ENT Health

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Tuesday, October 30, 2012

Elbowed by Your Spouse While Sleeping? You May Have Sleep Apnea!

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Canadian researchers have determined that if a patient answers in the affirmative to two questions:

1) Do you get elbowed/poked while sleeping for snoring?
2) Do you get elbowed/poked while sleeping for stopping breathing?

There is a significant chance that the patient may have obstructive sleep apnea (OSA) with AHI score  more than 5.

This quiz has been dubbed the "Elbow Test".

Actual diagnosis for OSA is by sleep study.

Should OSA be actually diagnosed on a sleep study, initial treatment includes CPAP machine followed by oral appliance and potential candidacy for surgical interventions.

“Elbow Test” May Predict Sleep Apnea. Chest 10.22.12

Wednesday, October 24, 2012

"Mother's Kiss" to Remove Nasal Foreign Bodies

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In 1965, a general practitioner Vladimir Ctibor described the "Mother's Kiss" technique of removing nasal foreign bodies in a child.

Essentially, a trusted adult (like a mother) places her mouth over the child's mouth as if to perform mouth-to-mouth resuscitation. While pinching off the unaffected nostril, the adult than blows gently into the child's mouth until resistance is felt caused by the child closing the glottis. At that moment, the adult gives a sharp explosive exhalation to deliver a strong puff of air that passes up into the nose and out the unblocked nostril. If successful, this air puff will also blow the foreign body out the nose as well.

If the adult blow's air when the child's glottis is open, air will just go into the lungs rather than up the nose.

Prior to the procedure, the child is informed that the mom will give the child a "big kiss," hence the name of this procedure.

Now... does this technique actually work?

According to one meta-analysis, it works about 59.9% of the time.

The way I consider it... it can't hurt to try before using instruments to manually remove the nasal foreign body. A "mother's kiss" is certainly a more comfortable and familiar approach for a child versus the alternative.

However, one warning point... the child should be calmly breathing during this procedure. If the child becomes hysterical during the procedure, the child might strongly inhale through the unblocked nostril and potentially suck the foreign body (if small enough) down into the lungs making an unlucky situation into a medical emergency.

Another point for those uninformed... do NOT use this procedure on ear foreign bodies. It will NOT work. The ear canal is a closed container with no inlet or outlet for any air pressure produced by a "Mother's Kiss." In fact, trying to perform this procedure on the ear may cause a ruptured eardrum and even permanent hearing loss.

Removal of Foreign Bodies from the Nose. NEJM 1985; 312:725.

Efficacy and safety of of the "Mother's Kiss" technique: A systematic review of case reports and case series. CMAJ 2012. DOI:10.1503/cmaj.111864 (full length pdf)

Tuesday, October 23, 2012

What do Earthquakes Have to do with Thyroid Masses?

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I'm not sure what is going on within the Italian Court system, but in October 2012, the Italian Court convicted 7 scientists to jail terms for not accurately predicting the 2009 L'Aquila earthquake that ended up killing over 300 people.

Also in October 2012, the Italian Supreme Court ruled that cell phones caused one man's brain tumor.

Since when does the Court decide on matters of scientific validity?

And even more importantly, what does this have to do with ENT???

I'm sure people here and there will shake their heads and say how ridiculous. "Unbelievable" that the Italians Courts have made such a stupid decision.

I hate to break it to you all... but it happens ALL THE TIME, especially in the field of medicine. The Court and Lawyers have profoundly influenced how medicine (and now seismology) is practiced whether scientifically valid or not. No matter how ridiculous it may be seen in hindsight or not.

Let's go back to those poor convicted earthquake scientists...

At least in Italy, it's likely that these Court decisions will having a chilling influence over how scientists will behave in the future whether scientifically valid or not. For every single minor tremor, scientists will now have to weigh potential for jail-term if they are inaccurate with their predictions (even though everybody knows predicting major earthquakes accurately is impossible).

I can imagine them to report in the future every single minor tremor as a potential threat of a major earthquake and as such, citizens of Italy are warned to take precautions and evacuate the area for 1 month.

I wonder how Californians will react to such predictions.

