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April 28, 2010

Feeling Dizzy or Having Vertigo? There's an iPhone App for That!!!

On April 22, 2010, Clearwater Clinical Limited released an iPhone application that helps clinicians diagnose and perform the Epley maneuver in patients with BPPV (Benign Paroxysmal Positional Vertigo).

The way it works is by placing the iPhone over the patient's forehead and than following the instructions as shown on the iPhone through each of the Epley steps.

When I tried it out, it does seem to correctly take the patient thru the appropriate steps... however, I would add one more step. Place a tissue between the iPhone and patient's forehead before use (for sanitary reasons).

Click here to download the (FREE) app from iTunes!

Click here to read more about dizziness in general.

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

April 26, 2010

Sudden Hearing Loss Can Be Due to Erectile Dysfunction Medications (Cialis, Viagra, etc)

It's been a few years since the warning has come out from the FDA regarding sudden hearing loss in men who take viagra, cialis, and other erectile dysfunction (ED) medications. In 2007, the FDA authorized more prominent labeling that such drugs may potentially cause sudden hearing loss because of this concern.

This concern initially stemmed from a 2007 case report of
bilateral profound unremitting sensorineural hearing loss in a 44-year-old male patient that occurred after ingestion of viagra 50 mg/day for 15 days.

Another more recent 2010 study quantified that such erectile dysfunction medications may actually double the risk of hearing loss. With sudden hearing loss, one can also experience tinnitus as well as ear fullness.

As such, it's nice to review this rare condition that may lead to permanent hearing loss, tinnitus, ear fullness for which only hearing aids may help. Of course, one can suffer this sudden condition without taking such medications.

If you experience sudden hearing loss (whether taking ED medications or not), see your local ENT as soon as possible as there is a window of opportunity during which certain interventions may help reverse and restore your hearing back to normal! Such intervention include:

• High doses of prednisone
Intratympanic steroid injection into the ear
• Hyperbaric oxygen therapy

Click here to read more about sudden hearing loss.

Phosphodiesterase type 5 inhibitor use and hearing impairment. Arch Otolaryngol Head Neck Surg. 2010 May;136(5):488-92. doi: 10.1001/archoto.2010.51.

A case of sensorineural deafness following ingestion of sildenafil. Journal of Laryngology & Otology / Volume 121 / Issue 04 / April 2007, pp 395-397

April 25, 2010

Fauquier ENT YouTube Recognized as a Top Medical Video Channel!

It was with pleasant surprise that I discovered that the YouTube channel our office manages has been recognized by Goomedic (an informatics blog) for providing influential medical videos. We apparently are ranked #13 (out of 30) along with University of Maryland Medical Center (#1), CDC (#8), and British Medical Journal (#10).

For those curious, we get about 250,000 views a day on average.

Check out our YouTube video channel here.

See the full list of influential medical videos here.

What is High Quality Research?

Patients (and health professionals) are inundated with information overload regarding "research studies" that prove this or prove that on TV, magazines, radio, etc.

Who do you trust? How can you determine if a given study is worthwhile while dismissing others?

Well, it unfortunately takes some homework...

1) Determine WHO did the research. Clearly, research published by Harvard University is more "trustworthy" than research done by XYZ (XYZ being an institution you have never heard of before).

2) What journal was it published in? Not all journals are created equal. First, make sure the journal is peer-reviewed. What that means is that experts in a given field read and determine if the research is worthwhile before publishing it. Some journals do not have this vetting process and pretty much publish anything that crosses their desk. Second, the more reputable the journal, the more rigorous the review process before the research is published.

Highly regarded peer-reviewed journals include:
• New England Journal of Medicine
• Annals of (insert medical specialty)
• Archives of (insert medical speciality)
• Journals produced by national medical organizations such as Otolaryngology-Head & Neck Surgery published the American Academy of Otolaryngology-Head & Neck Surgery

3) What kind of research is it? A randomized, prospective, placebo-controlled, double-blinded research is the best quality. Anything less has the potential to provide conclusions that may not be entirely correct. Let's talk about each of these research study components:

Randomized: Subjects are selected at random. For example, if you are doing a study on pain control, the results may be different if you only select patients who are healthy without any medical problems versus patients who have chronic pain or recently underwent surgery.

