid as ex-prescriptions now OTC.

It's available for purchase in most pharmacies and even on Amazon.

Read more about how reflux medications work here.

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30% of Patients with Reflux will NOT Respond to Medications

Specifically, patients who are suffering with throat symptoms of reflux will often not respond to proton-pump inhibitor (PPI) medications. Such throat symptoms include throat-clearing, phlegmy throat, cough, hoarseness, and globus. Known as LPR (laryngopharyngeal reflux), a study was done measuring the pH at the throat level after 4+ weeks of twice daily PPI.

This retrospective study found that although 67.4% had symptom normalization, 32.6% of patients showed no subjective or objective treatment response. For all patients whose symptoms did not normalize, pH scores also did not normalize.  For individuals whose symptoms normalized but whose pH scores did not normalize, there was a significant decrease in upright pH score.

Based on these findings, one should NOT assume that lack of response to reflux medications indicative of reflux being an incorrect diagnosis. Further study with a pH or impedance monitoring should be performed in non-responders to help figure out what is going on.

Reference:
Effects of Proton Pump Inhibitor Therapy for Laryngopharyngeal Reflux on Posttreatment Symptoms and Hypopharyngeal pH. Otolaryngol Head Neck Surg. 2014 Mar 19. [Epub ahead of print]

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Nasacort AQ Steroid Nasal Spray NOW Available OTC!

Sanofi announced in 2013 that the FDA had approved Nasacort steroid nasal spray to be made available over-the-counter (OTC) starting sometime spring 2014.

Well... It's now available for about $20. Here's where you can get it on Amazon.com.

Nasacort is a steroid nasal spray used to treat allergies in patients starting from the age of 2 years old. It is similar to prescription steroid nasal sprays like flonase, nasonex, etc. It is also the very first steroid nasal spray made OTC in the United States which can be both a blessing as well as a curse.

Why?

With Nasacort going OTC which will certainly make it more convenient for patients, I also anticipate that the other prescription steroid nasal sprays including flonase, nasonex, qnasl, zetonna, veramyst, etc will become much harder to prescribe due to insurance requiring patients to use OTC Nasacort first. Worst case, insurance may even simply stop paying for the prescription steroid nasal sprays.

After all, this is exactly what happened with prescription reflux and anti-histamine medications.

Source:
FDA Approves Sanofi's Nasacort(R) Allergy 24HR for Over-the-Counter Use. Wall Street Journal 10/11/13

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Nasacort Steroid Nasal Spray to be Available Over-The-Counter!

Sanofi announced today that the FDA has approved Nasacort steroid nasal spray to be made available over-the-counter (OTC) starting sometime spring 2014.

Nasacort is a steroid nasal spray used to treat allergies in patients start from the age of 2 years old. It will also be the very first steroid nasal spray made OTC in the United States which can be both a blessing as well as a curse.

Why?

With Nasacort going OTC which will certainly make it more convenient for patients, I also anticipate that the other prescription steroid nasal sprays including nasonex, qnasl, zetonna, veramyst, etc will become much harder to prescribe due to insurance requiring patients to use OTC Nasacort first. Worst case, insurance may even simply stop paying for the prescription steroid nasal sprays.

After all, this is exactly what happened with prescription reflux and anti-histamine medications.

Source:
FDA Approves Sanofi's Nasacort(R) Allergy 24HR for Over-the-Counter Use. Wall Street Journal 10/11/13

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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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Do Reflux Medications Increase Risk of Esophageal and Throat Cancer?

Image by Steven Fruitsmakk from Wikipedia

Over the last 30 years, the incidence of esophageal cancer has been steadily rising in spite of increased use of reflux medications. In fact, one can almost say that there is an inverse relationship between risk of esophageal cancer and reflux medication usage.

BUT, it is also a foregone conclusion that reflux increases the risk of esophageal and throat cancer too. So, why would there be an increased incidence of esophageal cancer when reflux is being better "controlled" now more than ever with medical acid suppression?