In medicine, especially in the field of radiology and pathology, diagnostic dilemmas equivalent to what Italian seismologists go through are common. For fear of the Court and Lawyers, radiologists and pathologists commonly overcall grey areas leading to further testing and even surgery for ultimately reasons that were totally unnecessary.

Thyroid masses is one particularly thorny area for both radiologists and pathologists.

In radiology, they will report every single nodule and cyst no matter how small for fear of Court and Lawyers. In the huge majority of the time, such thyroid masses are benign and no intervention is needed. However, should one of those nodules/cysts actually end up being thyroid cancer, the radiologist may end up being sued if he did NOT report them. As such, they are all reported and the burden of lawsuit than falls upon the doctor who ordered the CT scan or ultrasound in the first place.

What does this mean for the patient? For fear of Court and Lawyers, patients will end up getting more tests done and even undergo surgical removal "just to make sure" that it is not cancerous.

Which leads to the next diagnostic dilemma...

In pathology, fine needle biopsies of such thyroid masses is common. However, making a pathological diagnosis is sometimes quite difficult, especially if cancer is on everybody's mind. So what is the pathologist to do if he is uncertain whether cancer is present or not? For fear of Court and Lawyers, he makes an ambiguous statement:
There are some atypic cells suggestive of cancer. Clinical correlation recommended.
Now the legal burden is on the surgeon. The surgeon, for fear of Court and Lawyers, will now suggest to the patient that to be absolutely sure there is no cancer present, it is perhaps best to remove the thyroid gland.

Low and behold, many patients who undergo thyroid removal for such ambiguous findings on radiology and pathology reports end up with no cancer found in the thyroid gland. All that testing and surgery was, in the end, totally unnecessary.

The judgements of four physicians have been consecutively affected and compounded with each other for fear of Court and Lawyers:

  • Primary Care Doctor who ordered the CT scan or Ultrasound of the thyroid gland
  • Radiologist who reported the thyroid nodules/cysts
  • Pathologist who interpreted the needle biopsies of those nodules/cysts
  • Surgeon who ends up removing the thyroid gland based on the pathology and radiology results

Does this actually happen???

Absolutely. All the time.

In fact, it happened to the President of Argentina who had her entire thyroid gland removed for fear of cancer, but ended up that no cancer was found. Read more.

Monday, October 22, 2012

Cheerleading A Dangerous Sport from an ENT Perspective

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The American Academy of Pediatrics (AAP) published its first policy statement regarding cheerleading due to the increasing rate of injuries found in this increasingly competitive sport.

Who knew that although the overall risk of injury is lower than other sports, it has one of the highest rates of catastrophic injuries including closed-head injury, skull fractures, cervical spine injuries, paralysis, and even death.

After all, cheerleaders do not wear protective gear and safety is utterly dependent on external factors such as spotters and floor protection.

From an ENT perspective of a solo private practice, cheerleading is one of the leading causes of facial fractures in a student population.

Such fractures include nasal bone and orbital blow-out fractures sustained from elbows and other flying limbs.

Although AAP made 12 recommendation to make this sport safer, I was going to suggest that all cheerleaders should wear face-guards to minimize risk of facial trauma.

Here's one called Mueller Nose Guard. Available for purchase on Amazon.com .
Cheerleading Injuries: Epidemiology and Recommendations for Prevention. Pediatrics 2012;130:966-971.

Saturday, October 20, 2012

Tinnitus: Top 12 Topics I Teach

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by Dr. Richard Thrasher, III

Tinnitus. It’s a subject I discuss at least 2-3x every time I hold a clinic. There’s a lot of misinformation out there. I’m going to break it down the way that I describe it for my patients in clinic. There is far more information out there that I’m not going to go into, but these are the bullet points I think most everyone with it should at least hear once.

1 – Tinnitus is common. If you took every person on the planet and individually put them in a soundproof booth with a complete absence of sound, 98% of those people would hear a noise in their ear.

2 – It’s a real noise. Your ear is making it. So when you think it’s all in your head, you’re right, but it’s not an imaginary sound. There is objective tinnitus, when I can hear it too and there is subjective tinnitus when only you can hear it.

3 – Tinnitus comes from the latin tinnire meaning “to ring.” However, some people hear crickets, some buzzing, some the ocean in a shell, and yet others hear a hum. Tinnitus now has come to mean any noise in your ear.

