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May 24, 2017

When is Sinus Surgery Appropriate for Recurrent or Chronic Sinus Infections?

Normal CT Sinus Scan
When a patient suffers from chronic or recurrent sinus infections, sinus surgery is an option to consider especially when medical management has failed. There are the obvious candidates where any reasonable ENT would agree sinus surgery is required, but as with much of medicine, there are times when a patient may get several diametrically opposite opinions whether sinus surgery is recommended or not.

Such opposing recommendations at its core occur due to what a CT scan of the sinuses show.

To begin, let's start with a representative case of a patient who has suffered from chronic recurrent sinus infections. This patient reports 6+ sinus infections per year over the past 5+ years. This patient has been on a number of antibiotics including amoxicillin, augmentin, cefdinir, z-pack, and levaquin along with oral steroids, daily saline flushes, oral allergy medications, and steroid nasal sprays.

First, let's talk about the obvious sinus surgery cases.

On physical exam, large nasal polyps are seen with pus pouring out of the sinuses. A CT Sinus scan obtained shown below reveals sinus cavities that are completely opacified indicating profoundly diseased sinuses. (Black indicates air just like the black around the head. Anything but black indicates something other than air in the sinus cavity, presumably sinus disease.)

Unlike the normal CT Sinus scan at the top, note that the
sinus cavities are completely greyed out.
I would warrant that 100% of ENTs would recommend sinus surgery in this particular situation.

However, WHAT IF the nasal endoscopic exam was essentially unremarkable AND the CT Sinus scan obtained came back completely normal as shown below? Again, the same exact patient history as stated above.

Normal CT Sinus Scan
In this scenario, a patient may get different recommendations if they pursued several different ENT opinions. Some ENTs would recommend sinus surgery based on history in spite of normal exam and CT sinus scan. The argument being that it just happened to be normal on the day of the examinations. The analogy being, if a child has a history of 7+ strep throat infections in the past year, but the exam happened to be normal on the day he sees an ENT, tonsillectomy and adenoidectomy would still be recommended.

However, the majority of ENTs (myself included) would argue against sinus surgery in spite of the history. Why?

The counter-analogy I use in this scenario is an abscess of the skin. A surgeon would cut open the skin ONLY IF an abscess is present in order to "release" the pus (incision & drainage or I&D). Sinus surgery is kind of like that, but it's the sinus rather than the skin... As such, doing sinus surgery with a normal CT Sinus scan is like cutting open the skin when no abscess is present... for example, if only a rash or cellulitis is present, neither of which is a reason to cut open the skin.

Furthermore, based on clinical criteria alone, sinus infections are notoriously difficult to diagnose. Sinus infections can be confused with viral infections, allergies, and even deviated septum with enlarged turbinates.

Typically, an aggressive workup is pursued beyond a CT scan and endoscopic exam to evaluate all other possibilities on the assumption that the patient may have been misdiagnosed with recurrent sinus infections when the symptoms were actually due to something else. My favorite statement being,
"maybe the antibiotics did not work for your sinus infections because you never had a sinus infection in the first place."
What does this workup entail?

Allergy testing and if positive, AGGRESSIVE allergy management including even allergy shots. (Sometimes, if the allergies are bad enough, taking just one allergy medicine is inadequate. One may need to take several allergy medications.)
• Evaluate for large inferior turbinates or deviated septum that may cause persistent symptoms of nasal congestion and feeling stuffy. Treatment would be turbinate reduction and septoplasty... not sinus surgery.
• Evaluate for possible immunodeficiency. It just may be that the patient is getting recurrent infections, but not because of any underlying sinus anatomic issues, but because the immune system is much weaker than normal leading to the inability to fight off infections as easily as someone with a normal immune system.
• Miscellaneous considerations include neurologic (trigeminal migraine, contact point headache, etc) as well as autoimmune abnormalities.

If and only if this workup comes back normal and the patient continues to get bona fide sinus infections that are culture positive, sinus surgery can potentially be considered even if the CT Sinus is normal. However, in just this type of scenario, it may be worthwhile to get a 2nd opinion just to ensure nothing got missed.

May 15, 2017

Why Does Airplane Food Taste So Bad?

Image by Wikipedia
People universally complain about how bad airplane food is... However, the reason may surprise you in that it's not the airline's fault, but your body's.

Based on research performed in 2010 at the Fraunhofer Institute in Germany where they have a replica airplane cabin and can simulate different altitudes, cabin pressure, cabin external wall temperature, relative humidity, noise level, vibration, light, air circulation, etc... food scientists discovered that high altitude (low cabin pressure) and dry air essentially degrades the human sense of smell and taste to a state equivalent to having a bad viral cold.

And everyone knows how food tastes with a bad viral cold.

Researchers found that at about 8,000 feet where air pressure is much lower than at ground level, the detection and recognition thresholds of odorants become much higher confirming that the sense of smell becomes more impaired as the pressure decreases. When it comes to taste, the threshold for detecting salty and sweet was also much higher while bitter was not noticeably affected. The threshold for monosodium glutamate (MSG) and umami (or savoriness), was only slightly impaired at low pressure.

