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June 30, 2016

Dr. Chang to Become Chair-Elect of AAO-HNS Committee

It has recently been announced that Dr. Chang will become the new Chair-Elect of the Public and Media Relations Committee within the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS), an international organization for ENT surgeons. This one year term from 2016-2017 will subsequently transition to position of Chairperson for 2017-2019. He has been a committee member since 2014.

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June 24, 2016

Saddle Nose Deformity Nose Job [VIDEO]

new video has been produced showing how a "saddle nose" or "ski-slope nose" is corrected. This video was created with Dr. Stephen Park who is a Professor and Vice-Chair of Otolaryngology, Division Chief of Facial Plastic Surgery.

A saddle nose deformity is when the nose bends downward between the forehead and tip of nose resulting in a shape similar in appearance to a ski jump slope. It could be congenital or acquired. Acquired causes include prior rhinoplasty, intranasal drug abuse (most commonly cocaine), excessive decongestant nasal spray use (afrin, zicam, 4way, etc), trauma, etc.

This is the second of 5 videos that will be created describing the most common rhinoplasty procedures.

The first was nasal hump removal which can be watched here.

Please keep in mind that although Dr. Chang may have helped produce these rhinoplasty videos, he does not actually perform them.

June 10, 2016

Velopharyngeal Insufficiency (VPI) After UPPP or Uvula Excision Surgery

Image 1: Normal open position
One of the main risks of uvula excision and UPPP (uvulopalatopharyngoplasty) surgery to treat snoring and obstructive sleep apnea is velopharyngeal insufficiency (VPI). This complication is when the soft palate is not able to adequately lift and close off the back of the nose from the throat.  When the VPI is large, food and liquids can come out the nose during swallow and there may be a hyper-nasal speech quality. When the VPI is very small, a patient may report a constant sense of phlegm or mucus behind the soft palate and even up in the back of the nose that exacerbates with talking and swallowing.

If you look at Image 1 obtained by real-time MRI scan (mid-sagittal section), the blue arrow points to the soft palate and the red arrow is the back wall of the nose/throat. With normal nasal breathing, the soft palate is in a down position allowing a communication between the nasal cavity and throat thereby allowing air breathed in through the nose to pass down into the throat.

However, when eating and talking, the soft palate will lift up and close off this passage between the soft palate and back wall. You can see this in Image 2. The purple arrow points to where the soft palate has closed up against the back wall preventing any air (or food/liquids) from getting up into the nose.

Image 2: Normal closed position.
When UPPP or uvula excision surgery is performed, care must be taken to NOT remove too much palate tissue otherwise the patient may not be able to lift the soft palate high and back far enough to close up against the back wall. In Image 3, you can see what happens when the patient is unable to close this area off when too much uvula/palate was excised. The orange arrow points to a persistent opening between the elevated palate and back wall. This condition is known as velopharygeal insufficiency (VPI).

Image 3: Orange arrow pointing to VPI during attempted plosive and sibilant sounds.

In this situation, food, liquids, mucus can be forced up behind the soft palate with swallowing/talking. If this opening is particularly large, food/liquids can even come out the nose. A hyper-nasal speech quality is also present.

Occasionally, a "partial" VPI may occur whereby the soft palate does technically close off against the back wall, but only in the top aspect leaving the bottom part of the soft palate still separated from the back wall. In Image 4, you can see this "partial" VPI. The yellow arrow points to this persistent separation between the soft palate and back wall.

Image 4: Yellow arrow pointing to "partial" VPI during attempted plosive and sibilant sounds.
With "partial" VPI, the main complaint is constant phlegm sensation behind the soft palate exacerbated with swallowing and talking. This occurs because the saliva in the mouth gets forced up into the "pocket" behind the soft palate created by the partial soft palate closure.

In order to correct VPI whether partial or not, one has to close off any potential opening between the soft palate and back wall. If the VPI is small, injection of filler agents like fat, collagen, hydroxyapatite can be performed into the back wall bringing it forward towards the soft palate so that the soft palate can now seal up against the back wall.  If the VPI is large, more aggressive surgery is required whether it be a soft palate lengthening procedure (best performed by cleft palate surgeons) or inserting graft material into the back wall.

