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May 01, 2016

The Clogged Ear Tube - How to Unclog It?

Clogged Ear Tube
Once the decision has been made to place ear tubes for one reason or other, typically for chronic ear infections, eustachian tube dysfunction, or serous otitis media, the ear symptoms resolve until either the ear tube prematurely comes out... OR the tube becomes clogged usually with earwax, very thick mucus, granulation tissue, or dried debris.

After all, the tube works by allowing ventilation between the middle ear space and the ear canal. With a clogged ear tube, this communication gets cut off and the situation reverts to the way things were before the tube was even placed.

So what to do other than physically removing the ear tube and replacing with a brand new tube?

If granulation tissue is present, I typically try steroid containing ear drops, typically ciprodex, cortisporin, tobradex, etc. The steroid often will cause the granulation tissue to involute and disappear with time. If particularly exuberant granulation tissue is present, gelfoam (dissolvable sponge) can be placed right over the granulation tissue prior to initiating ear drops.

The earring is on the tragus.
If very thick mucus is present, I typically try to suction the thick mucus out of the tube's opening. Sometimes, it is SO very thick that even direct suctioning is unable to dislodge. In this situation, one can again try ear drops as mentioned above with aggressive tragal pumping to try and "dilute" the thick mucus to enable it to drain out properly. The other type of ear drop that has been perhaps just as helpful in this situation is soapy water... I typically instruct patients to fill a one ounce eye dropper with distilled water followed by one drop of no-tears baby shampoo.

It is worth reiterating that ear drops will NOT work unless aggressive tragal pumping also performed after the drops are placed. Tragal pumping is performed by pressing the tragus against the opening of the ear canal repeatedly several times. This maneuver forces the ear drops down into the ear canal where the clogged ear tube is located, otherwise the drops tend to float in the ear canal without really reaching the tube itself.

With dry debris or earwax, the first thing to try is manual removal, assuming the patient can tolerate. Removal is performed using micro ear instruments under a binocular microscope.  One can either remove through the ear canal... OR push the debris through the ear tube where it can fall into the middle ear cavity. If removal not possible, one can again try ear drops with aggressive tragal pumping.

Ear drops helpful to unclog a clogged ear tube.

• Prescription ear drops with or without steroids, typically ofloxin, ciprodex, cortisporin, cipro HC, etc.
• Soapy water (one drop of no-tears baby shampoo mixed into one ounce of distilled water)
• Oil based drops like mineral oil, baby oil, sweet oil

I'm personally NOT a fan of the following ear drops due to risk of pain and even ear damage... and so should be avoided:

Hydrogen peroxide
• OTC earwax dissolving solutions like cerumenex and debrox
• Vinegar
Swimmer's ear drops

The reason why there's pain and risk of damage is because once the ear tube unclogs, the ear drops can now traverse the ear tube and into the middle ear space. The middle ear space is very sensitive and such substances can trigger severe pain/burning (kind of like alcohol on an open wound).

Tube that is open without any clogging.

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Dr. Chang Quoted in WebMD Article

WebMD.com published a story that quoted Dr. Chang regarding ways to treat at home bad breath otherwise known as halitosis.

It is a common question for which Dr. Chang has already written more comprehensively about here.

But at least in this particular article, he is quoted as saying:
Eating the yogurt, you swish it all around in your mouth while you’re enjoying it, and hopefully, you get it to work for your mouth... If you can breathe through your nose but use your mouth out of habit, especially when you sleep, a chin strap might help. It lets you get used to keeping your mouth shut in bed or around the house until it becomes second-nature.
Read the full story here.

Source:
Natural and Home Remedies for Bad Breath. WebMD.com. Accessed 4/16/16.

April 13, 2016

One Tonsil Larger than the Other a Sign of Cancer?

Not uncommonly, a patient will present to an ENT clinic with only ONE tonsil being unusually large compared with the other side. Typically, such patients have no pain, no sore throat,  no preceding illness, no trouble swallowing, etc. Really, no symptoms other than one tonsil being very large. The main concern from an ENT perspective is that this may suggest the possibility of cancer.

What is the risk of cancer in such a situation where an asymmetric tonsil hypertrophy is present? Depending on the study, it can be anywhere from 5-10% in an otherwise healthy patient without any other risk factors or symptoms. Of course, if other risk factors are present including smoking, alcohol use, neck mass, pain, sore throat, difficulty swallowing, etc, the risk of malignancy increases. Factors that decrease the possibility of cancer include being female and a child.

Cancers that commonly produce a unilateral enlarged tonsil include lymphomas and squamous cell carcinomas. Other more rare cancers include extramedullary plasmacytomas, Hodgkin's disease, leukemia, and metastatic neoplasms.

In order to diagnose whether cancer is present or not, the entire tonsil needs to be removed (tonsillectomy). Taking only a small superficial sample of the tonsil via incisional biopsy is NOT recommended as it may miss the cancer if it is occurring deep within the tonsil.

As such, tonsil removal is not just for recurrent infections, but also to evaluate for presence of cancer and should be undertaken in patients where one tonsil is significantly larger than the other. Indeed, ENT's are trained to consider unilateral tonsillar hypertrophy cancerous until proven otherwise and diagnostic tonsillectomy should be pursued.

References:
Unilateral tonsillar enlargement. Otolaryngol Head Neck Surg (1979). 1979 Nov-Dec;87(6):707-16.

