Upper Lip Tie and Posterior Tongue Tie Treatment Without Sedation

It seems that in the past few years, upper lip tie and posterior "hidden" tongue tie has become increasingly recognized as factors affecting breast-feeding which correspondingly has led to higher numbers of referrals for evaluation and treatment.

Prior to 2011, I probably received only one or two consultations a year to evaluate these two conditions. Ever since than, it seems more and more infants are being diagnosed with these two conditions, especially by lactation consultants.

Anterior tongue tie and upper lip tie have historically been easily treated in the clinic under local anesthesia using common tools any ENT has.

Posterior tongue tie, given its relative rarity (at least from a referral basis), has historically been treated under sedation in the operating room given the need for specialized equipment and more aggressive surgical dissection.

However, given the increasing number of referrals for posterior tongue tie evaluation, specialized instruments needed to treat this condition have been purchased in order to address this condition without the need for sedation (assuming an infant). Young children with teeth may still need to be sedated.

Although laser is commonly used to treat this condition in the dental world, ENTs rely more on scissors and fine electro-cautery/coblation instruments which is what I use.

Read more about these conditions:

Anterior Tongue Tie
Posterior Tongue Tie
Upper Lip Tie

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Man Sues ENT for Wrongful Tracheostomy

Image from ParaMedicine101

In December 2012, a West Virginia man suffered angioedema causing tongue swelling due to a not uncommon reaction from lisinopril. Presumably due to airway concern from the tongue swelling, an urgent tracheostomy (cutting a hole in the throat) was performed.

The patient later filed suit against the ENT who performed the tracheostomy stating that it was unnecessary as the tongue swelling was getting better. [link]

Although a tracheostomy is not always performed for tongue swelling due to angioedema, it also is not unusual to do so, mainly because the alternative outcome is airway loss and death. It is a judgement call on the physicians who are caring for a patient with angioedema whether close monitoring alone is sufficient versus performing a tracheostomy. If the tongue swelling is large enough to cause some airway obstruction, no physician or ENT would ever question the need for a tracheostomy, regardless of whether the swelling "might" be getting better or not.

If one waited until the airway became critical before performing a tracheostomy, the risk of death and complications become MUCH larger. As such, a tracheostomy is performed well before there's any chance of airway loss. (Intubation is not recommended or at times even possible as the act of trying to intubate may trigger airway loss.)

Indeed, the patient who is suing the ENT may not be alive today to sue the ENT if it weren't for the tracheostomy. Instead, it would be the family who would be suing the ENT for wrongful death for NOT doing a tracheostomy.

Check out this lawsuit where an ENT did NOT perform a tracheostomy for airway swelling resulting in death. Here's another lawsuit for similar though under more convoluted circumstances.

Source:
Clay Co. man says doctors performed unnecessary tracheostomy. West Virginia Record. 1/29/14

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New Incisionless Device to Correct Reflux by Medigus

A new trans-oral incisionless device to surgically treat reflux was announced by Medigus, an Israeli company, called the "SRS system." It is a competitor to two other incisionless devices currently available: Stretta (Mederi Therapeutics) and Esophyx (Endogastric Solutions).

Common to all incisionless devices is the fact that the procedure is performed using an endoscope introduced through the mouth threaded down into the stomach. At this point, the technique used by the devices to tighten the valve separating the esophagus and stomach varies.

With Stretta (first on the market), radiofrequency energy is used to induce scarring of the valve causing it to constrict.

With Esophyx (next to market), a 270 degree 2-3cm fundoplication is performed by manipulating the esophago-gastric tissue in a rotating twisting manner and anchoring in place using 12 or more full-thickness polypropylene fasteners.

With SRS, the stomach is folded up against the esophagus and anchored in place using a few staplers. Watch the video below to see how this system works.

The technique that is best for a given patient will vary based on surgeon's comfort and experience with the device as well as unique patient variables. As such, no technique is perfect or applicable to everybody. Also, only time will tell if this or any other incisonless technique provides long-term reflux relief with minimal risk and side effects.

Ask your GI or general surgery specialist on what option is best for you.

