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May 25, 2016

Mouth Taping to Treat Snoring and Dry Mouth

A patient brought to my attention a Buteyko breathing method that involves taping the mouth shut before going to sleep to prevent mouth-opening and mouth-breathing. By preventing the mouth from opening while sleeping, it can prevent the mouth from drying out as well as decrease not only snoring intensity but also reduce sleep apnea severity.

This technique of mouth taping does work based on small studies. A 2015 study found that snoring and sleep apnea scores improved significantly with mouth taping. However, I should also state that the study did NOT find that mouth-taping cured snoring nor sleep apnea. Just decreased the severity. Obviously, mouth-taping only applies to individuals who sleep with the mouth open.

A more conventional treatment for mouth-breathing while asleep would involve wearing a chin strap, but the chin strap can cause some individuals to feel claustrophic. If nasal obstruction is present, this needs to be corrected first as well.

Should one desire to try mouth-taping, here are the instructions:
  1. Obtain a roll of medical tape that is hypoallergenic, porous, and non-waterproof. 3M Micropore Tape works well, but if you have sensitive skin, paper tape can be used too.
  2. Apply lip balm to the lips and than purse the lips inward slightly while closing the mouth.
  3. Apply the tape vertically in the midline such that the lips are taped together. You can tape in such a way that only the middle third of the lips are covered. Only a 1.5 - 3 inch strip is needed. (If you have a mustache or beard, you may be out of luck and a chin strap would be the way to go.)
  4. If the tape sticks to the skin too much such that it hurts to remove or irritates the skin too much, apply the tape on and off to your clothing before applying in order to reduce the stickiness.
That's it!

Reference:
Novel porous oral patches for patients with mild obstructive sleep apnea and mouth breathing: a pilot study. Otolaryngol Head Neck Surg. 2015 Feb;152(2):369-73. doi: 10.1177/0194599814559383. Epub 2014 Dec 1.


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Jaw Movement Causing Tinnitus and/or Clogged Ear Sensation

Not uncommonly, a patient can present with complaints of tinnitus, clogged ears, and hearing loss influenced by jaw movement. Specifically, opening or clenching the mouth excessively makes the tinnitus and clogged ear sensation worse. Relaxing the jaw decreases these symptoms.

For some ear symptoms, contraction of the middle ear muscles (stapedius and tensor tympani) may contribute to "muffling" of sounds. Inflammation of the jaw joint can lead to ear pain... but some other ear symptoms like tinnitus and clogged ear sensation are harder to explain.

With such symptoms, it has always been unclear what the exact physical mechanism is behind these two complaints although the temporomandibular joint (TMJ) has always been felt to be the root suspect. Even though the exact mechanism is unknown, treatment that helps include myringotomy and/or TMJ rehabilitation.

However, a paper published May 2016 may have figured out the exact mechanism behind how the TMJ influences tinnitus and clogged ear sensation.

In this particular patient, jaw opening exacerbated tinnitus and clogged ear sensation. Researchers performed a high resolution CT scan of the TMJ with mouth in both closed and open position. What they discovered was a connection between the mandibular TMJ fossa and middle ear space as revealed by a gas collection around the joint capsule with and without mouth closed position.

With mouth widely opened, a gas bubble developed in the joint capsule. With mouth closed, this resolved.

The question than becomes how did air from the middle ear space get sucked into the jaw joint capsule?

According to this paper, based on CT scan, the petrotympanic fissure is thought to be the tunnel connecting the middle ear space to the TMJ (see image below denoted by **). Normally, this fissure should be closed, but in this patient, was found to be patent allowing a communication between the ear and TMJ. The jaw movement was felt to act like a hydraulic pump sucking air in and out between the middle ear and joint capsule.

Creating a hole in the eardrum completely resolved this patient's ear symptoms by eliminating the pressure differential across the eardrum.

However, now that the anatomic basis for jaw movement leading to ear symptoms has been figured out, potential other therapeutic options may become available (i.e., surgical closure of the petrotympanic fissure). Of course, there may be more than one cause for ear symptoms due to the TMJ, but this is a good first step!

Reference:
Transient Hearing Loss and Objective Tinnitus Induced by Mouth Opening: A Rare Connection Between the Temporomandibular Joint and Middle Ear Space. Otol Neurotol. 2016 May 19. [Epub ahead of print]

May 24, 2016

Hope for the Best and Prepare for the Worst

Image from Wikipedia
This quote probably ranks somewhere in the top 3 among surgeons when operating on "challenging" cases. It simply is not enough to know how to perform an operation, but also plan for any possible complications that might occur when minutes if not seconds count. Certainly, the surgeon does not want to waste time coming up with a plan B or C on-the-fly if something untoward happens... but rather, it has already been figured out even before the initial incision was made.

That got me wondering where exactly did this quote come from... Doing a google search comes up with numerous sources including Lee Child, Denis Waitley, Steve Hunnewell, etc.

But perhaps the true source of this quote comes from John Jay, an American statesman, diplomat, one of the Founding Fathers of the United States, signer of the Treaty of Paris, and first Chief Justice of the United States (1789–95).

