Do Ear Candles Actually Remove Earwax? [video]

About once a week, I have a patient who presents to my clinic with a history of ear candling for earwax removal due to clogged ear sensation.

About once a month, I have a patient with ear canal and/or eardrum damage due to using an ear candle in an attempt to remove earwax.

I even have on occasion patients who I thoroughly remove earwax under the microscope, who than go home, perform an ear candle, and inform me of all the "earwax" that I missed.

Well... I've decided to make a video (see below) illustrating how ineffective ear candling is in removing earwax as well as how it could be even harmful. The other aspect of this educational video is to show how misleading ear candling is when it comes to earwax.

Please note that we are aware that the  "official" way to use an ear candling is small end down into the ear, but for this video, we have elected to use it the way most "lay" public would (small end up).

[SPOILER ALERT!!! A burning ear candle actually creates debris that looks like earwax. As such, an ear candle "works" whether it is in the ear or not.]

References:
Ear candles: Efficacy and safety. Laryngoscope 106 (10): 1226–9.

Ear candling: Should general practitioners recommend it? Can Fam Physician 53 (12): 2121–2. PMC 2231549. PMID 18077749.

Ear candles can be purchased on Amazon.com for you to "experiment" with.

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ENT Uses Laser Resulting in Patient Death

In 2010, an ENT used a Sharplan laser with an Omniguide Sidefire Adapter to address a superficial lip hemangioma.

The tip of the laser probe was inserted through a small incision made to one side of the hemangioma and activated. Seconds later, the lip and surrounding tissues immediately swelled up indicating trapped gas. A second incision was made in an attempt to release the buildup of gas (analagous to popping a balloon to release air). A short time later, the patient's vital signs dropped and in spite of life-saving measures, was pronounced dead within 2 hours.

The official autopsy report declared death due to "arterial embolism." [link]

What happened?

In the operation of the Sharplan laser, there are two channels present in the laser probe. One channel carries the laser and the other channel carries compressed helium gas that flows over the probe tip to cool it down (a laser is essentially a very focused beam of light and is quite hot... just like direct sunlight which is unfocused).

The helium gas pressure flow can be varied between 50-70 psi (pounds per square inch). Just for a frame of reference, car tires are pressurized to about 35 psi.

What essentially happened at the time of the procedure was helium gas built up within the lip under too high a pressure. Some of this helium gas (as a bubble) entered the blood stream where it blocked blood flow to vital organs like the brain and/or heart resulting in death

To prevent this complication, when using a Sharplan laser, the manufacturer specifically states to keep the probe perpendicular and at least 5mm away from contact with soft tissues. The probe should be completely away from any blood vessels.

I did want to add that Sharplan lasers are no longer made. In fact, it is also appears that the company that makes this laser no longer exists.

Take home message?

A surgeon should be the master of the tools he uses. Not understanding the operation of a tool can lead to unintentional, but disastrous mistakes.

Secondary message?

Lasers are dangerous, even if used properly.

There's a reason why many ENT's (including myself) have voluntarily elected to no longer use lasers at all for any purpose. Lasers introduce additional risk to a procedure that can be performed in alternative and safer ways with just as good an outcome.

It's not just arterial embolism that can occur. Lasers can also cause life-threatening hemorrhage from blood vessel damage (death of a 5 years old child), airway fire (laser can ignite oxygen), blindness (laser can reflect off metal surfaces and bounce into somebody's eye), etc.

Smart Laser, Dumb Surgeon

If lasers must be used, depending on the procedure, there are two different "styles" of laser that can be utilized. For simplicity's sake, I'll describe these two laser types as:

1) Smart Laser, Dumb Surgeon
2) Dumb Laser, Smart Surgeon

For style #1, the "smart laser, dumb surgeon," the laser is used much like the flash of a camera. You just have to aim the laser in the general vicinity of whatever it is the surgeon wishes to address, typically a vascular lesion like a hemangioma. When the laser is activated (typically a KTP or PDL laser), the laser selectively attacks the lesion without damaging the surrounding tissue. The surgeon is "dumb" in that all he has to do is crudely aim the laser in the general vicinity and the "smart" laser will do the rest. Watch a video of this type of laser in action here.

For style #2, the "dumb laser, smart surgeon," the laser (typically a CO2 laser) is used more like a handgun. It needs to be precisely aimed, precisely activated, precisely used. If the surgeon makes a mistake in aim, activation, or use, unintentional damage (and even death) may occur. The surgeon has to be "smart" in that he needs to precisely guide the "dumb" laser which will destroy anything in its path.


