Stroboscopy of the vocal cords is a special exam whereby a scope is introduced down into the throat where the vocal cords can be directly visualized. Using a special light, the vibration of the vocal cords can be examined and allows identification of subtle pathology that can contribute to a raspy voice.
The exam is recorded and can be played back at any speed to allow for careful analysis.
Here is a YouTube video our office has made showing how this exam is performed!
This claim is based on several studies published whereby “the total amount of reflux time was significantly greater” when the subjects laid on their right side after eating a high-fat meal.
This makes sense anatomically. Keep in mind that the stomach is located on the left side and the esophagus (swallowing tube) is located in the middle (comes off the stomach's "right side" so to speak). When you lay down on the right side, gravity is literally "emptying" the stomach into the esophagus located in the middle. Laying on the left side has gravity keeping stomach contents inside the stomach as the middle is now above the stomach.
Of course, the best thing to do is lifestyle changes to minimize reflux including- avoid eating high-fat, spicy, acidic foods as well as not eating/drinking within 3 hours of laying down when the stomach is empty. Keeping the head and chest elevated 30 degrees is also helpful thereby using gravity to help keep things down. Mattress wedges are helpful. Should lifestyle changes not help, there are plenty of medications that can help.
Our office has been instrumental in bringing the Apple iPad to Fauquier Hospital allowing physicians to access MediTech.
In order for physicians to see how MediTech can be accessed and used on the iPad, our office has created a YouTube video tutorial. Not only is MediTech shown, but also PACS. This video has been added to our YouTube channel.
Please note that this video is in REAL-TIME. It has not been speeded up. The system we are using is Citrix Version XanApp 5 and MediTech Client/Server v5.6.4 PP13.
Our office has produced a new video on what/how a normal swallow looks like from BOTH an x-ray as well as endoscopic view. In order to best illustrate the swallowing mechanism, a modified barium swallow test is shown. The video has been uploaded to our YouTube channel and can be watched here.
Watch the video below as well as the slow motion action of what the epiglottis does from the inside during a swallow!
On October 19, 2010, there was a CBS episode of NCIS (Naval Criminal Investigative Service) called "Cracked" in which Special Agent Tony DiNozzo developed acute laryngitis.
The show's chief medical examiner, Dr. Ducky Mallard, examined Special Agent Tony DiNozzo and instructed him on strict voice rest for 24 hours which Tony ignored.
If I was on the show, I would have performed a much more thorough examination that would include fiberoptic laryngoscopy (and/or stroboscopy) in which the vocal cords could be directly examined as shown in this video:
Based on his hoarseness, lack of productive cough, and acute onset, I suspect Tony developed acute VIRAL laryngitis. Here's an example of what I suspect I would have seen on laryngoscopy if one was done (video is actually stroboscopy, a much more intensive examination than laryngoscopy):
This exam is different than acute BACTERIAL laryngitis in which pus on the voicebox would be seen as shown in this video (also stroboscopy):
Overall, treatment for acute viral laryngitis is strict voice rest as the esteemed Dr. Mallard recommended, though 24 hours is a bit optimistic. I probably would have prescribed a course of steroids to help with the swelling as well as hydration.
I read with interest an MSNBC article that describes a brand new surgical treatment for Meniere's Disease, a debilitating disorder in which a patient suffers spinning attacks that last for hours to days. The treatment is an electrical device surgically implanted into the vestibular system of the ear, much like a cochlear implant for deaf individuals.
The device, called "UW/Nucleus Vestibular Implant," is surgically installed behind the affected ear with a small wire threaded into the labyrinth system.
In a rough manner of speaking, this new device restores balance by sending electrical impulses to electrodes implanted in the bony ear, disrupting a vertigo attack when it occurs. Consider it like a defibrillator for patients prone to ventricular tachycardia.
It does NOT cure Meniere's... it just allows a vertigo attack to be quickly aborted before it gets bad.
It is currently undergoing clinical trials at the University of Washington under direction of Dr. Jay Rubinstein and Dr. James Phillips.