Nasal endoscopy can certainly be performed to evaluate for VPI, but keep in mind it can only assess closure on the top nasal aspect for closure... not on the bottom aspect as seen in Image 4. Some examples of VPI seen on nasal endoscopy can be seen here.

A new method for the study of velopharyngeal function using gated magnetic resonance imaging. Plast Reconstr Surg. 2002 Feb;109(2):472-81.

Evaluation of velopharyngeal insufficiency with magnetic resonance imaging and nasoendoscopy. Ann Plast Surg. 2000 Jan;44(1):8-13.

June 07, 2016

New Video on Nasal Hump Removal Nose Job

A new video has been produced showing how a nasal hump is removed. This video was created with Dr. Stephen Park who is a Professor and Vice-Chair of Otolaryngology, Division Chief of Facial Plastic Surgery.

This is the first of 5 videos that will be created describing the most common rhinoplasty procedures.

Please keep in mind that although Dr. Chang may have helped produce these rhinoplasty videos, he does not actually perform them.

June 05, 2016

Liquid Biopsy for Head and Neck Cancer

Liquid biopsy is when a simple blood draw is performed in order to detect cancer cells (CTC) or mutated DNA fragments (ctDNA) free floating in the bloodstream that has been shed from the cancer's primary or secondary sites. This test has been heralded as an alternative way to make a diagnosis instead of an invasive surgical biopsy whether by needle or excision.

Liquid biopsy has been developed mainly for detecting cancers of the breast, prostate, colon, ovarian, lung, and melanoma. Liquid biopsy for such cancers are also the basis for media reports including the widely read New York Times article published in June 4, 2016.

Unfortunately, liquid biopsy to detect cancers of the head and neck (HNC) has not been as fully researched and has a limited if any role at this time.

According to studies done to date, the following mutations were found in the blood of HNC patients (percentage noted in parentheses). Please note that these values were obtained from patients who have known advanced head and neck cancer (HNC):

• PIK3CA195 (30%)
• TP53 (50%-72%)
• BRAF (10%)
• AKAP9 (10%)
• PIK3CA(21%)
• FAT1 (23%)
• CDKN2A (22%)
• Other mutations include TRAF3, CASP8, NOTCH1, NSD1, HRAS, NRAS, AJUBA, MLL2, TGFRBR2, HLA-A, NFE2I2, FAT1, NFE2L2, and amplification of 3q26/28 and 11q13/22

Given these numbers have been obtained from patients with known advanced head and neck cancer, the percentages are probably much lower in the early stages.

Such numbers are far from the 90%+ detection levels quoted in media reports like the New York Times.

However, detection levels are much better when the saliva is also analyzed in combination with blood, especially for cancers originating in the oral cavity such as the tongue and tonsil. When both blood and saliva is checked for TP53, PIK3CA, CDKN2A, HRAS, NRAS as well as HPV (HPV-16,-18), cancer detection rates increased up to around 90% [link]. In fact, for early stage cancer, saliva had a significantly higher detection level compared with blood.

However, mutant DNA fragments were shown to be 10 times more prevalent in plasma than in saliva which could influence treatment regimens.

As such, when liquid biopsies become formally available for HNC, it will probably involve testing both blood and saliva for maximal accuracy and cancer detection from both a diagnostic as well as therapeutic reasons.

Before patients get too excited however, keep in mind that these results are based on very low numbers of patients and at this time, may only be used to monitor the cancer and suggest treatment regimens... not to diagnose it. Before such testing can be used with confidence and reliability for patients with head and neck cancer, further research with larger numbers of patients need to be undertaken.

As such, tissue biopsies are still required to diagnose head and neck cancers. Another thing to keep in mind is that current research for HNC liquid biopsies generally check for only one specific type of cancer called squamous cell carcinoma; granted, it is the most common type. However, there are many other head and neck cancers that current investigational liquid biopsies do not address including mucoepidermoid carcinoma, acinic cell carcinoma, adenocarcinoma, neuroendocrine carcinoma, thyroid carcinoma, etc.

In any case, for those interested, commercial testing is available for HPV in the saliva as well as most genetic mutations in the blood by private labs like Guardant Health. Testing for genetic mutations in the saliva is still not commercially available at this time.