The answer might be bile... the substance made in the liver and secreted into the small intestine via the gallbladder. Bile is what helps the body digest dietary fat.

But when bile not uncommonly refluxes into the esophagus... bad things may happen, especially when acid production has been suppressed by reflux medications.

Disclaimer... The following is hypothetical and unproven.

Bile, if it happens to be in the esophagus or throat, is more destructive to the mucosal lining when acid is suppressed.

Bile salts/acids have fairly complicated acid-base properties, but an over-simplified explanation for the purpose of this blog is as follows.

Bile in a chemically unconjugated state has a pKa of 7. When such bile is in an acid environment (pH less than 6), it is insoluble and relatively harmless. However, when unconjugated bile enters a relatively alkaline environment (pH greater than 6), it becomes water soluble and "active" in its ability to damage mucosal linings.

As such, when acid suppression is induced by medications like zantac and prilosec, yes... the acid is suppressed but by the very fact that it raises the stomach and distal esophageal pH to a relative alkaline state, any bile that may be present now becomes activated and causes potentially just as much damage as acid.

And that's why over a prolonged period of time repeated bile exposure in a relative alkaline environment may explain why esophageal cancer incidence seems to be increasing as the use of acid reflux medications has increased.

Proof?

Regardless of the "how," does taking reflux medications actually increase risk of cancer???

In one study (2011), patients taking proton pump inhibitors were 61.3% to 81.5% more likely to develop esophageal pre-cancerous lesions or frank cancer (adenocarcinoma).

In another study published in the summer of 2013, it was found that patients with reflux were found to have a 78% increased risk of developing throat cancer. What researchers also found was that taking antacids for reflux (but NOT proton pump inhibitors or H2 blockers) seemed to protect against the development of throat cancer by 41% in patients with frequent heartburn.

To reiterate, antacids reduced risk of throat cancer... but NOT proton pump inhibitors like prilosec and H2 blockers like zantac.

Why? Because antacids work transiently to neutralize acid, but not suppress acid production whereas proton pump inhibitors and H2 blockers actually suppress acid production for a prolonged period of time.

The transient nature of acid neutralizers like TUMS allow for acid to still be produced thereby theoretically preventing bile from becoming soluble and damaging.

Prediction

So which is worse for you? Acid reflux or bile reflux? I'm not sure... but personally, I predict that once additional studies are performed that may ultimately strengthen the relationship between bile reflux and mucosal injury that may lead to cancer formation, reflux medications may go out-of-favor along with a class-action lawsuit. That's a big if... I might end up being completely wrong.

Of course, that may be the reason why drug companies specify that such reflux medications should not be used longer than 2 months and prescribing information stress "short-term" treatment rather than long-term.

More Confusion

We can also throw more mud into this messy predicament... Pepsin, which is a stomach enzyme that breaks down proteins, can also damage esophageal and laryngeal mucosa. However, it is most active in an acidic environment. Once pH levels rise above 6.5, pepsin becomes inactivated. At pH 8.0, it becomes irreversibly inactivated.

As such, acid and pepsin cause damage in an acidic environment. Taking reflux medications to eliminate the acid creates an alkaline environment.

However, an alkaline environment than activates bile which can also cause damage.

Treatment

So what to do?

Ideally, given this no-win situation, the best way to treat reflux would be to keep bile where it is supposed to be (in the small intestine) and acid/pepsin in the stomach where it is supposed to be.

As such, I suspect that even more emphasis will be placed on lifestyle/dietary changes for reflux control. Medication-wise, use of antacids and barrier-type medications like alginate will become the main way of treating reflux long-term while medications that suppress acid will be prescribed only for short-term treatment spans.

