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January 31, 2011

Why Do We Have Earwax?

This question was addressed in today's Washington Post.

The question itself wasn't really addressed, but the article did contain good general information.

Read more about earwax here.

Read the Washington Post article here.

Watch a video of earwax being removed by an ENT specialist under the microscope:

January 30, 2011

A Crime For Doctors to Ask About Guns?

When I saw this report on ABC about a Florida politician wanting to make it a crime if a physician asks about guns in the home or else face 5 years in jail and up to $5 million fine, I could not believe it.

Who cares that more children die of accidents than of diseases.

It is standard practice for pediatricians to provide guidance on a variety of unintentional injury-prevention counseling for infants, preschool-aged children, school-aged children, and adolescents as well as their parents. These include:
  • Traffic safety
  • Burn prevention
  • Fall prevention
  • Choking prevention
  • Drowning prevention/water safety
  • Safe sleep environment
  • Cardiopulmonary resuscitation
  • Poison prevention
  • Firearm safety
  • Sports safety
According to the American Academy of Pediatrics, gunshot wounds account for one in 25 admissions to pediatric trauma centers in the United States. Furthermore, a gun in the home is 43 times more likely to be used to kill a friend or family member than a burglar or other criminal.

As the trite but true saying goes, an ounce of prevention is worth a pound of cure.

And in this day where healthcare costs are spiraling, how precious and common-sense it is to ask and provide guidance on firearm safety and security at a cost of one physician visit rather than a child accidentally getting shot and using up hundreds of thousands of dollars worth of surgeries, hospitalizations, studies, physician visits, etc.

Read the ABC report here.

Why as an ENT am I even bothered about this? It's because I often have to ask similar but what some people may consider very private questions akin to asking about guns (ie, oral sex).

Office-based counseling for unintentional injury prevention. Pediatrics 2007 Jan;119(1):202-6.

Link Between Oral Sex and Head & Neck Cancer

USA Today published a pretty accurate article regarding the rise of certain head & neck cancers with the increased popularity of oral sex and number of sexual partners.

The factor that creates this link is the HPV virus which is associated with tonsil and tongue cancer. Alcohol and tobacco use is more highly linked with such oral cancers, but HPV does appear to be an independent risk factor.

A 2007 study in the New England Journal of Medicine found that younger people with head and neck cancers who tested positive for oral HPV infection were more likely to have had multiple vaginal and oral sex partners in their lifetime. Having six or more oral sex partners over a lifetime was associated with a 3.4 times higher risk for oropharyngeal cancer; cancers of the base of the tongue, back of the throat, or tonsils. Having 26 or more vaginal-sex partners tripled the risk. The association continued to increase as the number of partners in either category increased.

Of greater concern is that "French" kissing may also potentially be a mode of transmission.

The good news (if one is a young, non-smoker diagnosed with HPV-positive tumors) is that about 85% of non-smoking people with HPV-positive tumors survive. That number drops to 45 or 50% in people who smoke and are HPV-negative.

Th take-home message here is that even if you are a non-smoker and non-drinker, you can STILL develop head and neck cancer. Oral HPV infection is strongly associated with oropharyngeal cancer among subjects with or without the established risk factors of tobacco and alcohol use and that oral HPV infection can occur through sexual activity.

Furthermore, it is possible that the HPV vaccine (ie, gardasil) may also be protective (studies pending) for both women AND men.

Of note, there are currently 3 FDA approved HPV vaccines:

• The bivalent HPV vaccine (Cervarix) which addresses HPV 16 and 18;
• The quadrivalent HPV vaccine (Gardasil) which prevents four HPV types: HPV 16 and 18, as well as HPV 6 and 11;
• And finally Gardasil 9 which prevents 9 HPV types: 6, 11, 16, 18, 31, 33, 45, 52, and 58.

Read the USA Today article here.

Of note, our office does offer the HPV spit test to see if HPV is present in the mouth/throat.

Human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007 Sep 13;357(11):1157; author reply 1157-8

Human papillomaviruses in head and neck carcinomas. N Engl J Med. 2007 May 10;356(19):1993-5.

Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007 May 10;356(19):1944-56.

