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February 27, 2015

Early Exposure to Peanuts May Reduce Peanut Allergies, but Choking Risks Remain!

Image from Wikipedia
In response to peanut allergies and children being in the news this week (Feb 2015), the American Academy of Otolaryngology—Head and Neck Surgery is cautioning parents and caregivers about choking risks especially posed to young children and infants by peanuts, tree nuts, and nut fragments.

The 2015 NEJM study on peanut ingestion and allergies in children suggested that exposing infants to peanuts before age 1 (even as young as 4 months) actually helped prevent peanut allergy from developing, lowering that risk by as much as 81 percent. Instead of provoking an allergy, early exposure seemed to help build tolerance.

Although this research is great news on possible interventions to help prevent such food allergies from developing, please caution parents and caregivers that whole peanuts or peanut pieces should never be fed to children under age four years, due to the risk of choking and aspiration. When introducing to an infants' diet, use of smooth, not chunky, peanut butter is advisable. Spread a thin layer on toast, crackers, or fruit.

Although babies should never be given peanuts, only because they pose a choking hazard, peanut protein in safe forms are a different story!

Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. NEJM 2015; 372:803-813February 26, 2015DOI: 10.1056/NEJMoa1414850

Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Aller Clin Immuno 2008 Volume 122, Issue 5, Pages 984–991. DOI:

Feeding Infants Peanut Products Could Prevent Allergies, Study Suggests. NYT 2/23/15


Treatment reduces kids' peanut allergy risk up to 86%. USA Today 2/23/15

Exposing infants to peanuts causes big reduction in peanut allergy, study shows. Washington Post 2/23/15

February 26, 2015

Are ENT Endoscopes at Risk for Infecting Patients?

Note the instrument port which is the inner channel
In the media, there have been reports of contaminated endoscopes that have been incompletely sterilized causing life-threatening infections in patients. The endoscopes that have been implicated in these unfortunate infections transferred from one patient to another are known as duodenoscopes or EGD scopes.

The main concern that patients have are whether similar (non) sterility issues are also found in endoscopes used in the ENT world. The blunt answer is no...

The EGD scopes and endoscopes used by ENT's are completely different.

To explain, let's use the analogy of a plain old drinking straw. EGD scopes require cleaning and sterilization of not just the outside of a drinking straw, but also the inside channel (instrument port in pic above). ENT scopes as a general rule do not have an inside channel at all (there are the rare exceptions).

As you can imagine, it is very difficult to clean and sterilize the inside channel and that's where the sterility issues have occurred with EGD scopes that is a moot point with ENT endoscopes.

In any case, because ENT scopes lack an internal channel, cleaning and sterilization is pretty straightforward. In many ENT offices, soaking in antibacterial, antiviral, and antifungal chemicals for a certain period of time is all that is necessary.  Here is one study demonstrating that soaking in such chemicals for as little as 5 minutes can achieve sterility, though most offices soak for 20+ minutes just to be on the safe side.

Table from Arch Otolaryngol Head Neck Surg. 2012;138(2):119-121
EGD scopes require complex machinery whose sole job is to clean the outside of the scope as well as the inside channel and may take over an hour to perform. Clearly, this standard is insufficient given patient infections from use of this type of scope.

Now, that's not to say that ENT do not use scopes that have an internal channel... we do.

But, at least in our office, whenever the occasion is required that a scope with channel is needed, we utilize sterile disposable sheaths that contain a channel that goes over the scope. These sheaths are then thrown out after every single use.

After Deadly Infections, F.D.A. Asks Device Makers About Cleaning Methods. NYT 2/25/15

Disinfection of Flexible Fiberoptic Laryngoscopes After In Vitro Contamination With Staphylococcus aureus and Candida albicans. Arch Otolaryngol Head Neck Surg. 2012;138(2):119-121. doi:10.1001/archoto.2011.1204.

February 22, 2015

Personal Steam Inhalers/Humidifiers to Treat Cough and Congestion

People with an upper respiratory infection with cough have found that taking a hot steam shower is often helpful for their symptoms. It can ease the nasal congestion and calm the coughing down. Due to these beneficial effects and the fact that dry airways can make a cough worse, a humidifier is a helpful device to have in a room.

Beyond a humidifier, one can also purchase personal portable steam inhalers designed to put over the face. Cost can run anywhere from $20 to several hundred dollars. 

Compact humidifers can also be placed near the bedside on a nightstand to help while sleeping (in addition to a room humidifier that is placed on the floor). These usually are under $50.

Keep in mind that though humidity may help with cold and cough symptoms, it could make asthma/COPD worse if you have it. 

Here are some personal steam inhalers you can purchase on Amazon.

Here are some compact humidifers that can be placed on a nightstand near the bed.

February 11, 2015

Video of Cochlear Hydrops (What Happens in the Inner Ear)


This video demonstrates what is thought to occur in Cochlear Hydrops within the inner ear. It is hypothesized that Cochlear Hydrops is due to an excessive amount of fluid buildup within the endolymphatic chamber causing symptoms of tinnitus and ear fullness. No dizziness is present.

February 08, 2015

A Study on Nose-Picking (You Know You Do It)

Image courtesy of imagerymajestic at
I could write a lengthy blog about why we pick our nose... but I think the results below speak for themselves. In this particular study on rhinotillexomania (or compulsive nose-picking), 200 adolescents were surveyed.

The conclusion is it's a common behavior. Interestingly, they study found 12% of the survey population picked the nose purely for pleasure.  Other interesting facts (from another study on nose-picking) include 65% use the index finger to pick the nose, 20% the pinky, and 16% the thumb.

Although nose-picking may be considered an issue with cosmetic or etiquette consequences, medical problems may arise from rhinotillexomania including epistaxis, septal perforations, cellulitis, etc.

At the very least, cut the fingernails short to minimize potential medical problems from chronic nose-picking.

A Preliminary Survey of Rhinotillexomania in an Adolescent Sample. Journal of Clinical Psychiatry, vol. 62, no. 6, June 2001, pp. 426-31.

Rhinotillexomania: psychiatric disorder or habit? J Clin Psychiatry. 1995 Feb;56(2):56-9.

February 07, 2015

Flonase Steroid Nasal Spray Now OTC

GlaxoSmithKline announced in July 2014 that the FDA has approved Flonase steroid nasal spray to be made available over-the-counter (OTC). It has now arrived! Flonase joins Nasacort which is has been available for purchase OTC for some time.

Flonase is available to purchase on Amazon now as well.

Flonase and Nasacort both are steroid nasal sprays used to treat allergies in patients. It is similar to prescription steroid nasal sprays like nasonex, omnaris, ceramist, etc. It is also the second steroid nasal spray made OTC in the United States which can be both a blessing as well as a curse.


With Nasacort and now Flonase going OTC which will certainly make it more convenient for patients, I also anticipate that the other prescription steroid nasal sprays including omnaris, nasonex, qnasl, zetonna, veramyst, etc will become much harder to prescribe due to insurance requiring patients to use OTC nasal sprays first. Worst case, insurance may even simply stop paying for the prescription steroid nasal sprays.

After all, this is exactly what happened with prescription reflux and anti-histamine medications.

FDA Approves Flonase® Allergy Relief For Sale Over-The-Counter In The United States. MarketWatch 7/24/14.

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