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August 28, 2014

Joan Rivers Suffers Respiratory Arrest During "Throat" Procedure

Image by David Shankbone of Wikipedia
It was reported today 8/28/14 that comedian Joan Rivers suffered some type of respiratory arrest during some type of sedated endoscopic procedure. According to reports, the endoscopy was done to "check her vocal cords."

It was also reported that this procedure was performed at Yorkville Endoscopy in New York City.

Just based on this limited information released to the public, I suspect the following...

1) The endoscopy procedure was probably an EGD which actually is an endoscopic procedure performed to check the esophagus and stomach, typically to evaluate for reflux damage. It is doubtful that the endoscopy was done specifically to evaluate the vocal cords mainly because sedation is not required to look at vocal cords alone.

Furthermore, Yorkville Endoscopy does not have listed laryngoscopy (endoscopy to check the vocal cords) as part of its services. Click here to see their list of services. Also if you look at the list of physicians at Yorkville Endoscopy, they are all gastrointestinal (GI) specialists... it's the wrong medical specialty if a vocal cord procedure was being performed. With vocal cord procedures, it's the ENT doctors and not the GI physicians who do them.

2) If respiratory arrest occurred during sedated endoscopy, it could be due to one of several factors:
  • Aspiration (that's why patients are instructed to eat and drink nothing after midnight before the procedure)
  • Severe laryngospasm
  • Over-sedation from the anesthetic (propofol is the typical anesthetic agent to sedate which also happens to be the drug that led to Michael Jackson's death)
3) She may have suffered a heart attack. Sometimes anesthesia and a procedure causes enough stress on the heart to trigger a heart attack. This is why most patients over age 50 must have an EKG done before the procedure to ensure the heart is in good health.

As more information is provided, the answers to questions that ultimately lead to Joan River's respiratory arrest will become apparent.

Stay tuned!

'Please pray': Joan Rivers, 81, rushed to hospital after she stopped breathing during surgery as her daughter asks for prayers. MailOnline 8/28/14

Joan Rivers Hospitalized Following Throat Surgery, Reportedly In Stable Condition. Huffington Post 8/28/14

Distractions During Surgery is Common

Patients often consider surgery to be performed in a setting where there are no distractions so that the surgeon can focus on the task at hand. Unfortunately, this impression is far from the truth where distractions abound and sometimes can approach on the chaotic.

Although anecdotal stories can be told, perhaps it is better to mention a few studies where third parties observed the goings on in the operating room.

A study done in 2013 observed 3,557 distractions over 32 separate surgical cases (averaging 111 distractions per case). 33% of the distractions were considered significant. The most common cause of the distraction was the circulator nurse or the anesthesiologist.

study in 2006 found a distraction occurred during surgery on average every 3.4 minutes.

Another study in 2007 found a significant number of case-irrelevant distractions which was felt to interfere with highly sensitive work. In this particular study, they noted that the surgeon himself accounted for 1/3 of the distractions.

What are some of these distractions that occur DURING surgery?

- Being informed of missing orders on next case or preceding case
- Time-Outs
- Preceding or next surgical patient wanting to ask a question
- Consult on an inpatient
- Equipment related questions for preceding, current, or following case
- Gossiping
- Missing equipment
- Door opening and closing (constantly)
- Change in OR staff personnel
etc, etc, etc

Most surgeons learn to block out such distractions in order to focus and operate safely. However, there are moments when distractions may reach a critical level of aggravation that the surgeon may need to speak up.

Also, a certain level of common sense must be present... Does the surgeon really need to be bothered in order to ask whether a tylenol can be given to a patient complaining of a headache... or can it wait until after the surgery is over.

Distractions and the anaesthetist: a qualitative study of context and direction of distraction. Br J Anaesth. 2013 Sep;111(3):477-82. doi: 10.1093/bja/aet108. Epub 2013 Apr 16.

Distracting communications in the operating theatre. J Eval Clin Pract. 2007 Jun;13(3):390-4.

Measuring intra-operative interference from distraction and interruption observed in the operating theatre. Ergonomics. 2006 Apr 15-May 15;49(5-6):589-604.

August 27, 2014

Best Headphones for Kids

MacWorld did a nice review on the best headphones for kids which is important given the increasing use of electronic devices in the classroom. It should be noted that the best headphones for adults are not the best headphones for kids due to important discrepancies in size, durability, and absence of volume-limit controls.

From an ENT perspective, volume-limit controls are the most important factor when picking a set of headphones for a child as such circuitry prevents the headphones from playing audio at damaging levels (above 85 dBHL per CDC).

