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September 27, 2014

Video of Epley to Treat BPPV (Posterior Canal)

This is the third in a series of videos our practice is producing on inner ear dizziness. This video demonstrates how the Epley maneuver is performed to treat posterior canal BPPV. Also demonstrated is what happens within the inner ear when the maneuver is performed correctly. The first video was on how the inner ear balance system works which can be watched here.

Soon to come are two more videos specifically regarding treatment of superior and lateral canal BPPV.

September 22, 2014

New Video on Tonsillectomy and Adenoidectomy (Re-mastered and in HD)

Back in 2007, I uploaded a video on tonsillectomy and adenoidectomy which may have been cutting age at the time, but much has changed in the YouTube world including the usage of high definition and wide-screen format. I also purchased a new microphone since than so narration does not quite sound like I'm yelling all the time.

You can watch the "old" version tonsillectomy and adenoidectomy.

And here are the two new videos refreshed for 2012 that have been remastered and in HD:

September 21, 2014

Video on How the Dix-Hallpike Maneuver Diagnoses BPPV Dizziness

This is the second in a series of videos our practice is producing on inner ear dizziness. This video demonstrates how the Dix-Hallpike maneuver is performed to diagnose BPPV. Also demonstrated are the different types of eye-twitching (nystagmus) that suggests what type of BPPV a patient may have. The first video was on how the inner ear balance system works which can be watched here.

Soon to come are videos specifically regarding treatment of BPPV. Watch this video!

September 20, 2014

Steroids Helpful After Tonsillectomy?

Pain is perhaps the most common dreaded fear patients have when considering tonsillectomy surgery.  After pain, bleeding is perhaps the 2nd greatest concern patients have. With both these issues, steroids play a key role by helping with one at the expense of the other.

In the 2011 Clinical Practice Guideline: Tonsillectomy in Children, the authors strongly recommend giving a single large dose of steroids to help with not just pain, but also nausea and vomiting after surgery. It is not just in kids... Steroids also help with pain control in adults.

So if steroids are so helpful, why is only a single dose recommended? Why not give more?

Although there is little evidence that a single dose of steroids significantly increases the risk of bleeding in the post-operative period, there is concern that the same may not hold true if too much is administered. As such, routinely giving more than one dose of steroids is NOT recommended.

However, even with a single dose of steroids, there is still persistent concern for bleeding in children as a recent 2014 study found. As such, the (?nominal) bleeding risks need to be weighed against the definite positive benefit patients have in terms of reduced pain, nausea, and vomiting.

Given this background, the vast majority of ENTs who routinely perform tonsillectomy do give a single dose of intra-operative steroids given it is felt that the benefit does far outweigh the risks.

Another steroid dose "may" be given orally if pain suddenly increases 5-7 days after surgery, but certainly not something that is recommended to be done routinely and best to be avoided if possible.

Clinical Practice Guideline Tonsillectomy in Children. Otolaryngol Head Neck Surg January 2011 vol. 144 no. 1 suppl S1-S30

Impact of Systemic Steroids on Posttonsillectomy Bleeding: Analysis of 61 430 Patients Using a National Inpatient Database in Japan. JAMA Otolaryngol Head Neck Surg. 2014 Sep 18. doi: 10.1001/jamaoto.2014.2009. [Epub ahead of print]

Effects of oral prednisolone on recovery after tonsillectomy. Laryngoscope DOI: 10.1002/lary.24958

Perioperative dexamethasone administration and risk of bleeding following tonsillectomy in children: a randomized controlled trial. JAMA. 2012 Sep 26;308(12):1221-6.

Dexamethasone and risk of nausea and vomiting and postoperative bleeding after tonsillectomy in children: a randomized trial. JAMA. 2008 Dec 10;300(22):2621-30. doi: 10.1001/jama.2008.794.

Steroids for improving recovery following tonsillectomy in children. Cochrane Database Syst Rev. 2011 Aug 10;(8):CD003997. doi: 10.1002/14651858.CD003997.pub2.

September 14, 2014

Video on How the Inner Ear Balance System Works

This is the first in a series of videos our practice is producing on how the inner ear balance system works (and when it doesn't) geared towards the lay public and general patient education. Soon to come are videos specifically regarding treatment of BPPV. Watch this video on YouTube or below.

