Sinus Infection Leads to Skull Removal in Child

The UK reported a 9 years old boy who had an extremely rare sinusitis complication that ultimately resulted in the left skull being removed temporarily.

Briefly, in Feb 2013, the child developed headaches and a droopy eyelid. Surgeons ultimately had to remove his left skull due to brain swelling and concern the bone itself was infected. Over the next few months, the child had to wear a bike helmet to protect his brain which was no longer protected by his skull. A few weeks ago, he underwent another surgery to cover the hole in his left skull with a custom-shaped ceramic plate.

No mention was made in the media about which sinus cavity led to this horrible problem.

But here's a guess without benefit of more information...

Based on the skull defect shown (see pics here), it appears that the parietal and temporal skull bones were removed. There are actually no sinus cavities in these regions. As such, the only thing that makes sense to me is that the left cerebral dural sinus (large blood vessels of the brain) became clotted off and infected secondary to a sinus infection, probably the ethmoid sinus cavities located between the eyes.

The blood supply from the ethmoid sinus cavities communicates with the cavernous sinus found at the bottom of the brain. This anatomic structure is a major source of venous drainage of the brain.

If the cavernous sinus gets inflamed/infected due to a sinus infection, it could lead to multiple facial abnormalities due to injury of the numerous cranial nerves that go through it including:

• Inability to move the eyeballs (CN3, 4, 6)
• Numbness, pain of the skin over the forehead and cheeks (CNV1, V2)
• Loss of pupillary constriction (CN3)
• Visual loss/changes (CN1)

Ultimately, the cavernous sinus could also become thrombosed.

Cavernous Sinus shown by red arrow. Taken from Sonoworld.

From there, the infection can spread to the rest of the brain via the dural sinus cavities and potentially can even lead to death if not treated promptly and aggressively.

How aggressively? In this particular case, the child had half his skull removed!

Thankfully, the vast, vast, vast majority of sinus infections do not lead anywhere close to this type of complication.

Source:

Boy, 9, has half his skull removed after sinus infection spreads to his brain - but he still manages to attend school thanks to a BICYCLE HELMET. MailOnline 8/26/13

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How Much Tongue Can Be Removed Without Affecting Function?

Unfortunately, whether through trauma or cancer concerns, parts of the tongue may be removed. When a part of the tongue is removed, the principal concern patients have is whether speech and swallow will be affected.

The answer to this question depends on 3 main factors.

• What orientation is the tongue removed?

• How much is removed?

• Will nerve function be preserved? The nerve is what makes the tongue move (specifically cranial nerve 12 called the hypoglossal nerve)

Regardless of how much or little of the tongue gets removed, if nerve function is lost, speech and swallow will be affected. As such, when tongue resection is performed, extreme care is taken to preserve nerve function and not to accidentally cut the hypoglossal nerve unless absolutely necessary (the nerve is invaded by cancer). As an FYI, this nerve is about 1.75cm off to the side of the tongue's midline.

When tongue removal is performed on the SIDE of the tongue, up to 1/3 of it can be removed without significant speech or swallow deficits ASSUMING nerve function remains intact and tongue tip is left alone. If more than 1/3 is removed, some degree of reconstruction will be required involving taking skin and muscle from the forearm to fill the space lost to the tongue resection (procedure is called radial forearm free flap).

If the tongue tip is removed, far less can be lost before it will start to affect speech. Why? Because the tongue tip is used to help articulate words. How much can be removed before it starts to affect speech depends on the tongue length and shape. Swallow is typically unaffected.

Typically tongue tip removal occurs through trauma when it may get bitten off during a seizure or bitten off by another individual as occurred to this man whose tongue tip was bitten off by his girlfriend when he tried to kiss her. [link]

Side of the tongue removal usually occurs through surgical excision due to cancer concerns.

Sleep Apnea

As an aside, there is another type of tongue removal procedure used to address obstructive sleep apnea where the central back part of the tongue is removed. This procedure is performed when the tongue is large and causes obstruction while a person is sleeping. If properly performed, no speech or swallow deficits will occur.