4 – Tinnitus is probably protective. It probably acts as a warning system. Much like pain is a warning to you that there’s something wrong with a part of your body, tinnitus is a warning that there’s something wrong with your ears. That’s because in the vast majority of cases, tinnitus is related to hearing loss. Pretend with me for a minute that you’re an antelope head buried low eating the high grass of the Serengeti. If you have hearing loss and don’t know it, you may not notice the lion sneaking up on you. However, if your ears are ringing, you may look up more, use your other senses more often, move around a bit more, and perhaps spot that lion before he eats you. Similarly, if our ears are ringing, maybe we’re more likely to look both ways before walking out into the street in front of that oncoming bus.

5 – Tinnitus can be made worse by many things. NSAIDs (ibuprofen and aspirin are the worst offenders), caffeine, diurectics, and many many other medications. Stress makes it worse. Our bodies release the same chemicals to both physical and emotional stress. These chemicals can increase the loudness of tinnitus. Stress can include poor sleep, pain, pressure at work, poor relationship with loved ones, financial strain, death, divorce, etc. Likewise, thinking about the tinnitus will frequently make it louder. The more you think about it the louder it gets.

6 – So what to do? You can see a good discussion of options at the American Tinnitus Association website and even on the Wikipedia article, although I think the former is more appropriate. The best site that I know of is from eMedicine.com which is written by doctors for doctors.

7 – Hearing aids are a great option for those who have significant hearing loss and tinnitus. They’re not magic, the tinnitus will be present when not wearing the hearing aid, but at least there’s relief there when you do need to hear things better, and not the ringing.

8 – The single most effective treatment of which I’m aware is tinnitus retraining therapy. The single best version of this (different than tradition tinnitus retraining) I have found is the Neuromonics device. It’s expensive but over 85% of patients who use it get a dramatic improvement in their tinnitus to the point they are happy with the results. In the DFW area, I usually refer patients to the Callier Center for their tinnitus clinic.

9 – A word on pills. OTC medications have been used for years to treat tinnitus. None have ever been found to be better than 40% effective. Many of these medications say that you have to use them for 3-6 months or longer to get benefit and I think this is bologna. I’ve never seen someone use it for a month and not have improvement but then suddenly started having improvement at 3 months that was attributable to those meds. Although there are many preparations (like Arches Tinnitus formula) most combine several elements but haven’t shown efficacy better than 1 ingredient alone (lipoflavanoids or sometimes called biolipoflavanoids). You can buy these alone, not mixed into some “super tinnitus killing” formula. They’re cheap, without risk of significant side effects, and work on up to 30-40% of patients. I think they’re worth trying.

10 – Acupuncture also works in about 30-40% of people. Problem is that acupuncturists know that it is more likely to fail than to work so the dishonest ones may tell you that of course they can treat tinnitus when they may not have much experience. If you want to try acupuncture, ask the therapist for references who have been treated for tinnitus.

11 – Other new interventions include transcranial magnetic stimulation (TMS). Google it. There’s not a great amount of data on it yet, but there are free studies for willing participants.

12 – I don’t like tinnitus that is unilateral (only in one ear) or which is pulsatile (instead of a constant sound). If it’s on one side and/or if it pulsates, this could indicate another problem. This kind of tinnitus definitely needs to be evaluated.

So there’s 12 things you may or may not know. Hope it helps somewhat. Visit us if it doesn’t, I can tell you the same thing in person, but more importantly we can test you to make sure there is not any more concerning problem as the cause.

Broken Owen Wilsons. .errr. .uh. .Noses

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Probably the most famous crooked nose I know belongs to Owen Wilson. He wasn’t born that way. He broke it twice. Once in a fight with another kid at school and once playing football with buddies.

Adam Foote was a great hockey player who spent much of his time with the Colorado Avalanche and has quite the crooked nose also from multiple fractures.

The reason I bring up these two noses is because they are some of the more famous extremes of the results of unreduced nasal fractures of which I’m aware. It’s quite easy to find a smorgasbord of other examples both worse and more tame with a simple search of Google Images.

So here are some key things to know about nasal fractures.

