Are Surgeons Dumber than Anesthesiologists?

The British Medical Journal in 2011 published a multicenter prospective comparative study comparing the intelligence of orthopedic surgeons and anesthesiologists. Before I give you the answer, a little history...

Traditionally, orthopedic surgeons have the unfortunate stereotype in the medical community of being  strong but stupid. Although making fun of orthopedic surgeons is a popular past-time among physicians giving rise to a number of jokes including:

What do you call two orthopaedic surgeons looking at a chest X-ray? ANSWER: A double blind study.

Anesthesiologists are considered quite the opposite. Although occasionally teased as gas-passers, they are respected as being quite the Einsteins.

Check out this video illustrating just how much smarter anesthesiologists are compared to orthopedic surgeons.

BUT... are such stereotypes true?

Well... according to the BMJ study conducted in three United Kingdom hospitals, orthopedic surgeons are significantly more intelligent than anesthesiologists based on IQ scores (the Mensa Brain Test version 1.1.0 was used to measure intelligence). The mean intelligence test score of orthopaedic surgeons was  105.19 compared with 98.38 for anesthetists (the higher the score, the smarter).

According to the same study, the orthopedic surgeons were not only smarter than anesthesiologists, they were also significantly stronger based on dominant hand grip strength.

So orthopedic surgeons are undeservedly viewed as being stupid when they are actually quite smart!!!

Reference:
Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study. BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7506 (Published 15 December 2011)

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Diagnostic Test for Laryngeal Sensory Neuropathy (Chronic Cough)?

Patients who suffer from a persistent chronic cough undergo a tremendous amount of testing, trials of medications, and seeing numerous specialists to try and make the cough go away. Ultimately, the cough may be found due to a rare condition called laryngeal sensory neuropathy which is treated with anti-depressant and even seizure medications. This nerve also may contribute to swallowing problems as well.

Because laryngeal sensory neuropathy is a diagnosis of exclusion, an extensive workup is required to rule out all other causes of cough including tests for reflux, reactive airway disease, allergy, etc. Given the time-consuming nature of evaluating a chronic cough, very smart researchers have been trying to develop a test that checks for laryngeal sensory neuropathy (LSN).

One such test called SELSAP (Surface Evoked Laryngeal Sensory Action Potential) is a non-invasive, surface evoked, sensory nerve function testing of the superior laryngeal nerve. Why the superior laryngeal nerve? It's because that's the nerve that is responsible for causing the sensation/urge to cough in affected patients. It's also the primary nerve that suffers from the neuropathy. [see references below]

The test basically involves placing an electrode to the side of the voicebox and another under the chin. A mild electric stimulus is than performed behind the ear.

Because this test is so new, it is unproven and unclear whether this test will ultimately provide valuable assistance in the evaluation of a patient suffering from chronic cough. Normative values have yet to be rigorously determined.

BUT... it is something that can be considered especially if the history is consistent with LSN and the SELSAP is "clearly" abnormal (HYPERfunctional). In such cases, appropriate treatment can be immediately started without going through the entire chronic cough workup first.

Of course, even though LSN treatment is started, it still behooves to still do the workup to ensure a person does not have more than one cause for persistent cough that would still need to be addressed for true cough resolution. Read more about LSN treatment failures here.

When it comes to swallowing difficulties, if SELSAP does come back abnormal (HYPOfunctional), it may suggest that there is "numbness" of the voicebox region preventing a proper swallow as the body does not "know" where the food is when it passes by leading to aspiration.

Be aware that not all places will offer such testing. Contacting a good neurologist is really one's best bet to see if they are willing to learn and perform SELSAP.

However, Dr. Kristin Williams in Warrenton, VA does perform this test.
Office Phone: 540-316-5980
384 Hospital Drive
Warrenton, VA 20186


References:
Surface-Evoked Laryngeal Sensory Action Potential Evaluation in Neurogenic Chronic Cough. Journal of Voicw, May 28, 2014.

A new noninvasive method for determination of laryngeal sensory function. Laryngoscope. 2011 Jan;121(1):158-63. doi: 10.1002/lary.21182.

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Hearing Test Administered Over the Phone

I was just made aware of this service in a Washington Post article published May 16, 2014. This screening hearing test is taken over the telephone and accomplished by listening to three-digit sequences presented in a background of white noise. The test-taker has to then enter the digits using the telephone keypad. Based on accuracy of the response, the test than adjusts the next query.

Normally, the cost to take this telephone hearing test is $8, but at least for the month of May 2014, it is free in celebration of "Better Hearing and Speech Month."