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Surgeon's Point-of-View (POV) Video Recording

Learning how to video record vivid, stable, high-def, and focussed shots from my (surgeon's) point-of-view has not been an easy endeavor due to technology limitations, though things do appear to be slowly improving. There have been pros and cons with most video-recording systems to date which I have summarized below. The "perfect" video-recording system has yet to be developed which must include all these elements:

• Wearable on headlight or glasses
• Camera located between the eyes that is maneuverable to adjust recording angle
• Head-up view to see what is being recorded real-time
• Manual white balance adjustment

• Manual exposure adjustment (bright lights used in surgery often confuse auto-exposure settings which result in washed-out pictures)

• Auto-focussing with adjustable zoom

• VERY good image stabilization

• HD video-recording

General Problems with Head-Mounted Video Recordings

The problem with current head mounted video-recording systems including Google Glass are several-fold. First of all, no matter how good you think you are staying still, there are constant micro-motions/tremors which produce unusable erratic videos. This annoying camera movement becomes even more pronounced when using cameras with longer focal lengths which is why most head-mounted camera systems come with a fixed, wide-angle lens which unfortunately takes away from the narrow-angle, focussed shot a surgeon would like recorded.

Also, the smaller and lighter the camera, the more inferior the optics resulting in poor video quality (compared to high-resolution, 3CCD, HD recordings which is what the surgeon's want).

These short-comings are common with all head-mounted video-recording systems. Unfortunately, there are even more problems depending the camera.

Google Glass (or any eyeglass side-mounted camera)

Typically, when a surgeon operates, the surgical field (green) is a certain distance from the his/her face. When in a comfortable position, wearing any type of head-mounted camera system located on the side like Google Glass unfortunately ends up video-recording a point that is above and to the side (purple) of what is actually desired.

In order to compensate the vertical offset, either the surgeon has to flex the head more or move the eyeglass down towards the lip.

To adjust the horizontal offset, the surgeon would have to turn and move the head to one side such that the camera has a more direct line shot into the surgical field... but that would mean the surgeon would be operating off-centered, almost looking over one shoulder.

Although doable, this is far from perfect or comfortable.

Central Head-Mounted Video Camera Systems

There ARE video-recording cameras that contain a camera that can be placed centrally over the forehead or between the eyes including Luxtec and SurgeonCam which are mounted on the headlight and PivotHead glasses (among others) where the camera is built into the frame between the eyes.

The headlight mounted systems'  camera angle can be adjusted to provide a more precise POV recording, but the general disadvantages of body-worn cameras still apply with constant erratic motion and wide-angle shots that do not specifically focus in on the surgical field.

The PivotHead glasses do provide perfect central shots, but still suffer from a vertical offset (orange) which cannot be adjusted like the headlight mounted systems.

Overhead Mounted Camera Systems

For the same reason the best photos are obtained by cameras fixed to a tripod, the best videos are often obtained by cameras fixed into position by a stationary object.

One object cameras can be attached to are overhead fixtures.. specifically the operating room lights.

Such cameras are attached typically to the light-handle of such overhead operating room lights which are directed down into the surgical field. Such systems provide excellent focussed, stable, high-quality video-recordings with one BIG disadvantage. The surgeon's head keeps getting in the way.

Also, the light-handle is positioned for optimal lighting of the surgical field... not optimal framing for capturing good videos.

Bed-Mounted Camera Systems

Using a Thompson Laparoscopic Retractor System, the video camera can be attached to one of the articulating arms and adjusted sterilely as needed. Using this retractor system can allow the camera to be positioned independently of the overhead operating room lights and to be as close to the surgical field as necessary.

The video is limited by how good the camera is that is attached. The best one I've been able to find is the Sony HXR-MC1 which incorporates a large-sized lipstick camera that is attached to a controller where manual controls for focus, zoom, white balance, exposure, etc can be made. Other than the built-in LCD screen, there are included plugs (Component, RCA, and with adapter S-Video) that allow what the camera is recording to be thrown up onto a large screen.

Other wireless video lipstick cameras are now being produced, but lack manual controls to adjust zoom, white balance, and exposure. Some offer real-time video display so it may be just a matter of time before all other manual controls found with the Sony HXR-MC1 become more widely available.

The main disadvantage with this setup is that the setup itself can get in the way of the surgeon.