January 25, 2011

Allegra Going Over-The-Counter March 2011!

For allergy sufferers, the prescription anti-histamine, Allegra, will be going over-the-counter on March 4, 2011.

And not just Allegra, but the full family of Allegra including those formulations for kids as well as Allegra-D which contains sudafed.

Click here for more info.

Allegra joins claritin and zyrtec which also used to be prescriptions but went over-the-counter in 2003 and 2007 respectively.

January 24, 2011

Bottles / Vials for Allergy Drops (Under Tongue) Immunotherapy

We have received a number of requests of where one can obtain allergy vials for use in SLIT (sub-lingual immunotherapy) whereby a drop is placed under the tongue to try and achieve allergy cure. This mode of treatment is an alternative to the more traditional allergy shots.

Our office provides both modes of immunotherapy.

Regarding the allergy vials themselves, you can obtain them from Edge Pharmaceuticals. They offer a number of different vial types as shown in the picture. They range in sizes from 15cc to 20cc and provide 40ul to 200ul drops with each dispensation.

Contact Info:
7264 NW 63rd Terrace
Parkland, FL 33067
Phone: 877-580-3343
Fax: 877-581-3343

Dr. Chang a Northern Virginia Top Doctor for 2011

Northern Virginia Magazine published their annual list of Top Doctors for 2011 in their February 2011 edition. Dr. Chang was listed as one of Northern Virginia's Top Doctor in the field of Otolaryngology (page 68).

Of note, Dr. Chang was nominated by his doctor peers opposed to nomination by a small panel.

January 22, 2011

Migraine Headaches Associated with Allergies & Response to Allergy Shots

A recent study published this month in the journal Headache reported an association of migraine headaches with allergy severity and response to allergy shots... but only in those less than 45 years of age.

The study suggested that lower "degrees of atopy" (or allergy) were associated with less frequent and disabling migraine headaches in younger subjects while higher degrees were associated with more frequent migraines. The administration of allergy shots was associated with a decreased prevalence, frequency, and disability of migraine headache in younger subjects.

The age cut-off used to described "younger" subjects depending on the measure described was either 40 years or 45 years.

Read the abstract here.

Of course, one must consider the possibility that perhaps what these patients are suffering from is not migraine headaches, but allergy triggered sinus headaches.

Our office provides allergy testing, allergy shots, and allergy drops. We also offer botox injections in the treatment of migraine headaches.

Allergy and immunotherapy: are they related to migraine headache? Headache. 2011 Jan;51(1):8-20. doi: 10.1111/j.1526-4610.2010.01792.x. Epub 2010 Nov 4.

Patulous Eustachian Tube Video

In perhaps one of the most flagrant cases of patulous eustachian tube I've ever seen, the New England Journal of Medicine published a video showing the eardrum moving with respiration.

Normally, the eustachian tube (which extends from the back of the nose to the ear) is closed unless one pops the ears (like when flying in an airplane). As such, one does not normally see the eardrum moving to and fro with breathing.

Symptoms this poor patient with patulous eustachian tube may exhibit include hearing one's own breathing inside the ear as well as autophonia (hearing yourself talk in the ear). Symptoms improve transiently when the head is placed in a dependent position (head between the knees).

Treatment is very difficult. Perhaps the best medical treatment for this condition is PatulEND Nasal Drops that works about 60-70% of the time. It is sold by the Ear Foundation in Santa Barbara, CA. One needs to sniff 2-4 drops of this medication 1-2x per day.

Other medical treatments that can be tried that may partially help with symptoms include placement of ear tubes, SSKI (super-saturated potassium iodide), premarin drops, and reserpine. Perhaps the best treatment I've seen for Patulous Eustachian Tube is that provided by Dr. Dennis Poe at Massachusetts Eye and Ear Infirmary in Boston, MA. He performs a minimally invasive endoscopic insertion of a tiny catheter into the eustachian tube. The catheter is just the right size that one can still pop ears easily to prevent eustachian tube dysfunction, but large enough so that one does not suffer the symptoms of patulous eustachian tube. There are other more invasive surgical obliteration methods that also works well, but with unfortunate trade-offs.

