New Video on "Where" Snoring Comes From and Treatment

Our office has produced a new video describing "where" snoring comes from determined by a simple procedure known as sedated or sleep endoscopy.

At its most basic definition, snoring is noise produced from a vibrating mucosal surface in the upper airway.

Though snoring can be defined simply, the tough question is WHERE are these vibrating mucosal surfaces? Because unless one can define WHERE the snoring is coming from, successful treatment can't be pursued definitively.

An office exam performed while a patient is awake is suboptimal as the patient is awake... and not snoring. As such, it is an educated guess where the snoring problem is stemming from.

To this end, there are three main levels where snoring can be produced and the best way to localize a snore is to perform the exam while the patient is asleep (induced by anesthesia) and snoring!

1) Nose
2) Mouth
3) Throat
4) All of the above

Watch the video to see how each of these areas can contribute to a person's snore as well as treatment options.

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Can What Makes a Lion Roar Help Human With a Weak Voice?

Researchers in Iowa have discovered what makes a lion or tiger roar so effectively. Apparently, there is a layer of fat within large feline vocal cords that makes the vocal cords especially prone to vibrate easily with minimal exhalation effort.

What import does this have to humans?

Well, there are patients who have a very weak voice due to vocal cord atrophy as well as vocal cord paralysis. Standard interventions include voice therapy as well as surgical procedures using an implant or injectable material in order to "bulk" up the vocal cord.

In fact... one such injectable material that has been used to inject into vocal cords is fat, typically taken from the belly of the patient!

Two points to keep in mind however...

Just like in lions and tigers, it DOES improve the vocal strength and volume to a patient who previously had a weak voice, may now have a much stronger voice after the procedure.

However, the second point is that by making the vocal cord "bulkier" you are making it thicker which can decrease the vocal pitch... just like a violin string where the thicker the string, the lower the pitch.

On another related note... human infants have fat within their vocal cords... that may be why something so small with tiny lungs can produce such a terrific loud cry!

Read a story in the NYT regarding this research here.

Reference:
Adapted to Roar: Functional Morphology of Tiger and Lion Vocal Folds. PLoS ONE 6(11): e27029. doi:10.1371/journal.pone.0027029

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Want to See a Specialist Doctor Who Does Not Take Your Insurance? There Are Options...

It is not unusual nowadays that a patient may want to see a specific medical specialist who unfortunately does NOT participate with their health insurance plan. This doctor is what is known in insurance parlance as a "non-par provider."

In this situation, there are two options.

1) The patient pays the medical bill (self-pay) and forwards the receipt to the insurance company who hopefully will reimburse the patient.

2) The patient can request a "Letter of Medical Necessity" from the primary care doctor to submit to the health insurance company requesting temporary non-participating provider (non-par) insurance coverage.

What does such a letter of medical necessity entail?

The best way to illustrate this course of action is to provide an example. In my practice, I offer several services that many other ENT specialists do not. As such, there are a large number of patients who travel from even as far away as Florida and Arizona to be seen in our Virginia office. Needless to say, many patients have health insurance plans that I do not participate with.

One such procedure is tonsil cryptolysis.

A sample "Letter of Medical Necessity" that a patient can request from their primary care doctor to submit to their insurance company is as follows (the same concept can apply to any type of procedure or specialist evaluation):

John Smith, MDCountry Lakes Family Practice

Dear [Insurance Company]:

I am writing this letter on behalf of my patient, Mary Smith (DOB: 01/01/1965), who has a 10 year history of cryptic tonsils with production of tonsiliths (tonsil stones) on a daily basis. 

Though this problem occurred intermittently during adolescence, it has recurred during adulthood and has become a chronic problem which has affected her overall quality of life.  These stones consist of debris collected in the crypts of the tonsils together with sulfur-producing bacteria which account for the acrid odor and taste.  

I believe Mary is a candidate for a minimally-invasive procedure called tonsil cryptolysis (coblation therapy).  This procedure uses a radio-frequency energy in combination with a conductive medium to form a low temperature (40-80° C) localized plasma field which allows the precise removal of affected tissue while maintaining the integrity of surrounding, healthy tissue.  This results in decreased pain and a significantly shorter recovery time as compared with more traditional methods of treatment.  This procedure can be done in the office under local anesthesia on eligible adult patients.

After an initial evaluation for candidacy, tonsil cryptolysis can be done in an office setting under local anesthesia.  Most patients (70%) require one session for complete amelioration of symptoms. 

As there are no area specialists offering tonsil cryptolysis, I recommend that Mary be evaluated and treated by a non-par provider, Dr. Christopher Chang of Fauquier ENT Consultants located in Warrenton, VA. Please provide temporary insurance coverage in order for Mary to be seen by Dr. Chang.

Sincerely,
xxxxxxx
Dr. John Smith

That's it!

If insurance declines coverage, than you are stuck with option #1 to self-pay if you really want to see a specific non-participating provider.

In any case, some unique services our office provides for which patients have requested non-par provider coverage include:

• Video/Audio Nasopharyngoscopy for Velopharyngeal Insufficiency
• Endoscopic Staple Diverticulostomy for Zenker's Diverticulum
• Botox Injections for Spasmodic Dysphonia
• Chronic Cough Evaluation
• Phlegmy Throat
• Chronic Throat Clearing
• Allergy Drops

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Singer Keith Urban to Undergo Vocal Cord Surgery

The year 2011 so far seems to be the year for vocal cord surgery in singers... John Mayer, than Adele, and now Keith Urban.

On Nov 3, 2011, it was announced that country singer Keith Urban will be undergoing vocal cord surgery to remove a polyp from his vocal cords forcing him to cancel/postpone upcoming concerts. Read ABC News report here.