Read more about this procedure here.

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Does WaxVac or EarVac Actually Remove Earwax?

The EarVac or WaxVac is a device that purportedly suctions out earwax. Shaped like a miniature hair dryer, one simply needs to hold it up to your ear canal in order to suction out the earwax. Recently, they have been marketing this device heavily, especially through TV commercials.

Now, does it actually work???

Not really... In fact, British researchers tested it out against the humble ear curette (Jobson-Home Probe). With their test population, the WaxVac worked in exactly ZERO percent of patients. The ear curette worked 100% of the time to restore eardrum visibility and 88% for subjective hearing improvement for the patient.

Why would the WaxVac work so poorly?

Think of a handheld vacuum cleaner. Even for a regular vacuum cleaner, it will only suck up debris only when it is right on top of it. One can't "vacuum" out a bedroom simply by holding the vacuum cleaner at the bedroom door entrance or hovering it around in the bedroom. The vacuum needs to be placed DIRECTLY over debris in order to suction it out.

Well, the same goes for the WaxVac.

Even when the ear canal is professionally vacuumed by an ENT under the microscope, it only works with some earwax types... and doesn't work at all for other earwax types.

I also wanted to point out the danger of using an WaxVac which has the potential to create high negative pressures when sealed up against the ear canal entrance which could lead to eardrum perforation as well as permanent hearing loss (similarly to kissing ear syndrome).

As such, I personally do not recommend this product. However, should you decide to purchase it, I would strongly urge people to do their homework before buying this unproven device. Even if it did work, beware that the company seems to make their money by scamming people with shipping charges [link]. 

Reference:

A non-randomized comparison of earwax removal with a 'do-it-yourself' ear vacuum kit and a Jobson-Horne probe. Clin Otolaryngol. 2005 Aug;30(4):320-3.


Watch how earwax is cleaned at an ENT office video.

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"Mother's Kiss" to Remove Nasal Foreign Bodies

In 1965, a general practitioner Vladimir Ctibor described the "Mother's Kiss" technique of removing nasal foreign bodies in a child.

Essentially, a trusted adult (like a mother) places her mouth over the child's mouth as if to perform mouth-to-mouth resuscitation. While pinching off the unaffected nostril, the adult than blows gently into the child's mouth until resistance is felt caused by the child closing the glottis. At that moment, the adult gives a sharp explosive exhalation to deliver a strong puff of air that passes up into the nose and out the unblocked nostril. If successful, this air puff will also blow the foreign body out the nose as well.

If the adult blow's air when the child's glottis is open, air will just go into the lungs rather than up the nose.

Prior to the procedure, the child is informed that the mom will give the child a "big kiss," hence the name of this procedure.

Now... does this technique actually work?

According to one meta-analysis, it works about 59.9% of the time.

The way I consider it... it can't hurt to try before using instruments to manually remove the nasal foreign body. A "mother's kiss" is certainly a more comfortable and familiar approach for a child versus the alternative.

However, one warning point... the child should be calmly breathing during this procedure. If the child becomes hysterical during the procedure, the child might strongly inhale through the unblocked nostril and potentially suck the foreign body (if small enough) down into the lungs making an unlucky situation into a medical emergency.

Another point for those uninformed... do NOT use this procedure on ear foreign bodies. It will NOT work. The ear canal is a closed container with no inlet or outlet for any air pressure produced by a "Mother's Kiss." In fact, trying to perform this procedure on the ear may cause a ruptured eardrum and even permanent hearing loss.


Reference:
Removal of Foreign Bodies from the Nose. NEJM 1985; 312:725.

Efficacy and safety of of the "Mother's Kiss" technique: A systematic review of case reports and case series. CMAJ 2012. DOI:10.1503/cmaj.111864 (full length pdf)

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Best Drops for Earwax Removal

It's about time, but some researchers actually put to the test to try and determine what is the best solution to dissolve/remove earwax.

