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July 19, 2017

Honey May Help With Chronic Eczema of the Ear Canal

Image from Amazon. Please note that
this honey was NOT used in the study
described
There was an interesting paper from the Netherlands regarding treatment of chronic recurrent eczematous otitis externa (ear canal skin inflammation) with honey ear drops with good success in 15 patients. Although it did not cure the problem, it did improve symptoms without the use of "medications."

Eczematous otitis externa (which should NOT be confused with acute otitis externa or swimmer's ear) is characterized by scaly, itchy, and inflamed skin involving the outer ear and ear canal. Secondary bacterial infections are not uncommon. Standard treatment involves repeated use of steroids and antibiotics which do help temporarily, but ultimately causes problems over the long-term so alternative treatment options would be ideal.

Such alternative treatment that have been tried in past include vaseline, sweet oil, mineral oil, etc in an attempt to avoid steroids and antibiotics. Now honey may potentially be considered as well.

The honey that was used in this study was called "Otomel" and is a medical grade honey produced by BFactory Health Products in Rhenen, the Netherlands. As such, there is no information in what type of honey this is, where it is produced, how it is prepared, etc.

But if you can manage to get your hands on one, the study called for using it 3 times per day for 2 weeks.


Reference:
Treatment of Recurrent Eczematous External Otitis with Honey Eardrops: A Proof-of-Concept Study. Otolaryngol Head Neck Surg. 2017 Jul 1:194599817718782. doi: 10.1177/0194599817718782. [Epub ahead of print]

July 18, 2017

Dr. Chang Quoted in SELF Magazine Article

In June 2017, SELF magazine published a story online that quoted Dr. Chang regarding earwax and its cleaning. He is mentioned in the last paragraph.
The ear canal is generally self-cleaning, so "the majority of folks don’t have to do anything," Christopher Chang, M.D., an otolaryngologist, previously told SELF. In fact, sticking a cotton swab in your ear is a recipe for disaster.

Source:
Watch This Earwax Extraction Video and Try Not to Look Away. SELF 6/26/17


July 17, 2017

Surgeons Should Operate Naked to Decrease Risk of Surgical Site Infections

Image courtesy of adamr
at FreeDigitalPhotos.net
This controversial claim was actually made by a well-respected surgeon, Dr. Dellinger, at a well-respected institution, University of Washington Seattle, and published in a well-respected journal, Clinical Infectious Diseases.

Although this research article's title is certainly published in jest, there is an underlying more serious message.

In any case, the argument goes like this:

    • FACT: Humans constantly shed skin flakes and germs from the skin. Wearing clothing like scrubs actively rub the skin aggravating the skin shedding with germs which can disseminate into the air.

    • FACT: Naked humans shed less skin and germs than clothed humans.

    • Therefore, naked surgeons would lead to a more sterile environment for operating on patients and decrease infection risk.

The study also found that male surgeons shed twice as much germs as women and that women wearing tights in the operating room shed more than those with bare legs.

In spite of the clear benefits from an infection standpoint, it is doubtful that surgical procedures will ever be performed with naked surgeons assisted by naked nurses and naked support staff.

And if hospital and government policies ever change in order to enforce naked surgery in the name of patient safety, I'm not sure the operating room culture would ever change to the point where snarky comments, inappropriate giggling, and staring would disappear to allow for the serious business of safe and competent surgery.


Reference:
Naked Surgeons? The Debate About What to Wear in the O.R. Clin Infect Dis. 2017 May 29. doi: 10.1093/cid/cix498. [Epub ahead of print]

July 04, 2017

Blood Thinner Use and Sino-Nasal Surgery (Septum and Sinus Surgery)

Cross-Section showing relationship of septum, sinus,
eye, and brain
There is an active abhorrence between blood thinner medications and ENT surgeons. Not only do blood thinners markedly increase risk of nosebleeds which often require nasal packing  (even without surgery), but it can complicate any type of sino-nasal surgery, particularly septoplasty and sinus surgery.

With septoplasty or sinus surgery (collectively called sino-nasal surgery), not only is the nasal mucosa is actively cut but bone is fractured and removed as well. An active persistent nosebleed after such surgery is common for 24 hours to as long as 10+ days. With blood thinner use, an ordinary typical post-surgical nosebleed can markedly increase such that nasal packing will certainly need to be placed to stop it.

Not only is the risk of a bad nosebleed higher after sino-nasal surgery when blood thinners are present, but also the risks associated with nasal packing itself are also higher.

Why is that?

After all, nasal packing applies pressure to any mucosal bleeding thereby stopping the nosebleed. It shouldn't matter if blood thinners are present or not... right? Unfortunately, it DOES matter especially when sino-nasal surgery has been performed.


