Flushing Ears with Cold Water Can Treat Somatoparaphrenia

Somatoparaphrenia is a condition whereby a person denies that a limb or an entire side of the body belongs to them, even if provided with irrefutable proof. This condition usually is accompanied by left-sided paralysis and anosognosia (denial or lack of awareness) of the paralysis often due to a parietal stroke.

What is interesting is that flushing the left ear with cold water (caloric vestibular stimulation) can temporarily treat/resolve somatoparaphrenia. Specifically, the protocol is flushing into the left ear canal 60cc of cold water (20 degrees Celsius) for one minute. During the stimulation, the patient is laid down and head tilted forward 30 degrees. If properly done, clear horizontal nystagmus with leftward slow phase can be seen for about 3 minutes.

Normally, flushing the ear in this manner is routinely performed as part of balance testing (ENG) to determine whether a person's dizziness is due to an inner ear problem or not.

In any case, how does vestibular stimulation help with somatoparaphrenia? I don't quite understand it myself, but according to one reference:

"vestibular input takes part in building up and updating the representation of egocentric space." [link]

Whatever that means...

References:
Can vestibular caloric stimulation be used to treat apotemnophilia? Med Hypotheses. 2007;69(2):250-2. Epub 2007 Feb 9.

Partial Remission of Hemiplegia and Somatoparaphrenia Through Vestibular Stimulation in a Case of Unilateral Neglect. Cortex Volume 28, Issue 2, June 1992, Pages 203–208

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Chin Strap May Help with Snoring

There is a relatively simple (and cheap) device that may help some people who snore called a chin strap. This lowly, humble, and low-tech device may benefit patients who typically snore when:

1) Lays on back, but not on side
2) Mouth-breathes when sleeping (but suffers no nasal obstruction)
3) Does not suffer from severe obstructive sleep apnea
4) Appears to be "slack-jawed" when sleeping (chin pushed back relative to upper jaw creating a pseudo-overjet dental appearance)

How (or more importantly why) does this device work?

When a person sleeps who also mouth-breathes AND has a chin that falls backwards, it also causes the tongue to fall back against the back wall of the throat causing a partial narrowing. It also causes the overall throat diameter to decrease causing the throat mucosa to loosen creating the perfect environment for snore production: a partially narrow airway resulting in negative pressure due to increased respiratory effort which triggers any loose mucosa to vibrate causing a snore sound.

A chin strap can be used to force the mouth closed into a more normal position (chin in normal forward position with teeth in normal occlusion). By preventing the chin from falling backward, it would prevent the tongue from falling backward. By preventing the tongue from falling backward, the partial airway narrowing could be avoided. By preventing the airway from narrowing, the throat mucosa would be more taught and less prone to vibrate as well as prevent increased respiratory effort and a "negative" pressure environment.

Where can you get one? There's a whole bunch that can be purchased on Amazon.com.

So there you have it... Of course, keep in mind that the chin-strap will NOT work for everybody as the snore production could be due to other factors unrelated to the chin, tongue, mouth position.

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Pediatric Sinus Development and Sinusitis

There is a tendency for any type of nasal drainage to be attributed to "sinusitis" in children. Especially in young children, "sinusitis" is a relatively rare cause for nasal drainage and congestion which is actually more commonly due to viruses and enlarged adenoids.

The reason why sinuses play a relatively minor role in nasal drainage and congestion is because sinuses are not fully developed in children. It probably is not until around the age of 7 years old that "sinusitis" starts playing a more major role in disease manifestations. And even than, viruses and enlarged adenoids still play a major role in sino-nasal discomfort and as such, antibiotics not typically warranted.

Take a look at sinus development from newborn to adulthood below. In newborns, sinuses are mere indentations in the facial bone (light green). Adult sinuses are denoted by the dark green/peach.

It is for these reasons that sinus x-rays (or radiological imaging in general) are not warranted in children under 2 years. First, there is not much there, and secondly, x-rays are notoriously poor at diagnosing true sinus pathology [more info]. From 2 years to adolescence, sinus x-rays provide some guidance as to the presence of possible sinusitis, but CT Sinus scans are the gold standard to evaluate sinus disease presence or absence.

