Flushing Ears with Cold Water Can Treat Somatoparaphrenia

Somatoparaphrenia is a condition whereby a person denies that a limb or an entire side of the body belongs to them, even if provided with irrefutable proof. This condition usually is accompanied by left-sided paralysis and anosognosia (denial or lack of awareness) of the paralysis often due to a parietal stroke.

What is interesting is that flushing the left ear with cold water (caloric vestibular stimulation) can temporarily treat/resolve somatoparaphrenia. Specifically, the protocol is flushing into the left ear canal 60cc of cold water (20 degrees Celsius) for one minute. During the stimulation, the patient is laid down and head tilted forward 30 degrees. If properly done, clear horizontal nystagmus with leftward slow phase can be seen for about 3 minutes.

Normally, flushing the ear in this manner is routinely performed as part of balance testing (ENG) to determine whether a person's dizziness is due to an inner ear problem or not.

In any case, how does vestibular stimulation help with somatoparaphrenia? I don't quite understand it myself, but according to one reference:

"vestibular input takes part in building up and updating the representation of egocentric space." [link]

Whatever that means...

References:
Can vestibular caloric stimulation be used to treat apotemnophilia? Med Hypotheses. 2007;69(2):250-2. Epub 2007 Feb 9.

Partial Remission of Hemiplegia and Somatoparaphrenia Through Vestibular Stimulation in a Case of Unilateral Neglect. Cortex Volume 28, Issue 2, June 1992, Pages 203–208

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Lawsuit Alleges Transcranial Magnetic Stimulation Paralyzed Patient's Face

University of Iowa Hospitals and Clinics is being sued by a patient who underwent an experimental transcranial magnetic stimulation (TMS) therapy which allegedly caused a facial paralysis which was than negligently treated. The trial is scheduled for Oct 13, 2013. [link]

Briefly, the patient in 2008 underwent experimental TMS to treat constipation and incontinence. TMS is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain using pulses of electromagnetic induction through the scalp. Researchers were hoping to learn more about the nerve connections between the brain and the rectum and how biofeedback training may affect them.

Unfortunately, the patient contended that the treatment gave her a severe headache and by the next day, a facial paralysis. She went to the emergency room and was given an anti-viral antibiotic to take, but no steroids.

Her facial paralysis worsened and she ultimately underwent facial nerve decompression surgery 12 days later which helped with her taste loss, but not her facial paralysis.

The lawsuit contends that:
1) The patient was not informed of the risks of TMS as it relates to facial paralysis
2) Steroids should have been prescribed and the patient immediately referred for nerve decompression surgery

Does TMS carry a risk of facial paralysis?

I honestly do not know much about TMS, but I can certainly state that I've never heard of TMS causing or carrying a risk of facial paralysis. In fact, TMS is used to evaluate facial paralysis by being able to assess the integrity of the facial nerve as well as predict its potential for regeneration after injury [link].

Hypothetically, could TMS cause cranial nerve injury and swelling leading to facial paralysis??? I suppose so, but will defer to people more knowledgeable than I to answer this question.

The timing is certainly suspicious in this case with paralysis occurring within 24 hours of TMS.

But if it can, it certainly is worth a published case report.

Even more importantly, patients who are currently undergoing TMS to evaluate their facial paralysis now need to be warned of the risk that the TMS test itself may make their facial paralysis even worse!!!

What about steroids?

Although some may consider medical management of facial paralysis still controversial, I personally feel that steroids SHOULD have been immediately prescribed without any anti-virals.

The current preponderance of evidence is that anti-virals make absolutely no difference in the treatment of facial paralysis... even when the facial paralysis is due to a virus [link].  I personally do not prescribe anti-virals for patients with facial paralysis regardless of etiology.

What about steroids? Moderate quality evidence show that steroids were significantly more likely than anti-virals to produce complete recovery [link #1; link #2]. I always prescribe steroids to treat facial paralysis.

What about facial nerve decompression surgery?

Now surgical decompression of the facial nerve can be considered controversial. Decompression entails removing part of the skull, moving the brain to one side slightly, and removing all bone covering the facial nerve.

The theory being that if the facial nerve is swollen as it courses through the skull from the brain to the face, strangulation followed by nerve death occurs. To use an analogy, if a finger starts to swell from trauma, a ring being worn may prevent blood flow and eventually cause strangulation of the finger. Treatment to reestablish finger blood flow is to cut the ring off. Facial nerve decompression is akin to cutting a ring off to save a swollen finger.

