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August 30, 2016

Hickey From Kissing Can Cause a Stroke (Rarely)

Image from stulala on WattPad
Apparently, a lover's aggressive kissing on the neck leading to hickey formation can potentially also cause enough trauma to the underlying carotid artery that it can lead to stroke and even death. Hard to believe that something that normally would cause no more harm than some teasing from friends has potential life consequences.

The first published report of a hickey leading to stroke was in 2010. In this case report, a 44 years old woman received a hickey over the right superior sternocleidomastoid muscle which triggered a clot to form in the underlying internal carotid artery. This thrombosis subsequently lead to a stroke which the patient ultimately recovered from with anti-coagulants. It took a few days for stroke symptoms to occur after the hickey.

In another report published in the media, a 17 years old teenager ultimately died after getting a hickey over the neck from his 24 years old girlfriend.

It is hypothesized that the suction created during an aggressive kiss not only can traumatize the skin causing the hickey, but also can traumatize the underlying carotid artery triggering clot formation which can than break off and cause an ischemic stroke. With any stroke, if massive enough, can also cause death.

Take a look at the image showing the path of the carotid artery in the neck and its ultimate destination in the brain. This artery is under the sternocleidomastoid muscle that extends from the clavicle to the back of the ear.
Image by BruceBlaus in Wikipedia

Overall, only 1% of neck trauma from any reason can lead to carotid artery injury with subsequent thrombosis and stroke. First described in 1872, the MOST common cause of blunt carotid artery injury is a motor vehicle action from rapid deceleration with neck hyper-extension/flexion.

A hickey can be considered a form a neck trauma and probably is THE most rare subtype of blunt carotid artery injury. After all, there are only TWO published reports of a hickey causing a stroke out of probably trillions of hickeys created over the centuries without any ill effect.

So, lovers should rejoice that it IS OK to kiss and if it happens to lead to a hickey, don't go rushing to the emergency room. You'll probably be just fine.

BUT, if you suddenly suffer stroke symptoms like a paralyzed limb, DO go to the ER!

Love bites—an unusual cause of blunt internal carotid artery injury. The New Zealand Medical Journal. 26th November 2010, Volume 123 Number 1326

Teenager dies from stroke 'caused by love bite from his girlfriend'. Independent. 8/29/16

August 28, 2016

Probiotic Nasal Flushes to Treat Chronic Sinusitis

For patients suffering from chronic sinusitis, the problem may lay more with the absence of "good" bacteria in the sinus cavities than "bad" bacteria that needs to be eliminated. A study in 2012 documented what normal bacteria colonization should be found in healthy sinus cavities versus those suffering from chronic sinusitis.

The study evaluated (only) 10 healthy patients and 10 suffering from chronic sinusitis. Within this small study population, they found over 1482 different species of "germs" were found in LOWER abundances in patients suffering from chronic sinusitis compared to healthy sinuses.

Yes... germs are found in healthy sinuses, but compared to diseased sinuses, there is a more abundant AND diverse composition of germs in normal sinus cavities. In particular, probiotic species Lactobacillus sakei was found to be particularly reduced in chronic sinusitis patients.  Other species also reduced in chronic sinusitis patients included Carnobacterium alterfunditum, Enterococcus mundtii, and Pediococcus pentosaceus.

Corynebacterium tuberculostearicum was the only bacteria found significantly increased in diseased sinus cavities compared to healthy sinus cavities.

Other studies have supported the decreased biodiversity and abundance of microbes in chronic sinusitis though the compositions are somewhat different between studies.

Based on these results, several research teams (UCSF and Baylor) are trying to determine the right cocktail of probiotics to add to nasal rinses that can be performed to help replenish the microbiotia of diseased sinus cavities back into a healthier (normal) composition.

Unlike the benefit found for the stomach and intestines, it has already been determined that oral intake of probiotics is NOT effective in the treatment of diseased sinuses [link] which is why focus is more towards nasal rinse applications.

Of course, that has not stopped some laypeople from doing their own research on themselves, most notably Lacto Bacto which documents alleged successful chronic sinusitis treatment by applying spicy fermented cabbage (Korean kimchi) to the nose.

Hopefully, in the next few years, research will provide commercially available effective probiotic sinus rinse treatments.

Sinus microbiome diversity depletion and Corynebacterium tuberculostearicum enrichment mediates rhino sinusitis. Sci Transl Med. 2012 Sep 12;4(151):151ra124. doi: 10.1126/scitranslmed.3003783.

