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May 31, 2010

Smoking is Highly Addictive in Kids (Teens and Babies) [video]

All it takes is one cigarette a month.

A recent study in Pediatrics that tracked the course of addiction to smoking among a group of sixth-graders found that smoking only one cigarette a month was all it took to become dependent.

In the study titled "Early Course of Nicotine Dependence in Adolescent Smokers," the researchers found that one cigarette a month or one cigarette a week was enough to keep addiction satisfied, but as time goes by, the child has to smoke cigarettes more and more frequently. So people may be addicted for more than a year before they feel the need to smoke a cigarette every day.

Read a NPR story on this research here.

Apparently, this may be true not only for tweens, but even infants... Here is a YouTube video of a 2 year old baby who has become addicted and is now a chain-smoker.

May 26, 2010

A New Method of Allergy Testing (Multi-Array Chip Technology)

A MIT researcher has developed a new and possibly more accurate blood test for allergies using multi-array chip technology. The paper is titled "Multidimensional analysis of the frequencies and rates of cytokine secretion from single cells by quantitative microengraving" and is published in the journal Lab on a Chip.

This chip technology uses a microscopic engraving process to create thousands to millions of tiny wells (or multi-array) on a chip where a different "blood test" can occur in each well. An overly simplified explanation of how testing occurs is as follows:

Inside each well, the chip manufacturer can place a different type of food or pollen protein such as milk or cat dander. A blood sample placed into the well will than allow allergic cells to "react" with the protein. If the cell (and therefore the person) is sensitized to the protein, the cell will release chemicals called cytokines that can be measured.

Given there are thousands to millions of wells, all of them microscopic in size, only a small amount of blood can be used to test for a whole array of food and pollen allergies.

Read the actual research here.

Unfortunately, our office does not utilize this innovative technology... yet... to test people for allergies. We use RAST. Using the results obtained, we are able to provide allergy shots or allergy drops.

Botox - A National Security Threat???

Botox which is commonly used for cosmetic and medical reasons can also pose a national security threat according to a story in the June 2010 Scientific American.

Before this claim can be dismissed out-of-hand, consider that consumer demand for botox is fueling a proliferation of illegal botox distributors. Botox, which is botulinum toxin made by a bacteria in food gone bad, is actually a lethal poison which could potentially be used as a potent biological weapon in large enough quantities. Illegal botox distributors in their quest to make more money can sell botox to terrorists (or be terrorists themselves selling to make money to fund its use as a weapon).

Read more about the story here. Read a LA Times article here.

On a lighter note, Dr. Chang performs botox injections for both cosmetic and medical purposes including facial wrinkles, torticollis, spasmodic dysphonia, etc. See the complete list here. We purchase our botox directly from Allergan, the manufacturer of botox.

May 25, 2010

Is Cancer Contagious? Well... it depends...

The literal answer to this question is YES... Cancer CAN be literally contagious, but only if you are a tasmanian devil, hamster, or a dog. I am excluding transmission of a vector that may lead to cancer like HPV. Rather cancer itself being contagious.

Fortunately, cancer has NOT been found to be contagious in humans... yet...

At this time, the only cancers I am aware of that is contagious are found in the animal world. And even in that world, there are only 4.

1) Devil facial tumour disease (DFTD) which causes a contagious cancer of the face in Tasmanian Devils ultimately resulting in death. The cancer originates in the Schwann cells and is suspected to spread when bits of cancer comes into contact with an open wound via biting (which Tasmanian Devils do a lot of to each other).

2) Canine transmissible venereal tumour (CTVT) is passed between dogs via sexual activity and has been known to science for about 100 years.

3) Contagious reticulum cell sarcoma of the Syrian hamster which can be transmitted from one Syrian hamster to another by means of the bite of the mosquito Aedes aegypti.

4) Clam leukemia affecting marine bivalves.

SO... the answer to whether cancer is contagious is YES!!! But not (so far) in humans.