Typically, surgical decompression of the facial nerve is pursued when facial paralysis occurs in the context of physical head trauma (ie, car accident). In the absence of preceding physical trauma, it would be the rare surgeon who would recommend surgical facial nerve decompression.

Obviously, the main question related to this lawsuit is whether nerve swelling occurred due to the TMS therapy necessitating surgical decompression. Presumably, an MRI scan was performed showing a highly inflamed and swollen facial nerve as well as significant nerve degeneration on ENoG testing. Supporting evidence (not mentioned in media reports) would be if profound hearing loss also occurred. Why? Because the facial nerve and hearing nerve both go through the same boney canal.

Malpractice?

TMS is not known to cause facial paralysis. As such, in a normal situation, this particular risk would not be expected to be included in the consent (as it has not been previously described). However, given this therapy was provided in the context of an experimental research protocol, the consent process is much more rigorous with much higher standards. With such higher standards, should risks never before seen be also included in the consent, especially if TMS has been performed many times for other purposes??? I don't know...

Certainly, my feeling as an ENT specialist is that steroids should have been given and not an anti-viral medication. Whether ENT specialist standards should apply to emergency room staff is harder to say.

Without more information, negligence as it pertains to delayed surgical facial nerve decompression is also hard to say.

Ultimately, we shall see what the court decides.


Source:
Lawsuit alleges Iowa doctors left patient's face paralyzed. Associated Press 8/13/13

References:
Transcranial magnetic therapy. Wikipedia

Electrical and transcranial magnetic stimulation of the facial nerve: diagnostic relevance in acute isolated facial nerve palsy. Eur Neurol. 2012;68(5):304-9. doi: 10.1159/000341624.

Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006851. doi: 10.1002/14651858.CD006851.pub2.

Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001869. doi: 10.1002/14651858.CD001869.pub4.

Do either corticosteroids or antiviral agents reduce the risk of long-term facial paresis in patients with new-onset Bell's palsy? J Emerg Med. 2010 May;38(4):518-23. doi: 10.1016/j.jemermed.2009.08.016. Epub 2009 Oct 21.

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Malpractice Lawsuit for Nerve Damage Sustained After Neck Cyst Excision

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

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

So what probably happened?

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

Image Modified from Wikipedia

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

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

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

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

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

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

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Singer Carnie Phillips Suffered from Bell's Palsy

Image by InSapphoWeTrust from Wikipedia

In March 2013, singer Carnie Phillips (of the Wilson Phillips) revealed that she suffered from a sudden left facial paralysis due to a condition known as Bell's Palsy.

Through a series of tweets, it was apparent that it came fast and started improving within a week.

Thought to be due to a viral infection of the facial nerve, it is commonly treated with prednisone with or without an anti-viral antibiotic (ie, valtrex). For most patients, full recovery occurs, but in some, normal facial movement is never regained.

For more info on facial paralysis, click here.

Source:
Carnie Wilson of Wilson Phillips reveals she has Bell's palsy. LA Times 3/19/13

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Google CEO Larry Page Suffers from Bilateral Vocal Cord Paralysis

Image by Marcin Mycielski from Wikipedia

Over the past year, there has been concern over the health of Google CEO Larry Page after missing a few important meetings and having a hoarse voice that is unusually soft and prolonged.

Apparently, it's because he suffers from bilateral vocal cord paralysis. [link]

He initially suffered from a unilateral vocal cord paralysis at the age of 14 years old. At that time, his left vocal cord became paralyzed after a viral URI. Beyond a viral infection of the nerve, no other specific cause was identified.

Than during the summer of 2012, he suffered another viral URI followed by the unfortunate paralysis of his opposite right side resulting in bilateral vocal cord paralysis. It is EXTREMELY rare that both vocal cords become paralyzed in this manner in the same individual.

With bilateral vocal cord paralysis, he now suffers from an even weaker voice along with reduced ability to exercise.

Now, why is that?

First, a basic anatomy lesson...

Briefly, the voicebox is composed of a right and left vocal cord that is attached on one end, much like a "V". When the vocal cords are apart, air moves in between the vocal cords into your windpipe that allows one to breathe. When a person wants to sing/talk or say "eee," the vocal cords come together and vibrate very quickly creating the voice. The vocal cords and their movement can be visualized on fiberoptic laryngoscopy (watch movie of this exam).

A "paralyzed" vocal cord is when one or both of the vocal cords do not move resulting in voice changes as well as difficulty breathing easily. Specifically, when both vocal cords are paralyzed, the vocal cords do not come together as tightly resulting in a weaker than normal voice. At the same time, given the vocal cords are not able to move apart, there is a smaller than normal opening thru which to breath resulting in shortness of breath, especially with exercise. Here are two video examples of when both vocal cords are paralyzed. Compare this to a normal example. Note the difference in how wide the vocal cords move apart.

