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June 30, 2010

New Drug Restores Hearing After Noise-Induced Hearing Loss

Researchers in New Zealand published a research paper where they describe significant restoration of hearing after hearing loss sustained after loud noise exposure with injection of a drug called 'ADAC'... at least in rats.

The drug (adenosine amine congener) activates adenosine receptors in cochlear tissues resulting in recovery of cochlear function. Early treatment starting six hours after noise exposure was the most effective and provided greater recovery than late treatment starting 24 hours after noise exposure.

This drug may potentially lead to new drugs to help humans with hearing loss sustained after loud-noise exposure.

Read the abstract of the research paper here.

Srdjan M. Vlajkovic, Kyu-Hyun Lee, Ann Chi Yan Wong, Cindy X. Guo, Rita Gupta, Gary D. Housley, Peter R. Thorne. Adenosine amine congener mitigates noise-induced cochlear injury. Purinergic Signalling, 2010; DOI: 10.1007/s11302-010-9188-5

June 27, 2010

RANDOM: A Human Life-Cycle Video in 90 Seconds

Title says it all... Wish more commercials strike a more human chord like this one did with me. NPR Radiolab did something similar with an "audio" life-cycle of a baby babbling to a young woman talking in about 90 seconds as well, though for the life of me, I can't remember which episode did that.

Video: Chopstick Enters Nose and Pierces Brain in Child

A reader recently emailed me this amazing AP video of a 14-month-old toddler who was playing in the kitchen when he fell, sending a chopstick up thru his nose and into his brain. Surgeons were able to remove the chopstick and the child did just fine.

However, it is quite likely this child has now permanently lost his sense of smell (anosmia) since the smell nerve is located where the chopstick entered the brain (cribiform plate). There is no way to "fix" nerve damage in this area after it has occurred (at this time).

Such trauma like this is unfortunately not uncommon, though not with such precise nasal entrance into the brain. More commonly, I've seen mouth and oral injury rather than nasal (fork or chopstick in the mouth while a child is playing).

June 26, 2010

Laryngeal Sensory Neuropathy (LSN) Chronic Cough Treatment Failure

Laryngeal sensory neuropathy (LSN) is a recently described condition felt to cause a chronic cough in patients when treatment for everything else (allergies, asthma, reflux, etc) has been evaluated and managed. Treatment for this condition is with neuropathic medications including neurontin, elavil, lyrica, nortriptyline, etc.

In the past few months, I have seen a few patients referred to me with chronic cough treated with these medications with minimal or no improvement. OR... the cough initially improved with such medications, but than over time, stopped working.

All these patients reportedly had a full workup with everything being normal and as such, was diagnosed with LSN. These patients were being solely treated with neuropathic medications and nothing else.

On review of their old records, it became apparent to me that these unfortunate patients actually suffered from MULTIPLE causes of cough that were not being treated. A common condition missed or not treated in these patients was non-acid reflux which can only be diagnosed on 24 hour multichannel impedance testing or indirectly on PepTest. Another more common scenario was the presence of mild acid reflux and allergies based on minimal reactivity on allergy testing and reflux that was present, but within normal range on 24 hour testing. Medications for allergies and reflux were tried, but didn't help and so was stopped. (Of note, none of the patients (prior to cough) ever had symptoms of reflux or allergies.)

WRONG!!! Treatment for both should have continued and very aggressively. Why?

Patients need to keep in mind that it is not unusual that a patient may have SEVERAL factors of cough as well, ALL of which need to be treated in order to resolve a persistent cough. Because laryngeal sensory neuropathy results in a hypersensitized larynx, problems with reflux and allergies which ordinarily would not cause a cough (or any other symptoms) in normal patients, will now cause a persistent cough. (This situation is even applicable in patients who have NEVER had any symptoms of allergies and reflux in the past.) In other words, though allergy testing may reveal only mild allergies and 24 hour pH study may show reflux episodes within normal range, these "mild" problems now need to be treated aggressively along with the neuropathy. To reiterate... laryngeal sensory neuropathy is a hypersensitized larynx. In this hypersensitized state, even a little bit of reflux or allergies will trigger a cough which normally would not. Each and every one of these conditions need to be treated aggressively to cure a persistent chronic cough.

The lack of treatment for each and every known cause of cough (even if mild) is the most common reason why treatment of laryngeal sensory neuropathy fails with neuropathic medication.

Case Report #1:

To illustrate, here is one case I saw a few months back...

Middle-aged patient who has had a chronic cough for about 15 years. Had a full workup done and found to have mild allergies to only alternaria mold (class 1) and dust (class 2). He did not respond to allergy medications and so these meds were stopped. Reflux workup did show significant reflux and so underwent nissen fundoplication which did help the cough by about 30%. His doctor than diagnosed him with LSN and tried him on a variety of neuropathic medication with some, but incomplete improvement. I was than asked to help figure things out.

