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July 31, 2010

Fauquier Hospital Featured in the Washington Post

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Not sure how I missed it, but I was recently informed that Fauquier Hospital was featured in the Washington Post on March 24, 2009 after the hospital received a "designated" status by Planetree Organization. That's a great honor especially when considering Fauquier Hospital is one of only 8 hospitals in the entire country with that honor.

What exactly does this designation mean in terms of patient care?

• Private patient hospital rooms
• Family and friends can drop by any time, day or middle of the night
• Food that's actually good
• Patient friendly architectural features including:
  • built-in sleeping accommodations for family members
  • carpeted corridors and additional windows
  • lamps have replaced overhead lighting
  • halls have been carpeted to keep down noise or are finished in faux wood for a warmer feel
  • community artwork hangs on the walls
  • barriers between patients and staff, such as those sliding-glass windows that close nurses off from patients and the public, have been removed
  • elevators for patients and the public are separate
  • no constant paging over the intercom system, either; instead, unobtrusive music plays all the time.
Also, a culture fostering patient care is presented.

Given I'm a physician on staff at this hospital, I can say it is all true!

Congratulations to the hospital!

Read the Washington Post article here.

Epiglottitis Killed President George Washington?

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I came across a great blog post by Michael Hebert regarding a book review of Joseph Ellis' biography His Excellency: George Washington.

Apparently, at the age of 67, President George Washington died in 1799. I quote from the blog post the following account:
"One morning in mid-December 1799, Washington went out, as it was his daily habit, on horseback from his home to inspect his Mount Vernon property. That particular day the weather was very cold and there was an ice storm. It is said that Washington spent five hours out in freezing rain, then returned home and dined with guests in his wet clothes because he did not want to keep them waiting. The next day he complained of a sore throat and was hoarse, but otherwise appeared well. The following night he awakened Martha to tell her that he felt a severe pain in his throat, and was having trouble breathing.
The next day his personal physician, Dr. James Craik, was summoned. Craik diagnosed the condition as life threatening, and hastily assembled a team of doctors for aggressive treatment. They bled him of five pints of blood, burned his neck, and gave him calomel, a mercury compound used as a purgative but which probably did little more than induce mercury poisoning. Finally, after several days of this torture, Washington displayed the judgment that made him a great president and told them to stop. According to Ellis: “Eventually Washington ordered his doctors to cease their barbarisms and let him go in peace. ‘Doctor,’ he muttered, ‘I die hard, but I am not afraid to go” (p.269). He expired a few hours later."
According to the biographer, Pres. George Washington died of a serious childhood infection called epiglottitis which is an infection of the soft tissue flap (epiglottis) guarding the entrance of the voicebox. It is for which the Hib vaccine given to all kids now makes this type of infection a rarity (in fact, in my entire 10 year career so far as an ENT, I've seen only 3 cases so far).

However, I do agree with the blog article that epiglottitis is unlikely to be the actual cause for Pres. George Washington's sore throat and eventual death. Given his ripe age of 67, he would have developed natural immunity to the germ (Haemophilus influenzae type B) that causes epiglottitis and as such, it would be highly unusual (but not impossible) cause of infection and death. As the blogger stated, a more likely cause of the sore throat that eventually lead to his death is a peritonsillar abscess, a far more common cause of sore throats that could lead to death if not treated. Indeed, I see about 3-4 peritonsillar abscesses in my clinic per month during the winter season. It is also not unusual for a person to go from normal to developing a peritonsillar abscess within 1-2 days.

Ludwig's angina is the other possible culprit the blog post addressed which I also find unlikely. Ludwig's angina in essence is an infection of the submandibular salivary gland and would have presented with a huge swelling under the tongue and under the jawline (see picture to right)... two symptoms I would think that would have been documented in George Washington's history.

In any case, it is entirely possible that his physicians may have contributed to his death... blood-letting of 3.75 liters... Gosh... a human adult has about 5 liters of blood. As far as I'm concerned... that's medical malpractice and one could argue first degree murder. Add mercury poisoning as well.

You can purchase the biography of George Washington here.

Reuters: Damp house linked to kids' risk of nasal allergies

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Reuters published a story on July 30 regarding a Finnish study that found that those children who lived in homes with dampness or mold problems were more likely to develop allergic rhinitis during the 6 year study period.