In any case, to summarize the findings from MacWorld in rank order from cheapest to the most expensive... (highest rated was the most expensive)

Sony MDR-222KD  (2.5 out of 5)

Cheapest, but worst of the bunch. Volume-limit controls are absent and has an open design which allows others to hear what you're listening to.

Kidz Gear KidzControl  (2.5 out of 5)

The volume-limit control comes via a separate adapter cable which I think is a bad idea. If a child wants to listen to music loudly, they can just remove the adapter. This model was also the least comfortable of the bunch.

Griffin Technology Crayola MyPhones  (3.5 out of 5)

Volume-limit circuitry works to prevent sounds from being damaging to young ears. Sound isolation is limited however.

MarBlue HeadFoams  (3 out of 5)

Probably the most "organic" of the headphones because the entire thing is made from semi-rigid EVA foam that is BPA-free without any visible metal or plastic components. The headband is also not adjustable. Volume-limit controls do not work either.

JLab JBuddies (2.5 out of 5)

Volume limit circuitry does not work. However, earpieces are hypoallergenic.

Lil Gadgets Untangled Pro  (3 out of 5)

Had the best sound, but NO volume limiting controls.

Fuhu Nabi Headphones (4.5 out of 5)

Designed for kids and adults and therefore can be used as a child becomes older and bigger. Offers excellent sound-limiting controls (as long as the child does not figure out the hidden switch that activates this feature). Offers excellent sound isolation.

August 25, 2014

Steroid Injection Into the Ear May Help Bell's Palsy

Intratympanic steroid injections are typically performed for sudden nerve hearing loss. However, preliminary research suggests that it may also help resolve facial paralysis due to Bell's Palsy.

In this prospective, double-blinded, randomized study, one group of patients received standard treatment with oral steroids and antiviral medications whereas the experimental group received the same medications PLUS intratympanic steroid injection as well. (I should mention that antiviral medications has not been found to be helpful in the treatment of Bell's Palsy.)

Although complete recovery rate was the same for both groups, time to recovery was shorter and better in the injection group.

Now why would injecting a steroid into the ear theoretically help with facial paralysis?

It's because the nerve that governs facial movement goes through the ear!

Facial Nerve in Yellow. Image from

Watch a video showing steroid injection into the ear below.

Intratympanic Steroid Injection for Bell's Palsy: Preliminary Randomized Controlled Study. Otology & Neurotology: August 13, 2014. doi: 10.1097/MAO.0000000000000505

August 24, 2014

Does Upper Lip Tie Removal Help Prevent Upper Front Teeth Gap?

It is not uncommon that I see a newborn or young child for upper lip tie with a specific parental concern for development (or existence) of a gap between the two upper front teeth. Also known as maxillary midline diastema, this condition is extremely common being present in up to 50%+ of children between ages 6 and 8.

It should be mentioned that upper lip tie frenulectomy (or frenectomy) is the complete removal of the upper lip tie surgically which is different from upper lip tie release that is performed to address breastfeeding difficulty and does not involve any tissue removal.

When it comes to upper front teeth gap or diastema, frenulectomy is the procedure under consideration (not the release). However, given it is unclear what role upper lip tie has in the development of diastema it also brings into question what role frenulectomy has in preventing or addressing diastema.


It's because this gap in the vast majority of children spontaneously resolves without any intervention by the age of 15 (only 5% have a persistent gap by this age). If you recall, 50%+ start out with a gap. Typically, there is a dramatic resolution of diastema between the ages of 9 and 11 years of age when the adult incisors and canines come in.

Furthermore, no correlation has been found between frenulum attachment site and diastema width, between frenulum thickness and diastema, or between frenulum height and frenulum width [study link]. Enlarged and low frenulum DO exist in the absence of diastema.

When upper lip tie IS removed, it seems to have only a minimal influence on diastema resolution. In one study, only 2 patients out of 27 had closure after frenulectomy alone. A much higher success rate was achieved with frenulectomy and orthodontics together. What would have been even more interesting (which was not done) is if the study included a group of patients who had orthodontics alone without frenulectomy.

In another study comparing children that had both upper lip tie and diastema, NO difference was ultimately found in diastema closure when comparing one group that had frenulectomy with another group that did not.

That's not to say that upper lip tie does not ever contribute to diastema (it can), but that there are many other reasons why this gap occurs.

Diastema may actually be a normal and temporary stage during dental development. The diastema naturally resolves as the adult lateral incisor and canine roots constrain the roots of the front upper teeth causing any gap to resolve spontaneously. The frenulum itself recedes further under the lip as the maxilla increases in vertical height.