The first thing I did was to instruct the patient to continue with the neuropathic medication that seemed to work the best for him (elavil 50mg twice a day). I also started the patient on allergy shots as well as an antihistamine and steroid nasal spray. I repeated a 24 hour pH and impedance testing to see if there was STILL reflux going on in spite of the reflux surgery. Lo and behold, there WAS both acid and non-acid reflux occurring, but on the high end of normal (much better than before his surgery). Based on this result, I restarted him on reflux medications daily.

Within 3 months, his cough completely resolved. I slowly tapered the elavil off. Once we both were convinced that his LSN was cured, the daily reflux medication was stopped and used only as needed. Allergy shots could have been stopped as well, but patient elected to continue them, but he no longer needed the daily allergy medications.

SO... what happened?

This patient apparently had allergies, reflux, and laryngeal sensory neuropathy causing his cough. Given he was being treated for only LSN prior to seeing me, that was why he had incomplete improvement of his cough.

I aggressively treated for all 3 factors of his cough. The mild allergies and reflux were brought under tight control preventing them from constantly (even if mildly) irritating his hypersensitized voicebox. Once his voicebox was in an "clean" environment, it was able to heal and desensitize with elavil. Once the voicebox was returned to a normal state, the reflux and allergy was now able to be treated like any other normal person.

The key thing to remember is that patients with LSN belong to a totally different sub-population of patients with a cough. One can NOT treat them as if they are part of the normal population. "Normal ranges" of reflux and allergies do not apply which actually makes sense if one realizes the voicebox in patients with LSN is hypersensitized.

Case Report #2:

In another similar case, the patient did respond completely to gabapentin with 100% resolution of a chronic cough that was going on for 10+ years. However, after 6 months of being on this medication, the chronic cough slowly started to come back. In this situation, it was ultimately found that he had reflux that was untreated and was responsible for causing persistent nerve irritation exacerbating the neuropathy. The neuropathy was successfully treated with gabapentin, but because of the reflux, the effectiveness of this drug eventually wore off.

Successful treatment of this patient's chronic cough required complete control of the reflux first followed by neuropathy medications.

What if EVERYTHING truly did come back normal?

There are a few things I've done in this situation where there's absolutely no evidence for any abnormalities on any testing, mild or otherwise.

• Botox injections to the thyroarytenoid muscle of the voicebox (similarly for spasmodic dysphonia treatment).
• Starting combo therapy using two different neuropathic medications, each of which seemed to help singly.
Capsaicin throat spray which appears to desensitize the hypersensitized nerve.
• Trial knocking out the superior laryngeal nerve documented to be abnormal on SELSAP with a local 0.025% marcaine injection. If there's a good response with minimal side effects, consider surgically cutting this nerve.

To read more about chronic cough due to LSN, click here.

  • Management of Recurrent Laryngeal Sensory Neuropathic Symptoms. Norris BK, Schweinfurth JM. Ann Otol Rhinol Laryngol. 2010; 119:188-191. Link
  • Chronic cough as a sign of laryngeal sensory neuropathy: diagnosis and treatment. Lee B, Woo P. Ann Otol Rhinol Laryngol. 2005 Apr;114(4):253-7. Link
  • Gabapentin in the Treatment of Intractable Idiopathic Chronic Cough. Mintz S, Lee JK. Am J Med. 2006; 119(5):e13-15. Link
  • Laryngeal Neuropathy as a Cause of Chronic Intractable Cough. Mishriki YY. Am J Med. 2006; 119(5):e5. Link
  • Sensory neuropathic cough: a common and treatable cause of chronic cough. Bastian RW, Vaidya AM, Delsupehe KG. Otolaryngol Head Neck Surg. 2006 Jul;135(1):17-21. Link
  • Effectiveness of amitriptyline versus cough suppressants in the treatment of chronic cough resulting from postviral vagal neuropathy. 2006. Jeyakumar A, Brickman TM, Haben M. Laryngoscope 116(12):2108-2112. Link
  • The irritable larynx syndrome. Morrison M, Rammage L, Emami AJ. Journal of Voice. 1999;13:447-55. Link
  • Vagal neuropathy after upper respiratory infection: a viral etiology? Amin MR, Kaufman JA. American Journal of Otolaryngology, 2001;22(4):251-256. Link
  • Cough and paradoxical vocal fold motion. Altman KW, Simpson CB, Amin MR. Otolaryngology-Head & Neck Surgery. 2002;127(6):501-11. Link
  • Botulinum Toxin A: A novel adjunct treatment for debilitating habit cough in children. Sipp JA, Haver KE, Masek BJ, Hartnick CJ. ENT Journal 2007;86(9):570-572. Link
  • Use of botulinum toxin type A for chronic cough: a neuropathic model. Archives of Otolaryngology-Head & Neck Surgery. 2010;136(5):447-452. Link
  • A new treatment option for laryngeal sensory neuropathy. Halum SL, Sycamore DL, McRae BR. Laryngoscope. 2009. Link
  • Postviral vagal neuropathy. Rees CJ, Henderson AH, Belafsky PC. Annals Otol Laryngol Rhinol. 118(4):247-52, 2009. Link

