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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

January 08, 2017

Why Does the Ear Hurt with Cold Air or Cold Wind Exposure?

Image courtesy of stockimages at
Not uncommonly, some people complain about ear pain (or otalgia) that lasts about 15-60+ minutes after the ear gets exposed to cold air or wind. The pain always resolves after the ears warm up, even if nothing is done. The pain is typically described as sharp or an ache deep within the ear canal. However, the pain may radiate around the ear and even below the ear into the throat.

Wearing ear plugs or ear muffs when in cold air prevents this pain from occurring.

Such discomfort also occurs when the ear is exposed to cold water (cold water swimming or SCUBA).

Why does this happen?

First of all, this cold air otalgia should be differentiated from ear pressure pain from barometric pressure changes induced by dramatic temperature differentials. If the ear pain is described more as "pressure," than you may be suffering from eustachian tube dysfunction. More info and treatment for eustachian tube dysfunction can be found here.

However, if the ear pain does not have any pressure discomfort associated with it, the otalgia is almost certainly due to sensory nerve over-stimulation... analogous to "brain freeze" that may occur when eating cold ice cream.

The skin of the ear canal is VERY thin without any fatty layer to insulate nerve endings from cold temperature stimulation.

Also, there are numerous different nerve endings that innervate the ear and the ear canal, almost like that found in the solar plexus.

C2-4 Spinal Nerves (via Great Auricular and Lesser Occipital Nerves): Pain mainly over the mastoid
Cranial Nerve 7 (via Posterior Auricular Nerve): Pain mainly behind the ear.
Cranial Nerve 5 (via Auriculotemporal Nerve): Pain main in front of the ear.
Cranial Nerve 9 (via Jacobson's Nerve): Pain deep in the ear.
Cranial Nerve 10 (via Arnold's Nerve): Pain deep in the ear, but more in the ear canal.

Over-stimulation of these nerve endings found in or around the ear from cold air exposure can cause pain.

Once the cold air stimulation has stopped, the pain from the nerve over-stimulation will subside.

Unfortunately, there is no cure for this condition. The best thing to do is prevent the ear from being exposed to cold air via use of ear plugs or ear muffs. Some individuals will be more prone to this than others, just like brain freeze from eating cold things.

January 07, 2017

Normal Radiological Appearance After Endoscopic Treatment of Zenker's Diverticulum (ESD)

Patient's who suffer from Zenker's Diverticulum report significant difficulty in swallowing, food regurgitation, aspiration, noisy swallowing, etc. These symptoms all stem from the abnormal presence of a "pouch" in the throat where food and liquids get trapped during swallow. The main way of diagnosing a Zenker's Diverticulum is a radiological test called the barium swallow.

Endoscopic staple diverticulostomy (ESD) is a minimally invasive procedure to eliminate the symptoms associated with Zenker's diverticulum without any incisions in the neck. Watch video below on how it is performed.

Should a repeat barium swallow be performed after a successful ESD procedure, much confusion often occurs as the Zenker's Diverticulum can still be seen even if all the symptoms have disappeared.

This is NORMAL. With the ESD procedure, the pouch is actually NOT removed. Rather, the common wall between the pouch or diverticulum and esophagus is divided preventing food and liquids from becoming trapped.

As such, during a post-operative barium swallow test, one can see the barium liquid pooling in the remnant pouch (just like before ESD surgery) with some differences compared with pre-operative appearance.

• reduced height of the partition wall by about 50%
• greater ease of barium passage down the ooesophagus past the remnant diverticulum
• height of barium supported in the substance of the residual pouch is significantly reduced
• greater diameter opening of the upper esophageal sphincter (because with ESD, a cricopharyngeal myotomy is performed)

Barium may still appear to be "trapped" in the remnant pouch (albeit much smaller amount) because during the ESD procedure, a "V"-shaped cut is made in the common wall. Towards the bottom of the "V" pointed cut, less than 1 cm of common wall is typically left still intact in order to minimize risk of esophageal perforation. This remnant common wall is why some barium may still appear to pool within the remnant pouch.