Humidity is also much lower in airplanes hovering around 30% which can dry out the nose and dull the olfactory nerve endings in the nose essential for tasting flavor in a food.

White noise from the drone of the airplane engines can also adversely affect perception of taste and smell independent of air pressure too. [link]

A Feast for Research. Fraunhofer IBP.

Why Airplane Food Is So Bad. The Atlantic 5/19/14

Airplane noise and the taste of umami. Flavour 2014, 3:2

May 13, 2017

Best HVAC Filters for Patients with Bad Allergies

For patients with bad allergies, management of symptoms include not just medications and allergy shots, but also avoidance. Avoidance entails not just physically avoiding allergy particulates, but also removing them from the air you breath as much as you can.

Outside of a school or work environment, the home is where a patient may spend a great deal of time. The home is where one can easily take steps to improve the air quality and therefore reduce allergy symptoms and need for (more) allergy medications.

Step 1:

Install good filters at ALL air intake ventilator grills. These air intake grills are typically found in a wall or ceiling and is where air goes IN. A good air filter would remove all particulates in the air over time that may cause allergy symptoms (ie, pollen, mold, dust, etc). Installing a good filter in this location (rather than at the air handler itself) also prevent the ducts and HVAC system itself from becoming dirty with dust and allergens over time.

Air filters are rated in how efficiently they perform this task using the MERV scale. MERV stands for Minimum Efficiency Reporting Value. MERV scales range from 1 to 16 with "1" being the least efficient and "16" describing the highest efficiency.

Obviously, avoid MERV 1 - 4 which does a poor job of removing allergen particulates.

MERV 5 - 13 is reasonably efficient in removing airborne allergen particulates.

As such, for patients with bad allergies, one should purchase air filters classified between MERV 13 - 16. These filters are expected to remove all allergen particulates at about 75% efficiency after a single pass. Before a patient gets all worried about 75% not being as good as 99%, keep in mind that in a home, air would pass through this filter multiple times. Such air recirculation would result in 75% of the particulates being removed from the air with each pass. After several hours, this would result in 99% particulate removal from the air. For those curious, HEPA filters have MERV ratings 17 - 20 which exceed 99% efficiency on a single pass, but honestly is probably not necessary for entire home use and can even potentially damage the air handler due to excessive strain (a lot more power is required to push air through). HEPA filters make more sense used in a portable unit for a single room (ie, bedroom).

3M uses a different rating system for some of their filters called MPR (Microparticle Performance Rating). MPR and MERV are basically the same thing. MPR 300 is equivalent to MERV 6; MPR 1000 = MERV 11; MPR 1500 - 2200 = MERV 12.

These filters can all be found and purchased on Amazon.

The key concept for clean air in the home using high MERV (or MPR) filters is "air recirculation". If you have a home's door or window constantly open, you are constantly bringing in NEW air along with allergens floating within. This goes to step 2.

Step 2:

Especially during bad allergy seasons, keep all windows and doors to the outside closed as much as possible to prevent allergens from the outside from getting in. Doing otherwise is defeating the purpose of the HVAC air filter which cleans the air by air re-circulation.

With air re-circulation, one can achieve good air quality even with MERV 5 - 13.

This also means to keep the HVAC fan turned ON at ALL times (do not set to auto).

Step 3 (optional):

Add a portable HEPA filter unit to a single room, typically the bedroom, to further ensure clean air beyond that provided by the home's HVAC system with high MERV filters.

Good portable HEPA units include those made by Dyson and Alen.

Step 4:

Change all air filters quarterly ideally and semi-annually at the very least. The filters WILL become dirty over time and not perform as well.

Step 5 (optional):

For those paranoid about air quality, one can install multiple filters to the home's HVAC system. This basically means to install an air filter at the air intake grill, at the air handler unit, and where air comes out into a room. With such cascaded systems, you may need to hire a company to help in the install. However, a "simple" multi-filter system which I use in my home is to use a MERV 8 at the air intake grill and another MERV 8 in the air handler unit.

In a work situation, one can (try) and install a high MERV filter where air comes out into the room where you work. You may not have any power to change filters at the intake or air handler locations, but you might where air comes out. Obviously, you can keep windows/doors closed and purchase a portable HEPA unit for your own personal use.

Step 6:

If you go outside, you may want to consider wearing a personal respirator or face mask. Click here for more info.

Good luck!

May 12, 2017

Facial Masks for Patients with Bad Allergies

Assuming a patient is already taking allergy medications and even undergoing allergy shots, the other component for good allergy symptom control is avoidance. You can certainly add good filters to a home's HVAC system, but what about outside??? What if avoidance is impossible? For example, if you need to cut the grass on your lawn and you have severe grass allergies or if you need to clean out a moldy basement and you have bad mold allergies?