June 22, 2010

Coffee Decreases Risk of Head & Neck Cancer

Researchers at University of Utah found that regular coffee drinkers who drank more than four cups of coffee a day had a 39 percent decreased risk of two types of head and neck cancer: oral cavity and pharynx cancers. In the study published in the journal of Cancer Epidemiology, Biomarkers & Prevention, they found however, that coffee did not decrease the risk of laryngeal cancer. Coffee contains over 1,000 different chemical compounds, including cancer-fighting antioxidants, and it’s those antioxidants that may provide a “plausible explanation” for reducing the cancer risk.

However, patients should not take this study as an excuse to increase their coffee intake specifically to counteract known cancer-causing behaviors including smoking, drinking alcohol, and chewing tobacco.

Read a CNN report on this here.

Coffee and Tea Intake and Risk of Head and Neck Cancer: Pooled Analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiol Biomarkers Prev, June 22, 2010; 1055-9965.

One-Size-Fits-All Injection that Can Cure Allergies!

Cytos Biotechnology has recently completed patient trials that suggests that a one-size-fits-all allergy injection can alleviate and potentially cure allergies, asthma, eczema and other allergy conditions including even food allergies!

This innovative medical treatment is known only as CYT003-QbG10. It is composed of pieces of synthetic DNA similar to those found in the bug that causes tuberculosis. The DNA fools the body into thinking it is under attack from a dangerous bug, kick-starting a multi-pronged immune response. The ability of a single formula to protect against more than one allergy suggests the jab is reprogramming the immune system by tackling the root cause of allergies.

Current allergy shots (as well as allergy drops) work by injecting the actual proteins that cause allergy in small doses that are slowly increased. For example, if you are allergic to cat, than actual cat protein is injected into you in slowly increasing amounts over time.

With CYT003-QbG10, there would be no need for allergy testing and in essence, if truly successful, patients can be cured of allergies with this type of vaccination, just like the childhood vaccines have near-eradicated polio, mumps, measles, etc. It is not clear how often the new vaccine would have to be given. But scientists envisage an initial short course of jabs, followed up by a booster session two or three years later.

Large scale human trials are supposed to begin in 2011.

Read more in this media report here.

June 19, 2010

The Perfect Computer for Healthcare and Electronic Medical Records

So I've been using computers in the healthcare setting for over a decade now. First at Yale than Duke. I've been thru the Veteran's Affairs Medical Center using Vista (New Haven, CT; Durham, NC; Asheville, NC; and Portland, OR). I've been at 5 different community hospitals on both the West and East Coasts. I've used all the different flavors of electronic medical records (EMR) in all these different locations/settings. I'm now using (not by choice) NextGen, Meditech, Rcopia, and PACS currently in the office, hospital operating suites, and inpatient settings.

Throughout this time period, I've used desktop computers, handhelds, laptops, netbooks, and tablet computers. I've even tried to cobble together a semi-functional iPad able to access all the different EMRs I need on a daily basis (read blog about this here).

What I discovered is that the perfect system (in my mind) is ALMOST there... just not quite yet. Maybe in the next few years, it will exist because all the pieces now exist! The bad news is that it does not exist RIGHT now.

So, here's my dream machine and the reasons. I hope some computer company is paying attention!

To understand how this all fits together, one needs to envision how my office works right now. There's a desktop computer in each exam room. Patients are taken back by a nurse and information inputted into the desktop computer. Than the computer is locked and the nurse leaves. The physician than soon follows, unlocks the computer, and then proceeds with further history, exam, and plans treatment which all gets documented in the computer. If tests are ordered (ie, hearing test, blood draw), the doctor leaves and sees another patient while the tests gets done before coming back. As such, the computer stays in the room with the patient. One can envision that there is a lot of back and forth into and out of an exam room movement of nurse, doctor, and patient. The computer gets locked every single time. Furthermore, I need EMR access when seeing patients in the hospital as well as during surgery.

First the Hardware:
• A tablet touchscreen (with no physical keyboard) 12 inches diagonal. That size hits the sweet spot. Any larger and the size itself becomes unwieldy to constantly move around as well as heavy by the end of a day. Any smaller and the screen real estate becomes so small to become inefficient. 12 inches diagonal also allows the possibility of an actual full-size virtual keyboard on the screen with adequate screen left-over to see what's going on.

My experiences with the iPad virtual keyboard was mixed (given it is somewhat smaller than full-size). I CAN do it and I did do it... I just didn't like it to the point I relied on a wireless bluetooth keyboard.

