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September 05, 2015

HPV Vaccine May Help Clear Oral Warts / Papillomas


Contrary to popular belief that it may take years for the HPV vaccine to be truly effective, Texas researchers reported they were able to completely clear all oral papillomas due to the HPV virus in an adult within 3 months of vaccination.

Specifically, they reported that a man in his 60s who suffered from recurrent oral papillomas in spite of multiple excisions was clear of all lesions within 3 months after receiving the quadrivalent HPV vaccine. Interestingly, this patient had HPV-32 which is not part of the HPV vaccine (HPV-16, 18, 6, 11).

Apparently, this is not an isolated case. In the reported literature, 8 others have noted the same improvement. Time to improvement was seen within 4 weeks of vaccination and resolution after 3 to 8 months.

Given these promising findings, quadrivalent HPV vaccination may certainly be worth pursuing in any patients of any gender at any age suffering from oral/airway papillomas.

Currently, there are two FDA approved HPV vaccines. The bivalent HPV vaccine (Cervarix) which addresses HPV 16 and 18 and the quadrivalent HPV vaccine (Gardasil) which prevents four HPV types: HPV 16 and 18, as well as HPV 6 and 11. Only the quadrivalent vaccine is licensed for use in males.

 Both vaccines are administered through a series of 3 intra-muscular injections over a 6-month period. The second and third doses should be given 2 and 6 months after the first dose.

Reference:
Effect of Quadrivalent Human Papillomavirus Vaccination on Oral Squamous Cell Papillomas. JAMA Dermatol. Published online September 02, 2015. doi:10.1001/jamadermatol.2015.2805
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September 04, 2015

Iron Maiden Singer Bruce Dickinson Has Tongue Cancer Due to HPV

Image by Wikipedia
Media reported that singer Bruce Dickinson completed cancer treatment for a golf ball sized growth on his tongue and in his right neck. The singer also suggested that it might have been caused by the sexually transmitted HPV virus.

Based on this information, I suspect the singer had Stage 3 HPV+ squamous cell carcinoma of the tongue that was treated primarily by radiation and chemotherapy. If any residual cancer was detected after this treatment, the rest would have been surgically excised.

For those who follow celebrity news, Michael Douglas suffered the same type of tongue cancer due to HPV and underwent the same type of treatment.

HPV has become one of the leading causes of oral cancer in those under 50... even more of a risk factor than smoking and alcohol. HPV is suspected to be transmitted through oral sexual contact.

Sources:
Iron Maiden Singer Bruce Dickinson Says He Got Tongue Cancer from a Sexually Transmitted Virus. People.com 9/4/15

September 03, 2015

Dr. Chang Quoted in SafeBee Article



Dr. Chang was recently quoted in an article about earwax published on SafeBee.com. He is quoted in two sections of the story. Read it here!

More info about earwax in general can be found here.

August 26, 2015

Can Acupuncture Treat Vocal Cord Lesions?

According to Chinese researchers, acupuncture certainly can help with phono-traumatic vocal cord lesions (nodules, polyps, or chronic laryngitis). In their study, 123 patients with these pathologies were than divided into genuine acupuncture, fake acupuncture, and no acupuncture groups.

The genuine acupuncture group received needles in nine voice-related acupoints for 30 minutes, two times a week for 6 weeks, whereas the fake acupuncture group received blunted needles that merely stimulated the skin surface in the same points for the same frequency and duration. The acupuncture points were Hegu (large intestine-4) and Lieque (lung-7) on each wrist; Lianquan (conception vessel 23) under the chin and 2 Renyin (stomach-9) points in the neck; and Zhaohai (kidney-6) on each ankle.

Significant improvement in vocal function was obtained in both the genuine and fake groups, but not the no treatment group. Even more interestingly, significant decrease in the structural size of the vocal cord lesions were found only in the genuine acupuncture group, but not the fake and no treatment groups.

These findings suggest that acupuncture may be beneficial for the treatment of vocal cord lesions due to phono-trauma.

Of note, this is not the first study to show vocal improvement with acupuncture... there was one done in 2006 on 24 patients using Renyin (stomach-9), Lieque (lung-7), and Zhaohai (kidney-6) acupuncture locations. There were 10 treatment sessions, each lasting 30 minutes, over a 20 day period.

What neither of these studies can answer is whether the acupuncture directly helped resolve the vocal cord lesions... or did it help resolve/improve the underlying muscular biomechanics of the voicebox which than secondarily helped resolve the vocal cord lesions. Furthermore, bias is probably very difficult to eliminate in these types of studies.

Reference:
Is Acupuncture Efficacious for Treating Phonotraumatic Vocal Pathologies? A Randomized Control Trial. Journal of Voice. Epub Aug 19, 2015.

A randomized treatment-placebo study of the effectiveness of acupuncture for benign vocal pathologies. Journal of Voice. 20:144-156, 2006

August 24, 2015

Slow Motion Video of Gleeking



Gleeking is when an individual is able to spray spit out of the mouth causing amazement if not disgust from surrounding people. This salivary spray comes out from Wharton's duct which is an opening located under the tongue tip that drains the submandibular glands located under the jawline.




Donny Osmond Undergoes Vocal Cord Surgery

On August 11, 2015, Donny Osmond underwent vocal cord surgery to remove a hemorrhagic polyp.  The year 2015 is turning out to be a doozy for injured vocal cords with 4 other celebrity singers being sidelined for vocal cord injuries.

Miranda Lambert - July 2015
• Meghan Trainor - July 2015
• Chad Kroeger - June 2015
• Sam Smith - April 2015
• Nathan Sykes - April 2013
• Nicki Manaj - August 2012
• Florence Welch - July 2012
• Maxwell - June 2012
• Keith Urban - Nov 2011
• Adele - Oct 2011
• John Mayer - September 2011
• Scott Weiland - September 2011

In any case, this unfortunate news about Donny Osmond was shared on Facebook.

Normally, the vocal cords are pearly white without any bump on it. Watch a video of how this exam is performed.


However, with aggressive voice use, the vocal cords can become inflamed and potentially lead to bump formation like a hemorrhagic polyp. With a bump on the vocal cord, the voice can become raspy and irregular.

Typically in this scenario, the voice is better in the morning and worse by the end of day with voice use.

When there is a hemorrhagic polyp as in Donny Osmond's case, the vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.


The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. When a polyp is present, the vocal changes are even more dramatic. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice very unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. 

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. There may even be mild pain associated with this occurrence.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

For Donny Osmond, it seems that he underwent a procedure called micro-direct laryngoscopy with excision of the hemorrhagic polyp given the strict 3 weeks of voice rest he is now on after surgery.

Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option that is often employed is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. The laser may resolve the polyp to the point that surgical excision may not even be needed. The laser is relatively non-invasive and I feel the risk of scarring to be less compared with surgical excision. Furthermore, a smaller polyp that is ultimately excised also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Donny Osmond, 3 weeks has been reported. For Adele who also suffered from a hemorrhagic polyp that required voice rest after surgery, it lasted nearly two months (Nov and Dec 2011). Voice rest is necessary because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won't heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

The vocal cord surgical wound MUST heal prior to talking let alone singing for normal recovery. That means strict voice rest. Strict voice rest means no talking, no singing, no whispering, no mouthing words, no throat-clearing, no humming, etc.

Read more about vocal cord polyps here.

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