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March 25, 2017

How Loud is it Where You Live?

The U.S. Bureau of Transportation Statistics has created an interactive comprehensive "noise map" showing how "loud" it is to live in different parts of the United States (for the year 2014). The map depicts data on noise produced primarily by airports and interstate highways. Noise pollution is worst where it is red (80 decibels or higher) and best where it is white (less than 40 decibels).

Check out how loud it is where you live here!

Click here to look at some noise charts comparing decibels to common sounds as well as when it may damage hearing. In my neck of the woods, the noise pollution is not that bad (Warrenton, VA):

However, the metro Washington DC region 45 minutes east is quite a bit louder:

That does not compare to how loud it is in New York City however:

March 24, 2017

Narrow Band Imaging Technology for Cancer Detection Now Available at Fauquier ENT!

Fauquier ENT now offers narrow band imaging (NBI) in the office to better detect cancer and other abnormal lesions in the throat. NBI is an endoscopic imaging technique whereby special filters are used to enhance visibility of vessels and other tissues on or near the mucosal surface. Specifically, it can better "see" dysplastic tissue including pre-cancerous lesions, cancer, and other abnormal mucosal lesions compared to normal light.

The way NBI optically enhances light is by utilizing the 440-460nm (blue) and 540-560nm (green) which is better absorbed by hemoglobin causing blood vessels to appear very dark. Typically, capillaries on the mucosal surface are displayed as a brown color whereas veins deeper under the mucosa appear as cyan.

Overall, the sensitivity, specificity, positive predictive values, negative predictive values, and accuracy for detecting cancer under normal white light were 41%, 92%, 87%, 82%, and 67%. However, cancer detection increased markedly using high-definition narrow band imaging with values at 97%, 84%, 88%, 96%, and 92% respectively.

Throat cancer under normal white light and NBI light.
The cancer is in the center of the photo.

Overall, NBI increases the diagnostic accuracy by about 22% compared to normal white light.

Made by Olympus, the way NBI is performed is via trans-nasal endoscopy whereby a thin black noodle is threaded through the nose and into the throat. The NBI light can than be activated allowing visualization for any abnormal mucosal lesions.

Additionally, the system our office has purchased can also perform high-definition stroboscopy in order to detect subtle vocal cord abnormalities that may lead to a hoarse voice.

European Laryngological Society: ELS recommendations for the follow-up of patients treatedfor laryngeal cancer. Eur Arch Otorhinolaryngol. 2014 Sep;271(9):2469-79.

Narrow band imaging and high definition television in the endoscopic evaluation of upperaero-digestive tract cancer. Acta Otorhinolaryngol Ital.2011 Apr;31(2):70-5.

The diagnostic value of narrow-band imaging for the detection of nasopharyngeal carcinoma. ORL J Otorhinolaryngol Relat Spec. 2012;74(5):235-9.

March 20, 2017

Tooth Fairy Gift Inflation

Graph from Delta Dental
When I was a kid in the 1970s, I remember getting perhaps about 50 cents per tooth from the tooth fairy. I was a bit surprised when I heard from colleagues and friends that the cost of one tooth has gone up since than to about 5 dollars. According to Delta Dental, a national dental insurance company, the current national average cost of one tooth is $4.66. Delta Dental has been putting out a survey every year since 1998 to see how much money the tooth fairy leaves behind for one tooth.

You can complete their survey here as well!

Check out the graph they have put out showing the S&P 500 and tooth fairy gift amount over time. Given the close correlation, how much money a tooth fairy leaves is an accurate predictor of how well the economy is doing overall!

Or, one can consider the tooth fairy gift amount in terms of inflation; it is about 10% per year. Overall inflation in the US economy is about 2% per year. Health insurance inflation rate fluctuates between 2-4%. College tuition inflation rate is about 5%.

March 16, 2017

Can Headaches Trigger Nosebleeds?

Image courtesy of stockimages
Ignoring high blood pressure headaches which can potentially rupture blood vessels in the nose leading to a nosebleed, can headaches in and of itself trigger nosebleeds? I encounter a few patients a year who report that a particularly bad headache triggered their nosebleed, also known as epistaxis.

But can this actually be true?

After all, headaches are common and nosebleeds are common. As such, statistically, two common events could at times occur simultaneously by chance alone leading to erroneous association or causation.

That said, there are a handful of reports that suggest that migraine headaches could potentially trigger nosebleeds. See references below.