• Bluetooth technology and WiFi are a MUST because...

• With this tablet computer, one can dock it without wires or connector pins (similar in concept to Motion Computing JR3400 with its FlexDock). The docking station allows for use of regular USB keyboards and mouse along with direct ethernet wired connectivity. My dream machine docking station and tablet would communicate with each other using bluetooth or some other alternative short-range wireless technology which makes direct physical connection unnecessary. This is important, because I would have the docking station in each exam room. When I leave the exam room, I would have the option of taking the tablet (and therefore the screen) with me. The constant connecting and disconnecting of current docks is quite the pain given it requires an actual physical connecting port as well as precise placement. With the constant connecting and disconnecting, it opens the possibility for breaking as well.

What would be even cooler would be if the tablet charges when in its docking station using inductive charging similar to how a Philips Sonicare Toothbrush recharges.

Why do I even want a docking station? Several-fold. Ergonomics... I like the screen at my eye level. Also, I can still see the patient while typing away. If I depended on the virtual keyboard like on the iPad, I'm looking down which is not patient-friendly as well as a pain in the neck (from looking down). Also, though I guess I can learn to type fast on a virtual keyboard, I think I would still prefer the physical full-sized keyboard if given a choice. Furthermore, though wireless WiFi for all internet connectivity is nice in principal, it does introduce potential security problems as well as speed issues (wired ethernet in my experience is still the most reliable and fastest way of communication along with being secure).

However, WiFi connectivity is still important as pretty much every medical setting has WiFi and so one does have continuous high speed wireless access. Also, it would allow me to read a little bit of what's going on with a patient before walking into an exam room (I would load up the patient's chart using the touchscreen before walking into the exam room and docking the tablet). I just do not want to always DEPEND on WiFi.

A WiFi tablet touchscreen like the iPad is also great as one can BRING your office with you where-ever you go like the hospital and operating room without bringing a keyboard, mouse, etc. It's all self-contained. It's intuitive. It's all neatly packed into a simple, elegant tablet touchscreen that's highly portable and usable.

• Proximity security whereby the computer tablet "knows" you are right there. When you are no longer around the computer, it automatically locks. When you come back, it recognizes you and it automatically unlocks, all occurring invisibly to me without requiring me to actually do anything. I HATE the fact that I have 4 different userids with 4 different passwords to access the various EMR programs. Though I try to, I do not always remember to lock the computer 100% of the time. It should be all automatic. Does the technology exist? It sure does... It's called Single Sign-On for one userid and password that unlocks it all. And Xyloc by Ensure Technologies to allow for proximity recognition using RF technology. All I ask is that this technology be built-in to the hardware!

In a clinic where I'm constantly moving around where the tablet may not always be with me, due to HIPAA and HITECH, the computer needs to be secured. Though I try, I can not always remember 100% of the time to lock the computer. And same goes for my medical assistants. The security should be automatic, invisible, and secure.

The problem with biometric verification like fingerprint scanning or even ID card swipes is that I have to REMEMBER to do it. And the mere fact of doing it is aggravating because I would have to do it SO many times in a given day.

• Sturdy construction. The tablet is going to move around... a lot... It needs to stay working after being dropped from at least a height of 3 feet.

Which Brings Me to the Software:
What can I say? I LOVE the intuitive and simple interface of the iPad. Now, there's a few things I would tweak about it to make it MORE relevant in the healthcare setting.

• Multi-Tasking is a must. As I literally use Meditech (hospital EMR), NextGen (clinic EMR), Rcopia (electronic prescribing software), and PACS (radiology viewing software) all day long swapping back and forth even with a single patient encounter, I need to be able to easily jump between all these programs without shutting down the others. From what I understand, this functionality on the iPad will soon be reality with the release of the iOS4 operating system later June 2010.

• I constantly move back and forth among Meditech, NextGen, Rcopia, and PACS all day long. As such, having a few physical programmable buttons on one side of the screen on the edge would be wonderful which I could just press and it would take me immediately to my program of choice. Keyboard shortcut works, but imagine what touch-strokes would be required when I'm using it in pure tablet touchscreen mode...

• Apps already exist to connect via Citrix, Remote Desktop Connection, or screen mirroring... so I would just use those programs. If I was prone to unrealistic wishful thinking, I would ask for a single EMR program that incorporates Meditech, Nextgen, Rcopia, and PACS, but I do not forsee anything like that happening for decades (if ever). So, I'm going to stick with what is possible.

• A "tablet pen" is 100% optional and not necessary for use... Tablet touchscreen would be used predominantly using a finger(s) just like on the iPad. Personally, I do not foresee myself ever using a tablet pen. It's just one more thing that can get lost.

That's pretty much it! Is that so much to ask for???