Furthermore, blood genetic mutation testing is ONLY indicated for advanced solid tumors at this time.

‘Liquid’ Cancer Test Offers Hope for Alternative to Painful Biopsies. NYT 6/4/16

A liquid biopsy for head and neck cancers. Expert Rev Mol Diagn. 2016;16(2):165-72. doi: 10.1586/14737159.2016.1127758. Epub 2016 Jan 18.

Detection of somaticmutations and HPV in the saliva and plasma of patients with head and neck squamous cell carcinomas. Cancer.2015;7(293):1–7

Detection of circulating tumour DNA in early- and late-stage human malignancies. Sci Transl Med. 2014 Feb 19;6(224):224ra24. doi: 10.1126/scitranslmed.3007094.

Comprehensive genomic characterisation of head and neck squamous cell carcinoma. Nature. 2015;17:576–82.

The mutational spectrum of squamous-cell carcinoma of the head and neck: targetable genetic events and clinical impact. Ann Oncol. 2014 Oct;25(10):1889-900. doi: 10.1093/annonc/mdu143. Epub 2014 Apr 8.

Detection of somatic mutations and HPV in the saliva and plasma of patients with head and neck squamous cell carcinomas. Science Translational Medicine 24 Jun 2015: Vol. 7, Issue 293, pp. 293ra104 DOI: 10.1126/scitranslmed.aaa8507

June 03, 2016

Can Ear Plugs Cause a 700 fold Increase in Germs in the Ear Canal? (Headphones, Hearing Aids, Stethoscopes, etc)

It was recently brought to my attention an interesting urban legend that wearing ear plugs can cause a 700 fold increase in germs in the ear canal. Curious about how this statement came to life, I scoured the internet and discovered the following info that may have relevance for people who regularly use earbud devices that require insertion into the ear canal whether it be ear plugs, headphones, hearing aids, stethoscopes, etc.

In 1992, US Naval researchers published a study that discovered that wearing for one hour a headset device (similar to ones distributed on airplanes for passengers) increases the bacterial counts on the ear buds from a baseline 60 organisms before use to 650 organisms... a 10.8 fold increase. The germs that were isolated included Staphylococcus spp, Streptococcus spp, Propionibacterium spp, and Peptostreptococcus spp.

One year later, the New York Times published a "Practical Traveler" story that stated that this 1992 research "showed a 100- to 700-fold increase in bacteria." And thus, an urban legend was born from an arithmetic error based on actual research. Even when taking the raw data from the original research with a baseline bacterial count range of 20-110 and after use count range of 120-1530, the maximum increase (taking the lowest and highest numbers) would still end up at most being 76.5 fold increase... not anywhere close to 100 fold increase let alone 700 fold increase.

That said... even a 10.8 fold increase in bacterial counts from wearing earbuds for just one hour seems alarming.

However, for the vast majority of individuals, this bacterial count increase has no clinical significance. After all, bacterial counts would increase no matter what the situation as long as there is gentle heat, humidity, and a surface present whether it be wearing gloves, wearing underwear, or using a toothbrush.

HOWEVER, if there are sores, abrasions, or active infection present in the ear canals or the individual suffers from some form of immunocompromise, care should be taken to clean the earbuds regularly and carefully (or avoid using it at all until issues resolve). If sores and abrasions are present, it would allow germs to enter the skin of the ear canal triggering an infection known as otitis externa, otherwise known more commonly as Swimmer's Ear.

For such affected individuals or for those who are healthy but germ-a-phobes, it may behoove to regularly clean the earbuds by wiping the surface with rubbing alcohol as well as drying the surface out completely by placing the buds in a drying box overnight or whenever not in use. The best drying boxes are those made for hearing aids, but also work for any type of earbuds.

Changes in the microbial flora of airline headset devices after their use. The Laryngoscope Volume 102, Issue 1, pages 88–89, January 1992

PRACTICAL TRAVELER; That Airline Pillow May Be Well Traveled. NYT 1/3/93

Ear Infection and Hearing Loss Amongst Headphone Users. Malays J Med Sci. 2002 Jul; 9(2): 17–22.

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