Risk factors for malignancy in adult tonsils. Head Neck. 1998 Aug;20(5):399-403.

Incidence of carcinoma in incidental tonsil asymmetry. Laryngoscope. 2000 Nov;110(11):1807-10.

Significance of asymptomatic tonsil asymmetry. Otolaryngol Head Neck Surg. 2004 Jul;131(1):101-3.

Palatine Tonsils Asymmetry: 10 Years Experience of the Otorhinolaryngology Service of the Clinical Hospital of the Federal University of Paraná. Int. Arch. Otorhinolaryngol. 2011;15(1):67-71


April 11, 2016

Buccal Ties and Breastfeeding

Green arrow points to right buccal tie adjacent to where
canine is erupting. Note how the buccal tie is tethered
to the entire height of the gingiva.
Buccal ties are perhaps the least well-known and most uncommon condition among the tethered oral tissues that can affect infant breastfeeding. The other more common types being tongue ties and upper lip ties.

Buccal ties are abnormal mucosal tethers extending from the cheeks to the gingiva. This situation is in contrast to the upper lip ties which are mucosal tethers extending from the midline upper lip to the gingiva and tongues ties which extend from the midline tongue to the gingiva and floor of of mouth.

The vast majority of buccal ties are small without any medical significance and can be safely ignored.

However in very rare situations, buccal ties can be quite severe and impede good latch with breastfeeding. Furthermore when smiling, severe buccal ties can cause discomfort as the cheek lifts and pulls away from the gingiva. Later in life as dentition appears, it may cause food entrapment leading to risk of gingivitis and cavities.

Fortunately, buccal tie releases are straightforward to perform and similar to the way tongue tie and upper lip tie releases are performed. Scissors, electrocautery, or laser can be used to perform the actual release with pros/cons to each method which may depend on the practitioner (our clinic utilizes all these different methods).

Just as with upper lip ties, stretching exercises are required to prevent reattachment.

Green arrow points to right buccal tie and the blue arrow points
to an upper lip tie. There is an irritation granuloma developing
on the buccal tie.


April 01, 2016

Putting Someone Else's Earwax Into the Ear - The Earwax Transplant!

There may be a certain "ick" factor with the idea of putting earwax from one ear into another to treat chronic ear diseases, but certainly it's not as bad as stool transplants to treat chronic colitis conditions.

The idea of earwax and stool transplants comes out of the theory that certain chronic diseases are due to the absence of "good" bacteria resulting in over-colonization of "bad" bacteria. If true, the theory goes that health may be restored to a chronically diseased ear by transplanting earwax from healthy ears.

This technique of earwax transplants was first described by Lloyd Storrs, MD in 1981 and was used to successfully treat chronic seborrheic dermatitis of the ear canal. Others have successfully treated chronic and/or recurrent fungal ear infections and otitis externa infections with this technique as well.

Per Dr. Storrs...
"The collected cerumen (taken from a healthy ear) is suspended in 50% glycerine and left for several weeks to sterilize. It is then strained through a fine filter having been heated so that its is workable. The material is dispensed to the patient in a small dropper bottle and the patient is instructed to place two drops in the external ear canal once a week." [link]
Although earwax can be taken from a complete stranger's ear... normally earwax that is transplanted is taken from the opposite (and hopefully healthy) ear in the same patient.

The other take-home message is that earwax is "good" for you and should not be vigorously removed. A totally clean ear may actually lead to chronic ear conditions! Of course, too much of it is not good as well due to hearing loss issues.

References:
Management of the ear canal seborrhea with cerumen. Laryngoscope. 1981 Aug;91(8):1231-3.


March 26, 2016

Student Shadowing in the Medical Office Going Extinct

Image courtesy of imagerymajestic
at FreeDigitalPhotos.net
Back when I was a high school and college student, shadowing a doctor in the medical office was common and fairly easy to accomplish. Make a few phone calls and set a few days and than you just showed up to get a glimpse into the world of medicine.

Fast forward to the present...

Over the years as a practicing doctor, I routinely get student requests to shadow me in my practice, though such requests mainly come by email rather than phone calls as I did it back in the day. Unfortunately, I have recently come to now refuse student shadowing and not for the reasons most lay public may suspect:

• Student shadowing takes up time... true, but not the main reason
• Student shadowing interferes with office workflow... true, but not the main reason
• Student shadowing results in medical mistakes... nope

The main reason student shadowing is so rare now is because of medico-legal liability stemming from HIPAA. And it's not just me... many physician practices have closed their doors to student shadowing due to HIPAA concerns as well.

HIPAA in a nutshell is a federal law passed in 1996 that prohibits doctors from sharing any private health information with anybody else without explicit permission from the patient. HIPAA penalties are based on the level of negligence and can range from $100 to $50,000 per violation (or per record), with a maximum penalty of $1.5 million per year.

In other words, if a student shadowing a doctor shares information seen in a doctor's office with peers, friends, family or worst case scenario, publicly on social media, the doctor and his office can suffer huge financial penalties, even if the shared information was not done with mischief in mind.

Which is really a shame... but most doctors including myself are not willing to put our careers/jobs in jeopardy for a student who we may not even know in the era of social media and sexting scandals.

When students are found in a medical office or hospital, it is done with legal protections in place, typically granted by the students' school so that any misdeeds committed by the student is borne by the student and the school and not the doctor or medical organization.


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