John Mayer Undergoes Second Vocal Cord Surgery

On August 27, 2012, media reported that grammy-award winning singer John Mayer underwent vocal cord surgery for a 2nd time in an attempt to permanently remove a recurrent vocal cord granuloma.

Fans know that in September 2011, John Mayer announced the cancellation of a number of concerts as well as an album due to the development of a vocal cord granuloma of his voicebox. Read a blog article about this.

On Oct 20, 2011, he underwent surgery for the first time to remove the granuloma and was on strict voice rest for several weeks with plans to resume live singing in the first quarter of 2012.

Unfortunately, on March 9, 2012, it was found that his vocal cord granuloma had recurred in the same location. In a statement he publicly released:

"Because of this, I have no choice but to take an indefinite break from live performing. Though there will be a day when all of this will be behind me, it will sideline me for a longer period of time than I care to have you count down."

Well, it seems that whatever intervention pursued since March 2012 did not work completely given the repeat surgery.

Given this is his second surgery for the same problem, I suspect that not only was the granuloma removed, but perhaps steroid was injected into the wound bed to try and prevent the tissue growth that may lead to granuloma reformation as well as application of mitomycin C, a chemotherapy agent. Post-procedure treatment with PDL or KTP laser may also be pursued to ablate any proliferative blood vessels that my encourage granuloma formation. Botox may even have been injected to partially paralyze his ability to bring the vocal cords together to prevent phono-trauma to the site.

Is this unusual that his vocal cord granuloma recurred?

Unfortunately, it is not...

Vocal cord granulomas are benign masses that commonly are due to repetitive mild vocal trauma resulting in exuberant growth of a specific region of the voicebox lining. An imprecise analogy of what a granuloma is would be a keloid of the skin. Unfortunately, such repetitive mild vocal trauma includes talking/singing, hence the high risk of recurrence. The key to treatment is to allow the granuloma site to heal COMPLETELY prior to any further phonotrauma (ie, talking/singing).

That means strict voice rest.

Indeed, John Mayer stated (or wrote) after his most recent surgery:

"Silent for the next few months, no singing for probably six, but all signs point to this being the last step in getting to perform again."

Strict voice rest as well as voice therapy helps as it eliminates the repetitive phonotrauma that promotes regrowth. Reflux control is also essential with medications.

Surgical removal of the granuloma may have looked something like this video...

To summarize, the steps followed when a granuloma-like mass is discovered on exam is as follows:

1) Trial restricted voice use and reflux medications. Voice therapy also strongly recommended. Strict voice rest is preferred if possible.

2) If no improvement after a period of time, surgical excision to ensure it truly is a granuloma and not cancer or some other pathology

3) Follow-up with steroid injections to the granuloma site. Watch video below.

4) Botox injection can be considered which chemically prevents complete vocal cord adduction preventing the repetitive trauma to the granuloma site.

5) Re-excision may be required at which time mitomycin C application can be tried.

Read more about voicebox granulomas.

Source:
Surgery silences singer John Mayer for a spell. CNN 9/1/12

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Yoga Pose to Treat Ear Pain or Pressure

So here's something I learned about yoga...

There is a yoga pose called Karnapidasana which can supposedly cure ear pain and pressure gradually over time. The term derives from "Karna" meaning ear and "Pida" which means pain, discomfort, or pressure.

So... who knows? Give it a try... if you can physically do it safely.

DISCLAIMER: Not recommended for those who are not flexible. Also, not something I personally recommend to treat ear pain and pressure.

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Find an ENT Doctor App

If you have an iPhone or Android, get the ENTLink App... You can search for an ENT by current location or by zip code. The search can be narrowed to a specific specialty area (laryngology, neuro-otology, rhinology, etc) as well.

Of course, you can search for the same information from the website.

Download the app for iPhone and Android.

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Yet Another Sinus Dilation Device - AerOS Sinus Dilation System

Sinus dilation has become all the rage in the past few years to treat chronic sinusitis, especially since CPT codes for this procedure has become available as of January 2012.

The first company was Acclarent who coined the balloon sinuplasty term.

Next was Entellus who produced their simpler system (XprESS and FinESS).

Now, there is SinuSys who has produced a new way to dilate the sinus opening without use of a balloon like Acclarent and Entellus. It is currently pending FDA approval, but is used in Europe.

