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Saturday, March 30, 2013

The Art of Facial Paralysis


Professional photographer Sage Sohier spent 3 years in a Boston ENT clinic photographing patients suffering from facial paralysis along with family members.

These intimate portrayals document the personal struggles patients with facial paralysis go through that is shared with family. Patients shown include children suffering from this malady.

Her collection of photographs include people with mild to complete degrees of facial paralysis, a condition that usually occurs on just one side of the face and can result from Bell’s palsy, cancer, stroke, accident, surgery, and congenital nerve damage. Sohier documented patients as they progressed through treatment capturing their progress over time, witnessing hope and excitement as they regained the ability to smile, speak, and eat.

Her collective photos resulted in a book About Face as well as a showing of her photographs to be displayed at the New York City Foley Gallery on April 17.

Learn more about facial paralysis here.

Sunday, March 17, 2013

Mal de Debarquement Syndrome - Rare Cause of Dizziness

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The BBC recently printed a story describing a rare condition called mal de debarquement which causes dizziness, typically after a boat cruise, though can occur with airplane flights and even a long drive in a car with switchbacks (going up/down a mountain).

Two signs that a patient has mal de debarquement are if they feel a rocking sensation for weeks or months starting AFTER a cruise and two, if they're much better when in motion like vigorous exercise, but feel much worse when staying still.

Read the story here.

Unfortunately, no great treatment for this condition beyond displacement type exercises (walking, running, bicycling... but NOT on a treadmill or stationary bike).

This condition was also in an article by the Washington Post in 2010.

Some Facts About Q-Tips and Ears

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In this week's episode of "Girls," Hannah, grappling with OCD, inserted a Q-tip deep into her ear canal and "heard air hiss out the hole" due to perforating her eardrum.

Although this scene came out of a TV show, this scenario is not uncommon and results in many ENT office visits every month.

Some facts about Q-tips as it relates to the ear...

It should never be used to clean earwax within the ear canal. In fact, on Unilever's website (the maker of Q-tips), the company explicitly states that Q-tips should only be used to "gently around the outer ear, without entering the ear canal." [link]

In fact, the word "ear" appears less than a dozen times on the entire Q-tip website.

Apparently, Q-tips are meant for many other uses beyond ears which play only a very small role in the world of Q-tips.

• Cleaning tiny spaces in ventilator grates
• Applying polishes to silverware
• Dust picture frames
• Clean keyboards and the computer screen
• Applying wood stain
• Clean tracks and grooves of medicine cabinets
• Clean small compartments of washing machines
etc, etc, etc

Thursday, February 28, 2013

Why Do Biopsy Results Take So Long? [video]

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One of the most common questions I get after a surgical procedure is how long it takes before biopsy results are back... especially when a mass was removed and there is a cancer concern.

Does it take a few hours? 24 hours? Days?

Disappointingly, it can take up to 7 days if not longer.

You want to know why?

Well, rather than explaining, watch a 6-minute video that explains the numerous steps that goes into providing a diagnosis after a mass is removed... in this particular case, a neck mass though the same steps apply to any mass removed from anywhere else in the body.

Special thanks to Robin Earl who spent hours hanging out in the pathology lab video-taping all the relevant video clips as well as Fauquier Health System for allowing this video to be made!

Wednesday, February 6, 2013

Negative Ear Pressure Causing Inability to Pop a Clogged Ear

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Have you ever closed the lid on an air-tight container containing a left-over hot meal and stuck it in the refrigerator? And than when you try to open the lid the next day once that hot meal cools down, it is REALLY hard to open the lid because of the accumulated negative pressure? In essence, the negative pressure has "locked" the lid down.

Well, something similar can also potentially happen inside the ear with eustachian tube dysfunction, especially with negative pressure (rather than positive pressure).

Eustachian tube dysfunction is a phenomenon whereby a person is unable to pop their ears to relieve symptoms of ear pressure, clogging, or fullness. It is much akin to the ear pressure a person experiences when flying, but at ground level. Traditionally, treatment of this condition involved medications like steroid nasal sprays and prednisone along with active valsalva (watch video below). Once medical treatment has failed, ear tube placement has been the step of last resort.

The question some patients have is WHY does it become so hard to get an ear to pop open with eustachian tube dysfunction...

It may be that the mucosal lining of the eustachian tube has swelled to the point that there is no opening present.

There may also be a physical obstruction blocking the eustachian tube due to large adenoidsnasal polyps, or some other nasal mass.

However, a lesser known phenomenon is due to the negative pressure itself creating a suction effect on the lining of the eustachian tube analagous to the stuck container lid mentioned in the first paragraph. The middle ear negative pressure itself may be literally "sucking" the lining of the eustachian tube closed. If the negative pressure is great enough, it may be very hard to get it open.

When this happens, the eustachian tube becomes "locked".

One can "mimic" this effect even in a healthy individual (not that anybody would want to try). When a swimmer dives deep into the water, some ear pain will start to develop due to the negative pressure building up in the middle ear. If the swimmer does not ear pop and continues to go deeper into the water, at around 3.9 feet, it may start to get very difficult to get the ear to pop open even with effort. At around 5 feet of water depth, it will become impossible to pop the ear open. Normally, swimmers and SCUBA divers continuously ear pop when diving at depth to prevent any ear discomfort.

As such, in situations where negative ear pressure is present and medications fail to resolve the ear clogging, a hole can be surgically made in the eardrum WITHOUT tube placement which will often resolve the symptoms fairly quickly. The hole "releases" the negative pressure to allow the eustachian tube to function normally. The analogy would be that once you release the negative pressure within an air-tight container, it becomes very easy to remove the lid thereafter.