16 percent of children whose parents reported dampness in the home went on to be diagnosed with allergic rhinitis over the next six years. That compared with just under 12 percent of children whose parents reported no dampness problems. Children whose parents reported any mold or water damage in the home at the outset were 55 percent more likely than other children to develop allergic rhinitis -- connected to any allergen, and not just mold.

Read the Reuters story here.

Reference:
Home Dampness and Molds as Determinants of Allergic Rhinitis in Childhood: A 6-Year, Population-based Cohort Study. Am J Epidemiol. 2010 Jul 16.

July 28, 2010

NYT: Can Foods Trigger Migraines (and Other Symptoms)?

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The New York Times published a story on July 26, 2010 discussing how foods can indeed trigger migraines. The story quotes a study where patients were tested for IgG food allergies and their diet modified to either include or exclude the suspect foods. What they found is that diet restriction based on IgG antibodies is an effective strategy in reducing the frequency of migraine attacks.

Patients should be aware that IgG food allergies are NOT the life-threatening allergies that may can cause airway swelling and even death (ie, peanut allergy). Such life-threatening food allergies are IgE mediated and not IgG. Patients allergic to IgG foods can STILL eat the foods they are allergic to, but it is recommended to limit the intake if they want to feel better.

Other alleged symptoms that IgG foods allergies can cause include the following:
• Nausea
• Fatigue
• Drowsiness
• Flatulence
Reflux
• Skin disorders
Globus
• Mild Sore Throat
• Dizziness
• Meniere's
Ear problems

All of these symptoms are mild and cause more annoyance rather than actual disability.

Read the NYT article here.

Reference:
Diet restriction in migraine, based on IgG against foods: a clinical double-blind, randomised, cross-over trial. Cephalalgia. 2010 Jul;30(7):829-37. Epub 2010 Mar 10.

USNews: Cold versus Allergies... How to Tell The Difference

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US News and World Report came out with a story on July 27, 2010 regarding how one can tell the difference between an allergy versus a cold, especially since each has symptoms in common.

Especially with mild symptoms, it may be hard even for an ENT to distinguish the two. Add chronic sinus infections and flu to the mix, it can be downright difficult without allergy testing, CT scans, and other types of testing to come up with a correct diagnosis.

To help distinguish among these possible illnesses, at least based on history, here is a chart our office has made.

NIH also has produced a chart that can be seen here.

Click here to read the US News & World Report story.

July 27, 2010

RANDOM: Orthopedics versus Anesthesia (Humor) [video]

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A friend forwarded this video to me... Though it is about ortho vs anesthesia, this type of conversation (or at least small elements of it) unfortunately happens all too often.

WP Medical Mystery: Sudden Hearing Loss

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The Washington Post on 7/27/10 published a story in its Medical Mystery segment describing a patient who had sudden onset of hearing loss in one ear with tinnitus (or buzzing in the ear). This sudden hearing loss is known as sudden sensorineural hearing loss and is considered an urgent issue for which a patient needs to see an ENT as soon as possible.

Why? Because treatment is most effective if given within 4 weeks of hearing loss onset. Treatment is with either high dose prednisone and/or steroid injection directly into the affected ear, a procedure known as intratympanic steroid injection.

Read the Washington Post article here.

Read more about sudden hearing loss here.

Of note, our office provides both forms of treatment.

July 24, 2010

Mattress Wedges for Reflux Treatment

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I often see patients with throat symptoms of reflux including:

Cough
Throat-Clearing
Phlegmy or Mucus Sensation in the Throat
• Mild Sore Throat
Swollen sensation in the throat
etc, etc, etc

Although this can be treated with medications including proton pump inhibitors (prilosec, prevacid) as well as H2-blockers (zantac, pepcid, axid, etc), there are some lifestyle changes which also can be just as if not more effective than medications. Such lifestyle changes include:

• Nothing to eat/drink within 3 hours of lying down to sleep (the stomach would be empty minimizing chance of reflux)
• No fatty, spicy, acidic, tomato-based products in the diet
• No caffiene
• No alcohol
• Keep the head elevated more than 30 degrees when sleeping

This last bit of advice where the head should be higher than your feet is best accomplished by tilting the entire body rather than just the head by using more pillows.

Why?