Why would the vocal cords both become paralyzed in the first place? The MOST common cause of bilateral vocal cord paralysis is surgery, especially thyroidectomy. Other less common causes include neck trauma, traumatic intubation, and cancer (especially lung or thyroid cancer). Regardless of cause, if the paralysis is permanent, the options are quite limited and require the sacrifice of either breathing or talking. You can't have both good breathing and a good voice. Please note that a patient may have bilateral vocal cord fixation and NOT paralysis which is treated completely differently.

Why can't you have both good breathing and a good voice when both vocal cords are paralyzed? Because in order to have a good voice, the vocal cords need to come tightly together... but given they are paralyzed, they will not come together to allow for a good strong voice.

In order to have good breathing, the vocal cords need to be widely apart... but given they are paralyzed, they will not be able to move apart to allow for good breathing. Which in essence means you can't have both good breathing and strong voice.

One or the other needs to be sacrificed... or a compromise of both is required resulting in so-so breathing and a so-so vocal quality... which seems to be the option Larry Page has gone with.

Well... there is ONE option in order to have good breathing and a good voice... and that's a tracheostomy with a one-way valve. The vocal cords could be fixated together to allow for good voice. To allow for good breathing, airway is achieved through the tracheostomy (hole in the neck that goes directly into the airway). A one-way valve is placed with the tracheostomy such that when breathing in, the valve opens up to allow air passage thru the tracheostomy, but when breathing out, the valve will close to force air up thru the vocal cords to allow for talking.

BUT, if tracheostomy is out-of-the-question.. than a patient with bilateral vocal cord paralysis is stuck with a compromise between the voice and breathing.

To explain this compromise of voice and breathing further, normally, when the vocal cords are both moving fine, the voice is at 100% and breathing is at 100%. However, with bilateral paralysis, the voice and breathing are now linked to each other and collectively can not exceed 100%. As such, a patient with new onset bilateral vocal cord paralysis may start with a 40% of normal vocal quality and 60% of normal breathing ability for a total of 100%. If a patient desires to improve the vocal quality from 40% to 100% (an improvement of 60%), then the breathing WILL correspondingly decrease 60% down to 0% (or vice-versa). The total percentage of vocal and breathing quality can never be more than 100%. If a patient wants the best possibly voice and breathing, than the compromise would be to increase the vocal quality 10% from 40% to 50%, but understanding that this 10% improvement in vocal quality WILL mean a corresponding 10% decrease in breathing ability from 60% to 50%. This 10% change means that in the end, the voice and breathing would both end up at 50% of normal.

Wondering what kind of workup is required as well as surgery to adjust the voice when both vocal cords are paralyzed? Click here to read more...

Source:
Larry Page Explains Why He Lost His Voice. Businessweek 5/14/13

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New Video on Thyroid Surgery and Its Complications

A new video has been created regarding how the thyroid gland is removed along with potential complications that may occur with this surgical procedure.

This video creation was a collaborative effort between myself and Dr. Henson, the general surgeon who performed the actual operation portrayed in the video. Assistance by Robin Earl and the surgical staff at Fauquier Hospital were invaluable as well.

Read more about the surgery here or watch the video!

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Stroke vs Non-Stroke Facial Paralysis

Image by Patrick Lynch from Wikipedia

A recent blog post about a ER doctor who was found negligent for not pursuing a stroke workup for an isolated facial paralysis did bring up an interesting medical phenomenon about what differentiates a facial paralysis due to stroke vs facial paralysis due to facial nerve inflammation.

To begin, the facial nerve innervates the entire half of the face. The nerve itself exits from the skull behind the ear and sends finger-like branches to all the muscles of the face (nerve is yellow).

So if something happens to the nerve, the entire face including forehead, around the eye, cheek, and lip would become paralyzed.

HOWEVER, if a stroke occurs that knocks out the part of the brain that governs facial movement on just one side, the patient will have facial paralysis only on the lower half of the face. The forehead on both sides will still move just fine!

Why is that?

At the brain level, the facial nerve branch that governs forehead movement is innervated by BOTH sides of the brain. However, the facial nerve branches for the remainder (lower part) of the face is innervated by only ONE side of the brain.

As such, if complete facial paralysis including forehead is present, it is NOT due to a stroke or any other brain problem. This condition is called Bell's Palsy.