The key difference associated with sino-nasal surgery is that bone is fractured and removed. Bleeding within bone (after fractured removal) can be stopped as long as there's nowhere for the blood to go and clotting occurs normally.

Unlike for mucosal bleeding, nasal packing does NOT compress and stop bleeding that occurs within the bone. Rather it only prevents the blood from coming out of the bone and into the sino-nasal cavity. The bleeding would still be occurring internally within the bone itself until it clots off.

The ONLY other way for any blood within bone to go other than out the nose is to go behind the eye (retro-orbital hematoma which puts patient at risk of permanent blindness) or up into the brain (intra-cranial hemorrhage which can potentially be life-threatening). Normally, these risks are not a concern EXCEPT if there is a large enough crack in the bone separating the nasal cavity from the brain and eye sockets allowing blood to pass through. However, keep in mind that micro-fractures are invariably present, even if surgery is perfectly performed.
Green denotes septal bone that is removed by fracture and purple denotes bone that is
removed during sinus surgery. Red arrows show where blood can go if bleeding does not stop
with nasal packing after surgery.

As such, overall risks are much higher when blood thinners are present because internal bone bleeding will continue (due to the blood thinner) even if nasal packing has been placed. However, if clotting function is normal, than the bleeding within the bone will quickly and automatically clot off before it causes any significant problems.

Most ENT surgeons will do everything possible to prevent the need for nasal packing after sino-nasal surgery (mainly for patient comfort, but also to allow a "safer" way for any bleeding to come out), but if blood thinners are present, many of these interventions may not work and nasal packing will HAVE to be placed.

• Cauterization
• Dissolvable foam or sponge placement
• Vasoconstricting or pro-coagulant medication use
• Medically keeping blood pressure low
• etc

Indeed, if bleeding occurs behind the eye or up into the brain, the first step to take is remove the nasal packing to allow blood to come out the nose instead.

As such, in order to minimize bleeding risks, it is essential that any blood thinners be stopped one week prior to sino-nasal surgery and ideally up to 2 weeks after surgery (given nosebleeds can commonly occur for up to 10+ days after sino-nasal surgery).

Of course, if the risks of not taking a blood-thinner is too high, than hard choices need to be made on the timing of the sino-nasal surgery. If the surgery is elective, it may be better to wait until blood-thinners are no longer medically required.


Background Info on Blood Thinners:

Blood thinners encompass two different classes of medications that work by different mechanisms: anticoagulants and antiplatelet.

Anticoagulants include warfarin (coumadin), heparin, dabigatran (pradaxa), apixaban (eliquis), edoxaban (savaysa), and rivaroxaban (xarelto).

Antiplatelet medications include aspirin, ibuprofen, clopidogrel (plavix), dipyridamole (persantine), and ticlopidine (ticlid).

Theoretically, no matter the medication, most patients will have normal ability to clot after stopping a blood thinner for one week. However, some newer medical agents theoretically require a shorter period of time before bleeding risk is minimized. However, given that bleeding complications of sino-nasal surgery could potentially be devastating and there may not be any easy way to neutralize the effects of some blood thinners, many ENT surgeons will specify being off all blood thinners no matter what kind for minimum one week prior to surgery and for 1-2 weeks afterwards, especially if the surgery is elective in nature. Another reason is because unlike for warfarin which utilizes PR/INR, there is no test to measure how thick or thin the blood is for many of the newer agents (if a reliable test could be performed, than there would be less "fear" of bleeding complications after surgery performed more quickly). In any case, here is a list below of how long it takes for blood to "theoretically" normalize after stopping a blood thinner.

• Warfarin (coumadin): 6 days
• Dabigatran (pradaxa): 4 days
• Rivaroxaban (xarelto): 3 days
• Apixaban (eliquis): 3 days
• Edoxaban (savaysa): 3 days
• Antiplatelet Medications (all of them): 7-9 days


June 28, 2017

Swab Culture is Inaccurate Test for Determining Tonsillitis

A fascinating study came out in June 2017 that compared the bacteria found on the tonsil surface by swab versus bacteria found within a core needle biopsy versus bacteria found within the dissected tonsil's core. The take home finding is that a swab culture poorly identifies the bacteria causing recurrent tonsillitis.

Based on 54 children who underwent tonsillectomy, researchers performed a swab, needle biopsy, and core dissection of all tonsils removed. Culture results obtained from all three different methods of sampling were than compared.

The infectious agent obtained from the dissected tonsil core is considered the most accurate to which  the other two methods (swab and needle biopsy) are compared.

