Does Sinus and/or Nasal Surgery Help with Sleep Apnea?

Bluntly, the answer is not really... Although it may make sense that improving nasal airflow should help with obstructive sleep apnea, the reality is that it does not make a profound difference. Indeed, there was a study in 2014 that looked into this question.

In this study, 3 groups of patients were looked at divided into patients with mild, moderate, or severe obstructive sleep apnea (OSA). These patients underwent sinus surgery, septoplasty, and turbinate reduction.

What was found was that patients with severe OSA with a mean AHI of 52 would go down to 43 (normal being less than 5) after surgery. Moderate OSA with a mean AHI of 22 down to 20. Patients with mild OSA did not have any significant changes to AHI at all.

In other words, for patients with moderate or severe OSA, although the AHI does decrease somewhat, it does not decrease enough that it really makes any clinical difference. Patients with moderate or severe OSA still had OSA... and still would need to use a CPAP or equivalent machine after surgery to correct their sleep apnea.

Although at first blush, these results may not make sense, it actually does make sense when you consider sleep apnea to be a multi-level disorder affecting not just the nose, but the throat as well.

For example, the back of the tongue may fall backwards obstructing the airway causing sleep apnea. Correcting nasal factors would have absolutely ZERO impact on tongue factors of OSA.

In order to determine where these other anatomic factors may be that may contribute to OSA, a sedated or sleep endoscopy is often performed. Watch the video below.

Granted, patients may STILL wish to pursue sino-nasal surgery due to discomfort with their sinuses and nasal breathing... but patients need to be aware that their OSA may still remain essentially unchanged!

Sino-nasal surgery may also help with CPAP compliance as lower pressures may be required to address OSA compared to before surgery. Why? Because the nasal passages are more open after surgery so it is easier to push air into lungs when using CPAP.

Reference:
Effects of Endoscopic Sinus Surgery and Nasal Surgery in Patients with Obstructive Sleep Apnea. Otolaryngol Head Neck Surg. 2014 Mar 31;151(1):171-175. [Epub ahead of print]

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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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Risk of Death From... Is...

Image courtesy of noomh / FreeDigitalPhotos.net

When it comes to risk of death from surgical procedures, it is illustrative to compare it to more common experiences.

Patients often become unduly concerned with certain risks including death without any true understanding of how rare the risk may be. Unfortunately, such rare risks may be THE reason why a patient may refuse a needed procedure in the erroneous belief that something rare has an unacceptably high chance of occurring to them.

In such situations, it may be beneficial to compare the chance of a rare risk with more common scenarios that a patient may be more familiar with.

The risk of death is... (In bold are surgical procedures)

Death from major surgery if performed within 30 days after a heart attack	1 in 7
Death from high risk open-heart surgery	1 in 20
Dying on the road over 50 years of driving	1 in 85
Dying from any cause in the next year	1 in 100
Annual risk of death from smoking 10 cigarettes per day	1 in 200
Death from UPPP surgery	1 in 500
ER treatment in the next year after being injured by a can, bottle, or jar	1 in 1,000
ER treatment in the next year after being injured by a bed mattress or pillow	1 in 2,000
Death by an accident at home	1 in 7,100
Death from tonsillectomy	1 in 10,000 - 35,000
Death by an accident at work	1 in 40,000
Death playing soccer	1 in 50,000
Death by murder	1 in 100,000
Being hit in your home by a crashing aeroplane	1 in 250,000
Death by rail accident	1 in 500,000
Being struck by lightning	1 in 10,000,000
Death from a nuclear power accident	1 in 10,000,000

References:

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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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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How Long Do Swallowing and Voice Problems Last After C-Spine Surgery ACDF?

I often see patients for swallowing and/or voice difficulties after cervical spine surgery (ACDF). In the vast majority of cases, reassurance that such "side effects" are not uncommon is the only thing I need to provide after a complete exam.

After all, both the voice box and swallowing tube are manipulated and pushed over to one side in order to perform cervical spine surgery from an anterior approach. Check out the video below that illustrates how this happens.

Beyond reassurance, the next question patients have is how long before things go back to normal. Until now, that was a hard question to answer.

A recent report was able to provide some numbers I can now use to help explain to patients. After anterior approaches to cervical spine surgery:

• 60% had a postoperative issue, including 27% with postoperative voice complaint and 48% with postoperative swallowing complaint
• Swallowing complaints that lasted beyond 1 year occurred in 28%
• Voice complaints that lasted over 1 year occurred in 9%
• Approaching spinal levels above C4 and exposing more than 3 spinal levels were 2 factors that significantly resulted in voice and swallowing problems

In certain patients with more extreme swallowing difficulties, barium swallow studies may be ordered. Swallow therapy can be helpful as well.

