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March 31, 2011

Generic Nasacort AQ Will Be Available June 15, 2011

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A generic version of Nasacort AQ will be available on June 15, 2011.

Nasacort AQ is an aqueous steroid nasal spray in the treatment of allergies. Currently, flonase (fluticasone) is the only generic steroid nasal spray available.

As such, the company has stopped sampling Nasacort AQ for many physician offices including ours.

March 22, 2011

ASHA Recognizes Dr. Chang for His Educational Videos

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ASHA, the American Speech-Language-Hearing Association, recently recognized the contributions that Dr. Chang has provided in ENT videos he has created for educational purposes.

In their recent newsletter on October 12, 2010, an article written by Judith Maginnis Kuster, MS, CCC-SLP, wrote an article titled "Videos on the Web". On page 24, she wrote:


Check out the videos she is talking about here.

March 21, 2011

Dr. Chang Publishes New Journal Article "Video Recording the Surgeon's Viewpoint Cheaply"

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An avid snowboarder, I purchased one of those helmet-mounted video camcorders in order record my athletic feats over a year ago. The one I purchased was called ContourHD and it can be mounted on the snowboard helmet and set to record by the press of a button.

It was at some point boarding down a black diamond trail that I had an epiphany... Why not use this helmet mountable camcorder in order to record surgical procedures in the operating room?

And... So I did with a few modifications to allow magnified narrow-angle shots... And I wrote a paper on it which was recently published in ENT Journal in March 1, 2011.

In any case, below is a picture of my creation mounted on a surgical headlight.

Read the article here (free registration required). Pubmed link is here.

See the full list of publications by Dr. Chang here.





March 20, 2011

Home Allergy Shots

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DISCLAIMER: This post is not meant to condone or promote allergy shots to be given at home. It is meant to promote discussion and make patients aware of the issues involved.

Allergy shots, unlike medications like claritin and flonase, offer patients with significant allergies a way to potentially be cured of their misery without the need for daily medication use. However, there is a small, but substantial risk for anaphylaxis and even death with allergy shot administration. After all, a patient is being injected with the very substances that cause their allergies. As such, many allergists will allow allergy shots to be administered ONLY within a medical setting. Also, the American Academy of Allergy Asthma and Immunology (AAAAI) specifically forbids allergy shots to be administered at home.

Furthermore, the allergen extracts used to make the allergy vial serum used for allergy shots carry a black box warning on the medication package insert:
"This product is intended for use only by physicians who are experienced in the administration of high dose allergy injection therapy, or for use under the guidance of an allergist. Allergenic extracts may potentially elicit a severe life-threatening systemic reaction, rarely resulting in death. Therefore, emergency measures and personnel trained in their use must be available immediately in the event of such a reaction. Patients should be instructed to recognize adverse reaction symptoms, be observed in the office for at least 30 minutes after skin testing or treatment, and be cautioned to contact the physician's office if symptoms occur. Standardized glycerinated extracts may be more potent than regular extracts and therefore are not directly interchangeable with non-standardized extracts, or other manufacturers' products. Patients with cardiovascular diseases and/or pulmonary diseases such as symptomatic unstable, steroid dependent asthma, and/or those who are receiving cardiovascular drugs such as beta blockers, may be at higher risk for severe adverse reactions. These patients may also be more refractory to the normal allergy treatment regimen. Patients should be treated only if the benefit of treatment outweighs the risks. Patients on beta blockers may be more reactive to allergens given for testing or treatment and may be unresponsive to the usual doses of epinephrine used to treat allergic reactions. This product should never be injected intravenously."
The downside of allergy shots is that they are given 1-2X per week not just for a month or two, but for YEARS. If shots are given only within a medical facility, the patient must commit a significant amount of time, travel, and gas in order to complete a shot series. There is also the time missed from work. In essence, the patient must approach allergy shots like a part-time job.

Given all this... what are the actual risks of anaphylaxis and death from allergy shots?

VERY small...

In one Mayo Clinic study on 79,593 immunotherapy injections over a 10-year period showed the incidence of adverse reactions to be less than two-tenths of 1 percent (0.137 percent). Most of the reactions were mild and responded to immediate medical treatment. There were no fatalities.