Here's how to take the test by phone:

1. Find a quiet place to take the test that is free from distractions. 
2. If you hang up in the middle of your test, you will have to start from the beginning. 
3. Use a telephone that plugs into a wall-mounted jack. Please do not use a cell phone. 
4. Dial our toll-free number: 1-866-223-7575 
5. Listen to the recorded instructions. 
6. At the end of the test, write down your test results for each ear and the date. The categories are: 

Within the Normal Range

Slightly Below the Normal Range

Poor

Further details of this test can be found here, but the test essentially is based on the speech-to-noise ratio (SNR) that is adjusted using an adaptive procedure seeking a threshold for 50% correct identification of the digit sequences. A set of 25 sequences provides a reliable SNR threshold in about four minutes of testing per ear. This method of testing is different from most hearing tests in that it uses digits in static noise, rather than pure tones. Because the test measures an SNR threshold rather than one based on the absolute level of tones, a reliable screening measure of hearing, despite the differences in sound levels produced by different telephones, can be achieved.

Of note, this method of testing was validated in Europe by scientists at VU University Medical Center in the Netherlands in 2004. The U.S. version began in 2008 with funding from the National Institute of Health and was validated in two studies performed at the Indiana University Hearing Clinic and the other in collaboration with clinics administered by the VA Health System.

If hearing is assessed to be abnormal, you can contact our office to undergo a more sophisticated hearing test for confirmation and next steps.

Source: 
Take this hearing test right now. I did, and the results were disturbing. Washington Post 5/16/14.

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At-Home Rapid Strep Testing

Rapid strep test kits can be purchased by anybody to be done at home which may save parents/patients a lot of money in doctor visits for those prone to strep infections. Indeed, should a rapid strep test be positive, than you know that a doctor's visit is definitely worthwhile. (A doctor visit may still be worthwhile since a sore throat may be due to something else like cancer, aphthous ulcer, sinus infection, reflux, etc).

Such home kits (which in fact are the same kits used in medical offices) can be purchased online through Amazon. The price is surprisingly affordable at around the cost of a single copay $30 to do 25 tests.

However, with the purchase of such DIY kits, there are some pitfalls patients should be aware of if they decide to proceed.

1) Perform the internal controls that come with the kit!!! The kit may be a dud and needs to be tested against itself to ensure accurate results whether negative or positive. If the controls do not work, throw the whole test kit out and buy another.
2) You must follow the directions precisely, otherwise the test results will be unreliable. In other words, if the directions call for 4 drops, than it MUST be 4 drops (not 3 drops or 5). If directions state to wait 4 minutes... you must wait exactly 4 minutes. This literally is like precision baking.
3) The test strips need to be kept in protected, sealed bag and used immediately after taking one out, otherwise the test results will be unreliable.
4) When swabbing the throat, you MUST get the cotton tip on the tonsil and/or back wall of the mouth which than must be rubbed around a couple times. Getting the tongue or cheek will increase the risk of a false negative. As such, it may be worthwhile to invest in some tongue blades to help push the tongue down in order to perform this test properly.

Should patients elect to start performing home strep tests, please be aware that physicians will be obligated to not only REPEAT the testing but also examine the patient to ensure antibiotics are appropriate. An actual throat culture may be performed as well which is the gold standard test.

1) Repeat testing is required because the patient may not have followed the instructions precisely. For example, the test strips must be read at 5 minutes (variable depending on the kit). If test results are read past 5 minutes, it may incorrectly show a positive result.
2) Some patients unfortunately fabricate test results just so they can get an antibiotic without an office visit.
3) Some patients unfortunately also fabricate test results in order to skip work or school for personal reasons not related to an actual medical condition.
4) There are situations that even though the strep test is positive, no treatment may be recommended. The patient may be a strep carrier for which treatment of any kind is not recommended.

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We Now Offer Rapid Saliva Test to Look for Laryngopharyngeal Reflux

When you compare a spit test to the current way of how throat level reflux (LPR) is determined via barium swallow, upper endoscopy (EGD), and 24 hour ph/impedance testing, it sounds quite attractive.

And we are one of the very few offices in the United States that offer this spit test. Even major laboratory companies like Labcorp and Quest do not offer this test yet.

How does such a test work?

It basically looks for a stomach protein called pepsin.

Given reflux is when stomach contents moves up towards the mouth and pepsin is a protein ONLY produced in the stomach... pepsin should NOT be found in the throat/mouth.

As such, the test can state yes or no whether LPR is present or not.

The steps to the test are as follows:

   

How good is the test?

Depending on the study, sensitivity ranges in the 80-100% (can actually detect reflux if truly present) and specificity is around 85% (truly no reflux if test is negative).

One test company is RDbiomed (in Europe) using their Peptest kit.

This test is currently not FDA approved yet and as such, is a test that is NOT covered by insurance at this time. Due to a special arrangement our office has with RDBiomed, the Peptest kit can be obtained in our office at a discounted price of $125 (compared to normal price of $175). Price includes the kit, test supplies, and courier shipping service.

Please note that this testing is ONLY offered to current patients of ours.

However, if you are not a current patient of ours, you can order this test yourself online as an individual without a visit to our office. It is recommended you take the standard 3 sample peptest. Click here for more information.

References:
Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope. 2005 Aug;115(8):1473-8.

Rapid salivary pepsin test: Blinded assessment of test performance in gastroesophageal reflux disease. Laryngoscope. 2012 Jun;122(6):1312-6. doi: 10.1002/lary.23252. Epub 2012 Mar 23.