Should vocal cord paralysis be seen on endoscopy, voice therapy and even vocal cord medialization injections can be performed to alleviate voice problems.

Reference:
Factors Predictive of Voice and Swallowing Outcomes after Anterior Approaches to the Cervical Spine. Otolaryngol Head Neck Surg. 2013 Dec 23. [Epub ahead of print]

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Acupuncture Alleviates Pain After Tonsillectomy in Children

The study showed that acupuncture significantly decreased pain after tonsillectomy in children (2-17 years of age) with reported pain levels before acupuncture of 5.52 (SD=2.28) out of 10 which fell to 1.92 (SD=2.43) after acupuncture.

This retrospective research was conducted in 31 patients who underwent a tonsillectomy within a 3 month period of time by Dr. James Ochi, one of only a handful of dual board-certified ENT and medical acupuncture in the United States. No study patients received any narcotics for pain control beyond tylenol, ibuprofen, and a single dose of intra-operative dexamethasone. The tonsillectomy itself was performed using electrocautery set at 24W.

The acupuncture points used for pain control are shown below and was performed bilaterally:

Image taken from the Research Paper

All patients received acupuncture at LI4 (between thumb and index finger). Additional points were found effective in relieving tonsillectomy pain and provided on an as needed basis at (in decreasing frequency) CV23, GV24.5 and GV20. Acupuncture points LI20, LI11, and LI10 were utilized in only a few patients.

LI4 point is hypothesized to work so well because:

"Stimulation at LI4 increases activity in the somatosensory cortex and a region of the brainstem known as the periaqueductal gray area, as revealed by functional magnetic resonance imaging, that are involved in processing pain signals." [link]

Although promising, in order to be fully convinced of the effectiveness of acupuncture for post-tonsillectomy pain, further research that is prospective, randomized, and controlled is required.

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

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


Reference:
Acupuncture instead of codeine for tonsillectomy pain in children. International Journal of Pediatric Otorhinolaryngology Volume 77, Issue 12 , Pages 2058-2062, December 2013

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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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Does Removing the Adenoids Decrease Risk of Ear Infections? Yes...

A recent meta-analysis has determined that risk of recurrent ear infections is significantly reduced if adenoidectomy is performed in combination with ear tube placement as opposed to ear tube placement alone. When stratified by age, removing the adenoids was found particularly helpful in children older than 4 years of age.

Combining results from over 15 studies containing over 71,000 children, the estimated rate of repeat ear tube placement for recurrent ear infections in children who also had adenoidectomy was only 17.2% vs 31.8% for children undergoing ear tubes alone. However this significance faded under the age of 4 years.

Why would adenoid removal influence ear infections?

First a little anatomy lesson...

In the back of the nose, there is an opening called the eustachian tube that goes up into the ear. That's why one is able to pop the ears when blowing into a pinched nose.

Image by Chittka and Brockmann from Wikipedia

The adenoids are located in the back of the nose immediately behind the eustachian tube opening. The adenoids can potentially lead to ear problems via two mechanisms. First, the adenoids could be very enlarged causing physical obstruction of the eustachian tube which can make it impossible to pop the ears. Second, the adenoids could be a reservoir of germs which can lead to ear infections given proximity to the eustachian tube.

As such, removal of the adenoids would allow the eustachian tube to function better as well as eliminate a potential reservoir of infection.

However, recommendation for adenoid removal typically occurs if a child requires a 2nd set of tubes which usually occurs around age 4. Adenoidectomy may be recommended with the initial set of ear tubes (after taking into consideration age) if other symptoms are present including nasal obstruction and a snotty nose.


Reference:
Adenoidectomy as an Adjuvant to Primary Tympanostomy Tube Placement: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2013 Nov 28. doi: 10.1001/jamaoto.2013.5842. [Epub ahead of print]

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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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First Implantation of Human Artificial Larynx Announced!

Image taken from DNA

ProTip SAS and Strasbourg University Hospitals announced that a fully artificial larynx was implanted into a human for the first time.

Made entirely of titanium, the surgery was performed in two stages into a man with throat cancer that required his entire voicebox to be removed (laryngectomy).

Stage 1:
In June 2012, the larynx was removed and a titanium tracheal ring was implanted in its place.

Stage 2:
In November 2012, a removable valve-based device was inserted into/onto the titanium tracheal ring via the mouth.

According to reports, this device allows for both breathing as well as phonation.

What is still unclear to me from reports scavenged on the internet are the following questions which I'm sure will become more clear as more information is provided:

1) What does the voice sound like?
2) How is breathing and phonation exactly accomplished?
3) How much is swallowing impacted?
4) What is the risk of extrusion?
5) How is the valve constructed to enable voice production?
6) How is aspiration prevented during swallow?


