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February 04, 2016

How Fast Should an Emergency Tracheostomy Take?

Image courtesy of digitalart at FreeDigitalPhotos.net
When faced with an emergency airway situation, a surgical airway may be required in order to save a person's life. Such surgical airways include emergency tracheostomy or cricothyroidotomy.

The main question here is how quickly should such a procedure take in order for it to be considered a success? Clearly, it should take less than 4 minutes given that is how long a brain can survive without oxygen before permanent damage sets in.

According to the literature, the range of what is considered "acceptable" duration of time to perform an emergency surgical airway ranges from 40 to 180 seconds. Most consider shooting for a goal of 90 seconds to be a reasonable compromise of how long an emergency surgical airway should take to perform.

Of course, success is defined not only on how quickly it can be performed, but also performed without complications which principally includes inserting the breathing tube somewhere other than the windpipe. Other complications include cutting into the esophagus or perforating the carotid artery.

Reference:
Emergency cricothyroidotomy: a randomized crossover trial comparing the wire-guided and catheter-over-needle techniques. Anaesthesia. 2004 Oct;59(10):1008-11.

A comparison of four techniques of emergency transcricoid oxygenation in a manikin. Anesth Analg. 2010 Apr 1;110(4):1083-5

Emergency cricothyroidotomy: A randomized crossover trial comparing percutaneous techniques: Classic Needle First versus Incision First. Acad Emerg Med. 2012 Sep;19(9):E1061-7.

Emergency cricothyroidotomy - a systematic review. Scand J Trauma Resusc Emerg Med. 2013 May 31;21:43.




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February 01, 2016

Oral HPV Spit Test Now Offered at Fauquier ENT!

Image courtesy of stockimages at FreeDigitalPhotos.net
Given the increasing concern for HPV triggered oral and throat cancer, patients have been requesting a way to check for HPV in the mouth, especially in those who are sexually active. Beyond a visual inspection using a tongue blade and an endoscope, our office now offers a spit test to evaluate for the presence of HPV by looking for its DNA shed into the saliva.

The typical patient, man or woman, who may benefit from this test include:

• Spouses or significant others of patients who have known oral HPV (worried about "catching" it from their partner thru kissing or oral sex). More info on this.
• Monitor patients with known oral HPV for clearance after treatment
• Patients with traditional risk factors for oral cancer
• Patients with suspicious oral lesions

This oral HPV spit test focuses on those common HPV infections known to more frequently progress to cellular changes causing papillomas and even cancer. The test is based on a similar test that is FDA approved for samples from the anogenital tract.

There are two types of oral HPV testing that we offer:

HPV Complete Panel which checks for 51 different HPV strains: 2a, 6, 11, 16, 18, 26, 30, 31, 32, 33, 34, 35, 39, 40, 41, 42, 43, 44, 45, 49, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 64, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 80, 81, 82, 83, 84, and 89

HPV High Risk Panel which only checks for HPV known to potentially cause cancer: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68

Generally speaking, we only recommend the HPV High Risk Panel as most other strains of HPV can be naturally and automatically cleared by the body's immune system without treatment, risk, or symptoms.

The test is performed as follows in our office and takes about one minute to complete:

Step 1: Patient swishes and gargles a saline solution for 30 seconds
Step 2: Patient spits the solution into a funneled collection tube
Step 3: Funnel is removed and cap is secured to top of collection tube
Step 4: Sample is labeled with patient name and date of birth and mailed to a laboratory
Step 5: Results received in about one week

This test MAY be covered by insurance (CPT 87624). However, coverage depends on your specific plan and if not covered by your insurance, will be a self-pay cost.

Keep in mind that this test, if positive, still does not tell us WHERE the HPV infection is located... tonsil? tongue? pharynx? palate?

A good visual examination is still required... and if any suspicious lesions are found, surgical biopsy is THE definitive way to test for cancer and check for HPV.

Of note, there are currently 3 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.

January 31, 2016

How to Dry the Ears if Water Gets In

A common question we get asked is what is the best way to dry out the ear if any water gets in?

I typically suggest using a pain old hairdryer to dry out any water that may be in the ears.  However, there are also commercial ear dryers for purchase including a manual air pump for the ear canal called Dryears. Also available is an electric ear dryer called EarDryer which also works quite well.