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Possible Blood Test for Oral Cancer Caused by HPV?

There might be a blood test which can possibly predict individuals who may develop oral cancer caused by HPV years before it happens. HPV, an abbreviation for human papilloma virus, encompasses over 100 different strains among which only a few can cause problems in humans. Specifically, HPV 16 can lead to cervical cancer in woman and oral cancer in both genders.

HPV triggered oral cancer is also the most common cause of oral cancer now exceeding even smoking and drinking alcohol.

Unlike HPV that causes cervical cancer which can be screened for by pap smears in women, there's currently no good screening test to look for HPV that might cause oral cancer.

However, that's not to say that researchers aren't busy looking for just such a test...

In June 2013, researchers published a possible blood test that might predict those individuals at risk for developing HPV oral cancer.

By analyzing blood samples taken from 638 patients with head and neck cancers, they discovered that antibodies against HPV16 E6 was present in pre-diagnostic samples for 34.8% of patients with oropharyngeal cancer and 0.6% of controls (healthy patients without cancer). Furthermore, HPV16 E6 was NOT associated with other cancer sites. The increased risk of oropharyngeal cancer among HPV16 E6 seropositive participants was independent of time between blood collection and diagnosis and was observed more than 10 years before diagnosis.

Now I should state that HPV16 E6, which is actually a gene found in the virus, only accounted for 34.8% of patients. It bears repeating... it was positive only 34.8% of the time. In other words, this test predicted oral cancer only one out of every 3 patients who actually developed cancer.

As such, it is not a very specific test... ideally, you want a number as close to 100% as possible, otherwise patients who test negative to this blood test may falsely think they are not at risk.

Now, the other problem is what if a patient DOES test positive to HPV16 E6?

Does that mean such patients need to undergo routine fiberoptic endoscopy screening examinations every few months or years? Are biopsies required or not if visual examination appears normal? If biopsies are required, how often and from where? After all, oral cancer encompasses the tongue, tonsil, pharynx, larynx, supraglottis, palate, buccal mucosa, etc, etc, etc. That's a lot of biopsies...

Coincident with the development of a good blood test is the need for research to develop a protocol of what to do with the results of such test information.

Reference:
Evaluation of Human Papillomavirus Antibodies and Risk of Subsequent Head and Neck Cancer. Journal of Clinical Oncology. Published online before print June 17, 2013, doi: 10.1200/JCO.2012.47.2738

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Do Nosebleeds Cause Stool Blood Tests to Become Positive?

As a general rule, an ordinary nosebleed will not cause a screening stool blood test (hemoccult or guaiac) to come back positive.

However, if the nosebleed is bad enough to consider going to the emergency room... and you are swallowing a lot of it... only than will it be likely that such stool tests will come back positive for blood.

To be precise, such stool tests turn positive only if there's at least 2+ teaspoons of blood leaking into the digestive system everyday (or swallowed from a very bad nosebleed).

Of course, there are MUCH more sensitive tests out there to determine if there's blood in the stool including heme-porphyrin or immunochemical tests, but have a high false-positive rate.

From an ENT perspective, immunochemical testing is interesting because this test uses antibodies to detect human globin epitopes which get digested in the stomach... so if there's a question of whether a patient's anemia is due to nosebleed or a lower GI tract bleed (ie, colon), immunochemical stool testing can answer the question.

Just as an FYI, if the nosebleed is severe, it is likely that you will end up getting your nose packed.

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The Problem with Universal Healthcare

I usually hit the delete key whenever I get a chain email... But this particular one caught my eye enough for me to read the whole thing. This story is probably impossible to prove or disprove (I tried to find the name of this professor), but the overall message was quite intriguing... enough so to share given its applicability to universal healthcare.

My healthcare commentary is provided after the end of the story below (to preface, I believe in a compromise of sorts... I guess I'm a centrist)...

An economics professor at a local college made a statement that he had never failed a single student before, but had recently failed an entire class. That class had insisted that Obama's socialism worked and that no one would be poor and no one would be rich, a great equalizer.

The professor then said, "OK, we will have an experiment in this class on Obama's plan".. All grades will be averaged and everyone will receive the same grade so no one will fail and no one will receive an A.... (substituting grades for dollars - something closer to home and more readily understood by all).

After the first test, the grades were averaged and everyone got a B. The students who studied hard were upset and the students who studied little were happy. As the second test rolled around, the students who studied little had studied even less and the ones who studied hard decided they wanted a free ride too so they studied little.

The second test average was a D! No one was happy.

When the 3rd test rolled around, the average was an F.

As the tests proceeded, the scores never increased as bickering, blame and name-calling all resulted in hard feelings and no one would study for the benefit of anyone else.