A vocal cord polyp would cause a mild rasp in the voice that is worse in the upper pitch range and soft voice. Onset delays and pitch breaks are common.

There are several theories as to why a vocal cord polyp may form on the vocal cord in the first place. My personal favorite theory is as follows. At some point, an acute traumatic event to the vocal cord occurred stemming from a yell, cough, excessive singing, or laryngitis. Depending on what happens next determines whether a polyp or cyst develops. With a cyst, the mucosal vocal cord lining breaks down and during the healing process a cyst develops due to entrapped cells meant for creating lining. A polyp, however, is in essence a blistering of the lining. Vocal cord nodule for comparison's sake is just callous thickening of the vocal cord lining.

Traditional standard of care management of a vocal cord polyp starts with voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). The main reason is that with voice therapy alone, it is not uncommon that the polyp may resolve to point where the vocal quality becomes acceptable and stable. However, more often, only mild improvement occurs with persistence of hoarseness. At this point, surgical excision is recommended. Watch video.

With a polyp, it is simply grabbed and removed at its base. Typically no sutures are used to close the incision after excision, mainly because sutures tend to promote scar formation that can adversely affect the voice. After surgery, STRICT voice rest is mandatory to allow the body to heal the surgical wound site. After about 1-2 weeks, the patient is allowed to start talking in small increments under the guidance of a voice therapist until complete healing has occurred in about 4 weeks. However, the vocal cord lining is "brand new" and careful voice use is recommended for at least 6 months (absolutely no screaming, yelling, or excessive voice use) which risks mucosal tearing and recurrence. Eventually, the patient may use their voice without restriction. Both for 1 week before and up to 3 months after surgery, reflux medications are recommended for reflux prophylaxis. Why? Because if there's ANY acid that washes over the surgical site from a reflux event, healing will not occur properly (imagine putting some acid drops into the eye after eye surgery). As a reminder, though vocal cord polyps can be removed with surgical excision, they can recur if underlying abusive voice behavior that led to the initial formation is not addressed.

Read more about vocal cord polyps here.

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The Doctors TV Show Does Chronic Throat Clearing

The Doctors TV show recently did a segment on chronic throat clearing. The ENT expert who explained this very annoying condition was Dr. Reena Gupta, a well-respected laryngologist with the Osborne Head and Neck Institute.

During this TV show, Dr. Gupta provided the two most common reasons for chronic throat clearing which were post-nasal drainage and reflux.

At its most basic explanation, mucus can come from the nose down into the throat (post-nasal drainage) OR mucus can come up from the stomach into the throat (reflux). The end-result is a person desiring to throat clear the mucus up and out.

However, there are other causes which were not addressed by Dr. Gupta during the show.

Other reasons for chronic throat clearing include:

Medication Side Effect
Food Allergies or Sensitivities
Zenker's Diverticulum
Laryngeal Sensory Neuropathy
Anatomic Triggers
PANDAS
Non-Organic Tic

Read more about chronic throat-clearing here.

Watch the TV show segment here.

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ENT Position Available With Our Practice

Our practice is looking for a board-eligible or board-certified otolaryngology-head & neck surgeon sometime in 2014 time frame with guaranteed income that first year followed by partnership.

We are located in Northern Virginia about 45 minutes directly west of downtown Washington DC and is run by Dr. Chang in solo practice. The practice itself is located on hospital grounds situated in the lovely tree-lined rural city of Warrenton, VA where one can even see the Appalachian mountains from our office. Many city amenities are available within a short 15 minute drive but without the traffic and hassle of big-city congestion.

Interest in general otolaryngology is a must with sub-specialty interest even better. Some facts that may be of interest:

• Full-service ENT office with audiology, hearing aids, allergy testing, and allergy shots
• Near-monopoly services in terms of ENT and allergy in the region. 1 of only 2 otolaryngologists in the county… no otolaryngology services in counties to the West. 1 of only 4 allergists in the county 
• Office fully on electronic medical records
• Office on hospital campus (one office and no satellite offices to cover)
• Hospital and Radiology fully on electronic medical records & PACS, all accessible via iPhone and iPad
• BrainLAB image guidance available
• Office will possibly be moving to a brand new medical office building (still on-campus) in near future with in-house ambulatory surgery center. Ownership opportunity available for both.
• Aggressive social media participation
• Semi-rural, small-town environment
• Call would be 1:3 (with calls rarely occurring after hours)

If there's any interest, please call or email!

For more information about our practice, check out our practice website!

Please note...

We will not deal with recruiters.

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Magic Ears Club Founded by Fauquier ENT Hosts Halloween Party

The Magic Ears Club kicked off its existence with a first ever Halloween Party on October 29, 2011 where over 15 kids from elementary to high school ages who wear hearing aids co-mingled and played games while their parents talked amongst each other their experiences. Prizes and free hearing aid goodies were also distributed.

Dr. Catie Chalmers, audiologist with Fauquier ENT who founded the Magic Ears Club, stated that the purpose of the club is to help parents, as well as their hard-of-hearing children, connect, share, and provide support for each other.

Being a member of this unique club means being able to participate in practice-sponsored parties as well as meeting new friends who also have "magic ears" (aka, hearing aids).

Furthermore, members can participate over the internet in either open or closed forums hosted by Fauquier ENT where members can ask questions or provide other meaningful support to each other wherever and whenever they wish.

The open forum is through Facebook which is open to all who support our goals whereas the closed forum is hosted through Yahoo Groups and limited to ONLY those individuals who are patients of Fauquier ENT.

For more information, go to http://www.MagicEarsClub.com

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