Read more about how cancer may become contagious in this Harper's Magazine article published in 2008 as well as this New York Times article in 2016.

Dr. Chang Receives Patients' Choice Award for 2009

For the year 2009, Dr. Christopher Chang was given a Patients' Choice Award. Apparently, only a handful of physicians receive this honor (less than 3% out of 720,000 active physicians). This honor is determined based on ratings provided by actual patient ratings.

Read more about Dr. Chang here.

May 23, 2010

Genetic Cause for Stuttering?

It appears that at least in some individuals, their stuttering may be caused by a genetic mutation, specifically a missense mutation in the N-acetylglucosamine-1-phosphate transferase gene (GNPTAB), which encodes the alpha and beta catalytic subunits of GlcNAc-phosphotransferase protein (part of the lysosomal enzyme–targeting pathway).

Other genetic mutations causing stuttering was found in the GNPTAB, GNPTG, and NAGPA genes. These genes encode enzymes that generate the mannose-6-phosphate signal, which directs a diverse group of hydrolases to the lysosome

This research was published in the February 2010 volume of New England Journal of Medicine.

Read the research here.

Vaginal Premarin Cream for Recurrent Nosebleeds?

It is an old trick of the trade where a physician may prescribe vaginal premarin cream to treat recurrent nosebleeds.

The premarin (estrogen) cream (just as it does when placed vaginally) causes the nasal mucosa lining to thicken thereby "burying" the superficial blood vessels that are often the culprits for recurrent nosebleeds. Application is by rubbing the cream 2-3X per day to the anterior wall of the nasal septum (Kiesselbach's plexus) where 90% of nosebleed sources are located.

Understandably, males may be reluctant to be prescribed this medication due to the small (but temporary) risk of breast enlargement given the very small amount that can be systemically absorbed (based on vaginal studies, less than 20 pg/ml).

Furthermore, given there are other good options for treating nosebleeds including nasal emollients, cauterization, and packing, this option is mainly for females who are scared to death of nasal cauterization/packing when other more conservative treatment fails.

The vast majority of research on use of premarin cream for recurrent nosebleeds is actually for treating individuals suffering from Hereditary Haemorrhagic Telangiectasia (HHT), also known as Osler-Weber-Rendu Syndrome.

Use of estrogen in the treatment of familial hemorrhagic telangiectasia. Laryngoscope. 1982 Mar;92(3):314-20.

Local oestrogen for recurrent epistaxis caused by familial telangiectasia. J R Coll Gen Pract. 1988 May;38(310):227.

Hormonal management of hereditary hemorrhagic telangiectasia. JAMA 1952; 149:1376-1380.

Intranasal topical estrogen in the management of epistaxis in hereditary hemorrhagic telangiectasia. Acta Otolaryngol. 2016;136(5):528-31. doi: 10.3109/00016489.2015.1129070. Epub 2016 Jan 25.

May 22, 2010

New Simple Blood Test In Newborns Can Predict Allergy Risk!

Researchers in Australia have discovered a certain protein extracted from umbilical cord blood can predict the allergy risk a given newborn has in the future. The research titled "Protein kinase Czeta: a novel protective neonatal T-cell marker that can be upregulated by allergy prevention strategies" was published in 2007 in the Journal of Allergy & Clinical Immunology. The protein called "Neonatal T-cell Protein Kinase C zeta" (PKCzeta) was lower in children who had evidence of allergic disease at 1 year (P = .001) and 2.5 years (P = .052) of age. They also determined that fish oil supplementation (4g per day in pregnant females) was associated with significantly higher PKCzeta expression (P = .014), whereas most other isozymes were reduced by fish oil supplementation.

What does this all mean? It suggests that pregnant females who ingest fish oil reduces the risk of allergy development in their unborn child.

At this time, as far as I know, the only place (outside research labs) that is able to test for this protein marker is in Australia. But perhaps it soon will become available in the US?

For now, US residents have only the skin prick or blood test RAST/immunoCAP to determine allergies.