Related iPad and MediTech Blog Articles:
6/12/10 iPad Use In the Medical Clinic and/or Hospital For the Surgeon Doctor
9/8/10 Dr. Chang Featured in Magazine Article on Using iPad with MediTech EMR
9/20/10 UPDATE: iPad and MediTech Electronic Medical / Health Records
10/12/10 UPDATE #2: iPad and MediTech Electronic Medical / Health Records
10/25/10 New Video Produced on Using MediTech on the iPad!

Strange But True (And Disgusting) Stories in ENT

True Story #1

There was an ENT named Dr. Lloyd Storrs of Lubbock, TX. He used to save all the earwax he removed from patients. With the collected earwax, he would heat it to melt it, strain it, cool it down, and then heat it again to make an unique earwax solution he would give to patients suffering from ear canal seborrhea with cerumen. Only 2 drops per week worked.

Strange but true... in fact, he wrote a paper about it. Read it here.

True Story #2

Earwax, by the way, is often a tasty treat for cats! And I do have a few patients who request that I save the earwax I remove from their ears so they can feed their cat with it.

True Story #3

Back in the day, ENTs would harvest cartilage taken from noses (septoplasty) as well as middle ear bones from ears (cholesteatoma surgery) and save them in the lab or locker. The harvested cartilage and bone was than "reused" at a later time to repair defects in patients who needed extra cartilage or middle ear repair.

Of course, nowadays, we no longer recycle ENT parts like this like we used to.

True Story #4

Leeches are often used after certain major head and neck surgery in order to prevent clots from forming in the surgical site. In fact, there are "medical grade" leeches which are sold by companies specifically for this purpose.

Here is one paper describing medical use of leeches.

True Story #5

Maggots are sometimes used to remove necrotic tissue from wounds in order to allow healthy tissue growth.

Here is a paper describing this mode of treatment.

If you have any other strange but true ENT stories, comment below!

Fauquier ENT Recognized by Organized Wisdom

Fauquier ENT has been selected by the healthcare website "Organized Wisdom" Medical Review Board as a top contributor helping people discover the best health information online. Pretty cool! Check out our profile here.

Fauquier Free Clinic for Free Medical & Dental Care

Did you know Fauquier County has a Free Clinic where medical and dental services are provided directly to patients for free and does not bill patients or deny services for lack of payment?

Furthermore, if you need any CT scans, x-rays, bloodwork, MRI scans, etc, all these testings are also provided for free! If you need to see a specialist, such as ENT (or pulmonary, endocrine, rheumatology, ID, etc), clinic visits/appointments are also for free with a referral from the Free Clinic.

There's a catch...

To be a patient of the Fauquier Free Clinic, basic eligibility requirements must be met in order to receive free care. To be eligible, the patient must live in Fauquier or Rappahannock County, cannot have health insurance, and household income must be under specified limits.

For more information, go to their website here.

Read more about free clinics in the state of Virginia here.

Read a media report about free clinics in the US here.

Hollywood! Otolaryngology is Cool, Isn't It?

So there are lots of television shows on ER physicians (ER, Chicago Hope), general surgery (Gray's Anatomy), OB & pediatricians (Private Practice), plastic surgery (Nip/Tuck), ID doctors (House), etc etc.

What about shows/movies where an otolaryngologist is the star? Any thoughts on this lapse by Hollywood?

Of course, there's Dr. McSteamy on Grey's Anatomy who started out as an ENT, but than is mainly portrayed as a plastic surgeon.

What's up with that???

June 18, 2010

Sunscreen CAUSES Skin Cancer?!!

On May 24, 2010, a study was released by the Environmental Working Group (EWG) stating that more than half of all popular sunscreens may actually increase the speed at which malignant cells develop and spread skin cancer because they contain vitamin A or its derivatives retinol and retinyl palmitate. In fact only 39 out of more than 500 products examined were considered safe and effective. Tumors and lesions developed up to 21 percent faster in lab animals coated in a vitamin A-laced cream than animals treated with a vitamin-free cream

Other additives cause harm including the hormone-disrupting chemical oxybenzone, which penetrates the skin and enters the bloodstream. Titanium dioxide that is made nanosized may also have serious health implications.

The full list of the best and worst sunscreens can be found on the EWG's searchable database here.

Read a media report here.

As an FYI, a few of the WORST sunscreens are:
• Banana Boat Baby Max Protect, SPF = 100
• iS Clinical SPF 20 Powder & Peter Thomas Roth Instant Mineral Powder SPF 30
• Hawaiian Tropic Baby Creme Lotion SPF 50
• Aveeno Baby Continuous Protection SPF 55
• Anthony Logistics for Men Sunstick SPF 15
• Panama Jack Naturals Baby Sunblock SPF 50
• Banana Boat Ultra Defense Sunscreen Stick SPF 50
• Baby Blanket Tender Scalps Scalp Sunscreen Spray for Babies SPF 45+

For your convenience, a few of the best (and safe) sunscreens are shown here:

The full list of other safe sunscreens can be found here.