With persistent sino-nasal symptoms in children in spite of medical management, nasal endoscopy can be performed to evaluate the nasal cavity as well as the adenoids. Initial surgical management include adenoidectomy with or without turbinate reduction. While sedated for surgery, allergy testing can also be performed. If symptoms persist after these interventions, a CT Sinus scan can be obtained and consideration for sinus surgery can be made. The reason why CT Sinus scans are not obtained earlier is because whether it comes back normal or not, management does not change unless there are unusual extenuating circumstances present (significant eye or facial swelling).

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What Caused Beethoven's Hearing Loss?

Image from Wikipedia

When Beethoven composed his 9th Symphony, it was an amazing accomplishment especially when considering he did so totally deaf.

It has been a medical mystery as to what caused his slowly progressive hearing loss to the point of deafness, but a recent publication suggests it was due to chronic low-level lead exposure consumed from wine tainted with lead.

FACT: High levels of lead were found deep in the bone suggesting chronic lead exposure over a long period of time.

FACT: Beethoven's physicians noted that he had alcohol dependence (profound liver damage was found on autopsy).

FACT: It is not unusual that wine in that time period was tainted with lead.

More significantly, the paper disputed the more common thought that his lead poisoning was due to taking excessive doses of lead-based medications administered by his doctor: lead was found deep in the bone indicating lead exposure over a long period of time and absence of physical exam signs/symptoms (ie, wrist drop) indicative of acute lead poisoning (lead consumed over a short period of time).

The paper also did rule out other causes of hearing loss including otosclerosis, autoimmune hearing loss, autoimmune inflammatory conditions, mercury poisoning, and syphilis.

Reference:
Lead and the deafness of Ludwig van Beethoven. Laryngoscope. 2013 May 17. doi: 10.1002/lary.24120. [Epub ahead of print]

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

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

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

Why might that be?

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

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

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

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

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

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

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

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Top 3 Reasons Why Your Child Can't Shake that Cough

Guest Blog Post by Dr. Julie Wei

Any parent who has lived with a toddler or preschooler knows the pain of hearing a child’s endless cough, daytime, nighttime, all the time... It seems as if the cough never clears up in a day or two, or after a cold, but may last for weeks. Even if it does clear up, it always seems to return without much warning, and can be more stubborn than your 4 year old about eating vegetables! If you are wondering why cough medications can't stop your child's cough, or for that matter, why inhalers for "asthma", another 10 days of antibiotics, and/or allergy medications are all not working, then continue reading. Have you dragged your child all over town to see yet another specialist to find out why they just keep coughing?

Here is what I explain to all families who come to see me about cough. Cough is an involuntary reflex, or protective mechanism the body has to get unwanted particles or irritants out of our airway. So if dust got into our windpipe, or a droplet of liquid goes into the airway accidentally while your child was drinking and trying to talk at the same time, or the phlegm that he/she gets with a viral illness... all of these things can make our children cough. While most children are thankfully not intermittently or continuously inhaling dust, or running around drinking with their head tilted while talking at the same time, the one frustrating thing about young children is the fact that they get 7-10 viral upper respiratory track illnesses, or colds every year. Each one of these “colds” last 7-10 days, and so pretty quickly, you can have a child with cold symptoms for a third of the year!

So... without further ado... the top 3 reasons why the cough is still hanging on...

NUMBER 3: Post-viral neurogenic cough or habitual throat-clearing. Whatever the reason was, your child started out having a bad cold and coughed due to being sick. Even after the fever and acute illness goes away after 7-10 days, their throat and voice box somehow stays irritated and they continue to cough. At some point, your child may not even realize that he/she is "coughing". Often these are children who are throat-clearing and not really coughing (more often in short annoying bursts, as often as every few minutes). If you no longer hear them "coughing" during sleep, but only when they are awake, then this is likely what your child has. These children often show no other signs of illness or discomfort. It's a difficult diagnosis to make and usually after all other reasons have been rules out. I often offer strategies to families to help break these habits such as creating a game (older than 3 or 4 years of age can do this) whereby a kitchen timer is used to help suppress the urge to "cough" starting from 30 seconds and working up to 5 minute intervals. School aged children who do not appear ill but have a “dry” throat clearing do very well with this exercise. Another option is when they get into a coughing fit, to distract them with chewing gum, having them count backwards from 20, hopefully distracting them from this habit.