To their great surprise, ALL FAILED and the professor told them that socialism would also ultimately fail because when the reward is great, the effort to succeed is great, but when government takes all the reward away, no one will try or want to succeed. Could not be any simpler than that. (Please pass this on) These are possibly the 5 best sentences you'll ever read and all applicable to this experiment:

1. You cannot legislate the poor into prosperity by legislating the wealthy out of prosperity.
2. What one person receives without working for, another person must work for without receiving.

3. The government cannot give to anybody anything that the government does not first take from somebody else.

4. You cannot multiply wealth by dividing it!

5. When half of the people get the idea that they do not have to work because the other half is going to take care of them, and when the other half gets the idea that it does no good to work because somebody else is going to get what they work for, that is the beginning of the end of any nation.

Healthcare is complex, but for simplicity's sake, universal healthcare is a type of socialism/communism... Medical care costs a LOT of money... It's not fundamentally free.  As such, if everybody universally can get free healthcare coverage, somebody has to pay... which typically means those who are wealthier ends up paying for those who can't afford it.

This also means that universal healthcare cannot provide "expensive" treatment for everybody... whether it be cancer treatment, the latest robotic throat surgery, or the newest type of test.

Rather, in order to pay for healthcare given to those who otherwise would not have any, healthcare coverage at the top end is decreased which includes the latest and greatest types of medical treatment.

As such, the "wealthy" will not only grow resentful for paying into this universal healthcare, but also because they would not be able to obtain the greatest medical care due to lack of coverage in such a system.

So, the wealthy will flee this system in some way... but with the exit of the wealthy, there will be less money in the system to pay for universal healthcare which would lead to an overall decrease in coverage for everybody else still in the system.

In some ways, we already do have a form of universal healthcare for those who can't afford it in the form of Medicaid and Medicare. Those who work (the "wealthy") pay taxes to fund these programs for those who do not work or are too poor to afford healthcare.

These programs DO provide good BASIC healthcare services. But these programs also do NOT pay for the latest and greatest in medical treatment either... Such treatment even extends to the doctors you are able to see. Some physicians no longer accept Medicare or Medicaid insurance as reimbursement for services are too low.

When looking into the origin of this story (which appears to have surfaced in 2009), I encountered another similar story:

A young woman was about to finish her first year of college. Like so many others her age, she considered herself to be a very liberal Democrat, and among other liberal ideals, was very much in favor of higher taxes to support more government programs, in other words, redistribution of wealth.

She was deeply ashamed that her father was a rather staunch Republican, a feeling she openly expressed. Based on the lectures that she had participated in, and the occasional chat with a professor, she felt that her father had for years harbored an evil, selfish desire to keep what he thought should be his.

One day she was challenging her father on his opposition to higher taxes on the rich and the need for more government programs. The self-professed objectivity proclaimed by her professors had to be the truth and she indicated so to her father. He responded by asking how she was doing in school.

Taken aback, she answered rather haughtily that she had a 4.0 GPA, and let him know that it was tough to maintain, insisting that she was taking a very difficult course load and was constantly studying, which left her no time to go out and party like other people she knew. She didn't even have time for a boyfriend, and didn't really have many college friends because she spent all her time studying.

Her father listened and then asked, 'How is your friend Audrey doing?' She replied, 'Audrey is barely getting by. All she takes are easy classes, she never studies, and she barely has a 2.0 GPA. She is so popular on campus; college for her is a blast. She's always invited to all the parties and lots of times she doesn't even show up for classes because she's too hung over.'

Her wise father asked his daughter, 'Why don't you go to the Dean's office and ask him to deduct 1.0 off your GPA and give it to your friend who only has a 2.0. That way you will both have a 3.0 GPA and certainly that would be a fair and equal distribution of GPA.'

The daughter, visibly shocked by her father's suggestion, angrily fired back, 'That's a crazy idea, how would that be fair! I've worked really hard for my grades! I've invested a lot of time, and a lot of hard work! Audrey has done next to nothing toward her degree. She played while I worked my tail off!'

The father slowly smiled, winked and said gently, 'Welcome to the conservative's philosophy.'

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How Much Radiation Exposure Occurs with a CT Scan? X-ray? Sunlight?

A common concern now is how much radiation exposure occurs with common radiological testing such as x-rays and CT scans, especially given the small increased risk of cancer with accumulated exposure over years.

Of note, ultrasounds and MRI scans do not emit radiation. MRI scans use magnets while ultrasounds use sound waves in order to obtain imaging information.

So, here's a chart comparing such tests with common environmental radiation exposure such as sunlight. Information taken from www.X-RayRisk.com:

Radiation	Amount
Sunlight (high-altitude city)	6 mSv per year
Sunlight (sea-level city)	3.1 mSv per year
Frequent Flyer	1 - 6.7 mSv
Single Airflight coast-to-coast	0.01 - 0.03 mSv
Smoke 20 cigarettes per day	53 mSv
CT Chest	7 mSv
CT Head	2 mSv
Nuclear Stress Test (Technicium)	9.4 mSv
Nuclear Stress Test (Thallium)	40.7 mSv
Barium Swallow	5 mSv
Mammogram	0.4 mSv
Chest X-ray	0.1 mSv
Dental X-ray (Bitewing)	0.02 mSv

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Sinus Mass Chance Finding (Incidentaloma)

The New York Times published a great story on the dreaded incidentaloma on Jan 17, 2013. An incidentaloma is essentially a chance finding of a mass most likely benign, that was incidentally discovered on a CT or MRI scan ordered for a completely different reason.