Surgical management of reflux will become much more accepted and popular for patients who suffer from bad reflux to try and restore proper anatomical compartmentalization of bile, acid, and pepsin. Surgical management will include LINX, TIF, Nissen, etc. (more info)

At the very least, certainly caution should be present when placing a patient on long-term acid suppression with medications like prilosec and zantac, especially when such medications are already known to cause a whole host of other problems including bone fractures, clostridium difficile infections,  and malabsorption of vitamins and minerals. (more info)

Special thanks to Dr. Kevin Gillian who assisted in writing this blog.


References:
Bile Acid. Wikipedia

Gastroesophageal reflux disease symptom severity, proton pump inhibitor use, and esophageal carcinogenesis. Arch Surg. 2011 Jul;146(7):851-8. doi: 10.1001/archsurg.2011.174.

Gastric Reflux Is an Independent Risk Factor for Laryngopharyngeal Carcinoma. Cancer Epidemiology Biomarkers & Prevention. Published Online First May 23, 2013; doi: 10.1158/1055-9965.EPI-13-0183

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991 Apr;101(4 Pt 2 Suppl 53):1-78.

Bile reflux gastritis and Barrett's oesophagus: further evidence of a role for duodenogastro-oesophageal reflux? Gut 2001 Sep;49(3):359-63.

Acid and bile reflux in erosive reflux disease, non-erosive reflux disease and Barrett's esophagus. Hepatogastroenterology. 55 (82-83), 442-7.

The role of bile acids in the neoplastic progression of Barrett's esophagus - a short representative overview. Z Gastroenterol. 50 (9), 1028-34.

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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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Treatment for Vocal Tremor

Vocal tremor is characterized by a rhythmic undulating vocal quality whenever talking, much akin to vibrato that can not be turned off. In the past, it was felt that use of botulinum toxin type A (botox) to treat vocal tremor was not possible nor realistic given the multiple muscle groups involved. This is in contrast to dystonias of the voice (i.e., spasmodic dysphonia) where only one muscle group is involved and is readily and easily treated with botox injections to the affected vocal cord muscle.

However over the past few years, several research papers have been produced that show that botox CAN alleviate (though not eliminate) vocal tremor both objectively and subjectively, though more than one site may need to be injected in order to produce vocal tremor relief. Such muscle sites include thyroarytenoid muscle, ventricularis muscle, lateral cricoarytenoid muscle, interarytenoid muscle, cricothyroid muscle, and strap muscles.

All these muscle sites are easily accessible either via, endoscopic guidance and/or EMG guidance alone. Indeed, physicians who already perform botox injections for spasmodic dysphonia should also be able to inject all the other muscle groups just as easily. [watch video]

Typically, "horizontal" vocal tremor is treated with thyroarytenoid, ventricularis, interarytenoid, and/or lateral cricoarytenoid muscle botox injections.

"Vertical" vocal tremor is treated with strap muscle botox injections.

Dosages are similar to that given to treat spasmodic dysphonia.

SO... for patients suffering from vocal tremor who do not respond well to oral medications (propranolol, primidone), consider botox injections!

Be aware that botox injections to treat vocal tremor may not be covered by insurance.

References:
A new paradigm for the management of essential vocal tremor with botulinum toxin. Laryngoscope. 2013 Apr 1. doi: 10.1002/lary.24073. [Epub ahead of print]

Botulinum toxin type A for treating voice tremor. Arch Neurol. 2004 Sep;61(9):1416-20.

Botulinum toxin for essential tremor of the voice with multiple anatomical sites of tremor: a crossover design study of unilateral versus bilateral injection. Laryngoscope. 2000 Aug;110(8):1366-74.

Tremor laryngeal dystonia: treatment of the lateral cricoarytenoid muscle. Ann Otol Rhinol Laryngol. 2004 May;113(5):349-55.

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What Reflux Meds are Best in Infants and Children?

Once a decision is made to start medications beyond the conservative ways of dealing with reflux, the most common reflux medications used to treat adults are also used to treat reflux in infants and children. They are the same exact medications, albeit at lower dosages.