Source:
California Health and Human Services Department of Health Report. Report completed 12/3/10. Received by Licensing & Certification Office 6/15/12.

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Fake Botox Being Sold to US Physicians: FDA Sends Warning

It is not just patients trying to save money when purchasing medications from online pharmacies located in Canada. It's doctors as well when it comes to expensive drugs like Botox made by Allergan which costs a physician practice $550 per vial (2012 price)... but if purchased from Canada, may cost hundreds less.

Unfortunately, just like prescription drugs purchased outside the US, foreign-purchased Botox may be a product that is potentially unapproved, counterfeit, unsafe, or ineffective. Indeed, medical practices that purchase and administer such illegally obtained and unapproved medications from foreign sources are placing patients at risk and potentially depriving them of proper treatment.

To address this dangerous practice, the FDA has alerted more than 350 medical practices that they may have received unapproved medications, including unapproved versions of Botox from foreign-based suppliers, especially from Canada.

Disclaimer! Our practice has ALWAYS purchased Botox directly from Allergan, the maker of Botox, and have never purchased Botox from a third party supplier, whether US-based or not, past and present.

The ones the FDA specifically listed on a watch-list of sorts under the umbrella of online Canada Drugs include:

• Quality Specialty Products (QSP)
• A+ Health Supplies
• QP Medical
• Bridewater Medical
• Clinical Care

Per the FDA, "many, if not all, of the products sold and distributed by these suppliers have not been approved by FDA. Therefore, FDA cannot confirm that the manufacture and handling of these products follow U.S. regulations or that these medications are safe and effective for their intended uses."

The FDA has also publicly released the names of physicians and physician groups who have purchased from these online sources... public humiliation in order to persuade a change?

However, it may not be just public humiliation, but even jail-time for one physician in a particularly egregious case (Botox not meant for human use was deliberately and knowingly injected).

It's not just doctors, but even medical institutions on the list (ie, University of SW Texas Medical Center).

Source:
Letters to Doctors about Risks of Purchasing Unapproved Versions of Botox and Other Medications from Foreign or Unlicensed Suppliers. FDA 12/19/12

FDA warns doctors of counterfeit Botox. Fox News 12/24/12

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How Can Nasal Obstruction Cause Post-Nasal Drainage?

Before talking about the nose, consider the way some home humidifiers work. There is a sponge, water supply, and airflow. Humidification occurs by having a fan blow air though the sponge that is soaked by a constant water supply. As the air passes through the wet sponge, evaporation occurs resulting in air humidification.

Well, the same thing occurs inside the nose. In a normal nose, about one liter of moisture is produced by the nasal mucosa every day (water supply). This nasal moisture production is what allows the air to be humidified as a person breathes (the fan) through the nose.

However, when the nose is obstructed preventing a steady airflow, there is a corresponding reduction in evaporation allowing for more moisture to be present inside the nose. With increased moisture, it may lead to the perception of increased post-nasal drainage.

So, how can post-nasal drainage be corrected in this situation?

Well, one can try to decrease nasal moisture production using medications like decongestants, anti-histamines, and/or nasal sprays. Or, one can try to alleviate the nasal obstruction to increase nasal airflow leading to increased evaporation thereby reducing the amount "drainage" (which actually is normal "water supply").

Alleviating nasal obstruction can also occur with decongestant, allergy, and nasal spray medications, but if there's not much improvement, one can consider surgical options if there are anatomic factors present.

Such intra-nasal anatomic obstructions include deviated septum, turbinate hypertrophy, adenoid hypertrophy, nasal polyps, etc.

There is a specific surgical procedure that can address each of these issues if present.

Of course, nasal obstruction does not automatically lead to post-nasal drainage. But it is only one of many other factors that may be present that can lead to this complaint.

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Does WaxVac or EarVac Actually Remove Earwax?

The EarVac or WaxVac is a device that purportedly suctions out earwax. Shaped like a miniature hair dryer, one simply needs to hold it up to your ear canal in order to suction out the earwax. Recently, they have been marketing this device heavily, especially through TV commercials.

Now, does it actually work???

