Vaccine to Prevent Throat Cancer

Spread through oral sex, it is well established that human papilloma virus (HPV) types 16 and 18 cause the vast majority of throat cancer especially in men... even more than smoking and drinking alcohol. What was not known, but suspected, was whether in BOTH men and women the HPV vaccine Cervarix (made by GSK) or Gardasil (made by Merck) would help prevent throat cancer as effectively as cervical cancer for which it is FDA approved for.

At least for the vaccine Cervarix, a randomized, control, double-blinded, prospective study has shown that it highly protects individuals from HPV 16 and 18 infection in the mouth/throat. The vaccine efficacy was calculated to be 93.3%. The big assumption being that reduced oral HPV 16/18 would lead to a decreased risk of throat cancer.

It is for these reasons that BOTH boys and girls are encouraged to get the HPV vaccine. We are talking about protecting our sons and daughters from getting throat and cervical CANCER later in life.

To be clear, more study is needed to really PROVE that such vaccines prevent throat cancer. For full disclosure, the weaknesses of this current study are as follows:

• It was performed only in women (the study would need to be replicated in males)
• The study lasted only 4 years... the question is whether life-long protection is present or will booster shots be needed?
• Does Gardasil also work for oral HPV 16/18?
• Does reduced HPV 16/18 presence in spit actually translate to decreased risk of throat cancer
• It is suspected that vaginal secretions carry a higher HPV viral load than the penis leading to a higher risk of throat cancer in men performing oral sex on infected women. As such, the other questions that need to be answered is whether such vaccines will:
     • Prevent a vaccinated woman from giving HPV to the man as well as
     • Prevent an infected woman to actually infect a vaccinated man?
     • Or, does BOTH partners need to be vaccinated to prevent HPV throat cancer?

It is truly an exciting time when vaccines can be given to prevent not only infections like mumps or shingles, but also cancer!

As a reminder, the HPV vaccines ONLY work when given to children before they become sexually active. It is too late to give the HPV vaccine for sexually active adults (ie, it won't work).

Source:
HPV Vaccine Found to Help With Cancers of Throat. NYT 7/18/13

Reference:
Reduced Prevalence of Oral Human Papillomavirus (HPV) 4 Years after Bivalent HPV Vaccination in a Randomized Clinical Trial in Costa Rica. PLOS One

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Maggots in the Ear After Trip to Peru

Image from Wikipedia

Adventurous international travelers have to worry about malaria and safe drinking water, but for one 27 years old British woman, she also had to contend with a maggot infestation in the ear after a trip to Peru.

It was not quite the 57 maggots found in one Illinois woman, but apparently this traveler recalled walking thru a fly swarm in Peru and that one fly did briefly enter her ear canal. However, it was enough for the fly (New World Screwworm fly) to lay its eggs causing maggots to hatch and slowly eat away her ear canal causing severe pain and scratching sounds within her head.

Surgery was required to remove the maggots. Less aggressive attempts to remove would only cause the maggots to burrow even deeper into her ear/head. Potential damage from the maggots include permanent hearing loss for obvious reasons, but also facial paralysis and taste changes given the facial nerve and chorda tympani (taste nerve) pass through the ear as well.

Fortunately, all maggots were successfully removed without any permanent damage.

Source:

British Woman Discovers Flesh-Eating Maggots Inside Her Ear. Medical Daily 7/16/13.

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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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Treatment for Vocal Tremor

Vocal tremor is characterized by a rhythmic undulating vocal quality whenever talking, much akin to vibrato that can not be turned off. In the past, it was felt that use of botulinum toxin type A (botox) to treat vocal tremor was not possible nor realistic given the multiple muscle groups involved. This is in contrast to dystonias of the voice (i.e., spasmodic dysphonia) where only one muscle group is involved and is readily and easily treated with botox injections to the affected vocal cord muscle.

However over the past few years, several research papers have been produced that show that botox CAN alleviate (though not eliminate) vocal tremor both objectively and subjectively, though more than one site may need to be injected in order to produce vocal tremor relief. Such muscle sites include thyroarytenoid muscle, ventricularis muscle, lateral cricoarytenoid muscle, interarytenoid muscle, cricothyroid muscle, and strap muscles.

All these muscle sites are easily accessible either via, endoscopic guidance and/or EMG guidance alone. Indeed, physicians who already perform botox injections for spasmodic dysphonia should also be able to inject all the other muscle groups just as easily. [watch video]

Typically, "horizontal" vocal tremor is treated with thyroarytenoid, ventricularis, interarytenoid, and/or lateral cricoarytenoid muscle botox injections.

"Vertical" vocal tremor is treated with strap muscle botox injections.

Dosages are similar to that given to treat spasmodic dysphonia.