This new system is called AerOs Sinus Dilation System and utilizes an osmotic self-expanding technology. A "simple" two-step insertion and removal of the device is required. Once inserted, the device gradually expands via low-pressure osmotic pressure in about 60 minutes. At that point, it can be removed.

The device itself is 5mm in size and exerts pressure of 2.5 ATM. The diameter is 3mm before dilation that ultimately expands to 5mm.

Compare this with Acclarent and Entellus balloon devices which are inflated to 12 ATM pressure and expands up to 7mm in size (depending on the model).

My personal concern with this device is the small size of 5mm... the surgeon will have to be super-precise for placement, otherwise, it'll fall out or do nothing.

Also, I question whether a 2mm dilation will actually make any difference. Prior studies have established that 4-5mm ostia size really is the minimal efficacious opening size. Larger is better, especially when the uncinate process is still intact as it would be in pure dilation cases. More study is required.

In any case, when (or if) this new device becomes available in the USA is unclear. It's all up to the FDA now.

Reference:
Feasibility of an osmotically driven, self-expanding device for sinus dilation to treat chronic sinusitis. Poster Presentation

Assessment of the short term patency of the maxillary sinus ostium following dilatation with an osmotic device in a sheep model. Jerome E. Hester, MD, David Edgren, BS, Andrea Koreck, MD, PhD, Jason Fox, BS, Janie Mandrusov, PhD, East Palo Alto, CA USA (Annual Meeting of American Rhinologic Society, September 2012, Poster# P-7).

Treatment of Maxillary Sinusitis Using the SinuSys AerOsTM Sinus Dilation System. White Paper 

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How to "Grow" Clean Air

The New York Times published a story regarding how common houseplants can purify the air of chemicals like benzene and formaldehyde.

This claim is based on NASA research performed in the 1980s when the agency was trying to figure out ways to keep the air quality as clean as possible within enclosed habitats (like a space station).

Of course, you can read the 27 page report... or read a mom-friendly book that summarizes the findings in an easy-to-understand language from Amazon.com.

"How to Grow Fresh Air" by Dr. BC Wolverton


The book reviews 50 common houseplants' ability to clean the air inside the home or office. Depending on the plant, chemicals that can be removed include benzene, formaldehyde, xylene, toulene, trichlorethylene, chloroform, ammonia, acetone, and alcohols. Such chemicals are emitted from electronics, drywall, adhesives, upholstery, carpet, paint, cosmetics, etc.

It is suspected that such chemicals may be the cause of "sick building syndrome" that induces symptoms of upper respiratory irritation, fatigue, headache, and congestion when afflicted individuals enter certain buildings.

My personal favorite plants are the fern and peace lilly, both which have a high rate of chemical vapor removal, easy to grow and maintain, and fairly resistant to insect infestation. Does the job and easy to care for.

BEWARE!!!

Now before running to the nearest greenhouse and buying numerous plants to keep inside the home, consider that though such plants remove chemicals from the air, the plants themselves may exacerbate allergies in sensitive individuals.

Why? Plants can increase dust (accumulated on the leaves) and mold allergens (in the soil).


Source:
Really? Some Plants Can Filter Airborne Chemicals. NYT 9/3/12

Reference:
Interior Landscape Plants Indoor Air Pollution Abatement. NASA 9/15/89

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Website Development Help

Given how extensive the practice website is (250+ webpages; 1300+ if including blog), I often get asked by patients and other offices how did I go about developing it.

First off, I am fortunate that I have some computer programming skills and have been creating websites since the 1990s. I have decent HTML knowledge with a dash of CSS understanding. I am clueless with  making new javascripts, but know how to use ones that have been already created.

As such this baseline knowledge of mine is sufficient to extensively look for answers to questions using google and if necessary, plagiarizing code that accomplishes a task I require.

However, I also bring in help when I need it. I have a few absolutely awesome and reliable computer programmers I tap when I need it including Chris Ferrell with PettyGroveFull (New York City) and Chris Mohler (Memphis, TN) who is a freelance programmer. 

They are both diligent, fair, trustworthy, and provide regular feedback (I have never even met them face-to-face).

Chris Ferrell re-designed my entire website incorporating HTML5 and CSS3 a few years ago.