You want not just the head tilted higher, but your chest too as you do not want the reflux entering the chest region either.

There are three ways of accomplishing this.

• Sleep in a chair
• Tilt the ENTIRE bed by placing 2-3 bricks under the legs of bed
• Get a mattress wedge!

What is a mattress wedge?

It is pretty much what it sounds like... It's a wedge you can place under the mattress so the mattress is tilted rather than the entire bed.

All sorts of wedge sizes and placement can be purchased. Here's a few I found on Amazon.com:

July 20, 2010

Regular Cell Phone Use May Cause Tinnitus

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Regularly using a mobile phone for at least four years seems to be associated with doubling the risk of developing chronic tinnitus (persistent ringing/roaring/hissing in the ear) based on a small study published online in Occupational and Environmental Medicine. Analysis of the results showed that the patients who had used a mobile before the onset of tinnitus were 37% more likely to have the condition than those in the comparison group. Those who used their mobiles for an average of 10 minutes a day were 71% more likely to have the condition.

The high microwave energy produced by mobile phones during use has been suggested as a possible culprit, but there has been no hard evidence to date.

Of course there are other studies that did not find a link between tinnitus and cell phone use like this one.

Increased risk of cancer has also been suggested with cell phone use though there is no definitive evidence to date.

Reference
Tinnitus and mobile phone use. Occupational and Environmental Medicine, 2010.

Cohort study on the effects of everyday life radio frequency electromagnetic field exposure on non-specific symptoms and tinnitus. Environ Int. 2012 Jan;38(1):29-36. doi: 10.1016/j.envint.2011.08.002. Epub 2011 Sep 10.

Airline Sued Over A Toddler Screaming On The Airplane

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Time Magazine published a story 7/20/10 describing a situation where Qantas Airlines was sued by a passenger who allegedly lost her hearing when a toddler on board screamed near her.

The passenger claimed that the Qantas flight crew was negligent in failing to take precautions to protect passengers and that she had suffered permanent hearing loss as a result.

Of note, the patient already wore hearing aids due to hearing loss.

Though most reasonable folks would side with the airline in that: "Plaintiff's injuries, if any, were caused by the arbitrary and volitional act of a three-year-old child. Flight attendants cannot predict when children aboard an aircraft are about to scream. There is no evidence that the child was screaming in the terminal, or on board the aircraft prior to the particular scream which allegedly caused the damage."

However, the passenger does have the legitimate point that loud noises can cause hearing loss... even sudden hearing loss.

Of note... the case was settled out of court.

Read more here.

Substance That Protects Farm Children From Developing Allergies and Asthma Later In Life Identified

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That beneficial substance identified is the plant sugar molecule arabinogalactan. It has been well known for some time that children who grow up on farms are less prone to allergies and allergic asthma. However, just what it is that protects them remained a riddle for a long time until now.

European researchers collected and analyzed stable dust from diverse farms in Germany, Austria, and Switzerland. What they found was arabinogalactan, a large sugar molecule, prevented excessive alertness of the immune system which would have developed into allergies and asthma.

The scientists now plan to investigate whether arabinogalactan can be used as prophylaxis or whether it is also suitable for the treatment of allergies and allergic asthma. It is conceivable that arabinogalactan could be used as spray or nose drops because it is highly water-soluble.

ReferenceArabinogalactan isolated from cowshed dust extract protects mice from allergic airway inflammation and sensitization. J Allergy Clin Immunol. 2010 Jul 9.

Effective Home Treatment for Benign Paroxysmal Positional Vertigo (BPPV)

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A research article was published in July 2010 that found use of a device called "DizzyFIX" had cure rates for BPPV (benign paroxysmal positional vertigo) of ~88% which is similar to standard treatment (Semont and Epley maneuvers) performed by a physician.

Although there are YouTube videos on how to do the Epley and Semont maneuvers correctly, unfortunately, patients rarely do it correctly when doing it privately at home resulting in prolongation of their symptoms.

The "DizzyFIX" device can be used at home and takes the patient through the CORRECT maneuvers to cure them of the dizzy attacks if due to BPPV (Benign Paroxysmal Positional Vertigo).

Watch a video here on how this device works.

Check out a flowchart on how to diagnose BPPV correctly and employ the correct maneuver to fix here.