Read more about this innovative treatment on MSNBC here.
Recently, there has been some confusion regarding whether our office deals with adults only or do we see kids as well... Strangely enough, we also get asked by parents whether our office sees adults when seeing a pediatric patient.
To clear up any confusion, our office does see kids AND adults... starting from birth to the elderly.
Dr. Chang who joined the office in October 2005, was named one of America's Top Physicians by the Consumer's Research Council of America in 2008 as well as a Northern Virginia Top Doctor for 2011 (to be published in February 2011).
Some common problems and procedures for which Dr. Chang sees kids specifically include:
Can I just express how totally excited and grateful I am to Fauquier Hospital Information Technology Department for upgrading their Citrix server?!! I can now access the hospital's MediTech EMR from anywhere using not only Windows PC, but also the iPad and Mac platforms as well!!! Even the iPhone, though the screen is a bit small...
GREAT job and appreciate how responsive the department as a whole has been!
On Oct 14, 2010, there was a story out of England about a hairdresser whose nose slowly collapsed due to damage sustained from breathing in hair clippings for 35 years.
Apparently, over a period of 20 years, the small hair clippings slowly caused damage to her septum to the point it caused a perforation. The perforation than led to infection which further weakened her nose structure to the point it started to collapse... a type of nasal deformity called a saddle nose.
Obviously, Botox by Allergan was the first and most popular to the point where its product name "botox" is being used interchangeably to mean any botulinum toxin product; much like "Kleenex" is used to mean any tissue product to blow the nose with or "Google" to mean "to search for" even if you use Bing.
Although all four products are made from the Clostridium botulinum bacteria, the four products are isolated from different strains of bacteria, have different molecular structures, and attach to different parts of the nerve. What does this mean for the end-user? It means that dosages are not equivalent across product lines. In other words, 1 unit of botox is NOT the same as 1 unit of myobloc. Furthermore, duration of effect may be different as well as immune response.
Also as an FYI, Botox, Xeomin, and Dysport are Botulinum toxin type A whereas Myobloc is type B.
Dr. Chang performs botox injections for a variety of problems using Botox by Allergan.
Well, that is according to the International Electrotechnical Commission (IEC). The "perfect" ear also known as IEC TR 60959, was "defined" in 1990 and is used to allow gadget manufacturers to standardise the acoustic performance of their headphones or cellphones. You can purchase this perfect ear here if you were so inclined.
Unfortunately, this perfect ear created in 1990 is actually not so perfect as it was defined using a series of 2D scans, taken at 2mm intervals. That meant individual manufacturers were left the subjective task of filling the gaps between adjacent scans. Consequently, there is variation between different models built to the standard.
Thanks to researchers at the National Physical Laboratory (NPL) in Teddington, UK, they have laser scanned a number of ears built to the IEC standard and used these to produce the definitive 3D model which will remove any ambiguity... and be even more perfect than it was before!
Before you ask, this perfect ear was developed through averaging many different peoples' ears.
On October 15, 2010, the FDA approved botox for use in migraine headaches. It is hoped that eventually, this procedure will soon be covered by most health insurance companies rather than the few who do so now.
This blog article is a continuation of prior blogs (6/12/10 and 9/20/10) I wrote on the use of the iPad with Meditech.
Since June 12, 2010 when I first wrote about my experiences of using the iPad with my hospital's Meditech EMR system, a LOT has happened...
First, the hospital has upgraded its Citrix infrastructure to allow iPad (as well as Mac) connectivity to the hospital's MediTech EMR using the Citrix Receiver app (free in iTunes). I reported this back in 9/20/10.
Since than, the hospital has done a remarkable job optimizing and speeding up the connectivity to the point where using MediTech on the iPad is JUST AS FAST as using it on a hospital networked desktop. Of course, the iPad needs WiFi access to achieve these speeds.
Furthermore, I can now access PACS directly via Citrix Receiver app on my iPad rather than going through MediTech which is just great!