More than 1 million injections were given without a fatality to 8,706 patients in allergy clinics at Roosevelt Hospital, New York City, between 1935 and 1955.

Worldwide, there were only 35 deaths reported from allergy shots between 1985 - 1993. It has been estimated that during that period there were 52.3 million immunotherapy procedures, making the incidence of fatality less than one per million (0.6692 per million). Data recently compiled by the Allergen Products Manufacturers Association (APMA) estimated the incidence of fatalities to be about three per 190 million annual injections, or approximately one per 63 million injections.

Now compare this to other medical interventions. Approximately 1 in 5000 exposures to a IV dose of penicillin or cephalosporin antibiotic causes anaphylaxis of which more than 100 deaths per year are reported in the United States. Fatal reactions to penicillin have ranged from 0.4 fatalities per million injections to 1 fatality per 7.5 million injections.

One to 2% of people receiving IV contrast (for a CT scan) experience some sort of systemic reaction. The majority of these reactions are minor, but fatalities have occurred in about 1 in 13,000 to 1 in 75,000 procedures in the 1980s (a more recent study has shown a decrease of 1 fatality in 169,000 procedures).

So... the main question now is should home allergy shots ever be allowed?

There are two ways of answering this question.

The first way is to consider any fatality due to an allergy shot (no matter how extremely rare) to be unacceptable, especially when considering the disease being treated -- allergies -- to be a quality of life issue rather than a life/death issue (heart transplant surgery). There is also that black box warning mentioned above.

The other way to view the answer is to consider things in perspective. There are MANY quality of life activities that people perform that has a risk of severe bodily harm if not death. Swimming results in 1,150 deaths per year in the United States alone. There are about 43,000 fatalities per year from car accidents.

Also, if one takes the stringent view that any fatality due to an allergy shot to be unacceptable, than patients should be monitored in a medical facility for not just 30 minutes or less, but 24 hours as late reactions can still occur the following day after an allergy shot! Indeed, in England, patients are required to wait under observation for anaphylaxis as long as ONE HOUR after each and every injection!!! In fact, the one hour observation was an improvement over the TWO hours that was imposed initially. Read more about this here.

So why draw the line at 20 minutes (or more) as recommended by the AAAAI in the United States? It's because the vast majority of severe reactions occur within the first 30 minutes. Beyond 30 minutes, severe reactions become less common (but NOT zero). Well, severe reactions are not very common to begin with... and if allergy shots must be given in a medical facility due to this concern... than should it not follow logically that no matter how rare the possibility, that patients MUST be observed for 24 hours no matter how small the risk of anaphylaxis than?

Why state that allergy shots must be given in a medical facility due to small, but possible risk of severe reaction on the one hand, and than state that there is a small, but acceptable risk of severe reaction after 20+ minutes of observation in a medical facility?

It is just through this thought process that some physicians who provide allergy shots allow home injections. At this time, it is estimated that about 15% of allergists allow home injections (based on a blinded survey of allergists).

IF home allergy shots are allowed (and this is by no means a recommendation or a statement condoning home allergy shots, but just saying in a hypothetical sense), it should be done only in carefully selected patients:

- Are on maintenance regimen (allergy shots are not being increased)
- No significant reactions during buildup and maintenance
- Proper training in administration (just like diabetics are trained to give themselves their shots)
- Epi-pen available and understanding in how to use
- In-office allergy shot with post-injection monitoring for a period of time with every new vial
- Only in adults
- CONSENT signed by patient informing of the risks as well as black box warning



References
Systemic reactions to immunotherapy at the Mayo Clinic. J Allergy Clin Immunol 1997; 99:S66.

The risk of inducing constitutional reactions in allergic patients. J Allergy 1957; 28:251-261.

Deaths associated with allergenic extracts. FDA Medical Bulletin 24, May 1994.

Allergenic extracts used in immunotherapy fatalities. J Allergy Clin Immunol 1997; 99:S67.

Nature and extent of penicillin side-reactions with particular references to fatalities from anaphylactic shock. Bull WHO 1968; 38:159.

Mortality during excretory urography: Mayo Clinic Experience. AJR 1982; 139:919-922.