With such incidentalomas, it leads to patient anxiety causing physicians and surgeons to order even more tests and procedures (which themselves may lead to other incidentalomas). The vast majority of such incidentalomas are "nothings" without any significance, but hard to persuade patients otherwise at times.

In the ENT world, incidentalomas are very common when CT and MRI scans are performed of the head for a headache, stroke, eye pain, dizziness, or some other non-sinus related complaint.

In the report, there is the statement of:

"There is an opacified mass inside the right maxillary sinus cavity [or some other sinus cavity] two centimeters [or larger] in size."

Compare the above CT scan (red arrow pointing to the mass) with a normal CT scan of the sinuses below:

IF symptoms are localized to the corresponding mass on the CT/MRI scan, than further management which may include surgery can be pursued.

However, the vast majority of patients have absolutely NO symptoms localized to the corresponding abnormality. Radiologists and ENTs report that such a mass is most likely a benign mucosal inclusion cyst for which there is no significance and nothing more needs to be done.

However, some patients due to cancer concerns, even insist on having surgery to get it removed, even in spite of the risks associated with surgery including brain fluid leakage, eye damage, etc.

I personally usually insist a patient get a 2nd opinion prior to any surgical intervention for an incidentaloma if I'm pressured to "do something" when my gut feeling is to "do nothing."

Source:
The Fallout of a Chance Medical Finding. New York Times 1/17/13

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Parkinson's Disease Diagnosed by Salivary Gland Biopsy

Taken from Wikipedia

Currently, diagnosing Parkinson's Disease (a degenerative neurological disorder) is hard, usually a clinical exam and assessment of symptoms by a neurologist with at best about an 80% accuracy rate. There is no "test" per se that can diagnose Parkinson's Disease... until possibly now.

According to a study released in advance of its presentation at the annual meeting of the American Academy of Neurology, which will be held from March 16 to 23 in San Diego, Mayo Clinic researchers have determined a submandibular gland biopsy can offer 82% certainty whether a living patient has Parkinson's Disease or not. What is so special about this particular gland located under the jawline?

In patients with Parkinson's Disease, an uniquely abnormal protein called alpha-synuclein protein can be found.

In order to "biopsy" the submandibular gland which produces saliva, it does require a head and neck surgeon given the gland's location under the jawline. Beyond the usual risks of bleeding and infection present with any type of surgery, additional risks with this biopsy include:

• Permanent lip paralysis as the nerve that goes to the lower lip is located right over this gland.
• Permanent tongue paralysis as the nerve that moves the tongue is located right under this gland.
• Permanent numbness of the mouth floor as the nerve that provides sensation in this location is also located right under the gland.

Also, there are questions that need to be answered before this test is available more widely including:

How early in the Parkinson's Disease will this protein accumulate in the submandibular gland? If there is an "accumulation" time period, when is the best time to do the biopsy than?

Does the biopsy require a bloc of tissue or can a needle biopsy be sufficient (thereby reducing some of the surgical risks)?

Will insurance pay for this procedure?

Also, when is the paper going to be published regarding these results and can others replicate these findings? Here's the presentation abstract...

Source:
New saliva gland test may better diagnose patients with Parkinson's. FoxNews 1/11/13

Salivary Gland Biopsy as a Diagnostic Test for Parkinson's Disease. AAN 65th Annual Meeting Abstract

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Elbowed by Your Spouse While Sleeping? You May Have Sleep Apnea!

Canadian researchers have determined that if a patient answers in the affirmative to two questions:

1) Do you get elbowed/poked while sleeping for snoring?
2) Do you get elbowed/poked while sleeping for stopping breathing?

There is a significant chance that the patient may have obstructive sleep apnea (OSA) with AHI score  more than 5.

This quiz has been dubbed the "Elbow Test".

Actual diagnosis for OSA is by sleep study.

Should OSA be actually diagnosed on a sleep study, initial treatment includes CPAP machine followed by oral appliance and potential candidacy for surgical interventions.

Reference:
“Elbow Test” May Predict Sleep Apnea. Chest 10.22.12

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Why Can't Some Contact Dermatitis Be Diagnosed by Blood Test, EVER?

I often see patients for allergies who desire allergy testing due to mysterious hive-like rash on the skin, and given many are fearful of needles, they opt for a blood test like RAST or immunoCAP to diagnose what they are allergic to. Some would even argue that skin prick testing would not be diagnostic.

Though such blood tests have become remarkably accurate (skin prick is still the most accurate way to diagnose what a person is allergic to), there are profound and significant limitations.

In order to understand why, first a little biology lesson.