Although the effectiveness of such drugs are clear in adults suffering from acid reflux, it is less so in children. As is true with so much of medicine, there's no clear answer to the question of what the best reflux med is for infants and children. According to one review of literature, the answer is decidedly mixed and variable depending on what outcome was looked at (subjective symptom improvement or objective test findings).

In fact, symptom improvement (or lack of) did not always correlate with objective test findings (24 hour testing, barium swallow, EGD, etc) of reflux improvement and vice-versa. The most common finding was reduction in reflux based on tests, but no significant improvement in symptoms. Such findings does bring into question whether the diagnosis of reflux was even accurate.

In any case, when looking at SYMPTOMS in infants (less than 12 years of age) use of proton pump inhibitors was decidedly not favorable (one study in support and 4 against). In children (over 1 year of age), proton pump inhibitors were found to be equally effective to alginates and ranitidine.

When looking at OBJECTIVE test findings, proton pump inhibitors were found to be equally effective in both infants and children compared with placebo, alginates, or ranitidine. For reducing histologic aberrations, proton pump inhibitors showed no difference compared with ranitidine or alginates.

Conclusion
If GERD symptom control is the main goal, proton pump inhibitors should not be used in infants. In older children, these medications are helpful but potentially no better than alginates and zantac which have better side effect profiles. As is true with most studies, more study is needed.

Reference:
Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011 May;127(5):925-35. doi: 10.1542/peds.2010-2719. Epub 2011 Apr 4.

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Medications that (Might) Help Tinnitus?

The blunt answer is that there is no drug or supplement that has been consistently found to help with tinnitus (ringing of the ears).

Here's a partial table showing all the research that has been done either proving or disproving effectiveness to treat tinnitus (info collected from this review paper).

For a more comprehensive list going over 17 drugs, click here.

Drug	Research That Supports	Research That Disputes	Conclusion
Benzodiazepines (alprazolam, diazepam, clonazepam)	#1, #2, #3, #4	#1, #2, #3	Caution due to addiction and may worsen tinnitus if stopped.
Antidepressants (nortriptyline, amitriptyline, trimipramine, sertraline, paroxetine)	#1, #2, #3, #4, #5	#1, #2, #3, #4, #5, #6	TCA may benefit only in patients with depression symptoms
Anticonvulsants (carbamazepine, gabapentin, vigabatrin, tiagabine)	#1, #2, #3, #4, #5, #6, #7, #8, #9	#1, #2, #3, #4, #5, #6, #7	Mixed results
Antiglutamatergics (caroverine, memantine, acamprosate)	#1, #2, #3, #4	#1, #2, #3, #4	No conclusion.
(Anti)Dopaminergics (sulpiride, piribedil)	#1, #2, #3	#1	Studies are weak.
Ginkgo Biloba	#1, #2	#1, #2, #3	Not effective.
Melatonin	#1, #2, #3	#1	Potentially helpful.

For more meds, click here.

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Can Melatonin Stop Ringing in the Ears (Tinnitus)?

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

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

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

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

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

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

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What are the Most Common Severe Drug-Induced Anaphylaxis?

Image by James Heilman, MD from Wikipedia

Interesting paper came out listing the most common severe drug-induced anaphylaxis. From a database of 333 patients who suffered from anaphylaxis,

• Anaphylactic shock (76.6%)
• Severe systemic reactions (10.5%)
• Acute laryngeal edema (9%)
• Severe bronchospasm (2.1%)
• Fatal in 6 cases (1.8%)

There were 270 cases (81.1%) of ambulatory anaphylaxis. Sixty-three cases (18.9%) occurred during anesthesia.

84 drugs were identified as being responsible for these cases of anaphylaxis.

• Antibiotics (49.6%)
• Muscle relaxants, latex and anesthetics (15%)
• NSAIDS (10.2%)
• Tylenol (3.9%)
• Iodinated or magnetic resonance imaging contrast media (4.2%)
• Allergy shots and vaccines (3.9%)
• Other drugs (13%)

Among antibiotics, amoxicillin (97 cases), other penicillins (four cases), cephalosporins (41 cases), quinolones (15 cases), and pristinamycin (seven cases) were the most common.

