Reflux Increases Risk of Throat Cancer by 78%

Brown University researchers found that frequent heartburn was an independent risk factor for not only esophageal cancer but also cancer of the throat and vocal cords. This conclusion was based on a large population study involving 631 patients with throat cancer and 1,234 without throat cancer as a control group.

The study group also did not heavily smoke, drink, or have HPV (other independent risk factors for throat cancer).

Individuals with frequent heartburn were found to have a 78% increased risk of developing throat cancer. What researchers also found was that taking antacids for reflux (but not proton pump inhibitors or H2 blockers) seemed to protect against the development of throat cancer by 41% in patients with frequent heartburn.

The explanation for how reflux can cause throat cancer is similar to how it can also cause esophageal cancer. With repetitive mucosal injury by gastric juices to the delicate lining of the throat, there is a cycle of healing and injury that may eventually trigger cancer development. Patients with reflux that reaches the throat level have a condition called LPR or laryngopharyngeal reflux. Although symptoms may be similar to the more common GERD, it is not unusual for patients to experience only throat symptoms without the heartburn. Such atypical symptoms include:

• Chronic cough
• Phlegmy throat
• Chronic throat clearing
• Vocal cord dysfunction
• Globus pharyngeus

It is also notable that it takes far less reflux episodes in the throat region compared to the esophagus in order to trigger mucosal damage... it takes fewer than THREE episodes per WEEK! [link]

In any case, more research is needed to determine at what point cancer risk increases in individuals with LPR, what type of reflux (acid?, non-acid?, pepsin?, bile?) triggers cancer concern, to what degree of reflux prevention is required to protect against cancer development.

Also more needs to be done to figure out why antacids help reduce cancer risk, but not other types of reflux medications.

References:
Gastric Reflux Is an Independent Risk Factor for Laryngopharyngeal Carcinoma. Cancer Epidemiology Biomarkers & Prevention. Published Online First May 23, 2013; doi: 10.1158/1055-9965.EPI-13-0183

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991 Apr;101(4 Pt 2 Suppl 53):1-78.

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T&A Helps with Pediatric Obstructive Sleep Apnea (But Watchful Monitoring OK Too!)

Researchers published in the New England Journal of Medicine that removal of the tonsils and adenoids absolutely helps with sleep apnea in kids along with improvements in behavior, quality-of-life, overall well-being as well as significantly greater reduction in symptoms... but apparently putting off surgery does no significant harm as well from a purely cognitive perspective.

464 children ages 5-9 years of age were randomly split into surgery or watchful monitoring groups (children with severe sleep apnea was excluded from the study). Although surgery helped in all measures tested, what surprised the researchers was that nearly half the children (46%) in the watchful monitoring group also spontaneous improved over a 7 month period of time without surgery. Furthermore, there was no difference between groups on a Developmental Neuropsychological Assessment.

Overall, surgery WAS beneficial, but it is notable that even without surgery, cognitive development was found to be no different than not doing surgery and nearly half improved to point surgery was no longer clinically indicated.

More relevant to clinicians and parents... what were the exact factors that led nearly 50% of kids with sleep apnea to improve over 7 months?

Was it a certain medication? Overall head growth? Treatment of allergies?

If there WAS an intervention, can it be replicated to all kids as something to try prior to surgical consideration?


Reference:
A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea. May 21, 2013 DOI: 10.1056/NEJMoa1215881

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Pitch Perfect's Vocal Cord Nodules

Becca (played by Anna Kendrick)

In the hilarious movie Pitch Perfect, Becca played by the lovely Anna Kendrick participates in an all-female a capella singing group.

During a critical juncture in the movie, one of the soloist Chloe (played by Brittany Snow) reveals she had been living (and singing) with vocal cord nodules.

The movie implies that Chloe's vocal cord nodules were surgically removed and that perhaps days later, she resumed singing, though not recovered to the degree that she's able to sing a solo.

Couple problems with this scenario which does not reflect reality.

Vocal cord nodules develop due to aggressive voice use, especially with poor talking or singing technique. As such, initial treatment is NOT surgical because if the underlying vocal behavior that led to vocal cord nodules is not corrected, they will just come back... and you can add some scarring as well due to the surgery itself (strict voice rest for a prolonged period of time after surgery is a must to minimize scarring complications).

Strict voice rest is also not the best course of action which will help initially, but again, if voice use resumes without the underlying bad vocal behavior being corrected, the nodules will just come back again.

So what is the correct course of action???

1) Aggressive voice therapy... Given Chloe is a singer, working with an experienced singing voice therapist would be of tremendous benefit. She can continue singing, but use of electronic amplification is a must to minimize increased compensatory volume (people tend to increase their voice in loud surroundings) and her singing should be limited to low impact vocalizations (think Silent Night rather than Ode to Joy).

2) Limit talking if at all possible and avoid being in conditions where there's a lot of noise. NEVER abuse the voice (no screaming, yelling, etc) which may be hard to do in a college setting with loud restaurants and bars.

3) If after a prolonged voice therapy and restricted voice use does not resolve the vocal cord nodules, only than would surgical intervention be considered. There are two flavors of surgical intervention: steroid injections to the nodules or excising the vocal cord nodules. Needless to say, there will be a mandatory prolonged period of strict voice rest after surgical intervention.

Read more about treatment here.