Prospective: The study starts when you begin administering the intervention or drug versus looking at historical data (hindsight is 20/20, but not a good thing when you are trying to prove something without bias).

Placebo-Controlled: This means that there is a separate "control" group which is given a sham intervention or a sugar pill not meant to help/improve the problem being studied. Why is this necessary? Because over 20% of the time, patients given this placebo report improvement... which means a given intervention or drug must demonstrate improvement above and beyond this placebo effect to be considered authentic.

Double-Blinded: This term means that both the patient and doctor have no idea whether the intervention is a placebo or the actual drug/intervention. Bias may occur if not double-blinded. For example, what if the doctor is being paid millions of dollars for a positive outcome of the research. With this kind of monetary influence, the results may become skewed towards a positive outcome.

Unfortunately, it is the rare research that incorporates all of these elements for one reason or another. Most research studies have only a few, but not all these elements. The less elements a given research contains, the less rigorous it is considered and the results considered less valid.

In conclusion, not all research studies are created equal. Some are highly trust-worthy and results are beyond question valid. Other research studies are almost worthless.

Don't automatically trust what you hear which is what our mothers' have told us all along. Check the info out yourself or ask where's the proof (and than validate it).

Does the EARDOC Work?

So I've seen a whole lot of hub-bub regarding a medical device called EARDOC.

The way EARDOC is explained to work is through vibrations conducted via the mastoid bone into the middle ear and eustachian tube by placing the device behind the ear and activating it.

The main question on my mind is whether it actually works... And on that point, it's less clear. There certainly is a lot of patient testimonials as well as marketing spots in support of its effectiveness. However, it would be nice to see independent testimonials as well as promotions NOT by professional bloggers. I find the negative reviews on to be most enlightening.

AND while it may work, it would be nice to have actual research done on this device to prove it.

According to their website, "The Eardoc was tested in the Top Medical University in Europe. The Eardoc test was performed with a Tympanometer on 40 Patients over 6 weeks, it shows with no doubt that the EARDOC opens the Eustachian tube and relieves the pain."

So where is the paper showing this? I did a pubmed search and nothing came up.

If it is a "Top Medical University in Europe", what is the name of it? If this product is so great, why is the university itself not promoting it and associating its name to a medical device that works so amazingly well on a problem that is so common?

I can say for one thing... they have a pretty aggressive marketing campaign going on via twitter and facebook.

In any case, what I CAN say is that it probably can't hurt to try it out (beyond losing $55 and extending your ear infection/pain which may get worse while waiting for it to work). For those curious, it is sold on Amazon as well as directly from the company.

Without further independent research evidence by a reputable institution (research that is published and listed in PubMed), it is not possible to say whether it truly works beyond placebo or if it is just a gimmick.

Here's a video explaining how the eustachian tube works:

However, here are some products that DO help to pop the ears:


NYT: Can botox stop essential tremor (hand, face, etc)?

On April 22, 2010, the New York Times published a short story entitled "Can Botox Stop the Hands From Shaking?"

The story goes on to report that "Intramuscular injections of Botox, or botulinum toxin, may play a limited role in the treatment of wrist and voice tremors in patients with essential tremor."

Indeed, I do agree with the "limited" role botox has on essential tremor (emphasis on limited) whether the tremor involves the hand or head/neck region which is what I deal with more often.

Botox works GREAT when only 1 or 2 muscles are involved such as muscular dystonias where discrete muscles are afflicted such as torticollis (sternocleidomastoid muscle and/or trapezius muscles) and spasmodic dysphonia (thyroarytenoid muscle).

Unfortunately, in most cases of tremor (not dystonia), multiple different muscles are involved and it is very difficult to pinpoint and inject every single muscle that is suffering from tremor. A patient can end up with over a dozen injections to hit each affected muscle, and still not get a perfect outcome due to overall weakness from having so many injections.