What all this basically means is that the ESD procedure resolves the abnormal symptoms associated with the Zenker's Diverticulum without removing the pouch. Due to the persistent presence of the pouch, a repeat barium swallow after ESD, if performed, will reflect the presence of the remnant pouch. Currently, the recommendation is that there is no need to repeat the barium swallow unless there is a concern for perforation or there is a recurrence of symptoms.

Normal fluoroscopic appearance status post-successful endoscopic Zenker diverticulotomy. Laryngoscope. 2017 Jan 4. doi: 10.1002/lary.26446.

The radiological appearances after the endoscopic crico-pharyngeal myotomy: Dohlman's procedure. Clin Radiol. 1997 Aug;52(8):613-5.

Long-term clinico-radiological assessment of endoscopic stapling of pharyngeal pouch: a series of cases. J Laryngol Otol. 2001 Jun;115(6):462-6.

Pharyngeal pouch endoscopic stapling--are post-operative barium swallow radiographs of any value? J Laryngol Otol. 1999 Mar;113(3):233-6.

Radiographic findings and complications after surgical or endoscopic repair of Zenker's diverticulum in 16 patients. AJR Am J Roentgenol. 2001 Nov;177(5):1067-71.

December 28, 2016

What Did Americans Stick into Their Ear, Nose, Throat in Last Year?

The Consumer Product Safety Commission (CPSC) maintains a database of injuries due to consumer products for which a patient ends up in the emergency room. Such injuries include sticking it into a body orifice for which the product was never meant to go either through self-infliction or by some other individual.

Although more interest may be generated in orifices related to proctology, urology, and gynecology, given this IS an ENT blog, we'll just stick with the ear, nose, and throat. The form to search the CPSC database can be found here.

SO... Without further ado, here is a partial sampling for 2015 according to the CPSC:

  • Earring
  • Earring backings
  • Hair clip
  • Plastic BB gun pellet
  • Paper and an eraser
  • Deflated balloon
  • Dog's paw
  • Beetle
  • Hairpin
  • "Placed toilet paper in ear so wouldn't have to hear neighbors"
  • Chess Piece
  • Plastic drinking straw
  • "Crayon stuck in ear for 2 weeks"
  • Paper napkins
  • Gasoline
  • End of shoelace
  • Wood stick
  • Hair band
  • Ball from eyebrow ring
  • Bead
  • Fake diamond

  • Pebble from the fish tank
  • Egg dye tablet
  • Baby wipe
  • "Stuck a raisin up his right nostril, brother tried to remove tweezers"
  • Plastic hearts in each nostril
  • "Was laying on his back at school when an eraser fell into his nostril"
  • Mini hockey sticks
  • Plastic snake
  • Magnets up each nostril
  • Stove pellet

  • Ruler
  • Dog shampoo
  • Straw
  • Sequins
  • Branch
  • Stale cake
  • "Inhaled a wasp while jogging"
  • Asthma inhaler
  • Paint-stirring stick
  • "Eating club sandwich and part of toothpick broke off, he swallowed it, scratched in throat, but able to finish the sandwich"
  • Glow sticks
  • "Was opening bottle of soda with his teeth and bottle cap fell down his throat"
  • Hoop earring
  • Blow dart
  • Canadian quarter
  • "Accidentally swallowed a pill bottle when taking his medication"
Of course, if only the database included patients seen in an ENT clinic, there would be an even longer and more varied list...

December 21, 2016

Argentine President Undergoes Vocal Cord Surgery

Image by Casa Rosada in Wikipedia
On Dec 20, 2016, media reported that the Argentine President Mauricio Macri underwent a 10 minute office procedure to extract a polyp from the vocal cord.

He reportedly went immediately back to work after the procedure.