Reactions to ionic and nonionic contrast media: A report from the Japanese Committee on the Safety of Contrast Media. Radiology 1990; 175:621-628.

March 14, 2011

Tonsillectomy WITHOUT Anesthesia in a Child [GRAPHIC]

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WARNING!!! 

This video contains a VERY GRAPHIC video of a child having his tonsils removed without anesthesia or sedation. This video is EXTREMELY disturbing. DO NOT watch it if you are easily shocked, offended, or have a weak stomach.

A colleague forwarded this video to me and though I regularly perform tonsillectomy, I myself felt quite disturbed by it.

Many readers have also informed me that the video is actually an adenoidectomy rather than tonsillectomy, but hard to say which procedure is being done.

In any case assuming video title is correct, in most countries, tonsillectomy is performed under general anesthesia (as shown in this video), but there are still some places in the world where this surgery is performed without any anesthesia or sedation. Although I have been aware of this method, I have never seen it done without sedated anesthesia until I watched this video. This particular video was recorded (supposedly) in Belarus.

I was debating whether to embed this video directly in this post, but ultimately decided against it.

To watch this graphic video, click here.

You have been forewarned regarding the graphic nature.

---------------------------------------------------

Tonsillectomy performed WITH anesthesia as done in most countries is shown here:

March 12, 2011

Auditory Neuropathy

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CNN published an article March 10, 2011 on a hearing problem called auditory neuropathy. At its essence, auditory neuropathy is when the inner ear is working fine, but the nerve going from the inner ear to the brain is impaired.

The hallmark of auditory neuropathy is a negligible or very abnormal ABR (auditory brainstem response) reading together with a normal OAE (otoacoustic emission) reading. A normal OAE reading is a sign that the outer hair cells are working normally.

Therein lies the danger that the article is about...

When a child is first born, all undergo a hearing test using either OAE or ABR testing.

Let's assume the newborn has auditory neuropathy and a newborn ABR testing is done. The hearing test will come back that the child failed and will be referred for further testing. If additional testing was done with ABR only (and not OAE), the child will be considered to have hearing loss and hearing aids will be recommended.

If OAE is done, the newborn with auditory neuropathy will pass the test and no referral will be made.

Really... the take-home message here is to ensure that if ABR was done and a newborn fails, additional testing that is performed must include OAE.

Read the CNN report here.

Keep in mind that people affected by auditory neuropathy may still have hearing loss and though they may be able to hear sounds, they may still have difficulty recognizing spoken words. Sounds may fade in and out for these individuals and seem out of sync.

Watch how ABR is performed in our office in the video below. We also do OAE testing.

March 09, 2011

Real-Time MRI Imaging During Vocal Performance (Soprano and a Beatboxer)

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A colleague of mine shared this amazing video demonstrating what is going on in the upper airway during a vocal performance of a soprano and a beatboxer via real-time MRI imaging.

Check it out here if the video is not showing correctly below.

March 08, 2011

Reporter Suffers Garbled Speech on Live TV

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Many folks are already aware of a Los Angeles reporter, Serene Branson, who was covering on live TV the Grammy's when she suffered symptoms of garbled speech (dysarthria being the medical term).



It was initially conjectured that she was in the middle of a stroke, TIA, seizure, or something else bad... but it finally was determined by her doctors that it was due to a migraine.

This scary incident brings me to explain what a speech and what a vocal problem is. First some definitions.

Voice is sound production. Speech is what ultimately comes out the mouth after the sound is modified by the throat muscles, palate, tongue, lips, teeth, etc. Examples of voice problems are hoarseness and breathiness. A speech problem would be stuttering, mumbling, or sounding nasal.

This distinction is very important as it helps point the right way to treatment. Otherwise time is wasted on the patient's part seeing inappropriate doctors.

Generally, voice issues can be treated by an ENT as it generally is due to some physical voicebox problem whether it be vocal cord paralysis, vocal cord nodule, or spasmodic dysphonia.

Speech problems are due to the dis-coordination of the throat and mouth muscles and is NOT because of a physical problem that can be addressed surgically (generally speaking, though there are exceptions). The problem is at the brain level.

So taking the reporter above as an example... her vocal quality was quite normal. What was abnormal was her speech. Given the speech difficulties, the problem was at the brain level and not the voicebox. As such, an ENT is NOT the right doctor to see, but rather a neurologist.

