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February 21, 2017

High Blood Pressure Medication Helps with Nasal Polyps!

Verapamil, a blood pressure medication, may help with an uncommon disorder called nasal polyps that afflict certain individuals causing significant nasal congestion, nasal obstruction, smell loss, and chronic sinusitis. Nasal polyps appear like a cluster of grapes within the nasal and sinus passages leading to subjective sino-nasal symptoms.

Although sinus surgery can physically remove the nasal polyps, whatever trigger caused their initial formation can lead to their regrowth. As such, medical management is required along with surgical treatment for long-term control.

Such medical treatment to try and prevent nasal polyp recurrence or growth include:

Allergy control with immunotherapy if applicable (i.e., allergy shots)
• Leukotriene inhibitor medications (i.e., Singulair, xolaire, etc)
Steroid nasal sprays
• Systemic steroids (i.e., prednisone)

Depending on other medical morbidities that may be present, additional treatment with monoclonal antibodies (i.e., nucala) may be required.

However, Harvard researchers have published that verapamil may be very helpful to add to the medical management for nasal polyp control.

The research conducted was a double-blind, placebo-controlled, randomized clinical trial. Verapamil's beneficial affects on controlling symptoms of nasal polyps is due to its inhibitory effect on P-glycoprotein, a protein pump found in the nasal lining and over-expressed in patients with nasal polyps leading to hyper-secretion of inflammatory chemicals. By suppressing P-glycoprotein with verapamil, the overall burden of inflammatory chemicals in the nose could be decreased resulting in improved symptoms.

More research is needed to see if this hypertension medication provides true, effective, long-term benefit... BUT... if a patient with nasal polyps also has high blood pressure, it may be worthwhile to take verapamil preferably over other kinds of blood pressure medications to help with both blood pressure AND hypothetically nasal polyps too!

Double-blind placebo-controlled randomized clinical trial of verapamil for chronic rhinosinusitis with nasal polyps. J Allergy Clin Immunol. 2017 Jan 11. pii: S0091-6749(16)31444-0. doi: 10.1016/j.jaci.2016.11.014. [Epub ahead of print]

Secreted P-glycoprotein is a noninvasive biomarker of chronic rhinosinusitis. Laryngoscope. 2017 Jan;127(1):E1-E4. doi: 10.1002/lary.26249. Epub 2016 Aug 31.

February 04, 2017

Former NFL Player Training to Become an ENT Doctor

Dr. Samkon Gado (former NFL player)
Stereotypically, elite athletes migrate towards the field of orthopedics, but one former NFL player has pursued a career in ENT. Samkon Gado, MD is currently a second year otolaryngology - head & neck surgeon at St. Louis University Medical Center. He formerly played for Kansas City Chiefs, Green Bay Packers, Houston Texans, Miami Dolphins, and St. Louis Rams.

He went to Liberty University for his undergraduate education followed by Medical University of South Carolina for medical school before ending up at SLU for otolaryngology training.

You can see his profile at SLU here.

Press release regarding his new career can be found here.

SLU coverage of his accomplishments can be found here.

He stated his intention to potentially sub-specialize in the fields of either neuro-otology or facial plastics and reconstruction.

Good for him and hopefully more elite athletes follow in his footsteps! Compared to orthopedics, ENT as a whole has very few former pro-athletes. Quite paltry in fact.

The only other former NFL player who is an ENT that I know of is John Frank, MD who used to play for the San Francisco 49ers in the 1980s. He is now a hair restoration expert working at the Anapelli Hair Clinic.