Conclusion

So there you have it... No perfect surgical POV video system yet... Maybe in the next few years if technology keeps moving the way it is.

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Should Risk of Death Always be Part of the Surgical Consent?

Ever since reports of alleged medical negligence came up in the case of 13 years old Jahi McMath who suffered cardiac arrest and subsequent brain death after a "routine" tonsillectomy that occurred Dec 9, 2013, the question has come up whether risk of death should become part of every single surgical procedure's informed consent no matter how rare that risk might be.

It also brings up the question whether patients would want to hear every single possible conceivable risk that may occur (which could ALWAYS include some infinitesimal risk of death) with even simple surgical procedure like ear tube placement for chronic ear infections.

[Disclaimer... I am not a lawyer and this is not legal advice.]

From the physician's perspective, Duke surgeons have thought about this quandary and here were their suggestions of what is considered "reasonable" when it comes to risk of death and the consent process:

• When the risk of death is so low as to be unexpected and highly improbable, including it as part of the consent may actually be misleading (may cause a patient not to pursue a needed surgical procedure due to unreasonable concern for a remote risk of death)
• When the risk of death is felt to be “high enough” to disclose, then this adverse outcome should be discussed among the risks, and the patient must be informed.
• How high should the risk of death be before one would want to include it as part of the consent process? This risk could be any chance at all to about 0.1% risk as a reasonable threshold.

From the patient's perspective, when it at least comes to anesthesia risks with children (which also has a remote risk of death), researchers were able to provide some numbers when it comes to consent:

• 87% of parents wanted to know the risk of death as a result of anesthesia. 13% did not.
• 68% of parents knew that risk of death was "extremely rare." 19% believed that risk of death occurs "once in a while," and 13% thought there was "no chance."
• 74% of parents wanted to know "all possible risks," 24% wanted to know only "those that are likely to occur," and 2% wanted to know only about those that would "result in significant injury."
• Mothers were more likely to want to hear all possible risks, whereas fathers were more likely to want to know only about those that are likely to occur.

Although media reports stated that Jahi underwent a "routine" tonsillectomy, that was actually not true. She underwent a UPPP surgery which is much more aggressive throat surgery than tonsillectomy alone. The reported risk of death with UPPP is around 0.2%. As such, disclosure of possible low risk of death would have been not unreasonable.

The risk of death for routine tonsillectomy is somewhere between 0.003% to 0.01%.

Just for comparison, the risk of dying from driving a car for over 50 years is 1.1% and annual risk of death from smoking 10 cigarettes per day is 0.5%. [Link] Note that these "mundane" risks of driving and smoking are higher than the risk of death associated with tonsillectomy or UPPP.

In the end, there is no set policy about when risk of death should be discussed. This disclosure has been left up to individual surgeons who use their professional judgement when that risk becomes large enough to merit discussion as part of the informed consent.

What do you think?


References:
Parental knowledge and attitudes toward discussing the risk of death from anesthesia. Anesth Analg. 1993 Aug;77(2):256-60.

Surgery and the D-Word: Approaching the Topic of Death and Dying with Surgical Patients. J Palliative Care Med 2:108. doi:10.4172/2165-7386.1000108

Risk perception and communication: recent developments and implications for anaesthesia. Anaesthesia 2001;56:745-55.

Risk language and dialects. BMJ 1997;315:939-42.

Safety of Adult Tonsillectomy: A Population-Level Analysis of 5968 Patients. JAMA Otolaryngol Head Neck Surg. 2014 Jan 30. doi: 10.1001/jamaoto.2013.6215.

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Normal Appearance After Turbinate Reduction

Normal mucosal blistering (turbinate reduction
done only on right side)

Often, patients become disturbed with the way the inside of their nose looks after a turbinate reduction to improve nasal breathing. However, many of the concerns are unfounded and the appearance though disturbing, is actually normal. It usually takes a FULL 2 weeks for the turbinate mucosa to heal to a more normal (and reduced) appearance. It is around 2 weeks that nasal breathing also markedly improves.