However, there is one speech issue that CAN be addressed by an ENT quite well and that is nasal-sounding speech due to irregular nasal airflow (either too much or too little).

March 06, 2011

Rapid Strep Test Positive But No Sore Throat

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Occasionally, I see patients who have received throat swabs for strep that have come back positive... even if they have no signs or symptoms of pharyngitis.

In this situation, there are 2 main actions a physician may take (I am biased towards one):

1) Prescribe antibiotics until throat cultures are normal
2) Do nothing

Personally, if a patient is without throat symptoms and has no history of rheumatic fever or kidney damage, I would not have even bothered obtaining a strep test. What for???

Also, a person can be a carrier for strep without suffering any health problems. As such, even if the strep test is positive, but if the patient has no symptoms, I do not recommend treatment. (Which again begs the question of why bother getting a strep test if no treatment will be recommended regardless of the test result.)

I would go so far even to say follow-up cultures are NOT necessary after antibiotic treatment for strep throat if a patient does not have any more symptoms and exam is normal.

Which is why I find it surprising when children and adolescent patients receive multiple courses of antibiotics when they feel perfectly fine, but have received treatment just because a strep test came back positive.

Of course... that's just my opinion as I do acknowledge that there's another school of thought which supports antibiotic treatment of all strep positive cultures with follow-up cultures to ensure eradication.

However, according to the 2012 clinical practice guidelines published by the Infectious Diseases Society of America (statement 12),
"We recommend that GAS carriers do not ordinarily justify efforts to identify them nor do they generally require antimicrobial therapy because GAS carriers are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for developing suppurative or nonsuppurative complications (eg, acute rheumatic fever; strong, moderate)."
Depending on the doctor you see, you will get different opinions. But it is good for patients to be aware of the varying views on this topic given how common sore throats are.

Reference:
Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis. (2012) 55 (10): e86-e102. doi: 10.1093/cid/cis629

March 05, 2011

Get a Nosejob Without Surgery!

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Well, only in Japan at least. Courtesy of Dr. Houtan Chaboki, I came across one of his posts showing this advertisement of a device that can mold your nose to the perfect shape (ie, rhinoplasty or nosejob)... all without cutting or any plastic surgery.

Before you go running off to buy one... I have been assured it doesn't really work.

However, before pooh-pooing molding as a scam, it IS an acceptable form of changing the shape of human features... such as the skull (craniosynostosis defects)... but only when the anatomic part being shaped is still cartilaginous.

March 01, 2011

Natalie Portman, Scientific Genius in REAL Life!

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The New York Times published a great article about the serious scientific credentials of some of hollywood's most celebrated stars, Natalie Portman among them.

As a student at Syosset High School on Long Island back in the late 1990s, Ms. Portman made it all the way to the semifinal rounds of the Intel Science Talent Search competition. Her project was a new “environmentally friendly” method of converting waste into useful forms of energy. She also went to Harvard University and studied neuroscience and the evolution of the mind.

Ms. Portman apparently is not the only actor with serious scientific credentials.

Hedy Lamarr, the actress considered the "most beautiful woman in Hollywood,” was a rocket scientist on the side, inventing and patenting a torpedo guidance technique she called “frequency hopping,” which thwarted efforts to jam the signals that kept the missiles on track.

Danica McKellar, who has appeared on such shows as “The Wonder Years,” “The West Wing,” “NYPD Blue” and “Young Justice,” graduated summa cum laude in mathematics from the University of California, Los Angeles, where she helped devise a mathematical proof for certain properties of magnetic fields — a theorem that bears her name along with those of her collaborators.


Mayim Bialik plays the adorably frumpy-nerdy neurobiologist Amy Farrah Fowler on the "Big Bang Theory" sitcom. In real life, she also has a Ph.D. from U.C.L.A. in neurobiology.

Read this great story in the NYT here.

Olympic Athlete Hopeful With Vocal Cord Dysfunction

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There was a recent article about Hannah Lupton, a heptathlete, who suffers from vocal cord dysfunction. This disorder is basically when the vocal cords come together during inhalation when it should be apart resulting in shortness of breath localized to the throat area.