In "classic" allergy (Type 1 hypersensitivity), there are antibodies called IgE floating around in the blood. When such antibodies come into contact with what a person is allergic to, it causes mast cells to explode releasing bioactive chemicals that triggers the classic signs of allergy including runny nose, sneezing, and hives.

The timing of exposure to reaction is very short... within minutes.

In this scenario, the allergy blood testing is appropriate... because such testing measures the amount of IgE antibodies floating around in the blood.

Unfortunately, not all contact dermatitis is due to this biologic response.

There is another type of allergic reaction that can cause skin manifestations that is NOT mediated by IgE antibodies at all!

Known as Type 4 Hypersensitivity, special cells called macrophages initiate the "allergic" reaction when it detects an allergic substance.

This type of reaction occurs hours to days AFTER exposure.

Obtaining a blood test for allergies will NOT diagnose this type of allergic reaction because the test measures the level of IgE which is not involved in this type of reaction!

The ONLY way to test for Type 4 Hypersensitivity is skin patch testing, typically performed by dermatologists.

Patch testing is performed on skin where the dermatitis is not apparent (typically upper back). The allergens are mixed with a non-allergic material (base) to a suitable concentration which is then placed in direct contact with the skin within small aluminium discs. Adhesive tape is used to fix them in place. The patches are left in place for 48 hours. The patches should not be exposed to sunlight or other sources of ultraviolet (UV) light. After 48 hours the patches are removed and an initial reading is taken one hour later. The final reading is taken a further 48 hours later. Additional readings beyond 48 hours increase the chance of a positive test patch by 34 per cent. The patient should refrain from washing until the last reading is taken.

Some chemicals produce an allergic reaction only when exposed to light (usually ultraviolet type A). If this scenario is suspected, patch testing is performed, one while exposed to UVA light and the other hidden in darkness. A positive light-reaction is made if the patch exposed to UVA light causes a skin reaction whereas the one hidden in darkness looks fine.

What are some common chemicals/substances that cause Type 4 skin reactions?

• Balsam of Peru: an aromatic mixture made from resins and essential oils. It is found in the haemorrhoid preparation Anusol, some perfumes and certain spices. 
• Caine mix: local anaesthetics found in preparations for sore throats, sunburn remedies, haemorrhoid preparations, Wasp-eze. Used by dentists and doctors for minor surgical procedures. 
• Carba mix: rubber 'accelerators' (chemicals used to speed up the polymerisation process in the manufacture of rubber). It is found in rubber gloves, shoes, bandages and elastic. Of those allergice to carba, 85 per cent are also allergic to thiuram. 
• Chlorocresol: a substituted phenol preservative that kills bacteria. It is widely used in medications and some cosmetics. It cross-reacts with Dettol, which you should also avoid if you have a chlorocresol allergy. 
• Chromate: a metal used for plating other metals to prevent rusting and in the manufacture of stainless steel. It is also found in cement and tanned leather. 
• Cobalt: found in jewellery, dental implants, artificial joints, jet engines. Most patients are also allergic to nickel, and some are also allergic to chromate. 
• Colophony: present in adhesives, plasters, paper, printing inks, medicated creams, glue tackifiers (stamps, labels), and cosmetics. 
• Epoxy resin: plastics, used mainly as adhesives in the industrial setting but also by DIY enthusiasts. Found in two-component glues, such as Araldite. 
• Formaldehyde: preservative frequently used in household products and in industry. Often found in cosmetics and shampoo. 
• Fragrance mix: used in patch testing, this collection of eight individual fragrances detects about 75 per cent of patients allergic to perfume. If you have perfume allergy, you will not be allergic to all fragrances, but you cannot tell from the label which fragranced cosmetics are safe. Avoid all cosmetics listing 'parfum' as an ingredient on the label. Also found in air fresheners, washing powders and candles. 
• Lanolin: produced by sheep to protect the fleece from the results of weathering. It is widely used in cosmetics, medical creams and bandages. 
• Latex: most commonly found in gloves used by healthcare professionals.
• Mercapto mix/thiazoles: a rubber accelerator found in rubber shoes, insoles, gloves and elastic. It is also a component of balloons and bandages. 
• MBT (mercaptobenzothiazole): another rubber accelerator. Neomycin: an antibiotic commonly used in ear and eye drops and creams to treat infected skin problems. Cross-reacts with other antibiotics. 
• Nickel: 10 per cent of women and at least 1 per cent of men are affected by nickel allergy. Nickel is released from metals such as alloys or electroplated items. Found in jewellery, keys, coins, zips and buckles, pacemakers and batteries. 
• Parabens: preservatives found in cosmetics and topical medical products to inhibit the growth of fungi and prevent slow deterioration. They are commonly used in cosmetics, household products, glue, shoe polish, shampoos and conditioners, sunscreens and medical creams. 
• PPD (paraphenylenediamine): a permanent hair dye that is very frequently used in hair salons and at home. Dyed hair cannot cause an allergy but the dye may do during application. Also found in skin paints, such as 'henna' tattoos, and occasionally in fur and leather dyes. Primin: a substance produced by the plant Primula obconica, a common houseplant. 
• PTBPF resin (para-tertiary-butylphenol-formaldehyde): a synthetic polymer used as an adhesive. It is often combined with leather or rubber to make shoes, handbags, watchstraps, hats and belts. 
• Thiuram (tetramethylthiuram disulphide or TMTD): another rubber accelerator that is also found in pesticides. People who are carba allergic often react to thiuram. Patients who react to the drug disulfiram (Antabuse), used for alcohol dependence, may also be allergic to thiuram. 
• Toluene sulphonamide formaldehyde resin (TSF resin): the commonest polymer in nail polish and a frequent allergen.