The eardrum hole typically heals closed in a few weeks and the clogged ear sensation will often not come back. If it does, the myringotomy (surgically creating a eardrum hole) can be repeated and if necessary, a tube can be placed to prevent the body from healing the hole closed anytime soon.

Saturday, February 2, 2013

Uvula Piercing

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It happens, but thankfully rare...

Ear piercing I will do, but truly uvula piercing is not something I would recommend given a whole host of problems it may cause including:

• Gagging
• Snoring
• Airway obstruction
• Uvular stretching
• Uvular bisection
• Accidental inhalation if it comes loose
• Uvular swelling
etc. etc. etc.

Indeed, most people would rather get their uvula removed rather than "enhancing" it!

Thursday, January 17, 2013

Another Egg-Free Flu Vaccine Approved by FDA

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First there was Flucelvax introduced in 2012 and now there is Flublock, both considered egg-free for those concerned with egg allergy in traditional flu vaccines.

Rather than being cultured in eggs, Flucelvax is cultured in mammalian cells and Flublock is grown in caterpillar cells injected by an insect virus containing the flu gene.

Both vaccines are approved for use in people 18 years and older.

Why the concern of egg-allergic patients with the traditional flu vaccine used to defend against both seasonal and pandemic flu virus?

Traditionally, the flu shot vaccine (both H1N1 and seasonal) are grown inside eggs which is where this concern arises. It also doesn't help that the pre-flu shot questionnaire specifically asks about egg allergy. Though egg-based, during vaccine production the egg protein is filtered out such that there should be no egg contaminants in the final vaccine. However, it is theoretically possible that some egg may still be present in the vaccine.

Although there is an infinitesimal possibility of egg contaminants, studies have shown that even patients with life-threatening egg allergy can still safely have the flu vaccine.

In spite of these reassurances, there are still concerns from patients and healthcare professionals which makes the availability of two different egg-free flu vaccines welcome news.

FDA approves next-generation, bug-based flu vaccine. MSNBC 1/16/13

Saturday, January 12, 2013

Compact EMG System for Targeted Muscle Injections

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An EMG system (ElectroMyoGraphy) is a critical piece of equipment when it comes to targeted muscle injections in and around the neck, especially when you cannot see or feel the muscle.

This scenario is especially true when dealing with spasmodic dysphonia for which targeted botox injections are quite helpful. Given the muscles that need to be injected are contained inside the voicebox and not able to be seen and felt from outside the neck, accurate injection is quite difficult without EMG guidance.

Watch a video of this procedure using a traditional EMG system.

However, such traditional EMG systems are "overkill" in terms of technology and cost when all it is being used for is muscle placement.

It was with great excitement that a compact EMG device has been developed for just such a need when all that is required is needle localization for directed drug delivery.

Check out the MyoGuide made by Intronix Technologies based in Canada. The US supplier is Ambu.

I've been using MyoGuide for a few months now and am quite pleased with its performance. It pretty much does exactly what I want it to do... no more or less. There is both audio and display feedback, though I mainly depend on audio. It runs only on batteries.

For head and neck muscle injections, I find that a volume setting of 8 and vertical sensitivity of 6 works best.

My personal preference is using Ambu Inoject 35mm 27G needle for ADductor spasmodic dysphonia and the Allergan EMG needle for ABductor spasmodic dysphonia.

For those interested in trying out this device, there is a 2 week free trial.

Friday, January 11, 2013

Parkinson's Disease Diagnosed by Salivary Gland Biopsy

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Taken from Wikipedia
Currently, diagnosing Parkinson's Disease (a degenerative neurological disorder) is hard, usually a clinical exam and assessment of symptoms by a neurologist with at best about an 80% accuracy rate. There is no "test" per se that can diagnose Parkinson's Disease... until possibly now.

According to a study released in advance of its presentation at the annual meeting of the American Academy of Neurology, which will be held from March 16 to 23 in San Diego, Mayo Clinic researchers have determined a submandibular gland biopsy can offer 82% certainty whether a living patient has Parkinson's Disease or not. What is so special about this particular gland located under the jawline?

In patients with Parkinson's Disease, an uniquely abnormal protein called alpha-synuclein protein can be found.

In order to "biopsy" the submandibular gland which produces saliva, it does require a head and neck surgeon given the gland's location under the jawline. Beyond the usual risks of bleeding and infection present with any type of surgery, additional risks with this biopsy include:

• Permanent lip paralysis as the nerve that goes to the lower lip is located right over this gland.
• Permanent tongue paralysis as the nerve that moves the tongue is located right under this gland.
• Permanent numbness of the mouth floor as the nerve that provides sensation in this location is also located right under the gland.

Also, there are questions that need to be answered before this test is available more widely including:

How early in the Parkinson's Disease will this protein accumulate in the submandibular gland? If there is an "accumulation" time period, when is the best time to do the biopsy than?

Does the biopsy require a bloc of tissue or can a needle biopsy be sufficient (thereby reducing some of the surgical risks)?

Will insurance pay for this procedure?

Also, when is the paper going to be published regarding these results and can others replicate these findings? Here's the presentation abstract...

New saliva gland test may better diagnose patients with Parkinson's. FoxNews 1/11/13

Salivary Gland Biopsy as a Diagnostic Test for Parkinson's Disease. AAN 65th Annual Meeting Abstract
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