If the forehead moves fine, but the rest of the face is paralyzed on one side, than it may be due to a stroke or some other brain-level problem. Of course, with a stroke, one would see not only facial paralysis with forehead sparing, but also paralysis involving other parts of the body (which makes it obvious).

Image by Patrick Lynch from Wikipedia

Take a look at the picture to the left illustrating the facial nerve branches. Nerve branches in solid yellow or orange come from either the right or left side of the brain. Nerve branches in yellow/orange hashes come from both sides of the brain.

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Breathing or Voice... You Can Only Have One...

Sounds like a choice taken out of a morbid horror movie...

"You can ONLY have one... Your voice or your breath..."

The victim than loses one or the other after making a choice getting either the tongue or head cut off with a knife.

But patients with vocal cord paralysis on both sides are essentially faced with this very question.

Normally, the vocal cords (TVC in picture below) found in the voicebox move to accommodate talking or breathing.

When the vocal cords are apart, breathing occurs allowing air to pass unimpeded between the vocal cords and down into the lungs. However, with talking, the vocal cords come together tightly and vibrate creating voice. Watch a movie.

However, when both vocal cords become paralyzed, they neither move apart to help with breathing nor come together to assist with talking. Indeed, the voice and breathing BOTH stink.

It is in just this situation that the choice of breathing or voice becomes important because a patient can not have both. Improving one will sacrifice the other.

To explain this connection of voice and breathing further, normally, when the vocal cords are both moving fine, the voice is at 100% and breathing is at 100%. However, with bilateral paralysis, the voice and breathing are now linked to each other and collectively can not exceed 100%. As such, a patient with new onset bilateral vocal cord paralysis may start with a 40% of normal vocal quality and 60% of normal breathing ability for a total of 100%.

Using this scenario as a starting point where vocal quality is at 40% and breathing is at 60% of normal...

If a patient chooses to improve the vocal quality from 40% to 100% (an improvement of 60%), then breathing WILL correspondingly decrease 60% down to 0%... and potentially die given the ability to breathe is lost. Why? Because the vocal cords can be surgically forced together to allow for voice... but given the vocal cords are paralyzed, they can not move back apart to allow for breathing.


If a patient chooses to improve breathing quality from 60% to 100% (an improvement of 40%),  then the vocal quality WILL correspondingly decrease 40% down to 0%... and lose the ability to talk. Why? Because the vocal cords can be surgically forced apart to allow for breathing... but given the vocal cords are paralyzed, they can not move back together to allow for vocal cord vibration.


The total percentage of vocal and breathing quality can never be more than 100%. If a patient wants the best possibly voice and breathing, than a compromise would be to increase the vocal quality 10% from 40% to 50%, but understanding that this 10% improvement in vocal quality WILL mean a corresponding 10% decrease in breathing ability from 60% to 50%. This 10% change means that in the end, the voice and breathing would both end up at 50% of normal.

In most cases of bilateral vocal cord paralysis, it is the reduced breathing and shortness of breath that bothers people the most. The voice isn't good, but when given the choice, most people choose to try and improve their breathing ability understanding their voice may further deteriorate.

To read more about such treatment options, click here.

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Can What Makes a Lion Roar Help Human With a Weak Voice?

Researchers in Iowa have discovered what makes a lion or tiger roar so effectively. Apparently, there is a layer of fat within large feline vocal cords that makes the vocal cords especially prone to vibrate easily with minimal exhalation effort.

What import does this have to humans?

Well, there are patients who have a very weak voice due to vocal cord atrophy as well as vocal cord paralysis. Standard interventions include voice therapy as well as surgical procedures using an implant or injectable material in order to "bulk" up the vocal cord.

In fact... one such injectable material that has been used to inject into vocal cords is fat, typically taken from the belly of the patient!

Two points to keep in mind however...

Just like in lions and tigers, it DOES improve the vocal strength and volume to a patient who previously had a weak voice, may now have a much stronger voice after the procedure.

However, the second point is that by making the vocal cord "bulkier" you are making it thicker which can decrease the vocal pitch... just like a violin string where the thicker the string, the lower the pitch.

On another related note... human infants have fat within their vocal cords... that may be why something so small with tiny lungs can produce such a terrific loud cry!

Read a story in the NYT regarding this research here.

Reference:
Adapted to Roar: Functional Morphology of Tiger and Lion Vocal Folds. PLoS ONE 6(11): e27029. doi:10.1371/journal.pone.0027029

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New Webpage on Thyroid Mass (Evaluation and Management)

A new webpage has been uploaded to our practice website describing the evaluation and management of a thyroid mass. Surgical removal is discussed along with risks involved.

Click here to read more!

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