September 10, 2014

Joan Rivers Underwent Unplanned Vocal Cord Biopsy Without Consent

Image by David Shankbone of Wikipedia
When it was first reported 8/28/14 that comedian Joan Rivers suffered some type of respiratory arrest during some type of sedated endoscopic procedure, it was unclear exactly what was done and what happened. According to initial reports, the endoscopy was done to "check her vocal cords."

Media reports have emerged citing an anonymous source that state an unplanned, un-consented vocal cord biopsy was done during the planned endoscopy procedure, most likely an EGD.

Of course to add mud to an already murky situation, Yorkville Endoscopy released a generic public statement that contradicted these reports stating "A biopsy of the vocal cords has never been performed at Yorkville Endoscopy."

However, should media reports be believed that a biopsy WAS performed and laryngospasm did occur, I suspect the following happened.

Joan Rivers had a planned, consented procedure to check her upper digestive system, most likely an EGD that was performed by a Yorkville Endoscopy GI specialist.

During the EGD, the vocal cords were checked and something abnormal was seen on the vocal cord. An ENT who apparently accompanied Joan Rivers that day decided to perform a vocal cord biopsy that was not planned for nor consented for.

When the vocal cord biopsy was attempted/performed, Joan Rivers' vocal cords apparently seized and closed up (condition called laryngospasm) which prevented her from breathing which eventually led to her cardiorespiratory arrest. A breathing tube was eventually able to be placed. The cardiorespiratory arrest may have occurred due to lack of airway not being obtained quickly enough OR the stress of the laryngospasm triggered a heart attack regardless of how quickly airway was obtained.

In any case, she unfortunately suffered anoxic brain injury and later died after life support was withdrawn a week later.

Assuming media sources have provided accurate information, what could have prevented this tragedy from happening???

Never mind the legal no-no's that occurred here:
  1. Consent SHOULD have been obtained PRIOR to the vocal cord biopsy
  2. No procedure should have been performed by anybody without proper credentialing and privileges for that facility (that's why doctors have privileges with certain hospitals and can not practice medicine in any other facility without such privileges.
What about the multiple medical lapses that occurred?
  1. With vocal cord biopsies, general anesthesia with endotracheal intubation (breathing tube placement) is typically required. With full airway control, the breathing tube can be temporarily removed, but this is only done while patient is paralyzed under full general anesthesia.
  2. Vocal cord biopsies CAN potentially be performed without intubation or general anesthesia ONLY if the patient is completely awake without sedation and has had adequate local anesthesia applied to the voicebox area. I suspect that Joan Rivers only had twilight anesthesia without any local anesthetic application to the vocal cords.
  3. IF vocal cord biopsies are performed, whether under sedated general anesthesia or completely awake, a local anesthetic must be applied to the vocal cord region before any biopsies to minimize risk of laryngospasm as well as post-biopsy coughing.
  4. IF laryngospasm occurs with airway loss, an anesthesiologist (if present) would have attempted forced high pressure mask ventilation. If airway is not able to be quickly restored (key word being quickly), a muscle paralytic agent (i.e. succinylcholine, lidocaine) would have been administered. This drug would have relaxed the vocal cord muscles allowing for a breathing tube to be placed. It should be mentioned that according to the New York Times, there is a good possibility no anesthesiologist was present during the case.
  5. IF for some reason airway is not able to be secured quickly via intubation, an emergency tracheostomy or cricothyroidotomy should have been performed. This procedure essentially is cutting a hole in the neck directly into the breathing pipe which would bypass the vocal cords completely.
One can argue that perhaps an emergency trach or cric was not performed because the facility lacked the tools/instruments (again, never mind that the vocal cord biopsy should not have even occurred in the first place in this facility). However, here's a story where an infectious disease doctor without formal surgical training performed an emergency trach in a restaurant with congressmen looking on.

Certainly if an untrained surgeon can perform a lifesaving trach in a restaurant, it surely could have been done in a medical facility.

Joan Rivers had surprise throat biopsy that cut off her air supply, source claims. Daily News 9/9/14

Source: Spontaneous Biopsy Caused Joan Rivers to Stop Breathing. OutPatient Surgery 9/10/14

At Surgery Clinic, Rush to Save Joan Rivers’s Life. NYT 9/9/14.

Doctor Present at Joan Rivers’s Procedure Wasn’t Authorized at Clinic. NYT 9/11/14

Joan Rivers' Endoscopy Clinic, Yorkville Endoscopy, Denies Performing Throat Biopsy on Late Comedienne. US Weekly 9/10/14.

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