Reference:
Severe drug-induced anaphylaxis: analysis of 333 cases recorded by the Allergy Vigilance Network from 2002 to 2010. Allergy. 2013 Jun 6. doi: 10.1111/all.12168. [Epub ahead of print]

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I Am Taking a Reflux Medication & My Symptoms are Not Improving!

On an almost daily basis, I get an email from somebody with the same exact question or near-variation:

"Dear Dr. Chang,  

I have been taking a [insert reflux medication] for [insert number] weeks and I see no improvement in my [insert symptom]. What should I do?"

The reflux medication typically mentioned include nexium, dexilant, prilosec, prevacid, protonix, or some other proton pump inhibitor.

The most common symptoms typically mentioned include:

• Globus

• Phlegmy throat

• Throat clearing

• Cough

What Should You Do?

Well, assuming you never have taken a reflux medication in the past, proton pump inhibitors work extremely well in suppressing acid; even at low dosages.

As such, if you indeed have been taking a proton pump inhibitor for at least 3 weeks and see no improvement in symptoms, one must consider the possibility that acid reflux may not be the problem.

I rarely if ever just increase the dosage of a reflux medication in somebody who previously was never on one. Increasing the medication dosage MIGHT be considered only if somebody has already been on reflux medication for some time baseline.

So if acid reflux is not the problem, what may be causing above-mentioned symptoms?

There could be an anatomic problem...

• Zenker's diverticulum

• Cricopharyngeal spasms/hypertrophy

• Esophageal dysmotility

• Esophageal web or stricture

etc

Essentially, there's something wrong with your swallowing tube such that things back up into the throat causing symptoms. Think of it like a clogged sink... the pipe (esophagus) has a physical issue that causes water to backup into the sink (throat).

Workup to evaluate these possibilities include trans-nasal endoscopy, EGD, barium swallow, and/or manometry.

It could still be a reflux problem...

Just maybe, it's NOT acid reflux however, but mucus or non-acid reflux. Standard reflux medications do not work for non-acid reflux. The best way to evaluate this possibility is to undergo a 24 hour multichannel pH and impedance testing. Of note, BRAVO or pH monitoring alone is NOT good enough. Impedance must be measured as well as having sensors near the throat level.

In the meantime, one could also try avoiding eating anything that contains dairy, egg, and wheat (flour). These foods are considered highly mucogenic (most people can relate to the fact that when drinking too much milk, the mouth and throat can get phlegmy).

Is it allergy?

Post-nasal drainage can sometimes lead to throat symptoms. If you do have some sino-nasal allergies, try taking a steroid nasal spray and an anti-histamine nasal spray. Oral medications typically do not work as well.

There's also a condition known a eosinophilic esophagitis that can cause throat symptoms. The only way to diagnose this condition is an upper endoscopy (EGD) with biopsies of the esophageal lining.

Summary

Now this article just scratches the surface in FULLY addressing an individual patient's throat symptoms. After all, not everybody is exactly the same. For a more in-depth evaluation and individualized treatment of YOUR throat issues, please make an appointment with your ENT.

Here are some related articles that may be helpful:

• Globus

• Phlegmy throat

• Throat clearing

• Cough

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What to Do and Care After Vocal Cord Surgery

When surgery is performed on the vocal cords, there are some very specific after-care that is required to allow for optimal healing. In order to understand the "why" such post-operative care is required, one must first understand how the vocal cords normally work. If you already know, just skip down to the bottom.

The vocal cords are arranged in the shape of a "V". When breathing, the vocal cords are open to allow air to pass through and down into the windpipe. When talking, the vocal cords come together and vibrate. Click here to watch a video.