Not really... In fact, British researchers tested it out against the humble ear curette (Jobson-Home Probe). With their test population, the WaxVac worked in exactly ZERO percent of patients. The ear curette worked 100% of the time to restore eardrum visibility and 88% for subjective hearing improvement for the patient.

Why would the WaxVac work so poorly?

Think of a handheld vacuum cleaner. Even for a regular vacuum cleaner, it will only suck up debris only when it is right on top of it. One can't "vacuum" out a bedroom simply by holding the vacuum cleaner at the bedroom door entrance or hovering it around in the bedroom. The vacuum needs to be placed DIRECTLY over debris in order to suction it out.

Well, the same goes for the WaxVac.

Even when the ear canal is professionally vacuumed by an ENT under the microscope, it only works with some earwax types... and doesn't work at all for other earwax types.

I also wanted to point out the danger of using an WaxVac which has the potential to create high negative pressures when sealed up against the ear canal entrance which could lead to eardrum perforation as well as permanent hearing loss (similarly to kissing ear syndrome).

As such, I personally do not recommend this product. However, should you decide to purchase it, I would strongly urge people to do their homework before buying this unproven device. Even if it did work, beware that the company seems to make their money by scamming people with shipping charges [link]. 

Reference:

A non-randomized comparison of earwax removal with a 'do-it-yourself' ear vacuum kit and a Jobson-Horne probe. Clin Otolaryngol. 2005 Aug;30(4):320-3.


Watch how earwax is cleaned at an ENT office video.

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New Anti-Meth Sudafed (Pseudoephedrine)

As anybody who suffers from nasal congestion and runny nose knows, the nasal decongestant medication Sudafed can only be obtained from behind the pharmacy counter after showing identification because Sudafed can be made into meth.

This restriction applies to not just sudafed, but any medication containing the active ingredient "pseudoephedrine" which is a precursor for most meth recipes.

Well, coming soon to a drugstore near you, a new nasal decongestant has been produced that can NOT be made into meth called Zephrex-D. It still contains the active ingredient pseudoephedrine.

Made by Westport Pharmaceuticals, Zephrex-D comes in a "tamper-resistant formulation that locks this active ingredient chemically so that it cannot be used in illicit methods of methamphetamine manufacture," but maintains full clinical benefits for patients.

This drug (30mg tablets) is currently available at several national and local drug retailers throughout Missouri with nationwide deployment in 2013. Combination drugs including Zephrex-D will also become available within the next year.

Obviously, this has the potential to ease purchase restrictions for nasal decongestant drugs.

Source:
Westport Pharmaceuticals launches Zephrex-D, a tamper-resistant PSE formulation. DrugStoreNews 12/4/12

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Keyword Optimization for Medical Websites

As a general rule of thumb, physicians are terrible at running a business... including their own practice. This unfortunate inability also extends to managing practice websites.

When it comes to websites, most physicians take the attitude of "if you build it, they will come" which is doomed to failure. The better way of phrasing it would be "only if patients can find you, they might come."

Finding you is the first step... And one important element of accomplishing this step are keywords.

Let's take the medical condition "eustachian tube dysfunction" which is an annoying malady of the ear causing symptoms of clogged ears, pain, hearing loss, fluid sensation, etc.

Now, if you are to build a webpage on this particular condition, there are some do's and don'ts.

DO embed keywords that patients will actually use when searching about this condition.

clogged, ears, hearing, loss, fluid, sensation, treatment, pain, infection, etc

DON'T use only keywords that medical healthcare professionals will use (though it can't hurt to also include).

eustachian, tube, dysfunction, myringotomy, tube, cochlear, hydrops, auditory, aural, etc

Sounds simple? It is... but it almost never happens! Common mistakes I see regarding keywords on medical webpages include:

1) What keywords? There aren't any!!!
2) Medical terminology used as keywords rather than descriptive terms a patient would use in a google search
3) Poor utilization of keyword ranking for a given webpage

What do I mean by "poor utilization of keyword ranking?"

Google and other search engines rank some keywords more highly than others. Such ranking of keywords depends on placement within the webpage's code.

Keywords found in the following locations are very important:

• Webpage document title (typically ends in .htm or .html). This is what the webpage document on the server is actually called.
• Title of webpage (words used in the title bar of the webpage)
• Meta keywords and description: Has become less important, but still wise to utilize.

Keywords found in the rest of the webpage including the body text is not nearly as important though still taken into consideration when the above have been addressed first.

Check out this humorous video made by Google regarding the importance of keywords:

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