The most common problem seen in the clinic regarding the eustachian tube is actually the complete OPPOSITE problem of patulous eustachian tube. It is eustachian tube dysfunction or the "clogged" ears whereby the ear feels full of pressure and one just is not able to pop the ears to release the pressure. In this situation, the eustachian tube stays closed, even when trying to pop the ears.

Check out the video below or here illustrating the problem with patulous eustachian tube.

January 20, 2011

Fauquier Hospital Now Offers 24 Hour Multichannel pH and Impedance Testing for Reflux!

As far as we know, Virginia Hospital Center's Heartburn Center in Arlington, VA and now Fauquier Hospital are the only places in Northern Virginia that offers 24 hour Multichannel Intraluminal Impedance (MII) testing to look for non-acidic reflux. Oftentimes, this test is combined with pH probe testing and manometry to measure the more traditional acid reflux as well as esophageal motility.  These tests are important when working up patients with symptoms of chronic cough, globus, phlegmy throat, and/or throat clearing when all other reflux measurements/testing have come back normal.

The testing is performed by placing a catheter through the nose and into the stomach AND leaving it in place for 24 hours. Patients often ask what this looks like... so here's a few pictures!
Here are the contact information for the locations that provide 24 hour Multichannel pH and Impedance testing:

Gastroenterology Associates
(in association with Fauquier Hospital)
402 Hospital Drive
Warrenton, VA 20186
Phone: (540) 347-2470

Virginia Hospital Center
Phone: (703) 717-4373
Fax: (703) 717-4374
Director: Kevin Gillian, MD, FACS
Nurse Coordinator: Susan McNeill-Smith, RN

Some over-the-counter medications used to treat relux are listed below:

Woman Undergoes Successful Voicebox Transplant

USA Today published a story on January 20, 2011 about a courageous woman who underwent a voicebox transplant October 2010. The surgery took over 2 days and was led by a team of doctors at the University of California, Davis Medical Center and included experts from England and Sweden.

The first voicebox transplant took place at Cleveland Clinic in 1998 on Timothy Heidler after a motorcycle accident and who now talks completely normally.

Read more of the story here.

Laryngeal transplantation and 40-month follow-up. N Engl J Med. 2001 May 31;344(22):1676-9.

Transplantation of the larynx--a case report that speaks for itself. N Engl J Med. 2001 May 31;344(22):1712-4.

Videos on Visual Illusions

Bumming around one early morning, I came across these fascinating videos on YouTube of visual illusions reminiscent of Escher's optical illusions... except these illusions are made of cardboard and without use of any magnets or editing (video or computer generated)... just VERY clever use of camera angles. Be sure to watch the end of the videos to see what is REALLY going on.

Much credit goes to the artist who started it all, Kokichi Sugihara. Here is a compilation of some of his work.

January 19, 2011

New Video on Vocal Cord Surgery Produced

Our office has created a new video on how vocal cord surgery is performed. The video has been uploaded to our YouTube channel. Read more about vocal cord surgery here.

Wireless and Cell Phones Increase Risk of Brain Tumors

In an ongoing controversy regarding whether cell phones and wireless phones can lead to brain tumors like astrocytoma, malignant gliomas, and benign acoustic neuromas, several recent studies published since 2009 containing long-term (10+ years) follow-up have lent support that it does.

The group at greatest risk for development of brain tumors have the following characteristics:

1) Use of cell/wireless phone younger than age 20 (the younger the age with first use, the worse the risk)
2) Use of cell/wireless phone for more than 10 years
3) The more hours of cellular phone use over time, the higher the risk of developing brain tumors
4) Risk higher with analog cell/wireless phones (instead of digital)
5) Risk higher with increased overall total exposure

By some estimates, subjects who used cell phones for at least 10 years had a 2.4-fold greater risk of developing a brain tumor.

Though unclear how exposure to a phone's microwave radiation leads to brain tumors, it is known that the cell signal is absorbed up to 2 inches into the adult skull. Even more worrisome is that the depth of penetration is even deeper in children.

The risk is not just to the brain, but even the parotid gland which sits just in front of the ear. In one study published in 2008 revealed an increased risk of parotid gland tumors with cell phone use. Also, contact allergy is another not uncommon risk with cell phone use.