Reference
Efficacy of a New Home Treatment Device for Benign Paroxysmal Positional Vertigo. Archives of Otolaryngol Head Neck Surg 136(7):682-683, July 2010.


July 18, 2010

Bursts of Fast Irregular Clicking Noise in the Ear

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Every once in awhile, I see a patient who complains of an irregular clicking (or vibration) noise in the ear that occurs in bursts and may last anywhere from a few minutes every few days to as long as days or weeks at a time.

Click.... click... click, click, click... 
CLICK... click, click... 
click... Click Click... click... ... ... ... CLICK

These irregular clicking noises in the ear should NOT be confused with tinnitus. Rather, irregular clicking noises in the ear are almost always due to muscle spasms... just like "eye twitching" or "facial twitching". BUT, instead of being able to "see" the twitching as with eye twitching, one hears the twitching instead since the muscles are located around or in the ear.

1) Palatal Myoclonus
2) Tensor tympani muscle spasms
3) Stapedius muscle spasms

The first potential cause (palatal myoclonus) can be diagnosed by seeing "spasms" of the soft palate that occurs in time with the clicking. Spasms of the soft palate can be visualized by simply looking in the mouth or by nasal endoscopy. Click here to watch a video of these spasms.

The reason one is able to "hear" the twitching is because the muscles of the soft palate extend up into the ear via the eustachian tube.

Treatment of palatal myoclonus is by botox injections to the muscles that are twitching.

Just like botox treatment anywhere else in the body, the effects are only temporary and needs to be repeated every 3-6 months.

Regarding tensor tympani and stapedius muscle spasms... these muscle are not able to be visualized as they are located within the middle ear. The tensor tympani attaches to the malleus ossicle (the "hammer" of the 3 middle ear bones) and the stapedius muscle attaches to the stapes ossicle (the "stirrup").

Image from Wikipedia

Just like any muscle in the body, these muscles can also "twitch" rapidly causing the clicking noise in the ear.

Unfortunately, there is no "test" once can obtain to diagnose this problem with absolute certainty. It is based purely on history and excluding palatal myoclonus as a diagnosis (no soft palate twitching seen even though the patient is able to hear it).

Even more unfortunately, the only way this problem can be treated is surgical... the muscle gets cut. Botox can not be utilized as one needs to be able to "see" or "feel" the muscle in order to inject botox. This surgery is performed by a neuro-otologic surgeon.

See the full list of surgeons who can perform this surgery here.

Read more about this problem here.

July 10, 2010

Doxycycline Helps Shrink Nasal Polyps

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A new research study was published that showed that the anbitiotic doxycycline (as well as methylprednisolone steroid) significantly decreased nasal polyp size compared with placebo. The effect of methylprednisolone was maximal at week 3 and lasted until week 8, whereas the effect of doxycycline was moderate but present for 12 weeks.

What patients suffering from nasal polyps need to realize is that such effects from steroids and even doxycycline are temporary... the nasal polyps come back.

Read more about nasal polyps here.

Read the research here.

Reference:
Oral steroids and doxycycline: two different approaches to treat nasal polyps. J Allergy Clin Immunol. 2010 May;125(5):1069-1076.e4. Link

July 04, 2010

Facial Fracture Face Mask for Athletes?

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I often see kids/adults with minor facial fractures that do not require any surgical intervention. These same kids/adults often play sports that often led to their initial facial fracture which they do not want to give up until complete healing has occurred (baseball, basketball, skateboarding, etc).

Here's one for nasal fractures:

July 01, 2010

Why Do People Have Morning Breath?

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The answer is actually pretty straight-forward... The human mouth is actually considered one of the dirtiest mouths among animals. In fact the human mouth contains so much bacteria, a human bite is considered more "dangerous" from an infection standpoint that a bite from a dog.

During the day, we constantly swallow and eat/drink which washes away the bulk of the bacteria. We also brush our teeth and gargle our mouths which also helps.

Unfortunately, during the night, none of these activities occur which allow bacteria to proliferate and produce the smells associated with bad breath.

What makes this situation worse is that you can only smell other peoples' bad breath and not your own. Why is that? It's because our sense of smell becomes desensitized to smells that's around continuously.

In other words, if you smell someone's bad morning breath for a long enough period of time, you will no longer smell it!

Read more about morning breath in the Washington Post here.
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