NUMBER 2: Chronic Rhinosinusitis (CRS). Your child may have developed true chronic rhinosinusitis which means inflammation from thickening of the lining inside their sinus cavities and their sinus "plumbing" is clogged up. Chronic sinus inflammation is NOT a bacterial infection so antibiotics will not make it go away completely, even if it seems to decrease the cough temporarily. This usually occurs in children older than 4, especially if they have underlying test proven allergies to common aero-allergens like trees, pollen, grass, dust-mites, and other environmental allergens. Sometimes this is bad luck and develops after your child has experienced a terrible viral illness, such that the mucous membranes inside the nasal passages were so swollen that the natural drainage points that lead each sinus cavity into the nasal passage are blocked, which then leads to the inflammation inside the sinus. Since there is a built-in mechanism called the "sinopulmonary reflex", children who have inflamed sinus mucous membrane lining will likely continue to cough until the nasal passage and sinus mucous membranes are no longer swollen and healthy again. The only way to truly know if your child has CRS is for him/her to get a CT scan, a special imaging of their sinus cavities which can involve some radiation exposure. These children tend to complain of a stuffy nose all the time along with the cough, and can't blow anything out of their nose even if they try. Mothers always tell me that their child is stuffy and can’t breathe well, leading to snoring, fatigue, sometimes headaches.

NUMBER 1: The Milk and Cookie Disease (MCD). Your child is coughing because day after day, night after night, their larynx (voicebox) is bombarded with stomach content backwash (gastroesophageal reflux and laryngopharyngeal reflux) coming up to and irritating the voicebox. The voicebox which enables humans to talk is also designed to "cough" as a way to keep unwanted materials from entering our airway. If it did not protect itself by coughing, then we would aspirate and possibly get pneumonia. Find out how your child can live and eat in "A Healthier Wei" and fight the Milk and Cookie Disease, by minimizing dairy and sugar in the evenings and then his/her voicebox can rest and not be in "fighting" mode all the time. I have met thousands of children who have chronic cough not because they are sick, but because they were eating a diet or drinking beverages containing too much dairy and sugar, as well as possibly greasy foods and processed foods. All these items increase likelihood of reflux or backwash and assault on the larynx. If the voicebox is always on “alert” and ready to “fight” and protect the body, then it really can’t relax and rest. I believe that when this happens chronically from MCD, and let’s not forget those 7-10 colds and how they also lead to an irritated overreactive cough, then together, this child has no chance and probably will cough, A LOT! By making changes in diet and dietary habits in children, we can decrease the chance of stomach backwash coming up to irritate the voicebox and cause cough, then hopefully your child only coughs when it is truly because of a cold. Don’t take my word for it, try “A Healthier Wei”. You will likely notice at least much less coughing, and coughing ending much sooner after a cold. I also ask parents to stop dairy/milk for up to 1 week during the time their child is sick. This is when digestion is not at its best, and things get sour and gross in the stomach increasing chance for reflux and more cough.

by Julie Wei, MD, FAAP

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Why Do Culture Results Take So Long? [video]

One of the most common questions I get after obtaining a culture of pus whether from the ear or the nose is how long it takes before the culture results are back... especially when MRSA is a concern.

Does it take a few hours? 24 hours? Days?

Disappointingly, it can take up to 5+ days if not longer.

You want to know why?

Well, rather than explaining, watch a 6-minute video that explains the numerous steps that goes into providing a diagnosis after a culture has been obtained... in this particular case, ear drainage though the same steps apply to any culture obtained from anywhere else in the body.

Special thanks to Robin Earl who spent hours hanging out in the microbiology lab video-taping all the relevant video clips as well as Fauquier Health for allowing this video to be made!

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Why Do Biopsy Results Take So Long? [video]

One of the most common questions I get after a surgical procedure is how long it takes before biopsy results are back... especially when a mass was removed and there is a cancer concern.

Does it take a few hours? 24 hours? Days?

Disappointingly, it can take up to 7 days if not longer.

You want to know why?

Well, rather than explaining, watch a 6-minute video that explains the numerous steps that goes into providing a diagnosis after a mass is removed... in this particular case, a neck mass though the same steps apply to any mass removed from anywhere else in the body.

Special thanks to Robin Earl who spent hours hanging out in the pathology lab video-taping all the relevant video clips as well as Fauquier Health System for allowing this video to be made!