A common theme is that migraine triggered nosebleeds typically occurred between the peak severity of the headache and the beginning of its resolution. Therefore, it could be considered a symptom of the resolution phase of migraine during which migraine suffers may also experience vomiting, sweating, lacrimation, etc. With respect to nosebleeds, the trigeminovascular system may be activated  causing significant vasodilation of blood vessels in the nose making them more prone to rupture and subsequent bleeding.

Of course, given the sparsity of medical reports on headache induced nosebleeds, it's hard to say whether there is a true association or not.

But it is something to keep in the back of the mind.

For individuals who have not yet been evaluated by a physician and especially a neurologist for recurrent migraine headaches, one can try some over-the-counter supplements that have been found helpful in reducing the frequency and severity. These supplements include butterbur 75mg 2x per day, magnesium oxide 400mg per day, vitamin B2 100mg 2x per day, and/or coenzyme Q10 100mg 2x per day.

Migraine-Induced Epistaxis and Sporadic Hemiplegic Migraine: Unusual Features in the Same Patient. Case Rep Neurol. 2012 May-Aug; 4(2): 116–119.

[New concepts on the diencephalic origin of epistaxis and migraine. Clinical observations]. Rev Neurol (Paris). 1968 Aug;119(2):229.

Migraine and recurrent epistaxis in children. Pediatr Neurol. 2005 Aug;33(2):94-7.

Intractable epistaxis associated with topiramate administration. Ann Pharmacother. 2006 Jul-Aug;40(7-8):1462-5. Epub 2006 Jul 5.

Migraine-induced epistaxis. Headache. 1986 Nov;26(10):517-8.

Epistaxis accompanying migraine attacks. Cephalalgia. 2007 Aug;27(8):958-9.

March 11, 2017

How a Gorilla Gets a Hearing Test

Ever wonder how a gorilla suspected of hearing loss gets a hearing test? Wonder no more...

Watch this news video clip showing how a gorilla suspected of hearing loss got a hearing test. This procedure is known as a sedated auditory brainstem response and is a test that is routinely performed on infants/children.

In order to undergo an auditory brainstem response test, you do NOT have to be sedated unless there is a concern the patient may not be cooperative (won't mess with the wires, ear plugs, electrode pads, etc).

Below is a video showing this test being performed on a human infant.

March 07, 2017

Metal Detector Instead of X-rays for Swallowed Coins and Other Metallic Objects

Handheld Metal Detector
Due to a recent rash of consults of patients swallowing coins and other foreign bodies mainly in kids but adults too, it occurred to me that a handheld metal detector similar to one that is used in airport security screening can quickly and easily determine whether a metal object is present within the body as well as where.

This quick screening can serve three purposes...

1) X-rays can be avoided along with its radiation exposure. Typically, a neck, chest, and abdominal x-ray may be taken.
2) It is a heck of a lot cheaper than an x-ray as well as trip to the emergency room.
3) X-rays can miss certain small metal foreign bodies like those made from aluminum, but a metal detector won't.

Question is does a metal detector, which uses a magnetic field to detect metal objects, actually work for this purpose?

Apparently yes according to several medical research papers (see references below). The information was convincing enough that my office has purchased one for just these reasons.

According to one study, when it comes to coins and button batteries, metal detectors have a sensitivity of 100% and a specificity of 91.7%. When ALL metal objects are included, the sensitivity drops to 89.1% and specificity down to 91.7%. Sensitivity is even lower at 71% if coins and button batteries are excluded.

The metal detector accurately localized where the object was 73% of the time.

A few case reports described a situation where an x-ray could not see the metal object (razor blade and aluminum tab ring), but the metal detector was easily able to detect it.

A word of advice when purchasing for medical uses... make sure you get the metal detector meant for lumber which typically can detect metal objects at greater depths (up to 6 inches) rather than one meant for security screening which is limited to less than 2 inches.

Diagnostic uses of metal detectors: a review. Int J Clin Pract. 2005 Aug;59(8):946-9.

Identification and topographic localization of metallic foreign bodies by metal detector. J Pediatr Surg. 2004 Aug;39(8):1245-8.

The use of a hand-held metal detector for localisation of ingested metallic foreign bodies - a critical investigation. Eur J Pediatr. 2004 Apr;163(4-5):257-9. Epub 2004 Feb 5.

Use of a metal detector in the location of a swallowed razor blade in the oesophagus. J Laryngol Otol. 1990 May;104(5):435-6.

Metal detector and swallowed metal foreign bodies in children. J Accid Emerg Med. 1999 Mar;16(2):123-5.

Using a metal detector to locate a swallowed ring pull. J Accid Emerg Med. 1995 Mar;12(1):64-5.

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