Help! My Ears Feel Clogged / Full (Eustachian Tube Dysfunction)

This blog article has been removed. 
You can find the entire article on the Fauquier ENT website here.

Better Air Filter Than HEPA? It's Called ULPA

HEPA is widely considered the gold standard when it comes to air filtration, especially for those patients suffering from allergies. What many people may not realize is that there are air filters even better than HEPA called ULPA.

HEPA removes 99.97% of particles 0.3 micrometers or more.

ULPA removes 99.999% of particles 0.12 micrometers or greater.

ULPA is correspondingly much more expensive.

Here are some HEPA filters sold on

Here is an ULPA unit sold on

June 16, 2010

Voice Sounds Different After Tonsillectomy and/or Adenoidectomy!

Every so often, I hear a parent state that their child's voice/speech sounds "different" after undergoing tonsillectomy and adenoidectomy. Beyond sounding less nasal which is expected, the other comment is sounding higher pitched or more feminine.

This observation is especially true when dealing with a male school-age child.

The reason for this voice (or really speech) change is because the upper airway is much larger and more resonant after the tonsils and adenoids are removed.

Just like a person's voice sounds different when talking in a closet versus a large auditorium, the larger opening through which the voice travels after surgery is much larger than before and as such, the voice/speech has to correspondingly change after surgery as well.

The change is also much more dramatic the larger the tonsils and adenoids are.

SO, do not be alarmed if your child sounds different after surgery, especially if the tonsils and adenoids were extremely large. It is actually an expected occurrence and not an indicator of anything bad, swelling, healing, etc.

Blood Type Group O Associated With Higher Rates of Post-Tonsillectomy Bleeding

In the July 2010 volume of International Journal of Pediatric Otorhinolaryngology, researchers in Ireland published an interesting finding that 63% of bleeding after tonsillectomy were in patients with Blood Type O. The general population Blood Type O is only 55%.

Although the authors were careful to state that this finding does not demonstrate causality, this association does suggest that patients with Type-O blood are more likely to suffer from secondary bleeds following tonsillectomy.

The other blood types are A, B, and AB.

Read the research here.

Read more about tonsillectomy here.

June 12, 2010

iPad Use In the Medical Clinic and/or Hospital For the Surgeon Doctor

To read what I consider the perfect computer for healthcare, click here.

UPDATE 10/25/10: Watch video of using MediTech on the iPad

To give a little background, I am a ENT (otolaryngology-head and neck surgeon). I see patients in all sorts of environments including the hospital, operating room, and outpatient clinic. In the hospital, I use MediTech and PACS while in the clinic I use NextGen. Admittedly, I was not entirely convinced the iPad would ever be useful in this varied medical setting which utilized different EMR platforms when it first came out earlier this year.

However, several developments have occurred that has since changed my mind due to the ingenuity of app developers and other progressive technology that allows the iPad to connect with hospital and outpatient clinic electronic medical records (EMR) regardless of operating system and security settings.

The information provided here is based on using an Apple iPad 16GB model with WiFi only ($499).


Foremost of these evolutions is the iPad/iPhone apps now available that allows for EMR access. To give some background, I use MediTech and PACS in the hospital and NextGen in the outpatient clinic. In order for me to access all electronic health records, two iPad apps are necessary:

1) LogMeIn: Wonderful app that allows the iPad to remotely control a Windows (or Mac) desktop computer anywhere in the world. The iPad app itself is $29.99. The LogMeIn desktop software (free) also needs to be downloaded to any desktop you want to access/control with the iPad. In essence, the iPad takes control of the desktop which you can see on the iPad screen. As such, any software including EMR programs like MediTech, NextGen, or indeed any other application (via Citrix) on the desktop, can be opened and visualized on the iPad. Click here to download this program.

The pictures below show MediTech as well as PACS being opened on the iPad using LogMeIn. The keyboard you see is a bluetooth keyboard wirelessly connected to the iPad (more on this below).

Of course, this method produces a slow response time as one is jumping through different networks to obtain medical records access (iPad --> LogMeIn --> Desktop --> Citrix --> Medical Records).

A more elegant solution would be direct Citrix/VPN access to the medical records (iPad --> Citrix/VPN --> Medical Records). Unfortunately, the hospital/clinic would need to upgrade their software in order to make this happen (which has not yet happened at my hospital). For those curious, the iPad software is called Citrix Receiver and is a FREE app download! Click here.

2) WinAdmin or Jump: Of course, if one is able to access medical records using terminal services (rather than citrix, VPN, etc), there's a perfect app for that called WinAdmin or Jump. Just punch in the same info you do to open terminal services on Windows and viola... the remote desktop appears on your iPad! Both  apps are iPad optimized and costs $8.99 for WinAdmin or $19.99 for Jump. Click here to download WinAdmin or here to download Jump. You can see a screenshot (to the right) where NextGen Master IM was opened up on the iPad using WinAdmin app.