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Why Does My Voice Sound Different on Recording and Treatment Options

Every so often, I have a patient who presents to my office with a complaint that their voice sounds different on recording than what they themselves hear.

In particular, singers who come in state specifically that their vocal recordings sounds slightly flat when they thought they were singing in perfect pitch.

So why does this happen? Unfortunately, it is physics and fundamentally integrated to how the ear, skull, and sound transmission work. In other words, it can't be "treated" with surgery or medications.

What other people hear when you sing or talk is air conducted sound that gets transmitted through the ear canal, eardrum, middle ear bones, and ultimately to the cochlea hearing organ (pathway A).

Image by Chittka and Brockmann Modified from Wikipedia

The sound the individual singer/talker hears is not only sound transmitted via the air (pathway A) but also by vibration of the skull itself directly to the cochlea hearing organ bypassing the outer and middle ear completely (pathway B). The mechanical properties of the skull enhance the deeper, lower-frequency vibrations.

Therefore, when a talker/singer listens to a recording of their voice speaking/singing, the bone-conducted pathway that they consider part of their “normal” voice is eliminated, and they hear only the air-conducted component in unfamiliar isolation (what everybody else actually hears).

SO... what is a singer/talker to do if they are disturbed by the way they sound to others? Particularly, what is a singer to do when they always sing a little flat when they truly think they are singing in pitch?

One can wear earplugs in order to hear only bone-conducted vibrations and get used to their alter-voice and undergo speech/voice therapy. OR... accept that their voice IS different.

For singers, I highly recommend using HearFones Headsetwhich is a funny looking head device that allows an individual singer to hear what they really sound like and more importantly what the audience would hear! In addition, while using HearFones, the singer would be able to hear himself more predominantly over the rest of the ensemble thus helping him to improve the quality of his/her individual vocal quality output.

Over time, singers will be able to automatically adjust their singing such that they no longer will need such a device to sing in tune with others when in familiar surroundings. BUT... in new environments (new concert hall, outdoor arena, etc), it is not unusual that their singing may become off again...

This is why professional singers often wear earpieces that convey sounds recorded by microphones placed in the audience... and also why they sometimes sound flat and out-of-tune when they don't!

It's also why it is VERY important to rehearse in a new place before a concert.

On a related note, most individuals state that they do not "like" they way they sound on a recording. However, according to one study, people unconsciously prefer their recorded voice over others.

Of note Dr. Chang was mentioned on NBC news regarding this question in this story.

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Why Does the Nose Whistle in Some People?

Though most people like the professional nose whistler shown here require an instrument to enable the nose to whistle, in others it occurs naturally due to unique anatomic features within the nose.

Why might someone's nose whistle?

Septal Perforation

The most common reason it may occur constantly is due to a hole in the septum (septal perforation). The septum is a wall that divides the right nasal cavity from the left side. Normally, it should be straight and without any openings.

However, when a hole is present in the septum and it is in just the right size and place, whenever air is breathed in and out the nose, it will whistle. In this situation, the hole is the "window" of the whistle and the nose itself is the mouthpiece.

Correction of this problem is by either closing the hole (septal button or surgery) or making it bigger such that the aerodynamics eliminate the conditions conducive to nasal whistling. As an FYI, surgical correction of a septal perforation is quite difficult.

Septal Deviation and Some Nasal Congestion

The other situation when the nose may whistle, but only intermittently, is when there is a deviated septum. In this scenario, the septum rather than being straight, it is slightly crooked to one side making one side more narrow than the other.

Add some slight swelling of the nasal lining such that the opening of the nose is restricted to just right size and shape, and it may whistle.

This type of nasal whistling is akin to grass whistling (blowing between two thumbs holding a blade of grass).

Thankfully, the nasal conditions that lead to nasal whistling is quite rare and requires the perfect storm of just the right amount of septal deviation with just the right amount of nasal congestion.

As such, correction of this problem is fairly easy as one needs to change either the congestion causing the nasal lining to swell with a nasal spray or anti-histamine OR fix the deviated septum. If the inferior turbinates are enlarged, they can be reduced in size as well.

Of course, one can take this unusual condition and make it a positive feature worthy of a concert hall... WITHOUT the assistance of any instrument!

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