A Single Sneeze Can Spread Throughout Entire Building

MIT researchers using high-speed cameras and applying fluid dynamics have discovered that although ejected droplets from a sneeze typically fall to the ground, the "cloud" of moisture from a single sneeze actually floats and can enter ventilation ducts and can potentially spread throughout an entire building or airplane. Watch video below.

These findings have profound implications as to how infections may travel within buildings and other contained structures like cruise ships and airplanes.

So although most people cover their mouths when sneezing in public, it also needs to happen in private even when there's nobody around. Of course, more study is needed to see if the sneeze "cloud" is even minimized with mouth-covering.

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Esophagoscopy without Sedation [VIDEO]

Here is a video demonstrating how esophagoscopy can be performed in the office without any sedation. The esophagus is the tube that connects the mouth to the stomach. The exam, called trans-nasal esophagoscopy (TNE), can be performed in any patient as long as the nose is large enough to accommodate the endoscope and lack a severe gag reflex. A very thin disposable sheath (like a condom) is used to protect endoscope and maintain sterility between patient use.

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What Does a Kiss Look Like from INSIDE the Mouth? [VIDEO]

Image from Wikipedia

A kiss is beautiful to behold and even better to give/receive... but it may be a matter of perspective, because what a kiss looks like from the inside is downright disconcerting. Check out this YouTube video...

On that note, I'm curious to know what kind of camera was used given it must have been tiny, and focus was unusually good given the varying focal length.

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

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

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

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

• Auto-focussing with adjustable zoom

• VERY good image stabilization

• HD video-recording

General Problems with Head-Mounted Video Recordings

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

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

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

Google Glass (or any eyeglass side-mounted camera)

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

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

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

Although doable, this is far from perfect or comfortable.

Central Head-Mounted Video Camera Systems

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

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

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

Overhead Mounted Camera Systems

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

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

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

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

Bed-Mounted Camera Systems

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

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

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

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

Conclusion

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

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Submental Intubation [video]

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

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

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

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

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

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Vocal Cord Tear Silences R&B Singer Frank Ocean

Image by Fred von Lohmann from Wikipedia

On July 25, 2013, R&B singer Frank Ocean was forced to cancel his entire Australian concert tour due to a small vocal cord tear.

After singing his opening night with a sore throat during which he reportedly sounded "noticeably off-key," he seeked medical attention and was informed of the unfortunate condition of his vocal cord. Listening to his voice on this YouTube video recorded during this fateful concert, his voice actually does not sound as bad as I would expect with a vocal cord tear. However, at time point 1:20, there was an obvious pitch break.

If a vocal cord tear was truly present, it must have been extremely small and not along the free edge because even with a small vocal cord tear located along the vibrating margin, the vocal quality would have been noticeably degraded throughout the vocal range. Why?


In order for the vocal cords to produce a clear voice, the vocal cords must come together and vibrate evenly. This vibration occurs on the vocal cord mucosa. ANYTHING that disrupts this mucosal vibration would result in a raspy voice including small bumps like a nodule or polyp, but also a vocal cord tear. Watch video of normal vocal cords in motion.

Small bumps typically cause problems in the voice only in the high range at quiet volumes because often the bump can vibrate along with the mucosa (just like a buoy on the ocean). As long as the vibration is unaffected, the voice comes out. As a bump gets bigger, a greater portion of the vocal range becomes affected.

A tear, however, depending on where it is located could affect the entire vocal range due to vibratory disruption as it moves to and around the tear (the tear acts like an anchored pillar in the ocean).

The only way to correct a tear is MANDATORY strict voice rest for several weeks. Further using the voice when injured like this may only "rip" the tear larger potentially causing a greater risk of scar formation and a permanent hoarse voice.

Strict voice rest means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the vocal cord tear preventing proper healing. I would even instruct patients to avoid even mouthing words as it causes the brain to "think" you are talking even if you are not. Essentially, the lips should always remain closed except when eating/drinking. The analogy would be if you have surgery done on the heel of your foot, you should not walk or put any weight on the heel, otherwise risk improper healing.

Here's an example picture of a vocal cord tear on both vocal cords in a patient suffering from viral laryngitis who did not quit using her voice for a prolonged period of time.

WHY would a vocal cord tear appear in the first place? Usually from excessively traumatic vocal abuse (ie, strong cough, scream, yell, etc).

Source:
Frank Ocean Suffers Tear to Vocal Cord, Scraps Australian Mini-Tour. Billboard Biz 7/26/13

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

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

Check the new (upgraded) video!

For more info about nosebleeds, click here.