When surgery is performed on the vocal cords, one is actually cutting into the actual organ that allows one to talk and make other noises.


As such, the care required after vocal cord surgery requires the elimination of any activity that may lead to damage to the surgery site and allow proper and safe healing.

I should mention that the following instructions are our opinion. Other laryngologists may have different after-care instructions.

Strict Voice Rest! 

This means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the surgery site. I even instruct patients to avoid even mouthing words as it causes the brain to "think" you are talking even if you are not. Essentially, the lips should always remain closed except when eating/drinking.

The analogy would be if you have surgery done on the heel of your foot, you should not walk or put any weight on the heel, otherwise risk improper healing.

Strict voice rest typically lasts for 1-2 weeks after surgery.

No Coughing or Throat-Clearing

Just as with talking, coughing and throat-clearing also causes the vocal cords to come together and should be avoided if at all possible. Narcotic strength cough-suppressants (ie, hycodan) are often prescribed to help suppress the urge to cough.

Take Reflux Medications

Reflux medications should be taken both before and after surgery to prevent any possibility of acid damage to the surgery site. Such medications should be taken EVEN IF you do not have any symptoms of acid reflux. I typically recommend patients to start such medications one week before surgery and to continue for as long as 3 months after surgery.

Voice Therapy

Voice therapy is recommended before surgery so that patients will understand what and how they are supposed to talk once cleared to do so after surgery. It's much easier to answer questions and practice proper talking technique before surgery rather than after surgery when you are on strict voice rest!

The rationale for voice therapy is to prevent continued phono-trauma to a freshly healing surgery site on the vocal cord. Often, if improper talking technique persists after surgery, the surgery site becomes damaged again or heals with abnormal scar tissue leading to the possibility of needing surgery again.

Voice therapy minimizes the likelihood of needing repeat vocal cord surgery in the future!

Restricted Voice Rest

Once the period of strict voice rest ends, the patient is slowly allowed to talk under voice therapy guidance. From this point forward over the next 4-6 months, the patient is under restricted voice rest.

Restricted voice rest is a fairly broad phrase, but essentially means to:

• NEVER abuse the voice (ie, yelling, screaming, loud talking, etc)
• Talk only when you must (ie, no social talking)

This period of restricted voice rest is important because it allows time for the new vocal cord tissue that has developed to not only heal, but also strengthen. Abusing the voice may tear the freshly healed surgery site which must be avoided at all costs!

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Does Acupuncture Help With Allergies?

Image from Acupuncture For All

According to one study, it does... Performed by researchers in China and Korea, they divided 238 patients suffering from allergies into 3 groups: active acupuncture, sham acupuncture, and no treatment.

They found that acupuncture, even if it was sham, did help significantly with nasal allergies. However, only active acupuncture helped with not just nasal allergies but also allergy symptoms beyond the nose!

Of course, when considering all the other research performed on this subject, the results are a bit more mixed with some reporting no improvement with acupuncture.

For those interested in avoiding medications and allergy shots, it may be something to consider trying. It can't hurt and it can potentially even help.

References:
A multicenter, randomized, controlled trial testing the effects of acupuncture on allergic rhinitis. European Journal of Allergy and Clinical Immunology. Volume 68, Issue 3, pages 365–374, March 2013

Acupuncture for allergic rhinitis: a systematic review. Annals of Allergy, Asthma & Immunology Volume 102, Issue 4 , Pages 269-279, April 2009

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New Webpage on Reflux Medications

Given the degree of ignorance I see about reflux medications, how they work, and limitations of such medications, our office has written up a new webpage that goes over the different categories of reflux medications with an explanation of how such medications help to address acid reflux. Such medications include:

• Antacids
• H2 Blockers
• Proton pump inhibitors
• Barriers
• Combinations

What is also explained are the limitations of such medications when it comes to disorders like non-acid reflux.

Check it out here!

Some example reflux medications that can be purchased over-the-counter:

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How Can Nasal Obstruction Cause Post-Nasal Drainage?