Let's take vocal tremor... Vocal tremor often has both a laryngeal, oral, as well as neck component (patient's head often shakes while talking). As such, if one theoretically wanted to inject botox for vocal tremor, all these muscles may potentially need to be injected:

• thyroartenoid
• thyrohyoid
• sternothyroid
• infrahyoid
• omohyoid
• sternohyoid
• posterior cricoarytenoid
• lateral cricoarytenoid
• sternocleidomastoid
• superior pharyngeal constrictor
• middle pharyngeal constrictor
• inferior pharyngeal constrictor
• genioglossus
• hyoglossus
• styloglossus
• plalatoglossus
• levator veli palatini
• tensor veli palatini
• palatoglossus
• palatopharyngeus
• platysma
• etc.

That's a lot of muscles... which means a lot of injections... which means overall increased risk of overall weakness... AND the tremor may still be present.

However, botox injections may STILL be helpful to reduce symptoms of vocal tremor, but complete elimination of vocal tremor may be not be possible to achieve. Read more...

As many people already know, botox works great for wrinkles because discrete muscles are involved (just like for dystonia).

Our office provides botox injections for wrinkles, torticollis, spasmodic dysphonia, etc... but not for tremor UNLESS it is involving only a few muscles (very rare!).

Read the NYT article here.

April 24, 2010

We Now Offer Sterile Ear Piercing Using Lab-Tested, Hypoallergenic, Packaged & Sealed Earring Studs

Our office offers ear piercing by a doctor to patients in a manner superior to that obtained in most commerical locations. The ear piercings we provide are:

• Performed in a sterile manner (numbing offered as well)
• Ear studs placed are hypoallergenic
• Ear piercing system used has been laboratory tested, packaged, and sealed
• Hypoallergenic studs and clasps are individually sealed with disposable earpiercer - avoiding any concern of cross contamination

Better yet, we can perform this procedure at the same time as ear tube placement as well as any other surgical procedures including tonsillectomy and adenoidectomy! If your child is going to be under anesthesia, what better time to place earrings as well!

If awake, we do offer EMLA numbing cream prior to piercing (which reduces the pain by about 50%) or freezing with an ice cube.

Read more here as well as to see what earring studs are available.

April 22, 2010

How Long Can You Survive Without Water or Food???

Well, according to a New Scientist article, with at least a supply of vitamins and water, you can survive over a year without eating. However, with vitamins but no water, survival time is sharply reduced.

"A human can be expected to survive for weeks without food, but a thirsty person deprived of water would last a matter of days. Without water, the volume of blood in your body drops, and with it your blood pressure. Blood becomes thicker and stickier, making it harder to pump around the body, so your heart rate increases to compensate. Even in a cool environment, you wouldn't last for more than a week without water."

Vitamins are necessary along with water as vitamins allow the body to metabolize fat storage. Otherwise, accumulated adipose tissue can't be utilized for energy.

Read the full article here.

Chronic Cough May Be Due to Obstructive Sleep Apnea!

A new study was published in the April 2010 journal Cough entitled "Chronic cough and obstructive sleep apnea in a community-based pulmonary practice."

Apparently 44% of patients with a chronic mysterious cough were found to have obstructive sleep apnea. In these patients, 93% had cough improvement when the obstructive sleep apnea was corrected!

Read the abstract here.

Of course, there are many other causes of chronic cough including reflux, asthma, allergies, etc. In rare cases, when all else comes back normal, the cough may be due to laryngeal sensory neuropathy.

April 21, 2010

How a Tracheostomy is Performed Step-by-Step with Pictures

Below is a step-by-step description with pictures of how a tracheostomy is performed. To read more about this procedure as what to expect with swallowing, eating, talking, etc, click here.

Step 1: Neck is sterilized with beta dine to clean the skin and draped to prevent any contamination from the environment.

Step 2: After the incision, underlying fat is removed.

Step 3: Dissection is carried down to the windpipe which is completely exposed in this picture. One can see the faint outlines of 2 1/2 tracheal rings.
Step 4: A small window is then created in the windpipe. In this picture, one can see the endotracheal tube inside the windpipe. This tube is slowly removed from the windpipe as the anesthesiologist pulls the tube out from the mouth.

Step 5: Once the endotracheal tube is removed, the windpipe and surrounding area is completely suctioned of all secretions and blood.
Step 6: The tracheostomy tube is then inserted and secured in place. That's it!