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New Video on Tongue Tie Release Procedure

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

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

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

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Sinus Headache [video]

I could describe it... but I think it's better if you just watch the video...

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New Movie Trailer for Fauquier ENT YouTube

It has been an amazing experience with how successful our videos have been on YouTube. We now have 60+ different videos of ENT procedures that has been viewed over 247 million times since 2007. We also now have over 12,300 subscribers to our video channel.

To celebrate, a movie trailer of sorts has been created to introduce new viewers to the sort of videos they will see and will continue to see from us.

Check it out! And... if you haven't yet subscribed to our video channel, please do so!

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New Video on Awake Tonsil Cryptolysis to Address Tonsil Stones

A new video has been uploaded describing a minimally invasive technique to address tonsil stones called tonsil cryptolysis.

This technique accomplishes the same thing as laser cryptolysis but at lower cost and increased safety. Just like laser cryptolysis, this procedure can be done awake without any sedation using only local anesthesia (the caveat being that the patient must have minimal/no gag reflex with easy visualization of the tonsils).

Watch the video below or on YouTube. Read more about this procedure here.

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Woman Drinks Beer Through Her Ear

Now I am not sure if this woman is actually drinking beer through her right ear at a Czech beer festival as reported by Huffington Post, but is it anatomically even possible?

Well the answer is that it IS theoretically possible though highly improbable.

In order for this to occur, there must first be a hole in the eardrum. Given an eardrum hole, beer can be sucked up into the ear canal (1), through the hole in the eardrum (2), into the middle ear space (3), through the eustachian tube (4), and down into the throat.

Now why would it be highly unlikely that the women is drinking beer through her ear?

1) The eustachian tube opening is VERY small (< 2mm). Trying to suck beer through the eustachian tube would be even harder than trying to suck beer into the mouth through a coffee stirrer.

2) The video would have been more believable if she pinched her nose up when drinking beer into the ear.  The fact that she is not makes it unlikely adequate negative pressure can build up in the back of the nose to the point that it would suck beer up into the ear. Not pinching the nose is equivalent to trying to drink something up into the mouth WITHOUT making a tight lip seal around the straw.

Even if you could drink beer through the ear, you really shouldn't because...

1) Beer contains alcohol and if this touches the middle ear region which is very sensitive, there would be quite a bit of pain akin to alcohol touching an open skin wound.

2) Alcohol can also potentially lead to permanent hearing loss if drawn into the middle ear. It's the same reason why earwax removal drops specifically caution against using it whenever there's a hole in the eardrum.

3) Beer in the ear could lead to an ear infection.

4) Lastly, if the beer is not at body temperature, it could lead to severe dizziness due to a phenomenon known as caloric vestibular stimulation.

So... don't do it... even if you could!

Source:
Woman Drinks Beer Though Her Ear? Czech Clip Appears To Show Crazy, Dangerous Stunt (VIDEO). Huffington Post 5/14/13

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How the Voice Anatomically Reverberates to Produce Speech

Came across this old school animation showing how sound produced in the voicebox reverberates in the upper airway, mouth, and nasal cavity to produce speech that everybody else hears.

To watch what it looks like from the inside, check this video out.

Source:

FFFFound! 5/23/11

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Surgical Video Recording: How I Do It

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

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

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

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

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

So that's how I now do it!

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

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New Video on Thyroid Surgery and Its Complications

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

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

Read more about the surgery here or watch the video!

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Kim Kardashian Gets Allergy Testing

Celebrity Kim Kardashian of Keeping up with the Kardashians reality TV show underwent allergy testing with Dr. Mirmelli. Allergy testing was accomplished via skin prick (our office performs allergy testing by blood draw instead called immunocap).

She apparently was allergic to her pet cat...

Kim apparently decided to let her pet cat Mercy go... a decision in contrast to what most cat-allergic people do.

Watch the video.

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Haptic Hearing Aids... The Next Generation of Hearing Aids?

If you think about it, current hearing aids are essentially just a volume knob to increase the sound volume for those hard of hearing.

However, as any audiophile will tell you, sound amplification alone does not mimic "true" sound quality as perceived in the mind. True sound quality involves not just sound, but also "sensation." That's why people still attend concerts or spend thousands of dollars on audio equipment for home sound systems. It's not just "hearing" the sound, but also "feeling" the sound.

This may sound like a trivial matter, but let's consider gaming... In the past, when manipulating a character within a video game, it required the use of a joystick. However, when using a joystick to make the character shoot a gun versus swinging a sword, it "feels" the same to the gamer. The joystick does not provide any tactile feedback to reflect what is happening in virtual reality.