My only complaint now (which may not be possible to address with current Citrix software) is the initial prolonged time it takes to get to the MediTech logon screen. After that, speed is quite zippy.
From my conversations with individuals in the know, the next step would be to create a "MediTech" app on the iPad, rather than going thru Citrix Receiver app.
Obviously, one way of doing this is if MediTech creates a native application for the iPad which does not appear to be likely anytime in the near future.
A more likely solution that may be achievable in the next few months is to create a "virtual" MediTech iPad app using Citrix as the engine "under-the-hood". This is an active area of development and I am optimistic that such a virtual MediTech iPad app will soon be available.
A new video has been uploaded to our office's YouTube Channel on Intra-Tympanic Steroid Injection used to treat patients who suffer sudden sensorineural hearing loss. The steroid injection is usually with decadron, though other types of steroids including methylprednisolone has been used.
Most everybody does it whether they admit it or not, both in kids and adults. In fact, according to one research survey, people do it about 4 times a day. In 7.6%, they do it >20 times a day!
Nose-picking, also known as rhinotillexomania in medical-speak, generally is a benign, sedentary (and private) solo activity, but when excessive, can lead to a number of medical problems including nosebleeds (25% of nose-pickers), septal perforation, staph infections, etc. In one extreme case, it even led to a self-inflicted ethmoidectomy (sinus surgery)!
Though most people pick their nose with their finger and use their fingernail to "dig" the golden nugget out, it is recommended to avoid use of the nail due to the danger of causing mucosal trauma (just like when itching the eye, use of the fingernail is not ideal). Using a saline nasal spray or saline flushes can help soften as well as minimize nasal crusting accumulation and enable one to "blow" the nasal boogers out. Humidification, especially when the air is cool and dry, is important to prevent hard nasal boogers from occurring in the first place. Nasal emollients like ponaris are also quite helpful as a preventative measure.
Now, it is a well-accepted fact that ENT physicians are the experts in removing unwanted nasal snot. So what's our secret?
Beyond our 5 years of surgical training, we have fancy equipment in order to obtain optimal visualization of nasal cavity. Use of a nasal speculum as shown below provides direct visualization of the entrance of the nose and suffices in most situations.
However, we are also skilled in the use of nasal endoscopic equipment to examine harder to visualize parts of the nasal cavity.
With visualization, we have at our disposal a large array of equipment that can be used for removal/retrieval. Our workhorse tool is the bayonet forcep. This tool is ideal for the hard nasal crusting in the front part of the nasal cavity.
When the booger is farther back, rather than using bayonet forceps, a tool with forceps only at the tip is utilized (ethmoid forceps). The neato thing with this instrument is that the tip comes in all sorts of different sizes and angles in order to reach into any part of a person's nose!
When the snot is more mucoid rather than hard, a suction device (frasier tip) can be used instead.
So, that's probably more information than you ever wanted to know about boogers, but there you have it!
Research has actually shown that sword-swallowing can cause sore throats! No kidding!
This particular research was based on 110 sword-swallowers from 16 different countries and was published in the British Medical Journal in 2006.
This research won the 2007 Ig Nobel Prize in Medicine. Watch a YouTube Video of a sword-swallower in action:
ENTs regularly perform a similar procedure when we perform "Direct Esophagoscopy". Just like a sword, it is an elongated rigid metal structure, except in the shape of a tube that we place through the mouth down towards the stomach. This procedure is used to look for mucosal lesions/masses (cancer) as well as retrieve foreign objects unable to pass. Gastroenterologists perform a similar procedure, but using a long flexible scope instead of a rigid scope. Some ENTs perform "Trans-Nasal Esophagoscopy" whereby instead of placing a flexible scope in the mouth (like the GIs do it) and threading down into the stomach, the scope is placed instead through the nose! Esophageal dilatation is another procedure similar to sword swallowing, but using stiff rubber in order to open up areas of narrowing in the esophagus.