In any case, during the first week, white plaques that may appear on the turbinates (picture below) are actually scabs which when wet turn white. It should be wet (and white) due to the regular use of saline nasal spray and/or flushes along with normal nasal secretions.  The turbinate mucosa may also occasionally even blister (picture above/right) producing a pale appearance like the inside of a grape. These are pictures of what the inside of the nose may look like about 5-8 days after a coblation turbinate reduction.

Be assured that such appearances are NORMAL and will typically resolve to a more normal appearance 2 weeks after the procedure. At that time any residual scabbing is typically removed.

White eschar/plaques (normal).

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Lawsuit for Botched Laser Vocal Cord Surgery

In February 2012, an ENT surgeon removed vocal cord polyps using a laser while the patient was asleep with a Medtronic Laser-Shield II endotracheal tube. Unfortunately, the laser perforated the endotracheal tube, ignited the 100% oxygen being used at the time resulting in catastrophic burns to the patient. [link]

Subsequent lawsuit resulted in favor of the patient who received an award totaling $30 million on 12/5/13.

What Happened?

Even though an endotracheal tube meant for use with laser procedures was utilized, if this specially designed tube sustains enough damage from the laser, it will either perforate or heat to a high enough temperature to ignite. Furthermore, 100% oxygen was administered by the anesthesiologist which just added gasoline to the flame.

Ideally, in such laser procedures, meticulous surgical technique is still required and care taken to avoid damaging the endotracheal tube, even if a "laser-safe" tube is used. The "weak" part of any laser-safe tube is the cuff that is inflated to make a tight seal between the trachea and the tube itself. As such, the cuff material is necessarily thin. Saline-soaked pledgets placed immediately above the cuff helps protect the cuff as well as use of a tube with two cuffs (in case one fails). Also, room air should have been administered to the patient in the event the tube fails in order to minimize oxygen in the area... and the patient placed temporarily on apnea whenever the laser is turned on.

The risk of fire among other reasons are why many ENT surgeons (myself included), have stopped using lasers for procedures done in the mouth and airway.

With vocal cord procedures, I still utilize cold steel techniques which has a zero risk of airway fire.

Sources:
Botched surgery will cost hospital. The Wenatchee World. 12/6/13.

Medtronic slips $18M verdict in surgical fire case. MassDevice. 12/10/13

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Tracheostomy Fire During Surgery Burning Patient

Image from Wikipedia

In early 2012, a surgeon was performing a trach (breathing hole in the neck) when the oxygen used during the procedure caught fire severely burning the patient. Apparently, the surgeon used an electrocautery device which most likely emitted a spark igniting the oxygen being given to the patient leading to the fire. [link]

What happened?

Tracheostomy procedures are performed typically in very sick patients who have been intubated for a prolonged period of time. Often, such patients require higher concentrations of oxygen than normal in order to maintain oxygen levels in the body.

Problem in this scenario is that higher concentrations of oxygen also mean a higher risk of accidental fire when using instruments that help stop bleeding like an electrocautery device.

During a tracheostomy, an opening is created in the windpipe (watch video below). This allows oxygen that is being given to the patient to leak out into the surgical field. If electrocautery is used in this oxygen rich environment, any spark from an electrocautery device can lead to ignition and a flash fire.

Typically, in order to minimize this risk of fire, the surgeon should avoid using any electrical instruments in the surgical field that may create a spark after entering into the airway. Cutting into the airway would allow oxygen to escape into the surgical field. That usually means meticulous surgical technique and controlling all bleeding BEFORE cutting into the airway. If possible, reducing the oxygen given to the patient as much as possible is also beneficial.

Nitrous oxide should be avoided as an anesthetic agent as it is also ignitable like oxygen.

If electocautery use is unavoidable after the airway is surgically entered, the endotracheal tube cuff should re-inflated and advanced past the tracheostomy incision. Vacuum suction should be applied to evacuate as much oxygen from the surgical field and if possible, a period of apnea while cautery is applied.


Source:
Revealed: The chief of surgery who set patient on fire when his electronic scalpel caused 'EXPLOSION' Mail Online. 5/6/12

References:
Airway fire during tracheostomy: prevention strategies for surgeons and anesthetists. Ann R Coll Surg Engl. 2001 November; 83(6): 376–380.