What they found was that:

• Culture results obtained from the three methods were in agreement only 63% of the time.
• 16.7% of the surface swab cultures grew something different from pathogens obtained via the other two methods.
• In another 5.6%, the surface swab culture came back negative while the two core cultures were positive for the same pathogens.
• The results of needle biopsy culture and dissected core culture were in agreement 85.2% of the time.
• In only 7.4% did the core needle biopsy culture fail to accurately identify the infectious agent.
• Overall, the sensitivity and specificity of core needle biopsy sampling was 100 and 50% respectively, compared with 82.9 and 30.8% for the superficial tonsillar swab.

In conclusion, getting a swab culture of the tonsil provides the wrong answer not uncommonly.

Obtaining a core needle biopsy provides a more accurate answer to the putative infectious agent, but I doubt that this more invasive test is something that can be tolerated in children in the office, especially given kids already HATE getting just a simple swab done.

As such, although the swab culture is unlikely to go away in the near future even though it's accuracy is questionable, one should consider the results only as a guide rather than a statement of fact and greater weight should be given to clinical findings in deciding whether a presumed tonsil infection is present or not.

Interestingly, the most common organism found in this study was staph aureus... not strep. Keep in mind that rapid strep tests can ONLY say whether strep is present or not... it doesn't tell whether any other organisms are present or not. Other organisms found include Klebsiella, Moraxella, Enterococcus, coagulase-negative staph, pseudomonas, and E coli.

While we are on topic, watch this video explaining why it takes several days to get culture results.


Reference:
A comparison of tonsillar surface swabbing, fine-needle aspiration core sampling, and dissected tonsillar core biopsy culture in children with recurrent tonsillitis. Ear Nose Throat J. 2017 Jun;96(6):E29-E32.



June 24, 2017

Hearing Loss Helped Thru Music Therapy

Image courtesy of surasakiStock
at FreeDigitalPhotos.net
 
I have observed that musicians tend to cope with hearing loss much better than those without a music background, even if both have the same level of hearing loss on a hearing test. In particular, musicians with hearing loss tend to understand speech much better in noisy environments whereas non-musicians with hearing loss have trouble even with a hearing aid.

I have also noticed that as one ages, understanding speech in noisy environments with multiple speakers becomes more difficult even with a normal hearing test, especially in non-musicians.

Why is that?

When it comes to understanding speech, normal brain processing is required to interpret the sound the ear picks up.

Speech and non-speech sounds are basically noise. What makes speech special is that there is meaning embedded within the sound. The ear's job is to just pick up sound no matter what the sound is. But it is the brain that takes in all the sound picked up by the ear, processes the sound, and than gives meaning by interpreting sound due to speech. Otherwise sound is just sound without any inherent meaning to it.

With age, not only does memory start to diminish, but also the brain's ability to process sounds start to diminish as well leading to not so much "hearing loss" per se, but "understanding loss."

That's why hearing aids can only help so much in this situation... hearing aids amplify ALL sounds as it is not able to distinguish between "speech" sounds vs other types of sounds. The brain STILL has to process all the sounds being picked up and give meaning to any speech sounds that may be present.

So why do musicians with or without hearing loss able to "understand" so much better than non-musicians in noisy environments?

It's because musicians have over years strengthened the auditory pathways and brain circuits to isolate melodies and pitches from one another. A violinist in an orchestra can literally hear individual sounds made from other instruments in the orchestra effortlessly.

A non-musician may be able to appreciate the orchestral music as a whole, but would have trouble humming/singing back the sound produced ONLY by the viola section, for example.


So how can a non-musician learn to understand better in noisy environments whether hearing loss is present or not? It's what I call hearing music therapy. This type of treatment is being investigated more aggressively now. NPR even did a story on this type of music therapy to help with hearing loss early in 2017.

For those patients who may benefit from this type of hearing therapy, I suggest the following:

1) Join a chorus (typically, a church choir)
2) Listen to classical music and pick one instrument to follow the sound it makes throughout the entire song ignoring all else. Start with trios before moving on to quartets, than string orchestras, than full symphonic orchestras. I usually suggest Mozart, Bernstein, or Copland as starting points.
3) Spend at least 30-60 minutes a day performing this activity (even if it is in a car going to and from work)

When doing such music therapy, it should not be a passive activity. One has to ACTIVELY listen and work at it regularly, otherwise, improvement will not be expected to occur.

More Info:
'Like Brain Boot Camp': Using Music To Ease Hearing Loss. NPR 5/31/17

Hearing and music in dementia. Handb Clin Neurol. 2015; 129: 667–687.

Auditory Reserve and the Legacy of Auditory Experience. Brain Sci. 2014 Dec; 4(4): 575–593.


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