Before talking about the nose, consider the way some home humidifiers work. There is a sponge, water supply, and airflow. Humidification occurs by having a fan blow air though the sponge that is soaked by a constant water supply. As the air passes through the wet sponge, evaporation occurs resulting in air humidification.

Well, the same thing occurs inside the nose. In a normal nose, about one liter of moisture is produced by the nasal mucosa every day (water supply). This nasal moisture production is what allows the air to be humidified as a person breathes (the fan) through the nose.

However, when the nose is obstructed preventing a steady airflow, there is a corresponding reduction in evaporation allowing for more moisture to be present inside the nose. With increased moisture, it may lead to the perception of increased post-nasal drainage.

So, how can post-nasal drainage be corrected in this situation?

Well, one can try to decrease nasal moisture production using medications like decongestants, anti-histamines, and/or nasal sprays. Or, one can try to alleviate the nasal obstruction to increase nasal airflow leading to increased evaporation thereby reducing the amount "drainage" (which actually is normal "water supply").

Alleviating nasal obstruction can also occur with decongestant, allergy, and nasal spray medications, but if there's not much improvement, one can consider surgical options if there are anatomic factors present.

Such intra-nasal anatomic obstructions include deviated septum, turbinate hypertrophy, adenoid hypertrophy, nasal polyps, etc.

There is a specific surgical procedure that can address each of these issues if present.

Of course, nasal obstruction does not automatically lead to post-nasal drainage. But it is only one of many other factors that may be present that can lead to this complaint.

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New Anti-Meth Sudafed (Pseudoephedrine)

As anybody who suffers from nasal congestion and runny nose knows, the nasal decongestant medication Sudafed can only be obtained from behind the pharmacy counter after showing identification because Sudafed can be made into meth.

This restriction applies to not just sudafed, but any medication containing the active ingredient "pseudoephedrine" which is a precursor for most meth recipes.

Well, coming soon to a drugstore near you, a new nasal decongestant has been produced that can NOT be made into meth called Zephrex-D. It still contains the active ingredient pseudoephedrine.

Made by Westport Pharmaceuticals, Zephrex-D comes in a "tamper-resistant formulation that locks this active ingredient chemically so that it cannot be used in illicit methods of methamphetamine manufacture," but maintains full clinical benefits for patients.

This drug (30mg tablets) is currently available at several national and local drug retailers throughout Missouri with nationwide deployment in 2013. Combination drugs including Zephrex-D will also become available within the next year.

Obviously, this has the potential to ease purchase restrictions for nasal decongestant drugs.

Source:
Westport Pharmaceuticals launches Zephrex-D, a tamper-resistant PSE formulation. DrugStoreNews 12/4/12

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Nasal Spray to Help Motion Sickness

Over the years, many NASA initiated research has resulted in new products and treatments geared towards advancing the space-program, but has eventually led to benefits to us earth-bound mortals including:

• the computer mouse
• telemetry
• weather satellites
• cochlear implant

NASA publication Spinoff highlights these research innovations that has benefitted the general public.

Well, you can now add dizziness treatment to another NASA innovation to help motion sickness.

Born of the need to quickly treat motion sickness which astronauts can suffer from up in space (imagine vomiting in zero-gravity), NASA developed a super fast-acting nasal spray to eliminate dizziness.

Called INSCOP, it is essentially scopolamine which already is found in injectable, patch, and pill form. But, this new NASA nasal spray formulation acts faster and more reliably than the oral tablet.

Under a joint agreement with pharmaceutical company Epiomed Therapeutics, it will hopefully soon become available to the public.

This is not the only NASA dizzy research either...

Earlier, they also figured out what movements triggered the worst motion sickness as well as what at-the-time currently available medication combination(s) worked best to combat it. Read more.

Source:

Pharmaceutical Product Development: Intranasal Scopolamine Metered Dose. NASA 2012

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