Another common remedy is to put a few drops of rubbing alcohol (isopropyl alcohol) into the ear canals after swimming. The alcohol makes it MUCH easier for the water to evaporate. An additional benefit is that the alcohol also kills any bacteria that may be present that may cause Swimmer's Ear (infection of the ear canal skin). The alcohol is also the main ingredient found in commercial preparations of Swimmer's Ear Drops. Of course, this product can only be used if there is no hole in the eardrum nor any ear tubes in place, otherwise it will hurt like heck!

Of course, one can also wear ear plugs, headbands, or swim caps to help prevent water from getting into the ear canals in the first place.

All products can be purchased on Amazon.


January 29, 2016

New Video on What Causes Ear Clogging from Ear Infection or Eustachian Tube Dysfunction



A new video has been uploaded to YouTube that explains the mystery behind ear clogging and why ear popping helps. Also explained is why it may become difficult if not impossible to pop a clogged ear, especially after an ear infection as well as how this situation can be corrected.

Ear conditions demonstrated in this video include:
Eustachian Tube Dysfunction
Ear Infection
Ear Tube Placement



January 28, 2016

Dr. Chang Quoted in SELF Magazine Article


SELF Magazine published a story about earwax which liberally quoted Dr. Chris Chang. The article was published on Jan 23, 2016 and was titled "Here’s What You Really Need To Know About Cleaning Your Ears With Q-Tips" and written by journalist Amanda Schupak.

Click for more information about earwax.

Source:
Here’s What You Really Need To Know About Cleaning Your Ears With Q-Tips. SELF 1/23/16.


January 22, 2016

Where Does Tinnitus Come From? Ear or Brain?

It is invariable that when a patient comes to an ENT office complaining of tinnitus or ringing of the ears that only they can hear, that this problem stems from purely an inner ear problem. The ringing that they hear is "coming" from the ear. However, the truth is WAY more complicated in that this phantom ringing actually comes more from the brain rather than the ear and as such, treatment (if any possible) is geared more towards the brain rather than the ear.

The analogy I often use to explain this phenomenon is phantom limb pain... For example, when a person gets their leg cut off for one reason or another, it is not unusual for that patient to experience phantom limb pain... i.e., suffer an itch of a foot they no longer have.

The implication being that phantom limb pain is not a problem of the missing leg itself... but rather the brain that still thinks you have a leg... as well as an itch on the foot you no longer have.

Similarly, tinnitus is when the brain thinks you are hearing a sound that doesn't exist in reality. Think of it as phantom limb "noise".

To further prove that tinnitus is actually more a brain problem than an ear problem... studies have been performed to see if the tinnitus persists even when the inner ear or hearing nerve is surgically destroyed or removed (due to tumor, disease, etc). After all, if the tinnitus truly is an ear problem, than removing the inner ear or hearing nerve should resolve the tinnitus, right? But that's not what happens.

In a 1981 published article, the researchers reported that when the hearing nerve itself was removed in 414 patients, only 40% reported improvement in their tinnitus. Of 68 patients whose hearing nerve was cut, improvement in tinnitus occurred in 45%, while 55% reported the condition to be the same or worse. In patients undergoing middle cranial fossa section of the vestibular nerve for vertigo or dizziness, most reported the tinnitus to be the same but a significant number felt that it was worse.

A literature search performed in 2002 identified 18 papers mentioning tinnitus status after vestibular nerve section, describing the experiences of a total of 1318 patients. They found that tinnitus worsened after surgery in about 16.4% (standard deviation 14.0). Tinnitus remained unchanged in 17% to 72% (mean 38.5%, standard deviation 15.6), and tinnitus improved in 6% to 61% (mean 37.2%, standard deviation 15.2).

Clearly, the ear is not the sole culprit when it comes to chronic tinnitus. Though the ear may have played a role in the initiation, the brain potentially plays a much more dominant role in tinnitus persistence.

References:
Tinnitus: surgical treatment. Ciba Found Symp. 1981;85:204-16.

The effect of vestibular nerve section upon tinnitus. Clin Otolaryngol Allied Sci. 2002 Aug;27(4):219-26.

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