Nasal fractures are common, but it’s important to recognize that they may represent more significant trauma. It’s always a good idea to have a nasal fracture evaluated unless you’re certain it’s the nose alone that is involved and not other bones. For example, it’s not uncommon for the orbit (bones around the eye) to be fractured at the same time if enough force is applied. This can cause some significant vision problems if unrecognized and untreated.

Bones in the face heal differently than any other bones in the body. When you break your arm, the fracture heals with new bone, making a solid connection that is often stronger than the original bone. Bones of the face (except for the mandible or jawbone) heal by what’s called fibrous union which means that the bones do not fuse with new bone, instead a nasal bone that breaks is always broken. It heals with thick scar tissue (collagen) which holds the bones together. This is nearly as strong as the original bone and actually provides some “give” for repeat trauma to the area

Not healing with new bone has a few implications. First, you can always feel the fracture. The skin over the nose is very thin and even if the bones are lined up perfectly, you usually can feel the fracture line even if there is no Owen Wilson evidence of it. Second, when a nose breaks, it heals in the position to which it’s fractured. If it’s knocked to the side, it will heal to the side like the guys above. If it breaks but remains normal in appearance, it will heal without any significant deformity.

However, because of fibrous union, scar tissue remodels for a full year following a fracture. Therefore, as the scar tissue heals and contracts, it can pull the bones into or out of alignment slightly. That’s why even with plastic surgery, the cosmetic appearance of the nose 1 month after surgery is not exactly the same as it is 1 year later. Look at celebrity nose jobs and the media will often report that they have had 2 in the last year, whereas remodeling actually caused the slight changes over that time

When the nose is deviated out of position from a fracture, healing will cause the fibrous union process to start almost immediately. Sometimes there is quite a bit of swelling that makes the degree of deviation difficult to assess. One trick is to have the patient stand under a bright light. There should be a light reflection that runs down the bridge of their nose. If the reflection is crooked, the nose is probably crooked and if the light reflection is straight, the nose is probably straight and swelling is just making it look crooked. This is not an absolute rule, but holds true most of the time. In the pictures that follow, the light reflection has a gentle “c-shaped” curve to it on the left (pre-procedure photo) and it is straight on the right side after correction. The picture is taken from a plastic surgery site that you can visit by clicking on the picture itself. (This patient also had some tip work done to the nose–there was more than simple straightening involved.)
The way the nose breaks it very consistent with most fractures. Most tend to be from trauma directed from one side or the other, such as occurs when someone is punched. It is not as common to have direct trauma straight on, but this occurs with air bag deployment sometimes. The following is my poor man’s attempt to diagram how most fractures create a deformed appearance. If you consider looking at the nose like you’re looking up the nostrils, it very much resembles a pyramid. The outer struts are the bones and the midline strut is the septum or the wall that divides the two sides of the nose. There are 2 ways that the bones can fracture 1 & 2, with 2 being the most common I see. In 1, the entire pyramid is deviated to the L (pretend your looking up someone’s nostrils) and the R strut has been pushed a little down (depressed) compared to the L side. The septum is also slightly deviated. In 2, the R nasal bone fractures in the middle and is also depressed with the L bone elevated and shifted as well.
To fix this, we simply elevate the bone on the R (from inside the nose and lifting upward) while pushing from the L toward the R on the outside of the nose to reduce the fracture(s), or in other words, line up the bones back in the midline. There are no cuts or incisions needed if this is done in a timely fashion.

One major thing I think should be clarified is when to have the nose evaluated. There is a common misconception that you shouldn’t see the ENT for at least a week to give the nose some time for the swelling to go down and have a better idea if any residual cosmetic deformity is present. Since fibrous union starts to develop immediately, it becomes so strong that by 2 weeks out it is nearly possible to rearrange the bones without re-fracturing the nose. In my experience, this is actually quite difficult in some patients even a week out although most of the time it’s not terribly hard to reduce these fractures if done in the first 10 days following the trauma. Therefore, I like to see patients on the day of the fracture if possible, before swelling begins, or 3-5 days after the trauma. By that time, most of the major swelling has decreased enough that I can see if there’s a need for reduction. If for whatever reason 14 or more days pass without a reduction, because of the remodeling that occurs for 12 months afterward, it is better to hold on any rhinoplasty (formal cosmetic surgery to repair the nose) for a full year. In some situations, it may be appropriate to repair sooner, like at 6 months, but this can only be determined by your surgeon.