That's when wearing a face mask or respirator may be beneficial to prevent inhaling large quantities of allergy inducing particulates.

Such "personal respirators" are classified according to criteria set by the National Institute for Occupational Safety and Health (NIOSH) and are classified into 3 distinct groups: N-Series, R-Series and P-Series.

The N-series protect against solid and liquid aerosol particulates that do NOT contain oil.

The R-series and P-Series protect against both solid and liquid aerosol particulates that MAY contain oil. The R-series are typically certified for only 8 hours of use after which it should be thrown out whereas the P-series are typically certified for 40 hours or 30 days of use, whichever comes first. Due to the limited effective duration of the R-series, most individuals will use P-series.

Within each of these groups, there are three different efficiency possibilities: 95, 99 and 100. These numbers represent the filter efficiency. As such, N95 represents a mask that will filter out particulates (0.3 microns or greater) with 95% efficiency. Obviously, the higher this number, the better the filter. A N100 or P100 mask is essentially equivalent to a HEPA filter.

For allergy purposes, the N-series work just fine with the N95 being adequate for most allergic individuals. Of course, one can always go with a higher rated mask such as N99 and N100 which work even better, but can cause an increased sense of air resistance when breathing causing some individuals to feel suffocated. If individuals are ALSO sensitive to chemical fumes, the P-series respirators should be used instead.

For individuals who are sensitive to plastics and/or polyesters that standard masks are made of, Vogmask does make N99 respirators made from organic cotton. However, they are quite a bit more expensive.

All these masks are available for purchase on Amazon.

For more info on filters for a home's HVAC system, click here.

Here are a few masks with different ratings in different series...

May 08, 2017

Expired Epipen Still Effective

Though one should always use an EpiPen that is not expired, it is better to use an expired EpiPen to treat anaphylaxis than to do nothing at all.

A few studies published between 2000 and 2017 suggest that epipens have a shelf-life much longer than the printed expiration date.

A study published in May 2017 as well as two earlier studies published in April 2015 and May 2000 suggest that even if the epipen is expired, it is still effective and safe for use in severe allergic reactions (anaphylaxis).

The May 2000 study examined expired EpiPen auto-injectors 1 to 90 months past the expiration date. What they found was that the older the EpiPen, the less effective it was due to decreased epinephrine bioavailability. The inverse correlation was 0.63 (months past expiration and decreased epinephrine content).

The May 2017 study examined the epinephrine concentration of 40 expired EpiPens and found that 29 months after expiration, the pens contained at least 90% of their stated amount of epinephrine. EpiPens 50 months past expiration had more than 84% of the medication.

As long as the solution is clear without precipitates or discoloration, it's fine to use expired EpiPens and it'll probably work just fine. Better an expired epipen vs nothing at all... BUT, still better to use an EpiPen that is not expired if given the choice!!!

Outdated EpiPen and EpiPen Jr autoinjectors: past their prime? J Allergy Clin Immunol. 2000 May;105(5):1025-30.

Epinephrine doses contained in outdated epinephrine auto-injectors collected in a Florida allergy practice. Ann Allergy Asthma Immunol. 2015 Apr;114(4):354-356.e1. doi: 10.1016/j.anai.2015.01.015. Epub 2015 Feb 21.

Epinephrine Concentrations in EpiPens After the Expiration Date. Ann Intern Med. [Epub ahead of print 9 May 2017] doi: 10.7326/L16-0612

May 02, 2017

Molecular Diagnostic Testing of Infections of the Ears, Nose, or Throat

ADN animationOur office has recently incorporated molecular diagnostic testing in order to identify and treat stubborn infections of the ear, sinuses, and/or throat. Traditionally, germ identification is determined by cultures whereby a swab of pus is plated on a growth medium. A microbiologist than evaluates these plates and provides a report of what germ has grown out visually.

In other situations like strep or mono, the test specifically looks for unique proteins that identify the germ (and ignores all other germs that may be present; for example, if a patient has a staph tonsillitis and a strep test is formed, the strep test will come back "normal").

In contrast, rather than "growing" out the germ or testing for a specific germ protein, molecular diagnostic testing determines what germs are present by sequencing ALL the DNA that is found within a swab specimen. Using PCR, all the DNA within a specimen is sequenced and than compared to a database of over 25,000 different microbes including viruses, fungus, and bacteria. A report is than provided listing ALL the germs within a specimen along with the germ amount and what antibiotic would work best to treat.

Antibiotic resistance is determined through identification of any DNA genes that confer such resistance for the germ of interest.

A sample report is shown below...

Although culture should be sufficient for the vast majority of patients with infections, there is a small subset that even with culture directed treatment, the infection persists or quickly recurs. It is in this small subset of patients that such molecular diagnostic testing may provide useful information that has eluded culture based testing.

The lab our office uses to perform molecular diagnostic testing is MicroGenDx in Texas. Our office has lab kits that are sent Fedex overnight to the lab once a swab specimen has been obtained. Results are obtained within one week which is similar to culture based testing.

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