Given a patient often has no idea why, how, when a hive reaction occurs, it is important to obtain a good history to see if a reaction is immediate or delayed as it may influence what type of allergy testing may be required.

BUT, the key thing for people to remember is that allergy blood testing and skin prick testing can NOT diagnose all allergies due to intrinsic factors.

Skin patch testing may be the ONLY test to determine what that mysterious hive reaction is due to.

AND, now you know why!

For physicians, skin patch testing supplies can be purchased at www.dormer.com. However, your local dermatologist should be able to perform such patch testing (our office does not).

In our area, Dr. Moshell at Georgetown is the expert in this field.

Phone: 301-951-2400
5530 Wisconsin Ave, Suite 730
Chevy Chase, MD 20815

Another dermatologist in Northern Virginia who performs patch testing is:

Kurt Maggio, MD
7512 Gardner Park Dr
Gainesville, VA 20155
Phone: 703-753-9860

Robert Gurney, MD
11315 Sunset Hills Rd
Reston, VA 20190
Phone: 703-437-7744

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What is Asymmetric Nerve Hearing Loss

Given my last blog article regarding an ENT who got sued for not doing an MRI after audiogram showing an asymmetric hearing loss, the question that should be on everybody's mind is what IS asymmetric nerve hearing loss on a hearing test?

I am sad to report that there is no clear consensus on what is asymmetric nerve hearing loss.

First of all, at its most basic definition, asymmetric nerve hearing loss is when hearing is worse in one ear when compared with the opposite ear due to nerve damage.

Technically, hearing should decrease equally on both sides over time, but when one side gets worse faster than the other, it can cause concern because:

1) A tumor can be pressing against the nerve causing it to slowly fail faster than the other ear's nerve which is not compressed.
2) There is a loud noise history with asymmetric exposure to the ears. One example is hunting with a rifle where the left ear would repetitively get noise-induced damage from the gunshot in a right-handed shooter.
3) Bad luck

The conflict is at what point is an asymmetry considered significant enough to warrant a workup which may include an MRI scan of the head and/or auditory brainstem response (ABR)? Also, for a given patient history, a physician/patient may elect to recheck hearing bi-annually to monitor for asymmetric progression rather than pursue workup immediately (further studies being pursued only if asymmetry progresses over time).

Is asymmetry defined as 1 decibel difference between ears? Is it 50 decibel difference?

Even if the decibel difference is agreed upon, than over what frequencies? All of them or just a few of the frequencies?

So for the purposes of a "medically" significant asymmetric nerve hearing loss, the definition must define not only HOW big the difference in hearing loss is present between ears but also at what frequencies.

In one paper, it is 15 decibels at just 3000 Hz.

In another paper, it is 20 decibels at any two adjoining frequencies (or 15 decibels at two adjoining frequencies between 2000 and 8000 Hz).

Get this... even when criteria is defined, one study found substantial disagreement among five expert judges on what hearing tests they considered showed asymmetry.

Even insurance companies are jumping into the fray in what they considered significant enough to warrant covering the MRI scan. At one point when I ordered an MRI scan of the head for what I thought was a significant asymmetry found in one patient's hearing test, the insurance company denied the test citing "that there needed to be other neurological deficits PLUS the asymmetry seen on hearing test before MRI scan would be authorized".

I personally pursue further workup using the 20 decibel difference at two adjoining frequencies OR 30 decibel at one frequency.

Assuming medically significant asymmetric hearing loss has been defined and is present...

What are the chances of something bad going on (i.e., tumor) when an MRI scan of the head is ordered for asymmetry found on hearing test?

Less than 10% (depending on study, can be as low as 1-4%).

Given such a low positive yield on testing, why even pursue a MRI scan?

Because of defensive medicine to avoid being named in a lawsuit if the affected patient just happens to be within that 10% found to have an acoustic neuroma.

Indeed, in one study, 40% of ENTs stated medico-legal concerns factored into their decision to get an MRI scan of the head.