Enter haptic technology. With haptics, when shooting a gun in a video game, the joystick will actually jump backwards to mimic what actually would happen in reality. When swinging a sword in a video game, the joystick will actually provide resistance to mimic the feel of swinging a sword with its weight and air resistance.

Haptic technology has also made robotic surgery a reality given it is very important for the surgeon to know that when a robotic arm/finger touches a living tissue, the surgeon is able to "feel" whether the tissue is "soft" or "hard" in order to deliver the proper amount of pressure to cut or move human tissue around.

Now consider using haptics within hearing aids. Sound would not only amplify, but also provide tactile sound sensation via bone conduction. Sound should become "alive" and more realistic, just like the difference between using a plain joystick versus one that uses haptics. Furthermore, adding bone conduction to the air conduction essentially adds 2 additional "speakers" for a total of 4 speakers (2 speakers via air conduction and 2 speakers via bone conduction). And more speakers produces more depth and realism to the sound... just like a home movie theater system which can have up to as many as 8+ speakers.

Now does this actually happen?

Well, it so happens there are regular headphones (high-end of course) to be introduced later in 2013 that incorporate haptics and for those who have used it, the experience is utterly magical.

I quote from Forbes journalist Jason Evangelho,

"I was downright giddy. I had the strongest desire to re-experience my entire music library with these headphones. I was hearing and feeling elements of the music I never knew existed..." [link]

When playing a video game with haptic headphones,

 "each cannon barrage was brutal; hearing the rapid fire of an assault rifle was crisp, pronounced, exhilarating. I could literally feel the roar and hum of the engine through both my hands and my ears." [link]

The technology marrying sound with haptics has been introduced by ViviTouch (subsidiary of Bayer) who has dubbed it "ViviTouch 4D Sound."

They have also partnered with Able Planet to create an ITC (in-the-ear) hearing-aid like device for sound delivery using Able Planet's Sound Fit ear piece. Sound Fit itself is an interesting device in that unlike ITC hearing aids which requires molding, Sound Fit literally molds to any ear canal when inserted analogous to memory foam mattresses that conform to any body shape/type when a person lays down. No customization is required. Such a form fitting device in the ear canal is important as it can transmit vibrations to the bone around the ear more effectively.

I feel that if the technology holds up and wows enough people, it will be inevitable that such haptic technology (and even Sound Fit ITC) will soon become incorporated into high-end hearing aids rather than just high-end headphones as they are now.

Of course, I could also be totally wrong...

Source:
'Deaf People Will Hear Again:' How ViviTouch and Able Planet's Haptic Technology Will Change The World. Forbes 1/25/13

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Video of Epiglottitis

The normal epiglottis is a very thin flap of tissue that closes over the windpipe when swallowing preventing food/liquids from going down the wrong way. Shown by the blue arrow in the picture, when the epiglottis becomes infected, it can swell in size to even obstruct the airway leading to death by asphyxiation. Indeed, epiglottitis is what is thought to have killed our first President George Washington.

Fortunately, epiglottitis is quite rare ever since the introduction and regular use of the Hib vaccine in the 1980s. Although rare, it is a problem that still occurs intermittently even today. Each time I've encountered it in the past, I unfortunately was always in a situation whereby video recording of the endoscopic exam was not possible.

Until one day, a patient with epiglottitis did walk into my clinic and I WAS able to video-record the endoscopic exam.

Briefly, this patient developed a severe sore throat with difficulty swallowing that occurred suddenly over a 24 hour period of time. Patient reported the severe sore throat was localized to the base of tongue region.

Without further ado, here's the endoscopic examination both before treatment and than again 1 week later after a course of antibiotics and steroids.

Note the markedly swollen epiglottis before treatment. Even after treatment, the epiglottis is still mildly swollen though much improved. Normal is shown in the picture above.

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Video and Audio Recording with RCA Connectors: Primer for Surgeons

In the medical world, video recording of surgical procedures is not unusual, especially when it comes to endoscopy.

A camera attached to an endoscope throws up a live image to a screen for the surgeon (and others) to watch. Video output for recording is now standard in such situations.

The monitor where the endoscopy procedure is viewed itself contains video output plugs.

The endoscopy equipment itself like the KayPentax EPK-1000 contains not just one video output, but 3... Two S-video and one RGB.

As such, one could hook up literally any type of recording device and get a beautiful video copied into any type of media very easily whether laptop computer, VHS, CD, thumb drive, etc.

HOWEVER, audio recording simultaneously with endoscopy is not typically a built-in feature and as such requires some MacGyver action.