The first mention of this quote was in a letter he wrote to Edmund Randolph on July 30, 1794:
...The subject of the debts is attended with difficulties. The minister has been informed that the law in Virginia relative to the evidence of book debts has, since the war, been made more strict than it was before. If the law has been thus changed, and made to apply to pre-existing transactions, there is room for complaint... I have read your thirty odd papers to and from and respecting Mr. Hammond and his complaints. You have, in my opinion, managed that matter well; continue, by all means, to be temperate, and put him in the wrong. Let us hope for the best and prepare for the worst. I confess I have hopes, but I also perceive circumstances and causes which may render them abortive... [link]
He used this same quote a few years later in Jan 1, 1813 in a letter to Reverend Dr. Morse:
The aspect of the times certainly continues portentous. To hope for the best and prepare for the worst, is a trite but a good maxim; especially when associated with the reflection that He who governs the world can restrain the wrath of man as well as the rage of the ocean. It is a favourable circumstance, that the delusion which, like an epidemic, has prevailed throughout our country, is abating in many of the States. Calamities sometimes afford good remedies for national distempers. [link]
And again in a letter to Judge Peters in Dec 26, 1820:
Here also the distress of the times is felt very sensibly. Habits of expense, unproductive speculations and debts injudiciously contracted, press hard both upon debtors and creditors. How long this state of things will continue, or how much good or evil will eventually result from it, cannot now be calculated. They who hope for the best, and prepare for the worst, will doubtless mitigate some of their troubles, and probably obviate the occurrence of some others. [link]
Reference:
John Jay, The Correspondence and Public Papers of John Jay, vol. 4 (1794-1826) [1893]. Online Library of Liberty

May 20, 2016

Singer Michael Buble Cancels Concerts Due to Vocal Cord Surgery

On May 18, 2016, Michael Buble announced on Twitter that he's canceling a few upcoming concerts due to an upcoming vocal cord surgery.

Few details are provided regarding the exact medical situation why vocal cord surgery is required for this wonderful singer. It could be nodules, polyps, cyst, etc. Regardless, voice rest is the normal typical requirement after surgical intervention. 

The past few years have been terrible for celebrity singers and their vocal cords. Here's a running list of singers sidelined by injured vocal cords.

• Michael Buble - May 2016
Kelly Clarkson - September 2015
Donny Osmond - August 2015
• Miranda Lambert - July 2015
• Meghan Trainor - July 2015
• Chad Kroeger - June 2015
• Sam Smith - April 2015
• Nathan Sykes - April 2013
• Nicki Manaj - August 2012
• Florence Welch - July 2012
• Maxwell - June 2012
• Keith Urban - Nov 2011
• Adele - Oct 2011
• John Mayer - September 2011
• Scott Weiland - September 2011



May 14, 2016

High Definition Real-Time MRI of Opera Singing

MRI technology has advanced tremendously over the years resulting in significantly higher definition of anatomy as well as real-time portrayal of movement. Such MRI technological progression is particularly noticeable in the depiction of singing anatomy. Check out the following videos over the years:

2016




2015




2011




May 13, 2016

The Different Types of Non-Allergic Rhinitis

Non-allergic rhinitis (NAR) is a condition where a person exhibits many allergy like nasal symptoms, but has normal allergy test results, normal CT Sinus scan, and/or normal structural nasal endoscopic exam. It is a condition loosely termed the "hypersensitive" nose. It is also known as vasomotor rhinitis.

NAR can be divided between non-inflammatory and inflammatory NAR.

Inflammatory NAR can also be further broken down into different subtypes based on nasal smear cytology.

1) NARES - Non Allergic Rhinitis with Eosinophils: This sub-type is characterized by >20% of cells being eosinophils on nasal cytology.

2) NARMA - Non Allergic Rhinitis with Mast Cells: This sub-type is characterized by >10% of cells being mast cells on nasal cytology.

3) NARNE -  Non Allergic Rhinitis with Neutrophils: This sub-type is characterized by >50% of cells being neutrophils on nasal cytology. 

4) NARESMA - Non Allergic Rhinitis with Eosinophils and Mast Cells: This sub-type is characterized by >20% of cells being eosinophils with concurrent >10% of cells being mast cells on nasal cytology. 

Although the different subtypes of NAR can be determined medically by nasal cytology, the clinical treatment for all remains essentially the same encompassing:

3) Saline flushing

With respect to NARNE, avoiding the offending chemical trigger often resolves this condition without the need for medications (for example, chlorine in swimming pools may trigger this response and by avoiding chlorinated swimming pools, NARNE may resolve spontaneously).

If nasal polyps develop, additional medical treatment can be initiated including:

1) Oral steroids
2) Steroid flushing

However, distinguishing the sub-type may provide further prognostic information in that NARESMA has the poorest response to medications. Also NARESMA has the highest chance for nasal polyps developing at some point in the future and for polyp recurrence after removal. NARESMA also has the highest risk for the development of asthma.

References:
Nasal cytology in children: recent advances. Ital J Pediatr. 2012 Sep 25;38:51. doi: 10.1186/1824-7288-38-51.

Non-allergic rhinitis with eosinophils and mast cells constitutes a new severe nasal disorder. Int J Immunopathol Pharmacol. 2008 Apr-Jun;21(2):325-31.

Nasal cytology: practical aspects and clinical relevance. Clin Exp Allergy. 2016 Mar 24. doi: 10.1111/cea.12730. [Epub ahead of print]

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