The difference between Jump and WinAdmin are several-fold. Jump has better mouse usage controls (there's a mouse!), better virtual keyboard (including Tab, Esc, Function keys), and allows for external keyboard text entry. WinAdmin does not (so far). But I guess you get what you pay for! Having used both, I personally prefer Jump (originally purchased WinAdmin because it was cheaper).

SO, I basically use Jump to access NextGen which is accessible via terminal services and I use LogMeIn to access MediTech (as well as PACS viewer). As soon as direct Citrix access is available (should the hospital upgrade their Citrix software), I would change to Citrix Receiver instead of LogMeIn in a heartbeat.


The keyboard is essential as I do a great deal of free-typing which is not easy (to type very fast) when using the iPad's virtual keyboard. As such, a bluetooth wireless keyboard is important for me to allow fast touch-typing. There are plenty of wireless keyboards out there... the one I use is the Apple Wireless Keyboard. However, this keyboard isn't perfect as the keyboard is bigger than the iPad and as such, needs to be carried around separately. I never even bothered getting the iPad Keyboard Dock as one MUST orient the keyboard vertically (in order to dock the iPad) which is not preferable when I used the iPad for accessing electronic medical records. For just that reason, I always keep the iPad screen locked in horizontal orientation.

As such, for me, the next piece of the iPad implementation for medical use is hardware. Here, I am most eagerly awaiting for the ClamCase which is supposed to be available for sale in Fall 2010. The "ClamCase" offers the perfect package in my mind:

• A nice case for the iPad for transportation
• A wireless bluetooth keyboard for freetyping
• Full use of the iPad as a standalone device in case I don't want to use the keyboard
• Keyboard fits within the case where you want it (so it can be opened up like a laptop)

What the ClamCase does that no other device offers is a wireless bluetooth keyboard BUILT-IN to the iPad case in a single beautiful package!

Here's a YouTube video showing the full features of the ClamCase:

Hopefully, it will live up to its hype and I will be basking in heaven using the iPad to do pretty much everything whether in the hospital, operating room, or clinic. Once multi-tasking becomes available with the next OS Upgrade (iOS4) later this month, that will be most awesome as than I can have NextGen, MediTech, and Safari up with Rcopia (the electronic prescribing program I use) all up and running simultaneously and I will be able to just switch among the programs without losing anything.

For now, I'm trying it out on a limited basis before ditching the old system (desktop computer in each exam room) and using iPad exclusively.

Will keep those interested updated on my experiences over time...

In meantime, read what I consider the perfect computer for healthcare here.

Related iPad and MediTech Blog Articles:
6/19/10 The Perfect Computer for Healthcare and Electronic Medical Records
9/8/10 Dr. Chang Featured in Magazine Article on Using iPad with MediTech EMR
9/20/10 UPDATE: iPad and MediTech Electronic Medical / Health Records
10/12/10 UPDATE #2: iPad and MediTech Electronic Medical / Health Records
10/25/10 New Video Produced on Using MediTech on the iPad!

June 09, 2010

Kids Who Eat Fish and/or Live On a Farm At Less Risk of Allergies Later in Life!

Researchers in Germany who have followed thousands of families with children have discovered that children who eat fish before the age of 9 months had less allergies 4.5 years later than children who did not eat fish at the same age.

Furthermore, they found that school-age kids living on/near a farm were two-thirds less likely to suffer from hay fever or asthma than children with no exposure to a farm.

These studies will be published soon. Read the media report here.

Our office provides allergy testing and allergy shots / allergy drops.

June 08, 2010

Bitter Taste Syndrome (Pine Nut Mouth, Artichoke Effect, Pineapple Tongue, Tomato Tongue, etc)

Ever eat something or brush your teeth after which everything tastes bitter or metallic?

This phenomenon is called bitter taste syndrome and often occurs after certain eating foods or after brushing the teeth. The altered taste lasts anywhere from a few hours to a few weeks.

Common food culprits include toothpaste, pine nuts, tomatoes, artichoke, pineapples, and certain medications.

Not everybody experiences this problem which is felt to be due to misfiring of the sweet taste receptor in the mouth.

If per chance you are suffering from this, not to worry... it will resolve with time. However, a little sugar or artificial sweetener in food (or on the tongue) can help as well as rinsing the mouth with watered-down milk-of-magnesia or chewing (non-mint-flavored) gum.

Earworms (The Song That Is Stuck In Your Head)

An earworm is when there is a tune that gets stuck in your head that lasts for minutes to hours. It wasn't really much interest for scientists to study until recently when they were able to determine the "characteristics" of a good earworm. In a study published in the British Journal of Psychology in November 2009 titled "Earworms ('stuck song syndrome'): Towards a natural history of intrusive thoughts", they found that the best earworms are:

- Repetitive songs with lots of la-la-las and doopity-doopity-dahs.
- Very familiar songs and it’s usually the chorus that gets stuck.
- Simple songs with sappy lyrics
- Happen when people are in a positive emotional state
- Person usually participating in non-intellectual activities, like walking
- Musicians’ earworm usually lasts longer

No good tricks to get rid of an earworm unfortunately, though there's lots of anecdotal suggestions.