Source:
ProTip and Strasbourg University Hospitals announce the first human implantation of an artificial larynx. MNT 10/9/13

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Life-Saving Emergency Trach Performed in Restaurant

On Sept 23, 2013, a physician performed a life-saving emergency tracheotomy in a restaurant on a patron who was choking on a piece of meat. [link]

While eating dinner at The Mark Restaurant in California, Dr. Royce Johnson, an infectious disease doctor affiliated with UCLA, performed this procedure on Pauline Larwood, a female supervisor and a community college trustee.

Dr. Johnson saved this woman's life using a pocket knife and the hollow cylinder of a pen after a Heimlich maneuver failed to work.

Interestingly, Dr. Thomas Frieden, director of the CDC, who was also present in the restaurant assisted in the care by monitoring Larwood’s pulse during the incident.

Also present in the restaurant witnessing the emergency procedure were:

• Francis Collins, MD (director of NIH)
• Farming and business moguls Lynda and Stewart Resnick
• Rep. Kevin McCarthy, R-Bakersfield
• Assemblywoman Shannon Grove, R-Bakersfield
• State senator Jean Fuller, R-Bakersfield

Although typically surgeons are the individuals trained to perform tracheotomies, bravo to Dr. Johnson who took the initiative in spite of the fact that he probably has never performed one.

I should also add that though media reports state that an emergency tracheostomy was performed, it is probably more likely that an emergency cricothyroidotomy was performed instead which is easier and less "bloody."

Source:
Dramatic dinner rescue involves knife, UCLA doctor and CDC chief. The Bakersfield Californian 9/24/13

CALIF. DOCTOR SAVES CHOKING DINER WITH KNIFE. The Associated Press 9/25/13

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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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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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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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Facial Plastic Surgery Leading to Clones? Scandal? Divorce? Lawsuits?

Earlier this year, pictures of the 20 finalists for Miss Korea 2013 went viral due to the clone-like appearance of the women. Such clone-like appearance is due to suspected plastic surgery undergone by many if not all of the contestants towards the idealized "Korean plastic face look." Fueling plastic surgery in Korea is the acceptance and popularization of plastic surgery encouraged by celebrity worship culture. Check it out:

Image Taken from MailOnline

Of course, it could be all the makeup and photoshopping that made these contestants all look alike. The reality is a bit more disappointing as shown in pre-makeup pictures published in KoreaBang.

In any case, a scandal of sorts occurred when before and after pictures of Miss Korea 2012 Kim Yu-Mi  surfaced. Note the complete lack of resemblance between her natural looks and her winning appearance (see pics below):

Image Taken From KoreAm

It is perhaps little wonder that with such high prevalence of plastic surgery, that it was only a matter of time before marital strife and even divorce would occur by men who have been "deceived" by a woman's "natural" beauty which was anything but.

Indeed, a Chinese man divorced and sued his wife in 2012 for being ugly... and won [link]. Apparently his wife's appearance became an issue when his daughter was born and resembled nothing like either parent (and allegedly was "incredibly ugly" to boot). After initially thinking his wife cheated on him, the wife admitted spending $100,000 on plastic surgery to become beautiful, and never disclosed this information before marrying him. The lawsuit was based on his belief that he married her under false pretenses of her being beautiful. See pics below.

Image taken from KDVR

I wonder if potential marriages in Asia are now preceded by full disclosure of any plastic surgery done along with the more usual disclosures of educational, family, and financial background.

Sources:

Chinese man sues wife for being ugly, wins $120,000. KDVR 10/26/12

Has plastic surgery made these beauty queens all look the same? Koreans complain about pageant 'clones'.  MailOnline 4/25/13

Miss Korea’s Plastic Surgery Scandal After Photos Surface. KoreAm 7/20/12

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Maggots in the Ear After Trip to Peru

Image from Wikipedia

Adventurous international travelers have to worry about malaria and safe drinking water, but for one 27 years old British woman, she also had to contend with a maggot infestation in the ear after a trip to Peru.

It was not quite the 57 maggots found in one Illinois woman, but apparently this traveler recalled walking thru a fly swarm in Peru and that one fly did briefly enter her ear canal. However, it was enough for the fly (New World Screwworm fly) to lay its eggs causing maggots to hatch and slowly eat away her ear canal causing severe pain and scratching sounds within her head.

Surgery was required to remove the maggots. Less aggressive attempts to remove would only cause the maggots to burrow even deeper into her ear/head. Potential damage from the maggots include permanent hearing loss for obvious reasons, but also facial paralysis and taste changes given the facial nerve and chorda tympani (taste nerve) pass through the ear as well.

Fortunately, all maggots were successfully removed without any permanent damage.

Source:

British Woman Discovers Flesh-Eating Maggots Inside Her Ear. Medical Daily 7/16/13.

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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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