Just because the nose is broken, doesn’t mean surgery is needed. If the bones are non-displaced and no cosmetic deformity exists, there is nothing to do. Or if the cosmetic appearance doesn’t bother the patient like with Owen Wilson or Adam Foote, there is nothing that needs to be done.

Assuming no fractures occur outside of the nose itself, there are three emergencies of which to be aware. First, is obviously bleeding (epistaxis). Second, is an open fracture (where bone is exposed due to a laceration in the skin. Third, is a septal hematoma. Sometimes blood will collect between the lining of the nose and the nasal septum. This blood can cause permanent damage to the nasal septum not unlike a boxer or wrestler with a cauliflower ear. The cartilage can die from this and cause holes in the septum (septal peforations) or severe nasal obstruction due to a deviated septum. The first two problems should be readily apparent, but the 3rd may not be noticed unless you have a doctor look on the inside of the nose. So here are the take home points:

Once a nose is broken it will always be broken, but it’s important to try to fix it in the first 10 days if possible for the best chance of a good cosmetic outcome without the need for invasive surgery later on.

Nasal fractures can be associated with more significant fractures of the face, particularly the bones around the eye

If you are concerned about a nasal fracture, call the ENT office as soon as you know about it–if someone tells you to wait for a week before doing so, don’t. Call. We can tell you how soon you should come in.

Most fractures can be repaired without significant difficulty and without complications, but there are emergencies that may occur and need to be addressed to prevent serious complications

Tongue Tie–And Not the Kind Politicians Have

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by Dr. Richard Thrasher

Ankyloglossia, or tongue tie, is a very common congenital condition, meaning it’s something with which you’re born. This picture from Dr. Ghorayeb’s site shows a perfect example of a pretty dramatic one.

Ankyloglossia is when the lingual frenulum (the band of tissue under your tongue which tethers it to the floor of your mouth) is either too short or extends too far to the tip of the tongue. It can then prevent normal tongue movement.

While often not signficant, a severe tongue tie can impede breast feeding in newborns. Infants do not breastfeed by using suction, rather the tongue works as pump to mechanically pull milk into the mouth. If the tongue cannot extend past the alveolar ridge (gum line) it makes it difficult to breast feed. This is the one urgent reason for a fix of this condition. Later on, ankyloglossia can affect how far the tongue can protrude from the mouth making things like licking an ice cream cone more difficult.

Another effect of severe tongue tie is on articulation of speech. To see how this can effect someone’s ability to enunciate words, try putting the tip of the tongue against the top of the lower teeth and holding it there while saying the alphabet. Not so easy to do, but possible.

There are many methods for freeing the tongue. The simplest is to simply cut the frenulum in infancy. Snipping the frenulum with Castro-Viejo scissors is my preferred method. If done before a newborn is 6 weeks old, it can be done in the office without local anesthesia. Some parents are quite concerned about what their baby will experience, but as long as they are less than 6 weeks, the frenulum does not have any significant blood supply and no significant nerve supply so it’s not dissimilar to cutting finger nails. Babies don’t like it, but you know it’s not a painful experience. Typically babies will cry for about 10-30 seconds if at all and there’s usually 1-2 drops of blood. I prefer to take kids older than 6 weeks to the OR, unless they are much older in which case we can numb the frenulum in the clinic similar to what’s done for dental work. Some doctors do this for all patients. I find that the numbing shot hurts more than the actual release in the newborns, however.

Another method involves removing the entire frenulum. Sometimes lasers are used for either method. I don’t use lasers because it provides no better result than scissors, takes longer, and there is a slightly higher risk of complications. Sometimes, we use advanced plastic surgery techniques in older children or kids who have had a recurrence of the frenulum after a release. This more often requires a trip to the OR, but in coooperative patients can be done in the clinic under local anesthetic.