Over time, I have received a number of emails from patients regarding the best type of Gaviscon Advance they should purchase for relief of NON-acidic laryngopharyngeal reflux (LPR). The blunt answer is to get the Gaviscon Advance Suspension/Liquid made by Reckitt Benckiser which contains at least 500mg of sodium alginate in 5ml dose (1 tsp) or 1 gram in 10cc dose (2 tsps). This formula of Gaviscon Advance cannot be purchased in the United States, but instead overseas via online pharmacies located in the United Kingdom (link). Occasionally, Amazon.com
does stock it.
The Gaviscon (without the "advance") sold in the United States is manufactured and distributed by GlaxoSmithKline (GSK) and not Reckitt Benckiser. The US brand of Gaviscon by GSK contains less of the key ingredient sodium alginate which helps with NON-acidic reflux. Alginate is a natural product derived from seaweed. The alginate reacts with the acid in the stomach to produce a "raft" barrier that acts as a physical block to reflux. It is the only non-surgical treatment that can physically prevent reflux disease regardless of whether it is acidic or not. Alginates work rapidly, are long lasting, inexpensive, and have no known side-effects.
Initial therapy to treat non-acidic LPR would be to keep the head of bed elevated more than 30 degrees. Best way to do this is by placing 2-3 bricks/books under the legs at the head of the bed to tilt the entire bed. Or, sleep in a chair recliner. Or, purchase a mattress wedge. Sleeping with several pillows is not adequate as one needs the chest region also to be higher than your stomach (not just the head).
Medications that may help include robinul forte, Maalox (less preferable) or Gaviscon Advance made by Reckitt Benckiser (RK) as stated above.
A reader informed me that INOVA Health System has developed a free iPhone app called InovaER that provides wait times of all 9 emergency rooms within its health system throughout Northern Virginia. The app was released Aug 4, 2010.
Pretty cool! Hopefully other hospital systems including Fauquier Hospital will join with other regional hospitals (Culpeper, Warren, Prince William, Haymarket) to create a similar program.
CareerBuilder and Dunkin' Donuts performed a survey that was released to public on Sept 27, 2010 that listed those professions who needed coffee the most in rank order. The survey was performed on 3600 workers throughout the United States.
According to the survey, the professions with the highest proportions of workers stating they are less productive without coffee vary widely. Those who need coffee the most are:
I personally have NEVER drank coffee... even during my residency when I worked 120+ hour shifts. I was too busy to wait in line to order coffee and never really picked the habit up of needing a caffeine buzz to function.
So... I came across a few references addressing treatment of hiccups (otherwise known as singultus) based on science rather than heresay. Here are a few methods than can be done at home without the need for medications or procedures.
It is felt that hiccups may be secondary to irritation of the phrenic nerve (which innervates the diaphragm). As such, scientific treatment of hiccups have relied on increasing PaCO2 (breath holding, breathing into a paper bag), therapy using diaphragm relaxation (baclofen or phrenic nerve block), or positive airway pressure.
So, one paper described a technique called supra-supramaximal inspiration that would increase PaCO2, diaphragmatic immobilization, and positive airway pressure. The technique is as follows:
Patients are instructed to inspire maximally, hold the breath for 10 seconds, then add an additional, small, “supra-maximal” inspiration, without any expiration. The breath is held for 5 seconds, followed by a third, “supra-supramaximal” inspiration, held for 5 seconds, before resuming normal breathing.
A variant on this technique requires an assistant. The assistant first applies firm pressure just anterior to the tragus of the ear, firm enough to completely occlude the ear canal. The patient than drinks a glass of water for about 10 seconds. If no liquid is available, the Valsalva manoeuvre would suffice.
In another method, pressure is applied to the sphenopalatine ganglion. This method involves sliding a finger (or thumb) to the junction between the hard and soft palate in the mouth. In this region, firm pressure is appled for 5-10 seconds towards the back-top part of the head. Enough pressure needs to be applied to cause some pain. One can massage this junction as well. I believe this method was reported in the New England Journal of Medicine, but for the life of me, I can't find the reference.