Dr. John Frank (former 49ers NFL player)

February 01, 2017

Video of Hearing Testing in Young Children (6 Months - 6 Years Old)

In celebration of Kids ENT Health Month, our office has produced a video demonstrating the various ways a child's hearing is tested from 6 months to 6 years old. After all, you certainly can't just ask them to push a button when they hear a beep as you would in an adult. This video shows the following different types of hearing testing done in children:

• Soundfield Auditory Testing (SAT) - 6 months to 2 years old
• Speech Awareness Threshold (SAT) - 2 years to 3 years old
• Speech Recognition Threshold (SRT) - 4 years to 6 years old
• Conditioned Play Audiometry (CPA) - 4 years to 6 years old
• Select Picture Audiometry (SPA) - 3 years to 4 years old

If the child is younger than 6 months old, Auditory Brainstem Response (ABR) or Otoacoustic Emission Testing (OAE) is performed. Video of this type of hearing test can be viewed here or below.

January 31, 2017

HPV Vaccine May Help Clear Airway Papillomas

Papillomas on the right vocal cord
HPV vaccine like gardasil can be used to help prevent not only genital warts, but also oral warts and warts of the airway. Such warts are known as papillomas and can keep recurring after surgical excision leading to lifelong morbidity. Although gardasil and other HPV vaccines are typically used to vaccinate young tweens, it has been found effective even in much older individuals.

In this study, the HPV vaccine decreased the incidence of surgeries for recurrent respiratory papillomas in 6 patients.

In another case study, a child who required repeated surgeries to remove recurrent laryngeal papillomas was "cured" after HPV vaccination. In two other studies, this vaccine minimized papilloma formation in the airway of a child (see references below).

Such improvement can also occur with oral papillomas. Specifically, a man in his 60s who suffered from recurrent oral papillomas in spite of multiple excisions was clear of all lesions within 3 months after receiving the quadrivalent HPV vaccine. Interestingly, this patient had HPV-32 which is not part of the HPV vaccine (HPV-16, 18, 6, 11). [Link]

Apparently, these are not isolated cases. In the reported literature, 8 others have noted the same improvement with oral papillomas. Time to improvement was seen within 4 weeks of vaccination and resolution after 3 to 8 months.

Given these promising findings, quadrivalent HPV vaccination may certainly be worth pursuing in any patients of any gender at any age suffering from oral/airway papillomas.

Currently, there are three FDA approved HPV vaccines:

• The bivalent HPV vaccine (Cervarix) which addresses HPV 16 and 18;
• The quadrivalent HPV vaccine (Gardasil) which prevents four HPV types: HPV 16 and 18, as well as HPV 6 and 11;
• And finally Gardasil 9 which prevents 9 HPV types: 6, 11, 16, 18, 31, 33, 45, 52, and 58.

All vaccines are administered through a series of 3 intra-muscular injections over a 6-month period. The second and third doses should be given 2 and 6 months after the first dose.

Of note, our office does offer the HPV spit test to see if HPV is present in the mouth/throat.

Recurrent laryngeal papillomatosis: successful treatment with human papillomavirus vaccination. Arch Dis Child. 2011 May;96(5):476-7. doi: 10.1136/adc.2010.198184. Epub 2011 Jan 10.

Immunological response to quadrivalent HPV vaccine in treatment of recurrent respiratory papillomatosis. Eur Arch Otorhinolaryngol. 2016 Oct;273(10):3231-6. doi: 10.1007/s00405-016-4085-3. Epub 2016 May 17.

Gardasil Vaccination for Recurrent Laryngeal Papillomatosis in Adult Men: First Report: Changes in HPV Antibody Titer. J Voice. 2017 Jan;31(1):104-106. doi: 10.1016/j.jvoice.2016.01.008. Epub 2016 Apr 8.

Effect of Quadrivalent Human Papillomavirus Vaccination on Oral Squamous Cell Papillomas. JAMA Dermatol. Published online September 02, 2015. doi:10.1001/jamadermatol.2015.2805

Intersurgical interval increased with use of quadrivalent human papillomavirus vaccine (Gardasil) in a pediatric patient with recurrent respiratory papillomatosis: A case report. Int J Pediatr Otorhinolaryngol. 2016 Dec;91:166-169. doi: 10.1016/j.ijporl.2016.10.032. Epub 2016 Oct 28.