Two main complications are possible with this procedure. First, as mentioned above, is re-tethering of the tongue. A scar band can form and replace the frenulum causing the same symptoms. Often the scar band is thicker than the original frenulum and requires more advanced techniques to resolve. The other risk is to the salivary gland ducts that have their openings at the base of the frenulum. Many young kids become aware of these ducts because they are responsible for the ability to “gleek”. If you’re not familiar with this term, present long before fans of the show, Glee, were around, you can watch a video about how to do it, but I have to warn you that for some it may not be something they want to watch. If these ducts are damaged from the procedure, pain, swelling, and infection can occur in the salivary glands beneath your jaw bone (submandibular glands). This can become a significant problem even requiring removal of the gland(s). Fortunately, this is extremely rare and I’ve never seen a case of it caused by this procedure.

If you’re concerned about the possibility of ankyloglossia, have it evaluated. It’s a fairly straight forward problem which is easy to identify and quite easy to fix in most cases.

Saturday, October 13, 2012

Synthetic Vocal Cords [video]

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Synthetic vocal cords being under development at MIT and Harvard... Very good video!

What are some of the vocal cord problems that may benefit from such a synthetic gel? Vocal cord paralysisvocal cord surgery to address polyps, cystsnodulesgranulomas, etc.

As an FYI... the synthetic vocal cord gel portrayed in the video is still under development and not available for patient use yet...

Video on Zenker's Diverticulum Surgery (Endoscopic Staple Diverticulostomy)

new video describing Endoscopic Staple Diverticulostomy to treat Zenker's Diverticulum has been produced.

For more information, click here.

Devices That Help Fix Clogged Ears

Clogged ears due to eustachian tube dysfunction or fluid in the ears is one of the most common complaints seen in an ENT clinic. Beyond medications like steroids & nasal sprays or even surgery (ear tubes) to resolve this complaint, a fundamental physical maneuver the patient MUST also be doing is called "valsalva". Valsalva is the attempt to "pop" the ears by yawn, swallow, or attempting to gently blow air out the nose that is pinched shut.

The yawn and swallow are passive maneuvers to pop the ear whereby trying to gently blow air out the nose while keeping it pinched shut to create intra-nasal pressure is an active maneuver.

The key concept is that medications do not pop the ears for you... YOU have to pop the ears yourself. Medications just help accomplish this task.

Typically, when things are truly clogged and it is very difficult if not impossible to pop the ears open, actively trying to pop the ears open is key. Yawning and swallowing typically is ineffective.

However, there are patients who can't quite grasp the idea of HOW to pop the ears by nose pinching. OR, they are too scared that they might rupture their eardrums (which could happen if the nose-blowing is too aggressive).

Furthermore, what about the 2 years old who doesn't even understand how to nose-blow let alone valsalva?

As such, there are two main devices to perform the active valsalva for such individuals. Please note, I have no financial ties to either companies to disclose.


The first is a simple balloon called Otovent (can be purchased on Amazon). In essence, you snug the balloon up against the nose and try to inflate the balloon up. The balloon itself provides the necessary and sufficient back-pressure into the nose resulting in an active valsalva. This is mainly used by children who can appreciate the visual feedback.


The second is an electronic device, EarPopper (also can be purchased on Amazon), that pushes air into the nose. So, rather than having the lungs "push" air into the nose to create intra-nasal air pressure, this device replaces the lungs and pushes air into the nose from the front. This device comes in two flavors: Home and Pro versions. 

Please keep in mind that there's another electronic device which supposedly helps with ear popping called EarDoc which is not recommended as it uses an unproven concept.

So there you have it...

Read more about this condition here.

Products That Help Pop the Ear Due to Eustachian Tube Dysfunction or Fluid in the Middle Ear:

Geared Toward Adults
Balloon Geared Toward Kids

Azithromycin Increases Risk of Death Slightly... Well, So Does Tylenol and Ibuprofen

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The media has made much fuss about a NEJM study suggesting a slight increased risk of death from taking azithromycin or z-pack. The more unhealthy you are, the higher the risk... no duh... (I would think the sicker you are, the greater the risk of death PERIOD... a sick person by definition is closer to death than a healthy person).

How slight? Compared to amoxicillin, about 47 additional cardiovascular deaths per one million courses of therapy.

Never mind the blatant biases found in the study nicely espoused on by cardiologist Dr. Wes in his blog.

Thinking you should never take a z-pack again due to this slight increased risk of death?

Well, good luck finding an alternative medication (of any kind) because they ALL have a potential risk of death.