The verdict was... WATER!

Better than mineral oil, liquid colace, and over-the-counter cerumenolytics (ie cerumol). Hydrogen peroxide was not evaluated.

How was this result determined?

Using guinea pigs, the researchers first tested whether each of these substances were safe should a hole in the eardrum be present allowing for the solution to enter the middle ear space. Colace was found to be the most ototoxic (meaning, potential for permanent hearing loss if a ear tube or a hole in the eardrum is present). Mineral oil and saltwater (normal saline) was found not to be toxic.

Next, they determined which substance provided the greatest degree of cerumen dissolving ability. Each substance was added to a cylinder filled with earwax for 5 minutes. They than determined how much weight was required for a 25G needle to fully penetrate through the earwax.

Water was found to provide far superior earwax dissolving ability compared to all other substances tested. Not surprising given water is considered the best universal solvent used to clean everything from dishes to cars to buildings.

What is the take-home message?

Given saltwater/water is completely safe for hearing even if there is a hole in the eardrum along with superior earwax dissolving ability, it seems to be a no-brainer to instruct patients with lots of earwax to use salt-water to get rid of earwax.

Reference:
Ototoxicity of intratympanic docusate sodium and mineral oil in the Guinea pig. Otolaryngol Head Neck Surg. 2012 Mar;146(3):455-60. Epub 2011 Nov 18.

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Nasal Hair Removal and Nasal Sores

It is not unusual that I encounter a patient who develops crusting and sores around the entrance to the nose where coincidentally nasal hair is found... in both men and women.

Other complaints/symptoms beyond crusting and sores include:

• Skin Splitting
• Pimple/Acne Formation
• Scabbing
• Ulcers

People often try applying lotion, neosporin, or cortisone cream... which does help, but not completely with recurrent flareups.

The most common triggers I find that lead to such recurrent sores are nose-picking and nasal hair removal.

The best thing is to avoid doing either... but... if one must...

Nose picking is pretty self-explanatory, but nasal hair removal does require some clarification.

People often use tweezers or even their fingers to pull the offending long nasal hair out for either cosmetic or annoyance reasons.

Yanking nasal hair out is not a good idea beyond the watery eyes it may bring. It causes micro-trauma to the surrounding skin and hair follicle that may lead to infection. Furthermore, just like any other place on the body where hair is removed, ingrown hair growth can also occur.

Aha! one might say... Use an electric nasal hair cutter! That's a good idea, but make sure it does not cut down to the skin for the same reasons as stated above. Also, ensure the blades are kept sharp to prevent hair pulling.

There are good nasal hair cutters and there are bad ones...

From personal testing of a variety of nasal hair cutters, I like the Groom Mate Platinum XL.

I'm sure there are other good ones, but it may also come down to personal preference.

Now, if there's an active recurrent nasal sore that's not healing, the best way to treat it is with prescription cortisporin ointment.

However, best to have a doctor to check it out as there are other more malicious reasons for a nasal sore including skin cancer.

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Singer John Mayer Undergoes Vocal Cord Surgery

In September 2011, grammy-award winning singer John Mayer announced the cancellation of a number of concerts as well as an album due to the development of a vocal cord granuloma of his voicebox. Read a blog article about this.

Last week on Thurs, Oct 20, 2011, he underwent surgery to remove the granuloma and is now on strict voice rest for several weeks.

Though removal sounds like a great idea, vocal cord granulomas are notoriously difficult to eliminate completely as they have a high risk of recurrence. Strict voice rest as well as voice therapy helps as it eliminates the repetitive phonotrauma that promotes regrowth. Reflux control is also essential with medications. However, it is not unusual that steroid injections to the granuloma site as well as even botox injection to partially and temporarily paralyze the vocal cord may need to be pursued for complete resolution.

Surgical removal of the granuloma may have looked something like this video...


Read more about vocal cord granulomas here.

Read a NY Magazine article about his surgery.

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