The details are sparse and it is unclear exactly what was done to extract the vocal cord polyp.

However, there are only a two ways a vocal cord polyp can be extracted in the office without sedation (that I know of).

1) Trans-nasal endoscopy with polyp extraction using cup forceps through a working channel
2) Trans-nasal endoscopy with laser ablation of the polyp, especially if it was vascular. The laser typically used in this situation is a pulsed-dye laser (PDL)

Given he immediately returned to work, I suspect that a PDL laser was used rather than cup forceps biopsy, because if cup forceps were used to remove the polyp, there would be a period of voice rest which is not necessarily required with PDL treatment.

There's also the timing... cup forceps biopsy is not easy to do in an awake patient and is much akin to playing a video game where one is trying to shoot a moving target precisely. 10 minutes is certainly possible, but more realistically, it probably would take more time than that.

PDL laser does not really require precise aiming. You just shine it in the general vicinity of the vocal cord polyp and fire the laser.

Watch video of how a PDL laser works in this situation.

Argentine president undergoes vocal cord surgery. Yahoo News 12/20/16

December 17, 2016

How Much Paperwork for a Doctor and Other Professions?

Image courtesy of Gualberto107
The Annals of Internal Medicine recently published a paper which investigated how much time a doctor spends on paperwork after following 57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics who were observed for 430 hours, 21 of whom also completed after-hours diaries.

The conclusion was during a typical day, 27.0% of their total time was on direct clinical face time with patients and 49.2% on "paperwork." The missing percentages were spent on other activities.

The explosion in paperwork probably occurred around the time when the government implemented electronic health records incentives and certification requirements known as "Meaningful Use." These rules came into existence when the American Recovery and Reinvestment Act of 2009 (Recovery Act) was passed into law.

If physicians successfully implement "Meaningful Use" requirements, bonus payments will be paid out that can be in the tens of thousands of dollars. About $63,750 per year if all steps followed.

If physicians do NOT implement "Meaningful Use" requirements, not only would these bonus payments not be given, but base pay would also be cut 1-3% on a graduated scale over time.

What exactly is "Meaningful Use?" It's basically paperwork. Lots of it. It's why a typical doctor's note  documenting a 5 min office visit may be 5+ pages long full of useless information.

So much of the paperwork being generated is actually self-inflicted in order to get a bonus pay AND avoid a base pay cut. These requirements apply to both hospitals as well as offices.

However, physicians do NOT have to comply with meaningful use, and a minority do not in order to avoid the unnecessary paperwork (like our practice).  Of course, elements of Meaningful Use that make sense ARE incorporated into practice, but everything else that do not are deliberately ignored. Of course, that means that such practices do not get bonus pay AND get a baseline pay cut.

But, that's OK... because it is not just about the paperwork... It's also a financial and patient care decision. The amount of time saved avoiding paperwork can be used to spend more time with patients as well as see more patients. So, even without the bonus pay on top of a baseline pay cut, the financial end result may come out almost the same, especially if taking into consideration the cost savings in avoiding expensive computer software updates to keep up with meaningful use requirements. I'm sure someone somewhere must have done a study on this trade-off.

Of course, there are paperwork that we have no control over related to insurance... authorizations for medications/tests/surgeries, disability paperwork for patients, etc.

Regardless, physicians do seem to cry a lot about how much paperwork we have to do... But honestly,  it's something that many professions have to deal with. It's definitely not unique to just medicine.

Lawyers seem to swim in paperwork... Piles and piles of it.

Police officers are estimated to spend about 80%+ of their time on paperwork.

Nurses spend about 80% of their time on paperwork.

Scientists spend a not insignificant amount of time on paperwork related to getting money to fund their research.

Teachers also spend an inordinate amount of time (~40%) on paperwork (grading homework and giving out grades).

Just personal observation through buying a home with a mortgage, I suspect the financial sector has quite a bit of paperwork as well.

Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. 2016;165(11):753-760.

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