Therapeutic use of the HPV vaccine in Recurrent Respiratory Papillomatosis: A case report. Int J Pediatr Otorhinolaryngol. 2017 Feb;93:103-106. doi: 10.1016/j.ijporl.2016.12.035. Epub 2016 Dec 27.

January 28, 2017

What is the Normal Body Temperature? The Fact and Alternative Fact

1800s Wunderlich Thermometer (the thermometer is over 12 inches long)
If you said 98.6°F, you are wrong... Of course you are just parroting back what you were told by your teachers, family, friends, colleagues... well pretty much everybody since 1871. That year, Dr. Carl Wunderlich at Leipzig University in Germany published a book called "On the Temperature in Diseases: A Manual of Medical Thermometry."

Dr. Wunderlich took the temperatures of over 25,000 patients under his care and determined the temperature of a normal human being was 98.6°F or 37°C.

This value has been parroted back ever since...

But two problems... He used an archaic, one foot long, thick thermometer that registered a temperature 2°C higher compared to modern thermometers. See picture above. You can see one at the Mutter Museum in Philadelphia as well.

Given that, what IS the normal temperature of a human being using the best thermometer modern medicine has to offer?

In 1992, nearly 120 years after Dr. Wunderlich's declaration of 98.6°F, researchers at University of Maryland determined that the TRUE temperature was... drum roll please...

slightly lower at 98.2°F or 36.8°C

What they also discovered was that the "normal" temperature varied in a given healthy individual by as much as 1 degree F throughout the day being lowest around 6AM and highest around 5PM. That said, the upper limit of normal remained consistently at 99.9°F or 37.7°C (Dr. Wunderlich stated 100.4°F or 38°C was the upper limit). Lower limit of normal was 96.0°F. Females also had a slightly higher normal temperature compared to males and there was a trend toward higher temperatures among black compared to white individuals.

In spite of these "more true" temperature values, 98.6°F has both the weight of history and momentum going for it resulting in perhaps an alternative fact that will stick with us for years to come.

Physicians (including myself) will continue to disregard any temperature below 100.5°F as a fever and will continue to consider 101.5°F to be the cut-off that would be considered clinically significant. Why? Because much of medical knowledge and protocols that have been developed over decades are based on the 98.6°F value and changing the defined temperature (even if it is more correct) would result in changes to numerous and varied protocols that have been already established.

This may certainly be one truth that coexists with an alternative truth, but at least these truths are better understood for what they are.

A Critical Appraisal of 98.6°F, the Upper Limit of the Normal Body Temperature, and Other Legacies of Carl Reinhold August Wunderlich. JAMA. 1992;268(12):1578-1580. doi:10.1001/jama.1992.03490120092034

On the Temperature in Diseases: A Manual of Medical Thermometry. Published in 1871. The New Sydenham Society. London.

January 09, 2017

The Artificial Larynx

Image from Protip Medical
We have had artificial lungs, artificial hearts, artificial kidneys... but now we also have an artificial larynx. Published in the New England Journal of Medicine in Jan 2017, French researchers described a patient who required the entire voicebox removed (laryngectomy) due to cancer and than implanted with a totally artificial larynx in 2015.

This patient is actually the second patient who has undergone artificial laryngeal implantation. The first occurred in 2012.

Typically with voicebox removal, a patient will have a permanent hole in the throat through which breathing occurs exclusively. With this procedure, the patient loses the ability to talk and smell (because all the air goes through the hold in the throat rather than nose or mouth).

With this artificial larynx, the patient is able to now do both processes the normal way, albeit the voice is at a whisper and some dysphagia is still present. Links to videos are included with the article.

Made by Protip Medical, the artificial larynx is made from titanium.

Also, available for implantation only in France at this time as far as I know.

Laryngeal replacement with an artificial larynx after total laryngectomy: the possibility of restoring larynx functionality in the future. Head Neck 2014;36:1669-1673

Implantation of an Artificial Larynx after Total Laryngectomy. N Engl J Med 2017; 376:97-98January 5, 2017DOI: 10.1056/NEJMc1611966

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