Outward pressure exerted on the upper teeth by bad oral habit may lead to diastema over time if left untreated. Such bad habits include thumb-sucking and biting the lower lip. Muscular imbalances, abnormal maxillary arch, dental anomalies, and malocclusions may also lead to diastema.

Because there are numerous reasons why diastema may occur, even textbooks specializing in pediatric dentistry do not recommend frenulectomy in young children (or younger) to address diastema until around age 11 AFTER the adult canines have come in.
"Recent trends justify significantly fewer maxillary labial frenectomies. These procedures should only be performed after it has been shown that the frenum is a causative factor in maintaining a diastema between the maxillary central incisors. This cannot be determined until after the permanent canines have erupted. Therefore a maxillary labial frenectomy prior to the age of 11 or 12 is probably not indicated." [Pediatric Dentistry: Infancy Through Adolescence, 4e (Pediatric Dentistry)]
"Parents are often concerned about spacing of the upper incisors, and they can be reassured that it will often reduce as the permanent upper canines erupt... There is some disagreement about the role of frenectomy in the treatment of diastemata, but it is very rarely indicated in the mixed dentition stage and is probably best carried out during active orthodontic treatment." [Paediatric Dentistry (Oxford Medical Publications)]
Unfortunately, if one google searches upper lip tie and upper front teeth gaps, all the aforementioned factors are ignored or glossed over giving the appearance that there is a uniform recommendation for frenulectomy as the standard intervention in order to prevent this condition... and it should be done using a laser.

The problem with laser is that there is a bias towards intervention for practices who own one. Lasers are expensive to purchase and maintain. As such, there is a (subconscious?) financial incentive to use it as much as possible even if unnecessary.

Upper lip tie frenulectomy is the perfect way to use the laser because it "makes sense" and improvement is nearly guaranteed...

Think about it... If frenulectomy is performed in newborns or toddlers due to concern for developing or having diastema, the procedure will be considered a success in the majority of cases. Problem with this statement is that diastema would have resolved in the vast majority of cases even if frenulectomy was NOT performed because that is what would have happened normally with time alone.

I should also add that there's also the risk of scar formation that may develop after frenulectomy that may actually be thicker and tougher than the upper lip tie itself which could theoretically increase risk of diastema.

At least for me, if upper lip tie frenulectomy is considered to address diastema concerns, I typically require the child to undergo a pediatric dental consultation with an office that does not own a laser in order to obtain as unbiased evaluation as possible.

If and only if pediatric dental evaluation recommends frenulectomy do I perform one.

In my area, I typically suggest pediatric dentist:

Dr. Jennifer Woodside
361 Walker Drive
Warrenton, VA 20186

On a historical note, in the early 1900s, upper lip frenulectomies were commonly performed to prevent diastema on the belief that upper lip ties were the sole cause of diastema. This surgery went out of favor by the mid-1900s when the upper lip tie was felt to contribute minimally if at all to diastema. It has only been in the last decade that there has been a resurgence of frenulectomies using the same outdated argument used in the early 1900s; that upper lip tie causes diastema. I blame this resurgence squarely on the use of lasers in dental offices and aggressive marketing of this "high-tech" treatment.

Does the maxillary midline diastema close after frenectomy? Quintessence International. 45(1):57-66. January 2014

The midline diastema: a review of its etiology and treatment. Pediatr Dent. 1995 May-Jun;17(3):171-9.

Management of maxillary midline diastema with emphasis on etiology. J Clin Pediatr Dent. 2008 Summer;32(4):265-72.

The labial frenum, midline diastema, and palatine papilla: a clinical analysis. Dent Clin North Am. 1966 Mar:175-84.

The superior labial frenum and the midline diastema and their relation to growth and development of the oral structures. American Journal of Orthodontics. Volume 39, Issue 2 , Pages 120-139, February 1953

The effect of superior labial frenectomy in cases with midline diastema. American Journal of Orthodontics Volume 63, Issue 6 , Pages 633-638, June 1973

August 22, 2014

Hole in Tonsil Area After Tonsillectomy

Rarely, a patient may notice a hole in the mucosa in the area where the tonsil used to be after removal. This hole typically is located in the anterior tonsil pillar as shown in the picture.

Typically, this hole appears not immediately after surgery, but 5-10 days afterwards. Known as a fistula, this is a temporary situation as this hole will close up over several months. Even holes much bigger than that shown in this picture will typically heal closed on its own without any specific intervention.

Fistulas after tonsillectomy occur depending on how thin the anterior pillar mucosa is and the degree of tissue devitalization after tonsillectomy.

Although benign and temporary, it can be annoying to the patient as food can get caught in this hole. But rest assured, they invariably typically close up with time alone without any specific treatment.
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