Sinus microbiota varies among chronic rhinosinusitis phenotypes and predicts surgical outcome. J Allergy Clin Immunol. 2015 Aug;136(2):334-42.e1. doi: 10.1016/j.jaci.2015.02.008. Epub 2015 Mar 26.

Decreased diversity of nasal microbiota and their secreted extracellular vesicles in patients with chronic rhinosinusitis based on a metagenomic analysis. Allergy. 2014 Apr;69(4):517-26.

Probiotics in the Treatment of Chronic Rhinoconjunctivitis and Chronic Rhinosinusitis. Journal of Allergy Volume 2014 (2014), Article ID 983635, 7 pages.

The One Probiotic That Treats Sinusitis. Lacto Bacto. 1/12/15

Probiotics as adjunctive treatment for chronic rhinosinusitis: A randomized controlled trial. Otolaryngol Head Neck Surg February 2009 vol. 140 no. 2 202-208

August 22, 2016

Chronic Cough due to Playing a Wind Instrument

Image courtesy of Iamnee
There have now been a few published case reports where playing a wind instrument caused a persistent cough... one of which ended in death.

Report in 2010 described a trombone player whose chronic cough for over 15 years was ultimately found to be due to a mold called fusarium as well as mycobacterium (cousin to TB) found growing inside his trombone. Each time he inhaled while playing the trombone, these germs inside his trombone was causing an allergic reaction, which led to hypersensitivity pneumonitis, a severe inflammation of the lungs.

The doctor who figured out the problem went on to investigate other wind/brass instruments of other players and found them all contaminated with germs.

Here's another report on a saxophone player who suffered from something similar.

Finally, a report published in 2016 described a musician who developed a severe hypersensitivity pneumonitis from playing his bagpipes which ultimately lead to his death. Cultures obtained of air samples inside the bag were found to contain the fungi Rhodotorula mucilaginosa, Fusarium oxysporum, various species of Penicillium, and Trichosporon mucoides.

This is not the first time bagpipes have been implicated in pulmonary disease. In 1978, Lancet published a report of a bagpiper who developed cryptococcal lung infection.

In any case, how should wind musicians clean their instruments to minimize risk of developing lung inflammation and chronic cough? Ideally,  clean the entire inside of the instrument with cloth and rubbing alcohol (isopropyl alcohol) after each use.

Of course, chronic cough can occur due to factors that have nothing to do with wind instruments including reflux, allergies, neuropathy, etc.

Trombone Player's Lung: A Probable New Cause of Hypersensitivity Pneumonitis. Chest. 2010 Sep;138(3):754-6.

Hypersensitivity Pneumonitis Due to Molds in a Saxophone Player. Chest. September 2010 vol. 138 no. 3 724-726.

Bagpipe lung; a new type of interstitial lung disease? Thorax doi:10.1136/thoraxjnl-2016-208751. Aug 22, 2016.

A microbiological survey into the presence of clnically significant bacteria in the mouthpieces and internal surfaces of woodwind and brass musical instruments.

CRYPTOCOCCUS IN BAGPIPES. Lancet. Volume 311, No. 8078, p1368–1369, 24 June 1978

A Warning to Clean Bagpipes. NYT 3/18/13

August 21, 2016

Pet Dog May Cause Recurrent Strep Throat

Image courtesy of alex_ugalek
In rare situations, strep throat infection bounces repeatedly among all family members. In such situations, the family's pet dog may be the carrier for strep that may cause such recurrent strep infections among the children and parents. See references below.

Fortunately, in the vast majority of situations, the pet dog has no role in recurrent strep throat infections. Indeed, many healthcare professionals are in fact skeptical that the dog has any role.

Personally, I'm a semi-skeptic, but open-minded to the possibility.

In any case, should the dog become a suspect, the vet should obtain cultures from not only the tonsils, but also the eyes and anus. Should cultures come back positive to human strep, the dog should be given antibiotics.

Otherwise, interventions that may help when a family suffers from recurrent strep throat include antibiotics given to all family members simultaneously as well as performing tonsillectomy in the family member who seems to get strep throat the most which often breaks this distressing intra-familial cycle.

Personal Health. NYT 3/20/1996

Recurrent pharyngitis in family of four. Household pet as reservoir of group A streptococci. Postgrad Med. 1983 Jul;74(1):277-9.

Group A streptococci in household pets' eyes--a source of infection in humans? Scand J Infect Dis. 1997;29(5):469-71.

The family pet as an unlikely source of group A beta-hemolytic streptococcal infection in humans. Pediatr Infect Dis J. 1995 May;14(5):372-5.