Step-by-Step Cartoons of Septoplasty Surgery to Correct Deviated Septum

Below is a step-by-step description with images of how septoplasty surgery is performed to correct a deviated septum. To read more about this surgery, click here.
Step 1:
A small incision is made inside the nose and the mucosal lining carefully lifted away from the septum on one side. It is during this stage of the procedure that one of the complications of the procedure, septal perforation, may occur. This complication occurs when the lining gets torn resulting in a hole as the mucosa is lifted away from the septum.
Step 2:
The septum is incised immediately in front of the deviation and the nasal mucosal lining is lifted away from the septum on the opposite side.
Step 3:
The deviated septum is now physically removed. One removes the deviated septum completely instead of forcing it into a midline position. Why? Because just like a young tree sapling, the nasal septum has "memory" and bending or forcing it into a certain position will last only temporarily before it springs back into its original position.
Step 4:
The nasal mucosal lining is reapproximated in the midline. There are several methods how this last step is performed. One method is to suture the lining back together like a quilt (NO nasal packing or septal splints are used). Occasionally, the nose is packed with septal splints or nasal packing material. Both methods are used in our practice depending on the physician and the condition of the septum itself.

To read more about deviated septum, click here.

If you are wondering how the nose is still supported after septoplasty, click here for more information.

April 20, 2010

Pollen Under the Microscope Appears Unearthly Beautiful Unlike the Misery They Cause!

Using an electron microscope he has in his basement (no kidding), Swiss photographer Martin Oeggerli obtained numerous pictures of pollen at the microscopic level. They are unbelievably beautiful to look at unlike the misery they cause at the macroscopic level.

The picture shown below is one of the pollens that cause hayfever...

To see more pics, click here.

To purchase these and other pollen images, go to this website.

Not Only Can House Dust Cause Allergies, They Harbor Bacteria That May Lead to Asthma

House dust already has a bad reputation for causing allergies and sino-nasal congestion misery. Now there's another reason to hate dust...

In the April 2010 issue of the journal Applied and Environmental Microbiology, researchers have found bacterial populations in household dust may determine whether or not a child living in that home develops asthma.

In the paper titled "Environmental Determinants of and Impact on Childhood Asthma by the Bacterial Community in Household Dust" researchers found "that the dominant bacterial populations in household dust are significantly influenced by environmental variables such as domestic animals and day care attendance. Further, the dominant bacterial populations are significantly correlated to asthma-related outcomes, supporting the hypothesis that the types of microorganisms present in homes in early life may play key roles in the development of childhood asthma."

Read the research abstract here.

April 18, 2010

Fauquier ENT Blog Included in the Webicina Collection for Otolaryngology!

I was pleased to learn that Fauquier ENT Blog (what you are reading now) has been included in the Otolaryngology section of Webicina, an aggregator of quality medical information, online courses and workshops.

Check it out here!

Doctor Sentenced to 5+ Months Jail For Using Non-FDA Approved Botox on Patients

A Houston physician, Dr. Gayle Rothenburg, was sentenced to 5½ months in federal prison on April 16, 2010 for injecting patients with a Botox product not approved by the Food and Drug Administration for human use. Read the full story here.

She did this in order to save money at the expense of patient safety.

Please note that in our office, we use ONLY the brand-name BOTOX made by Allergan Corporation. In fact, we purchase our BOTOX directly from Allergan Corporation and not through a third party supplier.

Always ask your doctor where they get their BOTOX from and make sure you are happy with their answer (buyer beware)!

Read more about this story here.

To see a full list of procedures we perform with BOTOX, click here.

April 17, 2010

New Webpage on Balloon Sinuplasty to Treat Chronic Sinusitis

A new webpage has been created describing the balloon sinuplasty technique to address chronic sinus infections.

Briefly, a balloon catheter (similar to angioplasty used to treat clogged heart arteries) is used to enlarge the openings into the sinus cavities without the need for any cutting or tissue removal.

Read more here.