Our office offers allergy testing by blood draw (RAST) as well as treatment with allergy shots and allergy drops.

The research abstract can be read here.

A media report can be read here.

May 21, 2010

Dr. Chang to be Featured in TV Medical News Program on CBS

On May 21, 2010, a video crew came to our office to film a segment on Dr. Chang and what he does (or rather a very small part of what he does) as an otolaryngology-head and neck surgeon.

Dr. Chang along with 9 other practices will be featured in a medical news television show "American Health Front" that will air on June 5, 2010 at 7PM on Channel 9 (WUSA-TV CBS).

The main focus of what Dr. Chang talked about are the different causes of nasal obstruction and their treatment including:

Septal Deviation
Turbinate Hypertrophy
Adenoid Hypertrophy
Nasal Polyps

May 20, 2010

Botox for Chronic Cough

There have been a few reports that discuss the use of botox to achieve significant improvement, if not cure, in adult patients with a chronic cough due to sensory neuropathy. In one report, researchers presented 4 case studies in which cough relief occurred after a median of 7 injections with a mean dose of 4.0 Units per treatment session for a mean duration of 25.7 months. In another report, Mayo researchers performed botox injection in 22 patients among which 50% reported improvement in the cough by at least 50%.

To watch a video of how the botox is injected into the voicebox to treat chronic cough, click here or watch below (the procedure is the same as that performed for spasmodic dysphonia).

Of note, the first to report on use of botox for chronic cough was published in 2007 in ENT Journal and was performed on kids. Click here to read that report.

I tend to use botox as a last resort when other medical management strategies have failed. Hidden triggers of cough including reflux, allergies, and asthma need to be addressed prior to consideration of botox. Often, I'll give a trial of neuropathic medications if laryngeal sensory neuropathy is suspected.

To read more about chronic cough, click here.

Botox is performed by Dr. Chang every Friday afternoon for spasmodic dysphonia, laryngospasm, as well as chronic cough! We also use botox for migraines, facial wrinkles, and torticollis.

Botulinum toxin A: a novel adjunct treatment for debilitating habit cough in children. Ear Nose Throat J. 2007 Sep;86(9):570-2.

Use of botulinum toxin type A for chronic cough: a neuropathic model. Arch Otolaryngol Head Neck Surg. 2010 May;136(5):447-52. doi: 10.1001/archoto.2010.59.

Bilateral Thyroarytenoid Botulinum Toxin Type A Injection for the Treatment of Refractory Chronic Cough. JAMA Otolaryngology - Head & Neck Surgery 2016 Jun 30;PMID: 27367917

May 19, 2010

Can Earwax Be Made Into a Usable Candle?

Can you make a candle out of ear wax? Well according to a scene in the movie Shrek, it sure can. However, in reality, earwax can not produce a candle that's any good.

This "myth" was attempted to be reproduced by the friendly gang of Mythbusters (a serial show on Discovery Channel), episode 136 (air date: Dec 28, 2009).

Earwax was collected from Tory’s ears and ignited alongside paraffin and beeswax which are two common materials used for candles. The earwax burned with some sparking and sputtering. More earwax was collected from other members of the cast/crew as well as volunteers without much more improvement. In the end, they attributed this poor result to the fact that the earwax material did not melt as smoothly as the paraffin.

What Mythbusters may not have realized is that not all earwax are physically the same. Earwax comes in a multitude of different consistencies as well as moisture content. A better test would be to create an earwax candle trying out these different earwax types to see if it makes any difference.

Other interesting facts:

- I have a few patients who like to take the earwax I remove from their ear to feed their cat. Apparently, cats like to eat earwax!
- There are quite a number of patients who come every 3-6 months to get their earwax removed by me.
- Earwax have different odors. I do not make it a practice to smell them, but sometimes it can't be helped given I'm so close to the ear when removing it.