August 19, 2016

Family Guy Nasal Spray Addiction

Peter Griffin on Family Guy
A patient came to my office one day with a chief complaint of being addicted to an over-the-counter nasal spray called Afrin. When asked why he started using it in the first place, he mentioned about that "one episode on Family Guy when Peter uses a nasal spray and feels invincible because he can breath so great through the nose and smell everything." Watch video below.

The implication being that he bought and used the nasal spray so he can breath amazingly well though the nose. Too bad it is only temporary.

Problem is, it should only be used sparingly for no more than a few days, otherwise one can eventually become addicted to the nasal spray. Over time, the patient will require using the nasal spray more and more frequently in order to achieve the same effect. Should the patient try to quit, extra-severe nasal congestion will occur which compels the patient to go back and start using the nasal spray again.

It's not just Afrin. There are other nasal sprays that have the same addictive potential including 4-way and Zicam. All these nasal sprays contain one of the following active ingredients: oxymetazoline, phenylephrine, pseudoephedrine. User beware!

When the patient mentioned Family Guy to me, not sure what I was thinking, but I thought it was a wholesome family friendly sit-com. Clearly, I don't actually watch Family Guy, but it got me curious about how this medical condition got represented in a pop culture cartoon let alone even being mentioned. Thankfully, there's a YouTube that shows this particular clip...

To read more about treatment options to address this condition, click here.

Please note that other classes of nasal sprays are NOT addictive such as steroid nasal sprays (flonase, nasacort, rhinocort, etc) as well as anti-histamine nasal sprays (astelin, astepro, patanase, etc)

The nasal sprays below are NOT addictive:

August 07, 2016

Hillary Clinton's Constant Throat-Clearing

Image by Gage Skidmore in Wikipedia
Many viewers noted that presidential nominee, Hillary Clinton, constantly cleared her throat during her speech at the Democratic National Convention on July 28, 2016 (watch video below). About 22 times in fact. Media have noted that this throat problem has been going on for far longer... since January 2016.

Why is she clearing her throat so often?

Is it manufactured as some have suggested?

Or could there be a medical reason for her throat problem? For what seems to be a relatively minor annoyance can require an unusually long and extensive workup to diagnose, treat, and resolve mainly because so many different conditions can cause this symptom. Indeed, Mrs. Clinton has been throat-clearing for at least the past 6 months if reports are to be believed. This obviates a simple answer or treatment.

Should Mrs. Clinton come to my office wondering what could be done to eliminate her unintentional chronic throat clearing, the following steps would be pursued:

1) Endoscopic laryngoscopy to evaluate for any physical problems in the voicebox region. Specifically, evaluating for any evidence of mucus collection in the hypopharynx which could be due to Zenker's diverticulum, esophageal dysmotility, laryngopharyngeal reflux, etc.
2) Depending on the endoscopic findings, trial of the following interventions may be recommended:
     • A reflux medication like nexium to address any reflux getting up into her throat. Avoiding fatty, fried, spicy, tomato-based foods would also be advisable.
     • Nasal sprays like flonase and astelin to address any post-nasal drainage that may be dripping down into her throat
     • Avoiding egg, wheat, and dairy which seem to increase the amount of throat phlegm in some patients.
3) Ensuring she is not taking any medications known to cause throat-clearing as a side-effect. The top two category of medications are ACE Inhibitors like lisinopril as well as ARB (angiotensin receptor blockers) like losartan, both used to treat hypertension. Less commonly, high cholesterol statin medications like simvastatin may be a factor.
4) Tests would be ordered including:
     • Allergy testing to evaluate for any allergic triggers
     • Barium swallow to evaluate for any esophageal pathology beyond the voicebox
     • Bloodwork to check for any autoimmune disorders like Sjogren's which may cause saliva to thicken and collect in the throat.

Depending on the results of the above initial steps, further testing may eventually be pursued including :

     • Esophagoscopy
     • 24 hour multichannel pH and impedance testing with manometry
     • PepTest
     • SELSAP

Although throat-clearing appears to be Mrs. Clinton's main symptom, other patients may complain of other related throat problems including:

     • Globus
     • Chronic cough
     • Phlegmy throat

Hopefully, Mrs. Clinton gets her throat symptoms resolved as soon as possible as it apparently is happening frequently enough to distract her constituents/audience where focus should instead be placed more on her message.

However, she as well as others who suffer similarly need to be aware that there are MANY different causes for chronic throat clearing and without knowing what is causing it, the treatment will be haphazard and commonly ineffective.

WATCH: Clinton's Constant Throat Clearing. DailyWire 7/29/16.

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