April 16, 2010

What a 24 Hour Multichannel pH and Impedance Testing Looks Like

I often order a special test called "24 hour Multichannel pH and Impedance Testing" when working up patients with symptoms of chronic cough, globus, phlegmy throat, and/or throat clearing.

This test measures any non-acid and well as acid reflux along with muscle contractility of the esophagus continuously over a 24 hour period of time.

The catch is that a catheter needs to be placed through the nose and into the stomach AND left in place for 24 hours. Patients often ask what this looks like... so here's a picture!

April 14, 2010

New Video On Balloon Sinuplasty for Chronic Sinusitis Uploaded

A new video describing balloon sinuplasty has been uploaded on our YouTube channel. Balloon sinuplasty is a relatively new minimally invasive sinus surgery technique to open up diseased sinus cavities without removing mucosa or bone.

In essence, the technique involves threading a tiny guidewire to first identify the sinus opening and than acts as a guide for the balloon catheter. Once the balloon is positioned at the opening of the sinus cavity, it is inflated thereby enlarging the sinus cavity opening.

Watch this sinus surgery technique below or on our YouTube channel here.

Here is an animation of what exactly is going on:

April 13, 2010

New Webpage on Cryptolysis: A Minimally Invasive Procedure to Treat Tonsil Stones

A new webpage has been created describing tonsil cryptolysis, a minimally invasive procedure to treat tonsil stones otherwise known as tonsiloliths.

The procedure we offer is similar to laser cryptolysis, but without the risks of laser use. Such risks involved with using a laser include:

1) No risk of airway fire (if a spark occurs due to laser use, it can ignite the air)
2) No risk of blindness (laser can bounce off shiny surfaces like metal and reflect out and burn the retina)
3) No risk of oral and facial burns (lasers do not burn just the tonsil, it can burn anything that gets in the way... in other words, do NOT turn your head, sneeze, cough, or gag if the laser is turned on!!!)
4) No risk of inhaling the plume of vaporized tissue (which can cause airway burns as well as spread infection)

Read more about tonsil cryptolysis here.

Give us a call to make an appointment with us to see if you are a candidate for this procedure!

April 08, 2010

CNN: Obstructive Sleep Apnea Increases Risk of Stroke

CNN on April 8, 2010 aired a story on obstructive sleep apnea (OSA) and the risk it poses to men who do not address it. Apparently, according to a new study out of the March 2010 issue of the American Journal of Respiratory and Critical Care Medicine ("Obstructive Sleep Apnea Hypopnea and Incident Stroke: The Sleep Heart Health Study"), the risk of stroke increases by as much as 3X if left untreated in men with OSA. The risk of stroke increases even in men with MILD sleep apnea. The risk appears higher in men than women mainly because men seem to get it earlier and live with it longer than women.

Read the CNN story here.

Read the research study here.

Read more about OSA and its treatment here.

Mouth Breathing Can Cause Major Health Problems

Everyone knows somebody who mouth-breathes due to nasal obstruction... What many may not realize is that chronic mouth-breathing can lead to health problems whether in an adult or child.

Especially in children, over time, whose mouth breathing goes untreated may suffer from abnormal facial and dental development, such as long, narrow faces and mouths, gummy smiles, gingivitis and crooked teeth. The poor sleeping habits that result from mouth breathing can adversely affect growth and academic performance. Many of these children are misdiagnosed with attention deficit disorder (ADD) and hyperactivity. In addition, mouth breathing can cause poor oxygen concentration in the bloodstream, which can cause high blood pressure, heart problems, sleep apnea and other medical issues.

A 2015 paper also reported that mouth-breathing leads to acidification of the secretions within the mouth which may lead to dental erosions and cavities. Without mouth-breathing, the intra-oral pH was a neutral 7, but with mouth-breathing, the intra-oral pH dropped down to a 6.6.

What can cause nasal obstruction leading to mouth-breathing?

Turbinate Hypertrophy
Adenoid Hypertrophy
Nasal Polyps
Deviated Septum

Read more about nasal obstruction here.