May 17, 2010

Lemierre's Syndrome on CT Scan

Lemierre's Syndrome is a constellation of signs involving the bacteria Fusobacterium necrophorum. The syndrome usually begins with tonsillitis that progresses to an infected clot in the adjacent jugular vein. Bits of the infected clot break off and spread throughout the body spreading the infection. If it gets bad enough, sepsis may occur.

Here is a CT scan showing the key sign of a clotted off jugular vein indicating Lemierre's syndrome (red arrow). A normal appearing jugular vein is indicated by the blue arrow.

May 16, 2010

Bad Breath Found to be Related to Types of Bacteria Rather Than Bacterial Amount

Researchers in Japan investigated whether bad breath was caused by the types of bacteria found in people's mouths as opposed to the overall amount of bacteria. In their research which was published in the May 2010 journal of Applied and Environmental Microbiology they found that there exists four types of bacterial community compositions. The two parameters for bad breath (the concentration of volatile sulfur compounds in mouth air and the organoleptic score) was noticeably lower in one of the groups. In this group that had very low bad breath, there were significantly higher concentrations of Streptococcus, Granulicatella, Rothia, and Treponema than in the other groups.

These results clearly correlated the global composition of indigenous bacterial populations with the severity of oral malodor. Call this the "good" bacteria.

There results also suggest alternative strategies to improve bad breath by trying to modify the bacterial composition rather than pursuing treatments geared towards elimination (or decreasing overall amount) of bacteria which do not work.

Of note, there was another (earlier) study that found that eating yogurt improved bad breath which goes along with this idea of altering bacterial composition instead of eliminating it to improve bad breath.

Of course, all this assumes a person does not have cryptic fetid tonsillitis for which tonsillectomy or cryptolysis would be of greater benefit.

Read the research here.

WP: Anatomy of Tinnitus

I recently came across this interesting webpage published by the Washington Post describing the biological pathways that results in tinnitus or ringing of the ears, complete with pictures.

It also describes how we "hear" which is actually not with our ears, but with our brains.

Tinnitus is becoming a much more common problem with loud noise exposure whether via military service in the Gulf from all the gunfire and explosions or listening to personal music players (iPod) too loudly.

Click here to read more about it.

WP: Anatomy of a Sneeze/Cough

I recently came across this interesting webpage published by the Washington Post describing the biological pathways that results in a sneeze or cough, complete with pictures.

Click here to read more about it.

May 14, 2010

Hidden Costs of Allergy Shots

Many people know what allergy shots are and do. What many may not realize are the hidden costs associated with them and it behooves a patient interested in getting them to know what they are getting into, not just in terms of medical, but also financial.

For those who don't know... Allergy shots are typically 1-2 injections administered to the upper arm once a week for a period of years… potentially as long as 5-10 years. These shots are given in an attempt to “cure” a person of their allergies such that after the shots are completed, there will be no more allergies OR the allergies have improved to the point that medications work quite well and taken only when needed. These shots MUST be administered in a medical office.

And as such, that's where the hidden costs behind the allergy shots begin. First, there are the copays involved with EACH allergy shot administered in the office as well as making of the allergy vials themselves. Given you have to be in a medical office to get them, there is also the time, travel, gas, and missed time from work to also take into consideration. At least in our office, we require all patients to have an up-do-date epipen at all times, so there's the prescription cost of this as well.

Ways to minimize or at the very least, anticipate the potential costs involved are as follows:

- Once you get established with the shots (in our office, typically 4 injections), you can get the shots administered in a medical office closer to your place of residence or work (thereby saving time, gas, and travel).
- Ask if it's possible to get the shots at home once you reach maintenance.
- See if you are a candidate for allergy drops (SLIT) which is NOT covered by insurance, but is a fixed cost AND they do not need to be administered in a medical office, but rather the comfort of your home/work.

Regarding possible copays, please check with your insurance company regarding amount of copays involved with allergy shots such that there won’t be any surprises with any bills you may receive due to this treatment.