Fatal inhalation injury caused by airway fire during tracheostomy. Acta Anaesthesiol Scand. 2007 Apr;51(4):509-13.

Tracheostomal fire during an elective tracheostomy. Chang Gung Med J. 2005 Mar;28(3):186-90.

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Actor Zac Efron Broke His Jaw

Image by Liam Mendes from Wikipedia

This past weekend, actor Zac Efron slipped in a puddle of water outside his home and fell resulting in a severe facial cut as well as a broken jaw. [link]

Unlike most facial fractures that do NOT require any surgical intervention, most jaw fractures do need to be surgically repaired and typically entail wiring the jaw shut. Often, a metal plate with screws will be utilized to stabilize the fracture as well.

The reason the jaw is wired shut is so that as the broken bone heals, it heals in such a way that the way the teeth comes together is normal (in essence, the teeth act as the cast for the jaw fracture). Of course, eating is limited to liquid diet and dental care is important as brushing the teeth thoroughly will be impossible.

The wires holding the jaw shut can be removed after a few weeks, but exact duration depends on the fracture location and severity.

Source:
Zac Efron broke his jaw this weekend. CNN 11/13/13

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Submental Intubation [video]

Holy moly... Never realized submental intubation was actually a procedure that really is performed. Check out this video (or watch below) showing a submental intubation being performed.

First, an incision is created right below the jawline slightly off from midline. Dissection is bluntly carried right to the floor of the mouth under the tongue. The endotracheal tube is than grasped and pulled through this opening resulting in a submental intubation.

Seems quick and elegant with minimal bleeding... but I have some big issues with this procedure. There are multiple avoidable risks associated with this approach including:

1) Permanent lip paralysis. The nerve that innervates the lower lip crosses right through this region.
2) Chronic submandibular sialadenitis. The duct that carries spit from the submandibular gland (one of the major glands that produce spit) to the mouth can potentally be injured resulting in stenosis and chronic salivary gland inflammation if not infection.
3) Permanent numbness of the bottom of the mouth. The nerve that provides sensation to the region under the tongue crosses right through this area.
4) Permanent tongue paralysis. The nerve that allows for tongue movement crosses through this area.

Rather than a submental intubation, why not perform a tracheostomy or cricothyroidotomy. With either of these alternative procedures, the risks are minimal (there is no risk of nerve damage).

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Surgeons Should be Good at Social Media

Not just surgeons, but also any procedural intensive medical specialties like interventional cardiology and radiology should be reasonably good at social media.

Why?

Because we have built-in time points within our daily routine schedule that enable such activities.

Let me explain... Between every surgical case, there is downtime that lasts anywhere from 15 minutes to as long as 45 minutes.

It is the time during which the operating room is being cleaned, sterilized, and new instruments are brought in and set up.

Before the days of social media, this is the time when many surgeons would read the newspaper/magazine, eat in the cafeteria, surf the internet, chat with staff, etc. Of course, any consults and paperwork that are pending would first be addressed.

But now... this time can be used for social media activities.

This time can now be used to read/write blogs, read/post tweets, and generally think of ideas worthy of sharing.

OR... if you are just sitting there waiting for a surgical case to start, check out my tweets or blog!

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Local Anesthetic Allergy

Rarely, a patient presents with a history of being allergic to lidocaine or another kind of local anesthetic. Often, the "allergic" reaction described (racing heart, light-headed, dizziness, etc) is more attributable to the epinephrine which is often used in conjunction with the anesthetic; therefore not a true allergy, but a not unexpected possible side effect.

Also, if a true allergy is present, it may not be to the anesthetic itself, but the preservative contained within, typically metabisulfite and/or methylparaben. The exception are single-dose vials which are preservative-free, unless they contain epinephrine. Any local anesthetic containing epinephrine, whether a single-dose or multi-dose vial, has metabisulfite in it. The preservative in the multi-dose vial of lidocaine and other anesthetics typically contain methylparaben. As such, the muti-dose vial of lidocaine with epinephrine would contain both metabisulfite and methylparaben.

In any case, if a true allergy to the anesthetic itself is present, there is the possibility that another type of anesthetic can be used. Why?