Intraoral pH and temperature during sleep with and without mouth breathing. J Oral Rehabil. 2015 Dec 15. doi: 10.1111/joor.12372. [Epub ahead of print]

Mouth breathing: adverse effects on facial growth, health, academics, and behavior. General dentistry 58:1 pg 18-25; quiz 26-7, 79-80

April 07, 2010

April 16 is World Voice Day

The American Academy of Otolaryngology-Head & Neck Surgery has designated April 16 to be "World Voice Day."

First started in 2002, it is observed every year on April 16.

Click here for more info.

For extensive information on how the voice works in both health as well as in disease, click here.

Fox News Story on Spasmodic Dysphonia

A Florida Fox News network aired a story on spasmodic dysphonia on April 7, 2010. Click here and it will take you to where you can watch the entire video segment.

Spasmodic dysphonia is a neurologic condition where patients suffer involuntary voice spasms resulting in an intermittent strangled quality voice with voice breaks or cut-offs (listen to examples here). Spasmodic dysphonia is most often treated with Botox injections to the voicebox. Dr. Chang performs such injections every Friday afternoon.

For more info on spasmodic dysphonia, you can check out the National Spasmodic Dysphonia Association.

April 06, 2010

RANDOM: Giant Stuffed Toys of Cells, Microbes, Germs, & Viruses

I recently learned of a company that makes stuffed animals... except they are not OF animals, but rather they are human cells as well as germs like staph, H1N1 virus, Lyme Disease, Strep, etc.

Though the diseases they cause are not fun, these stuffed microbes are cute and friendly.

Here are a few of my favorites. For a complete list of toys like these, click here

Here is Lyme Disease:

Here is a nerve cell:

And finally, here is Epstein Barr Virus (otherwise known as mono or kissing disease):

Office Air Conditioner Broken!!!

Our office air conditioner has been broken the last few days. As such, it is quite uncomfortably hot in the office. We have been working with maintenance to get this fixed ASAP. However, it may be a few days before it gets back in working order. Apparently, parts have been ordered.

Please be patient with us and know that WE are just as uncomfortably hot and miserable as you are!

In the interim, we have fans going throughout the office until the AC works again.

Story on Botox in the Washington Post

On April 6, 2010, the Washington Post reviewed a report by Consumer Reports on the use of Botox for a variety of ailments. In the story titled "Consumer Reports examines Botox as a remedy for headaches, back pain, tremors" is largely accurate, though there are some errors in the story.

In particular, Botox HAS been found to be effective for migraines contrary to what is stated in the story. A variety of research has supported this particular indication:

• Botulinum toxin type A (BOTOX) for treatment of migraine headaches: An open-label study. Otolaryngology—Head & Neck Surgery. 123(6):669-676, 2000. Link
• Treatment of migraine headache with botulinum toxin type A. Facial Plast Surg Clin N Am. 11(4):465-475, 2003. Link
• Procedures for administering botulinum toxin type A for migraine and tension-type headache. Headache. 43(8):884-891. Link
• Exploding vs. imploding headache in migraine prophylaxis with Botulinum Toxin A. Pain. 125(3):286-295. Link

In any case, our office does perform botox for headaches, TMJ, voice spasms, torticollis, and drooling. Of course, we also perform for facial wrinkles.

Read the full WP story here.

WP: Washington DC Has One of the Highest Pollen Counts in the Nation

The Washington Post on April 6, 2010 published a story entitled "Tree pollen kicks off Washington's allergy season." The story goes through explaining that though Washington DC is ranked 43rd out of 100 most challenging places to live with allergies (see ranking here), Washington DC often has one of the highest pollen counts in the nation on any given day during the spring season!

In fact, according to a study in last month's Annals of Allergy, Asthma and Immunology that tracked pollen counts in this area between 1998 and 2007, tree pollen amounted to 91.2 percent of the total annual pollen yield in the nation here.

What I typically suggest patients to do in such challenging allergy conditions is to try combo therapy... usually zyrtec in the morning and benadryl at bedtime. If necessary, add a 12 hour sudafed in the morning if the nose is runny. If these do not help, see your local doctor for consideration of adding a steroid nasal spray.

If worst comes to worst, getting tested for allergies and getting started on allergy shots or allergy drops would be most beneficial and offer the best chance of "cure."

Good luck with allergies!

Read the full WP article here.

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