Normally, during breathing, the vocal cords are apart as shown in the picture. When talking or swallowing, the vocal cords come together (TVC is True Vocal Cord).


Laryngospasm, which is the most severe form of vocal cord dysfunction, is when the vocal cords come together completely preventing any air from moving into the lungs resulting in a high pitched squeal when trying to breath. People may even faint due to lack of oxygen when this happens.

The vocal cord exercises as described in the news article may encompass these strategies among others:

METHOD 1: Breathing Technique
There are 3 steps to this particular method.
  1. As soon as one feels an attack coming, SLOWLY breath in through the NOSE. DO NOT BREATH IN THROUGH THE MOUTH! Sometimes deliberately holding breath for 5 seconds prior to nasal inhalation helps.
  2. More quickly exhale out the mouth with pursed lips.
  3. Continue slow nasal inhalation, and quick mouth exhalation with pursed lips until the episode passes.
Why does this work? For some reason, nasal breathing reinforces the brain to keep the vocal cords apart when inhaling. Quick inhalation through the mouth seems to do the opposite and encourage the vocal cords to close which exacerbates the problem. Also, quick inhalation reinforces the Bernoulli Principle that as a fluid (air in this case) passes through a pipe that suddenly narrows (the vocal cords), the pressure actually decreases which encourages further narrowing (or vocal cord closure). Therefore, SLOW breathing helps keep the vocal cords apart! You can test this principle yourself by sucking air on a narrow short straw slowly and than quickly. You will find that the straw will tend to collapse when sucking in quickly.

METHOD 2: Straw Breathing

This method essentially forces a person to decrease the speed of breathing allowing for vocal cord relaxation. In essence, cut a regular drinking straw to half its length. When an attack occurs, place the straw in your mouth and make a tight seal. Breath thru the straw (via mouth) until attack passes.

Patients with recurrent laryngospasm attacks typically keep a straw in their pocket/purse to have immediately on hand.

METHOD 3: Pressure Point

Another manuever that may work is firm pressure in the "laryngospasm notch." Basically, with an attack, quickly with your (or somebody else's) index fingers, press very firmly just behind both your earlobes where there is a notch between the bone of your mastoid process and ear. Press deep and forward towards the nose. It should hurt. If it doesn't hurt, you are not pressing hard enough. The attack should resolve within 10 seconds. Here is an article describing this method.

METHOD 4: CPAP

This particular method applies only if laryngospasm attacks occur mainly at night while sleeping. Essentially, one uses a CPAP machine which blows air into your lungs while you sleep. This treatment helps by preventing the body from believing it is "drowning" which would result in vocal cord adduction. By having a persistent positive airflow from the CPAP device, it also reinforces to the brain to keep the vocal cords apart. At worst case, if an attack occurs, the CPAP machine helps push air into your lungs past the vocal cords. Indeed... if you ask any anesthesiologist what they do when a laryngospasm attack occurs during intubation, they'll say apply strong positive pressure by mask (along with other things of course).

Make sure you use heated humidification. Please be aware that the air pressure being applied MAY actually cause laryngospasm due to direct vocal cord irritation of the forced air. Unfortunately, there's no way to predict someone who will respond vs someone who will do worse with this treatment method.

Other Treatments

Oftentimes, the above strategies help enough that a patient finds these attacks occur less frequently with decreasing severity over time until they altogether stop. Rarely, a benzodiazepine medication will be prescribed for these attacks to help with the anxiety aspect until the strategy is internalized. Working with speech pathology has also been found to be helpful. In certain situations, laryngeal sensory neuropathy (LSN) may be contributing to VCD and treatment geared towards LSN improves VCD. Of course, treatment of the trigger whether it be allergy, asthma, or reflux is important.

In rare cases, I will consider injecting BOTOX into the vocal cords which will physically prevent the vocal cords from coming together and as such, prevent the difficulty in breathing should an attack occur. In some people, it decreases not only the severity, but also the frequency of attacks. The way BOTOX is injected into the vocal cords is shown below in the video. Please note that the vast majority of patients upon whom I perform vocal cord BOTOX injections are those suffering from spasmodic dysphonia.



Read the news article here.

Read more about vocal cord dysfunction here.
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