There are two different classes of local anesthetics divided into amino esters and amino amides. Chemically, amino amides have an amide link between the intermediate chain and the aromatic end, whereas amino esters have an ester link between the intermediate chain and the aromatic end.

Amino Ester

Amino Amide

There are other differences. Pharmacologically, amino esters are metabolized in the plasma whereas amino amides are metabolized in the liver. Amino esters are unstable in solution, but amino amides are very stable in solution.

Amino esters are also much more likely than amino amides to cause allergic hypersensitivity reactions.

Amino Esters (only one "i" in the spelling of the name):

• Cocaine
• Procaine
• Tetracaine (in the form of cetacaine)*
• Chloroprocaine*
• Benzocaine (in the form of cetacaine)*
• Cetacaine (benzocaine and tetracaine)*
• Propoxycaine

Amino Amides (two "i"'s in the spelling of the name):

• Lidocaine*
• Mepivacaine*
• Prilocaine
• Bupivacaine*
• Ropivacaine*
• Levobupivacaine
• Articaine
• Etidocaine
• Trimecaine
• EMLA (lidocaine/prilocaine)

* is next to those commonly carried in hospitals.

Much appreciate the assistance of Margaret Rowe, PharmD who helped write this blog article.

Source:
Local Anesthetics. Emedicine 4/19/13

Local Anesthetic. Wikipedia

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Death From a Severe Nosebleed

Image by RIs from Wikipedia

Attila the Hun was one of the most feared enemies of the Roman Empire. Ruler of the Huns from the year 434 until his death in 452, his empire stretched from Ural River to the Rhine River and from the Danube River to the Baltic Sea.

Although there are numerous theories as to how he died, the conventional account is that he died from a severe nosebleed on his wedding night.

Some may scoff that only people in historical times die from nosebleeds... but it unfortunately still even happens in the present.

Yes... a life-threatening nosebleed can be fatal whether a historical figure like Attila or a modern day individual. And I am talking in people who are otherwise completely healthy (no hemophilia, ITP, Osler-Weber-Rendu, etc).

Indeed, a Seattle lawyer died from a nosebleed in 2008.

Two British individuals died from a nosebleed in 2008 and in 2011.

And those are just the ones that are reported in the media.

It is estimated that in 1999, 4 out of 2.4 million deaths in the United States was due to a nosebleed [link].

Fatal nosebleeds in a normal healthy individual are almost always due to an arterial bleed, notably the sphenopalatine artery located in the back of the nose. Other less common fatal nosebleeds may be attributable to the ethmoid arteries located in the top of the nasal cavity.

Treatment of such life-threathening nosebleeds depends on the situation, but may include:

• Nasal packing
• Embolization
• Surgical

Cautery as shown in the video below is rarely successful.

Sources:
Man died after suffering two-hour nose bleed. Mirror News 11/24/11

Man Dies From Severe Nosebleed. ABC News 12/2/11

Woman sues hospital after her husband dies of nosebleed. KOMONews 5/4/13

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Video of How Nasal Cauterization for Nosebleeds Is Performed (Silver Nitrate and Electric)

I made a nosebleed video a few years ago that was roundly criticized for being poorly made. The biggest complaint was the loud background music. As such, I have made a new video that I feel addresses many of the shortcomings levied on the original video. I also added additional footage of what different types of nosebleeds look like as well as adding bipolar cauterization as another method of cautery other than silver nitrate.

Check the new (upgraded) video!

For more info about nosebleeds, click here.

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New Video on Tongue Tie Release Procedure

Tongue tie is a common problem whereby a flap of tissue anchors the tongue tip to the bottom of the mouth. With tongue tie, it is impossible for a patient to stick the tongue straight out (licking an ice cream is impossible) and may potentially lead to problems with feeding in a newborn baby, speech articulation in a young school-age child, and french kissing in teenagers and older.

Due to the frequency at which tongue tie release is performed and the questions parents often have about how this procedure is exactly performed, a video has been created to show the steps on a newborn baby. With the gracious permission of one mom... check out this video.

Tongue tie may not be the only problem that may cause breast-feeding difficulty in an infant. Upper lip tie and posterior tongue tie may also be present.