Read about this in an MSNBC article here.

There was also an NPR Radiolab episode about this here.

Read the research paper here.

Please comment on your best trick to get rid of an earworm!

Fauquier ENT Social Media Update

I have had a few readers comment that our office should offer twitter, have a facebook page, or some other social media outlet...

My answer is that we actually already do! So here's the full list along with subscribers (as of June 8, 2010) for each and link.

YouTube Channel (1,865 Subscribers)

We get about 250,000 hits a day on YouTube!!!

Facebook Page (80 Friends)

Twitter (267 Followers)

Blog (~35 Subscribers)

Thanks to all who follow/friend/subscribe already!!!

June 06, 2010

Why Eating Asparagus Causes a Smelly Urine... You Know Who You Are!

About 50% of the population experiences a very foul smelling urine after eating asparagus. For those in the know, the odor is compared to rotting cabbage, ammonia, rotten eggs, etc. In fact, the smell is so foul, even the culprit person who is urinating can barely tolerate it himself!

For awhile there was an argument in the scientific community whether this phenomenon was due to a smell disorder or a urine problem...

Hypothesis #1:
EVERYBODY's urine smells... it's just that half the population can't smell it.

Hypothesis #2:
It's not a nose problem... it's a urine problem due to an inability to digest (or resorb) sulfur-containg compounds found within asparagus after breakdown. In fact, this would be the same mechanism that makes a skunk smell.

It ends up that possibly BOTH Hypothesis #1 (study link) and 2 (study link) are correct depending on the individual who is peeing and the individual doing the smelling. In other words, there are some individuals whose urine does smell after eating asparagus AS WELL AS some individuals who may or may not be able to smell this foul odor.

The exact culprit compound is still unclear however. The top contestants are methyl mercaptan, thioesters, and asparagusic acid.

Regardless, there's no harm in eating asparagus at all whether you stink or not... or whether you can smell or not.

Read more about this phenomenon in the Boston Globe here.

June 05, 2010

Dr. Chang Featured in TV Medical News Program on CBS 6/5/10

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 were featured in a medical news television show "American Health Front" that aired 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

June 04, 2010

New Video on Botox Injection for Spasmodic Dysphonia

A new video has been created and uploaded to our practice YouTube Channel describing botox injection for spasmodic dysphonia.

Two views are shown in the video... the first is what a patient sees as well as another view of what it looks like from inside the throat. Check it out!

Dr. Chang performs botox injections for spasmodic dysphonia every Friday afternoon. He also performs botox injections for facial wrinkles, torticollis, migraine headaches, TMJ, etc. Click here to see the full list.

New Webpage on Large Adenoids: Symptoms and Treatment

A new webpage has been created on problems associated with large adenoids and how it can be treated.

Large adenoids cause all sorts of symptoms that may be confused for other etiologies including:

Nasal obstruction
• Nasal congestion
Nasal sounding speech
• Runny nose (rhinitis)
Snotty nose
• Colored drainage
Allergy like symptoms
Ear pain, clogging, stuffiness
• Cough
• Post-nasal drainage

Correction of the large adenoids (medications or surgery) may eliminate all these symptoms!

Click here to read more about this as well as to watch videos on this subject.

June 03, 2010

Pulsatile Tinnitus Caused by Ear Tumor (Glomus Tympanicum)

The New England Journal of Medicine published a case report in June 2010 titled "Glomus Tympanicum" where a woman with a right pulsatile tinnitus is described. The pulsatile tinnitus was due to a tumor called glomus tympanicum.

The article includes a picture as well as video. If you watch the video carefully, you can actually "see" the pulsations.

The only way to treat this tumor is surgical excision by a neuro-otologic surgeon.

Read more about pulsatile tinnitus in general here.

June 02, 2010

USA Today: Article on Vocal Cord Paralysis Causing Breathy Voice

On June 1, 2010 USA Today published a story titled "Lost your voice? It could be vocal cord paresis." The story discusses how vocal cord paralysis can cause a breathy type of hoarse voice. The paralysis, if idiopathic, is suspected to be caused by a virus, just like Bell's Palsy causes a facial paralysis or a bad cold can cause a loss of smell. Listen to what a breathy voice sounds like due to vocal cord paralysis here.

Treatment for this rare condition include voice therapy and if that fails, surgery if the paralysis does not resolve.

Read the story here.

Read more about voice therapy and surgical treatment of the paralyzed vocal cord.

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VIDEO: How Does the Human Voicebox Work?


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