Why in the world would a surgeon want to record audio? Well, take ENT surgeons who perform vocal cord procedures where the voice is the main outcome measure. It would be great to be able to record not just the video, but the audio of the patient's voice as the procedure is performed.

So what to do?

The simplest way to record audio and video is to take a camcorder and record the screen. The camcorder will be able to record the video (via shooting the monitor) and has built in microphone to record the surrounding audio. One can also attach a lapel microphone and plug it into the audio jack of the camcorder if available.

The downside with this simple method is the video quality. You are after all recording a screen rather than getting the pure digital video signal which would provide the best video picture.

Well, the surgeon will need to obtain a digital AV converter box which has the ability to merge separate video and audio signals and merge it into a single AV signal that is then fed into a computer to record. With this setup, the computer is tricked into thinking the video and audio as coming from a single source like a camcorder.

The problem is that all AV converter boxes (as of Nov 2011) utilizes RCA audio ports (red and white).

One can not simply buy a microphone with appropriate RCA adapters and plug it into the AV converter box. IT WILL NOT WORK!

Why? Because RCA connectors contain no power. Typically, RCA connectors go from something that already has a power source like a DVD player, camcorder, or TV. The current crop of digital AV converter boxes assumes that the user is trying to copy a movie or show onto a computer.

But for the surgeon, that's not what is occurring.

We literally just want to connect a microphone (which inherently has no power supply) to the RCA audio ports on the AV converter box.

In order to do this, a power supply needs to be provided to the microphone BEFORE plugging it into the RCA ports.

What is this power supply unit? It's called a microphone pre-amp.

So the connections go something like this:

microphone on patient --> microphone pre-amp --> AV converter box --> computer to record

A variety of plug converters will be required in order to plug each component to each other.

For those who want to duplicate what I've specifically done, here are the components (Amazon links provided below):

1) Microphone - Olympus ME-51S Stereo Microphone
2) Microphone Pre-Amp - ART Tube MP Studio Mic Preamp
3) AV Converter Box - Canopus ADVC110 Converter

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Alternative Digital Archival System for KayPentax Strobe System

As a long-time user of the chip-on-tip all-digital KayPentax strobe system, I can certainly vouch for its amazing clarity of visualizing vocal cord pathology.

However, it's digital archival system to record, edit, and store video exams is to put it bluntly, subpar.

Which is why I've ditched that system, and put together a different one based on the Macintosh using its free (and included) but extremely powerful iMovie software which puts KayPentax's system to absolute shame. For those who know how to use iMovie, you know what I mean.

Potentially, this same setup can be applied to ANY medical imaging system.

What you need...

1) KayPentax Hardware:

• EPK-1000 Video Processor
• Strobe Light Hardware
• Chip-on-Tip Flexible Endoscope

2) Non-KayPentax Hardware (can be purchased on Amazon.com displayed below):

• Mac Mini
• Mic PreAmp (I use an Art Tube MP Studio)
• Canopus ADVC55 Converter Box
• Monitor
• Cables

In essence, you connect the KayPentax hardware together first.

Than add in the non-KayPentax hardware. The key most important piece of hardware that makes this all work is the ADVC55 Converter box.

This converter box essentially brings in the separate video and audio feeds from the KayPentax hardware and spits out a single AV signal that is transmitted to the Mac Mini via FireWire which iMovie interprets as a single audio-visual digital signal.

The video signal is obtained from the EPK-1000 Video Processor using one of its S-video out ports. The audio signal, which is amplified using the Mic PreAmp, is recorded from a microphone and split to the Stroboscope and another to the converter box.

Finally, the DIP switches on the converter box needs to be set as follows:

1 OFF
2 OFF
3 ON
4 ON
5 ON
6 OFF

That's it!

iMovie videos are than recorded, edited, and saved just like any other movie file taken from a camcorder.

Movie files can be saved by iMovie in any one of a variety of standard video formats that can be read by any computer. Super nice as a copy of the video file can be simply copied to a thumb drive and given to the patient. On the other hand, the KayPentax system records videos in a proprietary video format which first has to be converted to a standard video format before anybody else can play it. Annoying and time-consuming if a patient wants a copy.

Keeping the saved iMovie files secure is another story, but briefly, I would suggest encrypting the hard drive using Apple's built-in FileVault. Use WPA-2 Enterprise or 802.1x for WiFi connectivity, but best to just turn WiFi off completely. For those more advanced users, a secure networked RAID hard-drive can be used as a central storage repository for all saved video files which can be accessed by only those computers authorized.

Best to talk to your local IT expert to get the networking all set up and ensure it's all secure.

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