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Saliva Test for Laryngopharyngeal Reflux (LPR)

Various groups have been developing a fast, cheap, non-invasive saliva swab test to determine whether laryngopharyngeal reflux (LPR) is present or not. LPR may cause symptoms of:

• Hoarseness
• Chronic (ongoing) cough
• Frequent throat clearing
• Constant mucus or phelgm in the throat
• Dry or sandpaper like sensation in the throat
• Pain or burning sensation in the throat
• Feeling of a lump in the throat (globus pharyngeus)
• Problems swallowing
• Bad/bitter taste in the mouth (especially in morning)
• Asthma-like symptoms
• Ear pain and/or persistent ear infections
• Post-nasal drip
• Large lingual tonsils

When you compare a spit test to the current way of how reflux is determined via barium swallow, upper endoscopy (EGD), and 24 hour ph/impedance testing, it sounds quite attractive.

How does such a test work?

It basically looks for a stomach protein called pepsin.

Given reflux is when stomach contents moves up towards the mouth and pepsin is a protein ONLY produced in the stomach... pepsin should NOT be found in the throat/mouth.

As such, the test can state yes or no whether LPR is present or not.

How good is the test?

Depending on the study, sensitivity ranges in the 80-100% (can actually detect reflux if truly present) and specificity is around 85% (truly no reflux if test is negative).

One test company is rdbiomed using their Peptest kit.

Unfortunately, such testing is not offered in most labs except in Europe. (This test is currently not FDA approved and as such, is not even available for purchase yet in the United States. However, FDA approval is expected in 2014.)

However, we do offer this test in our office for current patients of ours. Click here for more info.

However, you can order this test yourself as an individual. It is recommended you take the standard 3 sample peptest. Click here for more information.

References:
Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope. 2005 Aug;115(8):1473-8.

Rapid salivary pepsin test: Blinded assessment of test performance in gastroesophageal reflux disease. Laryngoscope. 2012 Jun;122(6):1312-6. doi: 10.1002/lary.23252. Epub 2012 Mar 23.

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Chronic Cough Could be Due to Lung Cancer

BBC News recently reported that chronic cough may be due to lung cancer.

Here are my two cents on this condition in support of this assertion.

I often seen patients for chronic cough... not the kind that has been going on for only a few weeks, but the kind of cough that has gone on for over 1 or more years. Even 10-20 years.

It is not unusual for such patients to have seen an ENT, GI, pulmonary, and allergy specialists to try and stop their cough.

In particular, such patients may be informed their cough is not due to the lungs after getting a chest x-ray and pulmonary function tests which all come back normal along with lack of response to inhaler medications.

Unfortunately, some patients' chronic cough is due to lung cancer which is only discovered on additional studies including bronchoscopy and CT scan of the chest. Obtaining only a chest X-ray and breathing tests are not sufficient enough.

Now, it certainly is not necessary to perform these additional specialized studies in every patient who has been coughing for a few weeks... but when somebody has been coughing for over 1 year, a more intensive search for abnormalities is required.

In my clinic, it is not uncommon that a patient who has been coughing for over 1+ years ends up being found to have lung cancer.

Of course, there are other causes of chronic cough including reflux, allergies, post-nasal drip, medication side effect, etc that also needs to be looked into.

For more info on chronic cough.

Source:
Persistent cough 'could be lung cancer warning' BBC News 5/6/12

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Dental X-rays Linked to Brain Tumors

In a study spanning over decades, researchers have found an association between dental x-rays and increased risk of a non-malignant type of brain tumor called meningioma.

Of the four types of dental x-rays, only the full-mouth series was associated with this increased risk. More specifically, the risk was elevated with the aggregate number of full-mouth series in 10-year periods from approximately 15–40 years before diagnosis, with significant elevations in the 10-year periods beginning 22–30 years before diagnosis. The risks in these analyses were even greater when only women were considered.

One needs to be aware that radiation exposure from full-mouth series was much greater in the past than it is now and as such, this risk may be nominal (though not zero) with current dental x-ray technology.

However, it also should be a reminder that x-rays should not be routinely performed unless there is a very good reason to obtain especially in children who are more susceptible to radiation injury... and that applies to not only x-rays, but any kind of testing involving ionizing radiation including CT scans.

Some x-rays should NEVER be performed including sinus x-rays for sinus problems given a nearly 50% error rate in diagnosing the presence OR absence of sinus problems.

X-rays for nasal fractures is not recommended given x-rays rarely change how such fractures are managed.

Soft-tissue lateral x-rays to look for large adenoids should also be discouraged as nasal endoscopy can provide similar if not better information without any radiation exposure.

To know what the cancer risk is with different types of x-rays, check out this website!

Source:
Dental X-rays and the risk of intracranial meningioma. Cancer. Volume 100, Issue 5, pages 1026–1034, 1 March 2004

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New Video on Newborn Hearing Testing

Given how often we see newborns in need of hearing testing, we have produced a video showing how the two main types of non-verbal hearing tests are performed today: Auditory Brainstem Response (ABR) and Otoacoustic Emission (OAE).

Given newborns can not communicate whether they can hear or not, such hearing tests depend on the ability to detect nerve signals transmitting sound information from the ear all the way to the brain. This type of test is much like an EKG which can detect the electrical activity of the heart.

Watch the video to see how ABR and OAE hearing testing works in infants (as well as adults)!

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