Similar to z-pack, these other antibiotics also have an increased risk of sudden cardiac death:

• Avelox
• Bactrim
• Biaxin
• Cipro
• Diflucan
• Erythromycin
• Factive
• Floxin
• Foscavir
• Ketek
• Levaquin
• Sporanox
• Sulfa
• Tequin

It's not just antibiotics. These other common medications (not all-inclusive) also have an increased risk of sudden cardiac death:

• Benadryl (allergy)
• Pepcid (reflux)
• Albuterol (asthma)
• Prozac (depression)
• Serevent (asthma)
• Sudafed (decongestant)

The complete list can be found here.

Let's consider other popular drugs that also has an increased risk of death, though not necessarily from a cardiac trigger.

• ALL antibiotics due to a severe anaphylactic allergic reaction - Take Penicillin for example... about 300 die annually from penicillin allergic reaction in the US
• Tylenol causes liver failure - About 400 deaths per year in the US
• Ibuprofen causes internal bleeding - About 15,000 - 20,000 die per year in the US
• Alcohol related deaths - 75,000 deaths per year in the US
• Smoking related deaths - 443,000 deaths per year (one in five deaths) in the US

Never mind deaths from driving a car, accidental gunfire, drowning in a swimming pool, etc.

Life in general in the United States has a risk of death.

Azithromycin may up chance of sudden cardiac death. Heartwire 5/16/12
Popular Antibiotic May Raise Risk of Sudden Death. NYT 5/16/12
Azithromycin and the Risk of Cardiovascular Death. New England Journal of Medicine 2012; 366:1881-1890May 17, 2012

Name an ENT Who Has Won an Olympic Gold Medal

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He not only won one Olympic Gold Medal, but two in men's platform diving in 1948 and 1952.

Dr. Sammy Lee also won bronze medal in the 3 meter springboard and coached Bob Webster and Greg Louganis to their Olympic medals.

In terms of his medical career, he studied pre-med at Occidental College followed his MD from University of Southern California (USC) Medical School in 1947. He than went on to become an ear, nose and throat specialist.


ENT as Comic Book Hero (or Villain)

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I had no idea that ENTs with our head mirrors are relatively common in the comic book world alternately portrayed as heroes or villains. (Most of us have upgraded to a headlight powered by battery, but some of us ENTs still use a head mirror.)

There is a Family Practice physician who has compiled all the situations where ENTs were portrayed in comic book settings in his blog Polite Dissent.

The full list can be found here.

I have reproduced a few of my favorites below:

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.

Saliva Test for Laryngopharyngeal Reflux (LPR)

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Various groups have been developing a fast, cheap, non-invasive saliva swab test to determine whether laryngopharyngeal reflux (LPR) is present or not. LPR may cause symptoms of:
When you compare a spit test to the current way of how reflux is determined via barium swallow, upper endoscopy (EGD), and 24 hour ph/impedance testing, it sounds quite attractive.
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.

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).

Unfortunately, such testing is not offered is most labs. (Currently working on getting such testing available in our office.)

One test company is rdbiomed using their Peptest kit.


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.

R&B Singer Maxwell with Vocal Cord Hemorrhage

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At least that's what the Washington Post reported on June 22, 2012. This has resulted in cancellation of his summer tour.

Per media reports, his vocal cords are swollen with hemorrhage.

Some fans may recall that something similar happened to Adele in winter of 2011 which resulted in her also canceling a number of engagements. She ultimately had surgery to correct her problem.

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. If a voice is present, it is much deeper than normal due to the additional "weight" of blood and edema (just like a violin string where the thicker the string, the deeper the pitch). There may even be mild pain associated with this occurrence.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in a vocal cord polyp or vocal cord scarring. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel.

For that, surgical intervention is required.

Such surgical intervention is much like trying to get rid of varicose veins in the leg.

One option is to precisely cut it out. Watch a video on this approach (video shows a vocal cord mass removal, but just pretend the mass is a blood vessel as the approach is identical).

The other option is use of a laser which is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision (though not zero). Shown below is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser.

Read more about laser treatment of vocal cord pathology here.

Read the Washington Post story here.

How Does Cervical Spine Surgery Potentially Cause Voice and Swallow Problems? [video]

It is not unusual for an ENT surgeon to see patients with swallowing and voice difficulties after cervical spine surgery. In particular, the ACDF surgery (Anterior Cervical Discectomy and Fusion).