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Dangerous Tongue Patch Procedure for Weight Loss

Image from Wikipedia

There is a clinic in Beverly Hills who has been offering a risky "tongue patch" procedure in order to achieve weight loss of about 30 pounds in a single month. Although this clinic is currently the only one providing this "service" in the United States, it has been performed in Venezuela for quite some time.

In essence, a mesh made of marlex typically used for hernia repair is surgically sutured to the back area of the tongue and left in place for up to one month. While in place, this postage-stamp sized patch causes extreme discomfort if not pain whenever eating leading to a decrease in food ingestion and therefore weight loss. This non-FDA approved procedure is paired with a 800 calorie liquid diet.

In a normal swallow, the back of the tongue is required to help propel food down into the throat. With a patch in place, this step of the swallow becomes disrupted. Watch video to see how swallowing works here.

Does the concept work? In theory yes via starvation (hurts too much to swallow)...

Are there problems with it?

Absolutely and may even be considered highly unethical.

This procedure is associated with substantial risk including difficulty talking (you do need a tongue that moves well to enunciate words), infection, swelling, tissue overgrowth, and potential to dislodge leading to possible airway obstruction.

Why would somebody even consider this procedure? Well, if diet and exercise just doesn't work and financially, a desperate patient can't afford gastric lap band or bypass surgery... that's why some patients have pursued it.

Source:
Tongue Patch Surgery: Risky Weight Loss Procedure Draws Criticism. Yahoo News 6/5/13

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Why Would a Zenker's Diverticulum Recur After Surgical Treatment?

Zenker's diverticulum is an extremely rare disorder whereby a pouch develops in the throat leading to food and liquids getting caught causing symptoms of swallowing difficulties and food regurgitation. One of the best ways to address this rare condition is a procedure called endoscopic staple diverticulostomy (ESD).

Unfortunately, with any Zenker's treatment including ESD, there is a small percentage (~10%) that the Zenker's diverticulum recurs typically within one year of treatment (average 8.5 months).

Why might that be?

There are some known (and unknown) issues that may lead to recurrence including:

• Incomplete division of the cricopharyngeus muscle: If the pouch is small, the cricopharyngeus muscle may not be completely divided using the ESD method. It is a shortcoming inherent to the method itself and not a lapse on the surgeon's part. The only way to completely address the muscle when the pouch is small (less than 1 .5cm) is via external approach or use of a laser with its associated increased risk of complications.
• Unaddressed or persistent laryngopharyngeal reflux: Proton pump inhibitor medications are ALWAYS prescribed before and after surgery... even if heartburn symptoms are absent. However, even with such medications, there may be a certain sub-population that suffer from persistent throat-level reflux that may trigger the Zenker's diverticulum to reform. This factor is probably the single most important reason why recurrence may occur within months.
• Loose staples: After surgery is performed, all loose staples are removed to minimize recurrence from this factor.
• Idiopathic scarring of the common wall: Some unindentified inflammatory process leads to restenosis of the common wall.
• Unknown: Whatever factor lead to the Zenker's formation in the first place may cause it to happen again. Indeed, we actually don't precisely know what causes the Zenker's pouch to occur in the first place.

As such, if recurrence occurs years after treatment, it usually will suggest an incomplete cricopharyngeus muscle division. Repeat ESD can be performed with good results.

If recurrence occurs within one year of treatment, I typically will consider the possibility of persistent throat-level reflux (laryngopharyngeal reflux) that was not or incompletely addressed with reflux medications. Before performing ESD again after a recurrence, I will obtain a few studies to determine how significant throat-level reflux may be present.

That typically entails getting a 24 hour multi-channel pH and impedance testing with manometry. The most important result from this study is the frequency of proximal esophageal reflux events and as such, any other type of reflux study that does not include proximal esophageal or hypopharyngeal sensors would be considered inadequate. Ideally, it should be as close to zero as possible. If proximal esophageal reflux events are present, this needs to be thoroughly eliminated prior to revision Zenker's surgery... otherwise, the Zenker's pouch may yet again recur.

Manometry is performed to ensure the cricopharyngeus muscle (if present) is adequately "loose".

Of course, the barium swallow needs to be repeated as well.