SO... for patients suffering from vocal tremor who do not respond well to oral medications (propranolol, primidone), consider botox injections!

Be aware that botox injections to treat vocal tremor may not be covered by insurance.

References:
A new paradigm for the management of essential vocal tremor with botulinum toxin. Laryngoscope. 2013 Apr 1. doi: 10.1002/lary.24073. [Epub ahead of print]

Botulinum toxin type A for treating voice tremor. Arch Neurol. 2004 Sep;61(9):1416-20.

Botulinum toxin for essential tremor of the voice with multiple anatomical sites of tremor: a crossover design study of unilateral versus bilateral injection. Laryngoscope. 2000 Aug;110(8):1366-74.

Tremor laryngeal dystonia: treatment of the lateral cricoarytenoid muscle. Ann Otol Rhinol Laryngol. 2004 May;113(5):349-55.

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Singer Carnie Phillips Suffered from Bell's Palsy

Image by InSapphoWeTrust from Wikipedia

In March 2013, singer Carnie Phillips (of the Wilson Phillips) revealed that she suffered from a sudden left facial paralysis due to a condition known as Bell's Palsy.

Through a series of tweets, it was apparent that it came fast and started improving within a week.

Thought to be due to a viral infection of the facial nerve, it is commonly treated with prednisone with or without an anti-viral antibiotic (ie, valtrex). For most patients, full recovery occurs, but in some, normal facial movement is never regained.

For more info on facial paralysis, click here.

Source:
Carnie Wilson of Wilson Phillips reveals she has Bell's palsy. LA Times 3/19/13

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PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus)

Only in kids, there is a VERY rare (and controversial) disorder where strep throat infections can rapidly lead to involuntary tics including chronic throat clearing, cough, head/neck movements, sneeze, etc as well as OCD behavior. Known as PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus), it is felt to be an autoimmune reaction triggered by antibodies produced by the body when fighting a strep infection. With this disorder, an evaluation with a pediatric neurologist is warranted.

However, what role if any an ENT may play is less certain. Obviously, the main ENT related concern is whether tonsillectomy and adenoidectomy is helpful.

Certainly, this surgery should be pursued if the child meets the guidelines of when T&A should be performed from an infectious standpoint in any child:

• 7 or more tonsil/strep infections within past 12 months OR
• 5 infections in each of the last 2 years OR
• 3 infections in each of the last 3 years

However, it has been demonstrated that T&A does NOT seem to affect the onset nor influence the neuropsychiatric course of a child suffering from PANDAS.

According to one research, no significant differences were found between children who had T&A and those who did not in terms of PANDAS classification, and OCD or tic severity. In fact, most children with PANDAS had surgery before onset of neuropsychiatric symptoms and surgery did not affect symptomology.

More info about PANDAS can be found here.

To find a doctor who is familiar with PANDAS, click here.

References:
Tonsillectomies and Adenoidectomies Do Not Prevent the Onset of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococcus. Pediatr Infect Dis J. 2013 Mar 20. [Epub ahead of print]

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What Reflux Meds are Best in Infants and Children?

Once a decision is made to start medications beyond the conservative ways of dealing with reflux, the most common reflux medications used to treat adults are also used to treat reflux in infants and children. They are the same exact medications, albeit at lower dosages.

Although the effectiveness of such drugs are clear in adults suffering from acid reflux, it is less so in children. As is true with so much of medicine, there's no clear answer to the question of what the best reflux med is for infants and children. According to one review of literature, the answer is decidedly mixed and variable depending on what outcome was looked at (subjective symptom improvement or objective test findings).

In fact, symptom improvement (or lack of) did not always correlate with objective test findings (24 hour testing, barium swallow, EGD, etc) of reflux improvement and vice-versa. The most common finding was reduction in reflux based on tests, but no significant improvement in symptoms. Such findings does bring into question whether the diagnosis of reflux was even accurate.

In any case, when looking at SYMPTOMS in infants (less than 12 years of age) use of proton pump inhibitors was decidedly not favorable (one study in support and 4 against). In children (over 1 year of age), proton pump inhibitors were found to be equally effective to alginates and ranitidine.

When looking at OBJECTIVE test findings, proton pump inhibitors were found to be equally effective in both infants and children compared with placebo, alginates, or ranitidine. For reducing histologic aberrations, proton pump inhibitors showed no difference compared with ranitidine or alginates.

Conclusion
If GERD symptom control is the main goal, proton pump inhibitors should not be used in infants. In older children, these medications are helpful but potentially no better than alginates and zantac which have better side effect profiles. As is true with most studies, more study is needed.

Reference:
Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011 May;127(5):925-35. doi: 10.1542/peds.2010-2719. Epub 2011 Apr 4.

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