The key to understanding these issues is to first understand the anatomy involved.

The cervical spine is located in the back of the neck. In front of this spine is the esophagus (swallowing tube) and voicebox.

As such, when a spine surgeon goes through the FRONT of the neck in order to perform cervical spine surgery located in the BACK of the neck, (s)he has to move the esophagus and voicebox over to the side.

A plate is than fixated to the spine to fuse the cervical vertebral bodies.

Because of such manipulation of the esophagus and voicebox, it is not uncommon for a patient to complain of hoarseness and difficulty swallowing after surgery.

Fortunately, such problems usually dissipate with time, but not always.

Watch the video describing ACDF and how it can affect voice and swallow.

Bacteremia IS Present During Tonsillectomy!

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@ENTHouse brought to my attention a very interesting research regarding the presence of bacteria in the bloodstream during tonsillectomy, both elective and quinsy. Elective tonsillectomy is when the tonsils are removed in the absence of any significant infection. Quinsy tonsillectomy is when the tonsils are removed in the setting of a peritonsillar abscess.

The research involved obtaining blood cultures, tonsillar swabs, core tissue, and pus aspirates during the operation on 80 patients undergoing elective surgery and 36 undergoing quinsy surgery.

What they found was,
"Bacteremia was detected in 73% of patients during elective tonsillectomy compared to 56% during quinsy tonsillectomy. Significantly more blood culture bottles were positive for each isolate obtained from elective tonsillectomy cases compared to quinsy tonsillectomy cases. In all, 59% and 42% of electively and acutely tonsillectomized patients, respectively, had bacteremia with microorganisms that are predominant in bacterial endocarditis. Ninety-three percent of the isolated strains were sensitive to amoxicillin, and all were sensitive to amoxicillin with clavulanic acid." [link]
Amoxicillin with clavulanic acid is also known as Augmentin.

What is fascinating is the high rate of bacteria presence in the bloodstream during a routine elective tonsillectomy... even higher rates than tonsils which are actively and terribly infected. Perhaps because those with an active infection are already on antibiotics thereby suppressing bacteria in the bloodstream? Also, with an abscess, the pus pocket is already walled off by inflammatory tissue thereby preventing further leaching of bacteria into the bloodstream?

Regardless, these findings are especially interesting in light of the fact that antibiotics are not routinely recommended before, during, or after surgery!


Beastie Boys Adam Yauch Dies of Parotid Cancer

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On May 4, 2012, Adam Yauch, one of the founding members of the Beastie Boys, died of a "rare parotid gland cancer" that he had been battling since its diagnosis in 2009. For those who do not know what a parotid gland is... it is one of the major glands that produce saliva or spit and is located immediately in front of the ear (looks like fish eggs in the picture taken from Wikipedia). It is about the size of the palm of the hand.

It is unclear exactly what type of parotid gland cancer Adam Yauch had, but here's a list of what it could have been:

• Acinic Cell Carcinoma
• Adenocarcinoma
• Squamous Cell Carcinoma
• Mucoepidermoid Carcinoma

Thankfully, the vast majority of parotid tumors are benign growths such a pleomorphic adenoma or Warthin's tumor.

Typically, with any type of parotid mass, the sequence of events to diagnose and treat such masses occur in a standard fashion:

1) Mass appreciated by patient or primary care doctor
2) Patient sees ENT who confirms mass localized to parotid gland
3) CT scan of the neck with contrast ordered to further evaluate the mass
4) Fine needle biopsy obtained of the mass for pathologic diagnosis
5) Surgical excision performed... an operation called "parotidectomy"
6) If needle biopsy indicated cancer, neck dissection is also performed to remove all lymph nodes that may contain cancer followed by radiation therapy to the whole area.

Parotidectomy surgery is a "difficult" surgery mainly in the sense that one of the main risks of surgery is permanent facial paralysis. Why? It is because the nerve that allows facial movement goes right through this gland (in yellow in the picture above).

As such, the vast amount of time dedicated to this surgery which may last anywhere from one to several hours is identifying and isolating all involved branches of the facial nerve. The actual parotid gland mass removal takes less than 15 minutes. 

Read more about this surgery here.

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