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Hospital Charges vs Surgeon Charges

Some of the most bitter complaints I get from patients are their hospital bills. Apparently, this complaint is not unique to me given numerous media articles about perceived outrageous hospital charges for seemingly simple procedures (article #1 and article #2).

The healthcare system as it currently stands establishes 2 separate charges (surgeon and hospital) with any type of procedure performed in a hospital (even if not in an operating room). There is even a 3rd charge if anesthesia is provided.

The ONLY charge a surgeon has any control over is the surgeon's charge which often is the least expensive of the 3 charges. A common misconception is that the surgeon also has control over hospital and even anesthesia charges which is patently false.

Indeed, the surgeon is not even informed what the hospital or anesthesia charges are for any procedures performed. The surgeon also has no influence, say, or authority over what the hospital or anesthesia charges as well.

As such, if knowledge of total costs is desired with any type of procedure performed in the hospital, it is best to speak with a hospital representative of what the anticipated charges will be... not the surgeon because we actually do not know.

I should also mention that hospital charges are often 10 times or more greater than the surgeon's fees.

Read more about surgical fees.

Even for the SAME exact procedure, the charges vary greatly from one hospital to another.

In May 2013, the federal government released information on how a given hospital ranks in their charges for a given diagnosis or procedure (specifically Medicare, but all insurance base their charges on Medicare rates).

Check to see how your hospital ranks compared with other hospitals with respect to how high their charges are. The New York Times created a handy dandy map that illustrates hospitals which are "expensive" and those that are below average in terms of hospital charges.

I should mention that Fauquier Hospital where I have privileges charges at less than the US average.

Let's take an example to see how hospital charges can significantly influence how much you pay for the same exact procedure depending on which hospital you go.

Let's say you have health insurance with a 10% coinsurance and a $1000 deductible (meaning, before insurance pays for anything, you must pay at least $1000 and than an additional 10% of all remaining charges).

Let's say you decide to proceed with a tonsillectomy.

At hospital A, the surgeon's fee is $500, hospital charges are $5000, and anesthesia charges are $1000 for a grand total of $6500.

At hospital B, the surgeon's fee is $500, hospital charges are $10,000, and anesthesia charges are $5000 for a grand total of $15,500.

Clearly, whether you go to hospital A or B, you will pay $1000 deductible first.

So, at hospital A, the total charges (minus your deductible) billed to insurance will be $5,500 and at hospital B that cost will be $14,500.

Insurance pays 90% of these charges and you pay the remaining 10% (the 10% coinsurance as per the policy you have).

As such, having a tonsillectomy at hospital A will cost an additional $550 whereas at hospital B, you will have to pay an additional $1,450.

Now, it may seem the charge differences are extreme in the example, but sadly, hospital charges can truly be that dramatically different. Read this New York Times article for more information.

Of course, do keep in mind that the above example is over-simplified as reality does include things like fee schedules, allowable charges, etc.

Source:
Hospital Billing Varies Wildly, Government Data Shows. NYT 5/8/13

How Much Hospitals Charge For the Same Procedures. NYT 5/8/13

As Hospital Prices Soar, a Stitch Tops $500. NYT 12/2/13

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Surgical Video Recording: How I Do It

A number of people have asked how I go about video-recording surgeries... Beyond having hospital administration on board as well as obtaining appropriate consents from all involved parties, the technical aspects are actually quite straightforward.

I have tried all sorts of methods in order to obtain the closest and most vivid images possible. I tried cameras mounted on the surgical headlight which did work... but there was too much motion artifact leading to unusable footage. Even though I thought my head was absolutely still, it really was not.

What I found worked best is using the video tower used for sinus surgery in my hospital with the camera-head attached to the overhead light-handle. Thankfully, my hospital uses HD equipment with 3CCD camera-head, so the video footage is spectacular. And because the camera-head is mounted on a light-handle, the footage obtained is absolutely still.

The footage is recorded digitally directly onto a hard drive which I than transfer to a USB thumb drive.

Along with this setup, I have a roaming individual with a hand-held camcorder to obtain different angled shots to add variety to the final movie.

So that's how I now do it!

The specific video equipment I use is a Conmed Linvatec HD System... however any sinus surgery video equipment should work even if analog.

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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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