Digital rectal massage has been reported in the literature to help stop hiccups, mainly by disrupting the vagal afferent limb of the hiccup reflex arc. Name says it all. Essentially, you stick a finger up the anus and massage the area firmly until hiccups stop.
Direct vagal stimulation, such as by carotid massage, Valsalva maneuver, and ocular pressure have also been reported.
Symptoms of OSA that can be confused with dementia include trouble concentrating, inattention, difficulty staying focused, constantly dozing off during the day, and other cognitive deficits.
Unfortunately, many elderly patients live alone and nobody is around to see whether there are any sleep issues. Most elderly patients deny any sleeping difficulties and it is not until someone stays with them during the night (like on holidays when family members are around) that a sleep disorder is noticed.
They key thing is to consider OSA in the differential for an elderly patient who may be exhibiting some symptoms of dementia and to realize that one needs to talk to family members whether sleep issues are present.
CPAP is a machine that pushes air into a person while they are sleeping to treat obstructive sleep apnea, a medical condition where a person stops breathing multiple times throughout the night leading to all sorts of medical problems including increased risk of hypertension, stroke, peripheral vascular disease, heart attack, etc.
In order for this device to work, a mask must be worn while sleeping in order for the air to get pushed into the lungs.
It is considered the gold standard treatment for OSA.
However, a new study has found that prolonged use of CPAP masks lead to slight shifts in jaw and position of teeth along with other craniofacial changes. Previous studies have already reported midfacial hypoplasia in children using CPAP.
How long before such changes can occur in adults? In as little as 2 years.
Fortunately, there are other options beyond CPAP that can help minimize and possibly even cure OSA via surgical procedures.
A reader forwarded this video (below) to me about a singing cat named Monster. This cat has a supposed "vocal cord condition" which causes operatic singing when yawning. Check it out!
Now personally, I can't really think of a vocal cord condition that would cause a more beautiful voice. Wish I could perform fiberoptic laryngoscopy on a "normal" cat and this cat to see what differences are present.
According to a new study, people who work in noisy places for at least a year and a half could have triple the risk of a serious heart problem including a heart attack and severe chest pain compared to those who work in quiet environments. Of course, we all know such loud environment can also cause hearing loss.
6,000 people who were at least 20 years old and employed were surveyed from 1999 to 2004. Other heart risk factors including elevated Body Mass Index and smoking were statistically adjusted for.
Noisy occupations include not only welders, garage mechanics and forklift operators, but also dentists, construction workers, nursery school teachers and classical musicians.
Why would loud noises cause heart problems? It is felt that noisy environments typically are more stressful leading to higher levels of stress hormones which can contribute to heart problems. Still... quitting smoking and losing weight are more important to your heart health than avoiding noisy environments.
Oftentimes, I see patients come in with sinus x-rays with this or that finding. What many patients as well as physicians may not realize is that sinus x-rays are notoriously unreliable in determining whether sinus infection is present or not. Indeed, I NEVER order a sinus x-ray. Just how unreliable are sinus x-rays?
In adults, it may be literally a flip of the coin whether the sinus x-ray is providing a correct diagnosis compared with the gold standard CT sinus.
Depending on what study you look at, the specificity of a sinus x-ray hovers around 50% (how often it correctly states normal sinuses). Sensitivity is a little better at around 80% (how often it correctly detects actual sinusitis).
Several studies have concluded that sinus plain film x-rays are unreliable and no longer routinely indicated for the evaluation of nasal and paranasal sinus disease. When radiographic evaluation is indicated a limited CT series provides superior information.
Take home message?
Do not order a sinus x-ray when evaluating for sinus disease/sinusitis!!! Why bother ordering a test that is going to be wrong almost half the time?
(If a CT sinus comes back normal, the patient most definitely does NOT have acute or chronic sinusitis.)
Interestingly, sinus x-rays in kids (2+ years old) may be more reliable and in this sub-population, may be beneficial [Link]. But this study unfortunately did not include CT sinus scans to verify sinus x-ray findings. It should also be noted that sinus x-rays younger than 2 years old is also unreliable [Link].
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