The CPT codes to inquire with your insurance regarding potential copay amounts are:

95165 (Allergy Vial)
95115 (1 shot)
95117 (2+ shots)

Typically, the copays are much smaller than what you pay for a physician office visit, but rarely is it free.

For more information on allergy shots and testing, click here.

For more information on allergy drops, click here.

RANDOM: Media Confuses PA Students with Med Students in Medical Error

So I read this disturbing news report on MSNBC titled "Needle error puts 50 people at risk in N.M." where "MED" students improperly pricked multiple patients while testing blood sugar during a health fair.

Later in the article, the story stated "Students from UNM's physician assistant program conducted the free blood sugar tests during the cultural center's American Indian Week Pueblo Days."

I should hope that a reputable news media outlet like MSNBC understands that a med student and a PA student are NOT the same thing.

A PA student is a student learning to become a physician assistant and does not obtain a MD degree at the end.

Read the full story here.

May 12, 2010

TV Show "Glee" Character Rachel Has Laryngitis? Tonsillitis?

On May 11, 2010, Glee aired its eighteenth episode titled "Laryngitis". In this episode, Rachel suffered from a lost voice which was attributed to tonsillitis or is it laryngitis.

It was a bit confusing as it would seem her lost voice was attributable to laryngitis (title of the episode), but than she was diagnosed with tonsillitis by the TV doctor which really has nothing to do with laryngitis. I guess it is possible that she had TWO conditions going on at the same time even though she did not mention a sore throat at any time.

I can say for certain that the TV doctor was not portraying an otolaryngologist mainly because he was wearing a stethescope around his neck (our profession does not carry a stethescope on our person).

In any case, I doubt Rachel had tonsillitis. The main complaint with tonsillitis is a sore throat and not a lost voice. As such, she probably had a mild case of laryngitis which in most cases, only time, voice rest, and hydration should have been adequate. Antibiotics do not play a role in most cases of laryngitis which are virally induced.

May 10, 2010

LECTURE: Dr. Chang Guest Lecturer on Spasmodic Dysphonia INOVA Fair Oaks

Dr. Chang will be a guest lecturer for the Northern Virginia Spasmodic Dysphonia Support Group. The lecture will be held on October 20, 2010 from 7-9PM at INOVA Fair Oaks Campus, Medical Plaza Building, Conference Room A. The lecture topic is on Spasmodic Dysphonia, a laryngeal dystonia that results in altered vocal quality due to involuntary muscular spasms of the voicebox.

The support group leader is Paula Cooper (Email:

Dr. Chang provides botox injections for spasmodic dysphonia every Friday afternoon.

May 09, 2010

Storybooks to Help Prepare a Child for Surgery

Children love stories and as it so happens, there are a few books to help prepare a child for surgery so that hopefully everything won't be as strange or scary. All these books can be purchased from The first group is for tonsillectomy and/or adenoidectomy. The last group is for ear tubes placement.

May 05, 2010

New Video on Tonsil Cryptolysis to Address Tonsil Stones

A new video has been uploaded describing a minimally invasive technique to address tonsil stones called tonsil cryptolysis.

This technique accomplishes the same thing as laser cryptolysis but at lower cost and increased safety. Just like laser cryptolysis, this procedure can be done awake without any sedation using only local anesthesia (the caveat being that the patient must have minimal/no gag reflex with easy visualization of the tonsils).

Watch the video below or on YouTube. Read more about this procedure here.

May 01, 2010

Home Remedies Preferred Over Drugs for Kids' Coughs and Colds

In the May 2010 volume of Otolaryngology-Head & Neck Surgery, researchers at Johns Hopkins published an article entitled "Over-the-counter cough and cold medications in children: Are they helpful?"

The blunt answer is that they do not!

At least before the age of 2 years, one should stick to "home remedies" to address a young child's cough and cold. Such home remedies include humidity, saline spray, and bulb suctioning of the nose. When they are a bit older and coordinated, saline gargles can be added to the regimen.

Read the abstract here.

Read a LA Times article on this here.

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