Chris Mohler than optimized the website further and enabled mobile viewing more recently.

For other programming tasks that Ferrell and Mohler are unable to help with (programmers have their areas of specialty just like doctors!), I go to Elance which is an awesome website where one can post a job ("I need somebody to redesign my blog and move it to Wordpress") and various contractors looking for jobs can than bid on it.

Just like Amazon.com, contractors have star ratings from prior clients.

And given the work is digital, the you can tap anybody in the WORLD... so bids can come from not only North America, but India and Russia.

As such, prices can be quite competitive and much lower than what one would expect given contractors are competing against everybody else in the world!

Indeed, I currently have an ongoing project I granted to a programming group in Indonesia. So far, so good!

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Wrong Site Surgery Performed by ENT

In 2010, an ENT performed a tongue tie release on a 5 years old child who was supposed to undergo a tongue lesion biopsy (apparently 1cm in size over the central dorsal tongue). Tongue tie release was NOT consented for nor discussed with the parents who expected a tongue biopsy to be performed instead. In the investigative report performed by the Department of Public Health:

"When the surgeon was asked whether he examined the patient in the preop area prior to the surgery, he stated, "Usually, I don't examine anybody. I sometimes visit... In this case, there was no time to do a pre-operative visit. From now on, I need to see the patient prior to the surgery." [link]

According to the record, time-out WAS performed. Consent WAS in the chart for a tongue lesion biopsy. Records indicated that all mandated check-lists and time-outs were performed.

So what happened?

1) Surgeon Error: Let's face it... the surgeon made a mistake. Ultimately, it is his responsibility to ensure that the procedure goes smoothly which by definition means doing the correct procedure.

Seeing patients before surgery probably would have prevented this error. Not seeing the patient prior to surgery is not good practice.

Even if a surgeon employs a nurse practitioner or a physician assistant to see patients for him in the office or in the hospital, before any surgery, he personally should examine and discuss the upcoming surgery with all patients.

As an aside, at least once per week, I have patients calling who desire to schedule surgery without wanting to see me first for a consultation appointment. There are many reasons why I mandate that a patient MUST first be personally seen by me in the office PRIOR to any surgery scheduling. Preventing this scenario is one good reason why.

2) Nursing Error??? If the nurses knew what procedure was supposed to be done (according to the report, they did)... they should have spoken up! If they were too afraid to speak up, they should have contacted management to speak up for them... or ask the anesthesiologist to say something.

After all, patient welfare supersedes all else. Having wrong site surgery is the exact opposite.

However, to be fair in this particular situation, I do not believe the nurses knew what the surgeon was doing. Why???

The procedure was being done inside the mouth and a small child's mouth at that... honestly, nobody except the surgeon and possibly the anesthesiologist can really see what the surgeon is doing. The instruments used for tongue tie release is very similar to what would be used for tongue lesion biopsy.

3) Time-Out and Check-List Error: In a typical day, there are so many time-outs and check-lists being performed that it starts to get muted into background noise. It's just like the alarms and blinking lights that I imagine an instrument panel of a sophisticated machine would be for somebody who stares at it all day, everyday. You hear/see it... but than you don't hear/see it.

What people notice are sounds that are unusual for a given situation.

For example, cars make all sorts of noises when being turned on and moving somewhere. However, most people don't actually "hear" the sounds being produced by the car because of our lack of attention to it, because it is repetitive and continuous.

However, if one day, the engine starts knocking, that certainly gets a driver's attention and remembered.

Time-outs and check-lists suffer from inattention... even if performed.

They are a wonderful tool, but utterly undependable for long-term use.

So what would work given it must be done per regulations??? My suggestion would be to mix it up to prevent it from becoming "background" noise.

Have the time-out performed by different members of the surgical staff on every case rather than the same person. Ring a bell before doing time-out one time. On another time, have everyone dance a short jig before doing it. Whatever is done, do NOT make it repetitive which otherwise risks being inadvertently ignored.

The key is to make it different and notable each and every time in order to focus attention and prevent the task from becoming muted into the background.

Source:
CA Fines 14 Hospitals for Medical Errors. Health Leaders Media 8/31/12

Reference:
California Human and Health Resources Department of Public Health Report. 5/18/11

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