Finally, there's another scene where Chloe's voice was able to achieve an unusually low note. That does NOT happen with vocal cord nodules whether before or after surgery. Chloe's pitch range should remain the same. The only situation where her pitch would drop lower than normal would be if her vocal cords became diffusely swollen. Just like a violin string, the thicker the string or in this case vocal cord, the lower the pitch.

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Hospital Charges vs Surgeon Charges

Some of the most bitter complaints I get from patients are their hospital bills. Apparently, this complaint is not unique to me given numerous media articles about perceived outrageous hospital charges for seemingly simple procedures (article #1 and article #2).

The healthcare system as it currently stands establishes 2 separate charges (surgeon and hospital) with any type of procedure performed in a hospital (even if not in an operating room). There is even a 3rd charge if anesthesia is provided.

The ONLY charge a surgeon has any control over is the surgeon's charge which often is the least expensive of the 3 charges. A common misconception is that the surgeon also has control over hospital and even anesthesia charges which is patently false.

Indeed, the surgeon is not even informed what the hospital or anesthesia charges are for any procedures performed. The surgeon also has no influence, say, or authority over what the hospital or anesthesia charges as well.

As such, if knowledge of total costs is desired with any type of procedure performed in the hospital, it is best to speak with a hospital representative of what the anticipated charges will be... not the surgeon because we actually do not know.

I should also mention that hospital charges are often 10 times or more greater than the surgeon's fees.

Read more about surgical fees.

Even for the SAME exact procedure, the charges vary greatly from one hospital to another.

In May 2013, the federal government released information on how a given hospital ranks in their charges for a given diagnosis or procedure (specifically Medicare, but all insurance base their charges on Medicare rates).

Check to see how your hospital ranks compared with other hospitals with respect to how high their charges are. The New York Times created a handy dandy map that illustrates hospitals which are "expensive" and those that are below average in terms of hospital charges.

I should mention that Fauquier Hospital where I have privileges charges at less than the US average.

Let's take an example to see how hospital charges can significantly influence how much you pay for the same exact procedure depending on which hospital you go.

Let's say you have health insurance with a 10% coinsurance and a $1000 deductible (meaning, before insurance pays for anything, you must pay at least $1000 and than an additional 10% of all remaining charges).

Let's say you decide to proceed with a tonsillectomy.

At hospital A, the surgeon's fee is $500, hospital charges are $5000, and anesthesia charges are $1000 for a grand total of $6500.

At hospital B, the surgeon's fee is $500, hospital charges are $10,000, and anesthesia charges are $5000 for a grand total of $15,500.

Clearly, whether you go to hospital A or B, you will pay $1000 deductible first.

So, at hospital A, the total charges (minus your deductible) billed to insurance will be $5,500 and at hospital B that cost will be $14,500.

Insurance pays 90% of these charges and you pay the remaining 10% (the 10% coinsurance as per the policy you have).

As such, having a tonsillectomy at hospital A will cost an additional $550 whereas at hospital B, you will have to pay an additional $1,450.

Now, it may seem the charge differences are extreme in the example, but sadly, hospital charges can truly be that dramatically different. Read this New York Times article for more information.

Of course, do keep in mind that the above example is over-simplified as reality does include things like fee schedules, allowable charges, etc.

Source:
Hospital Billing Varies Wildly, Government Data Shows. NYT 5/8/13

How Much Hospitals Charge For the Same Procedures. NYT 5/8/13

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Gwyneth Paltrow's Dad Had Throat Cancer

Image from Wikipedia

Gwyneth Paltrow recently divulged that her father was diagnosed with throat cancer in 1998 and eventually passed away in 2002 due to pneumonia complications.

It is unclear exactly what type of throat cancer Mr. Paltrow had, but it could have been anything from tonsil cancer to vocal cord cancer.

Depending on the location, symptoms and physical signs (ie, neck mass) may have been present which ultimately would have required a biopsy. Once the type of cancer has been determined after biopsy, treatment would have included surgery, radiation therapy, and/or chemotherapy.

In any case, the actress credits her dad's cancer diagnosis as a wake-up call to a healthier lifestyle.

Source:
Gwyneth Paltrow; Father's Throat Cancer Diagnosis Encouraged Healthier Diet. Medical Daily 5/20/13

Gwyneth Paltrow Reveals Dad's Cancer Diagnosis Got Her on Healthy-Eating Track. Eonline 5/17/13

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Beyonce Cancels Concert Due to Dehydration (and Exhaustion)

Image from Wikipedia

Media has reported the superstar pop singer Beyonce cancelled her May 14, 2013 concert in Belgium on the advice of her doctors "due to dehydration and exhaustion".

Though the rumor mill is churning with the possibility of a pregnancy, I was more interested that a concert was cancelled due to dehydration concerns.

Why is hydration so important for voice production, especially in as athletic activity as singing?

With hydration, the glands that line the throat and voicebox produce nice thin secretions. With dehydration, the secretions become thicker and stickier and can adversely affect the voice.

Keep in mind that hydration with its associated thin secretions is like the oil that makes an engine run smooth. When a person talks or sings, the vocal cords vibrate very quickly. Hydration with its thin secretions allows the vibration to occur smoothly and consistently. If dryness is present, the vibrations will not occur as easily.

Watch the video below. You can see the secretions "dancing" on the vocal cords as it should with smooth, even vibrations producing clarity in voice production.

Regardless of what may have prompted Beyonce to cancel her concert, fans hope her recovery will be speedy!

Source:
Is Beyonce Pregnant? Singer Cancels Show; Rumor Mill Reignites. Huffington Post 5/14/13

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