Symptoms that a patient may exhibit that may suggest a brain tumor are subtle and include hearing loss or ringing of the ear on the same side the phone is used on.

It is interesting to note that it is just possible that the cell phone industry is aware of these risks even as it denies any risk of health problems with phone use. If you look in the small print booklet that comes with your cell phone, cell phone makers state that phones should not be in contact with your body or skin and should be kept a certain distance away when in use or when carrying around. Read more about this here.

However, all currently published results are based on retrospective studies and ideally, prospective studies will be required to provide more definitive results. However, that will take a long-time and perseverance on both the researchers as well as the subjects, since ideally, many of the study subjects should be children who are currently using cell phones.

In any case, to be on the safe side, it is recommended to talk on speakerphone or use a wired headset (not wireless), or avoid altogether if at all possible.

Even the CDC has had reservations regarding health risks due to cell phone use.

Risk of Brain Tumors From Wireless Phone Use. Journal of Computer Assisted Tomography, 2010; 34 (6): 799 DOI: 10.1097/RCT.0b013e3181ed9b54

Cell phones and brain tumors: a review including the long-term epidemiologic data. Surg Neurol. 2009 Sep;72(3):205-14; discussion 214-5. Epub 2009 Mar 27.

Mobile phones, cordless phones and the risk for brain tumours. Int J Oncol. 2009 Jul;35(1):5-17.

Cell phone use and acoustic neuroma: the need for standardized questionnaires and access to industry data. Surg Neurol. 2009 Sep;72(3):216-22; discussion 222. Epub 2009 Mar 27.

Cellular phone use and risk of benign and malignant parotid gland tumors--a nationwide case-control study. Am J Epidemiol. 2008 Feb 15;167(4):457-67. Epub 2007 Dec 6.

January 18, 2011

Dr. Chang Now a Contributing Author to Better Health Web Network

Dr. Chang was recently invited to become a regular contributing author to Better Health and its syndicate partners which include Harvard Health Publications, The ACP Advocate, ACPHospitalist, ACPInternist, Healthline, and MedHelp.

Better Health and its partner sites reaches approximately 10 million unique users per month and is growing.

Look for his contributions soon!

Dr. Chang is also a contributing author to KevinMD along with more traditional sources like textbooks and medical journals.

Read his bio on Better Health's website here.

Updated Google App Translates English<->Spanish Conversation in Real-Time

Earlier this month, Google released an incredible app (only for the Android market at this time) that can translate English to Spanish as well as Spanish to English in REAL-TIME allowing for a somewhat stuttered conversation with translations on the fly.

At this time from what I hear, it can understand English pretty good, but understanding Spanish is not quite as good. With time, I expect the accuracy to improve to the point that potentially, this app can replace human translators in the exam room.

What a boom to breaking down language barriers in the hospital and clinic. At this time, I have to enlist the help of the AT&T translation services.

One can only hope that it'll become available on the iPhone soon!

January 17, 2011

ENT Robotic Surgery

There has been increasing interest in using robots to help the surgeon perform complex surgical procedures within small spaces thereby saving the patient more invasive incisions. Especially in the world of ENT, surgery that may have required large incisions to the face and/or neck can now be accomplished without any incisions by using robotics to perform the same surgery, but entirely through the mouth.

Such robotic surgery performed through the mouth is called Trans-Oral Robotic Surgery, or simply TORS. The DaVinci system is the robotics platform that is most commonly used in TORS.

Using TORS and other approaches, head and neck surgeons have been able to remove the thyroid gland through the armpit, perform base of tongue cancer surgical excision (same cancer that Michael Douglas had), voicebox removal (laryngectomy), vocal cord surgery, etc.

In many of these and other surgeries, any procedure performed through the mouth traditionally was limited to two hands. With the DaVinci system, one technically can fit as many as FOUR "hands" inside the mouth enabling greater surgical flexibility and ease in performing fine dissections that otherwise would be impossible.

There are some downsides however... namely, use of robotic surgery is not compensated by insurance and as such, major medical centers are the only locations where such high-tech equipment is available.

At this time, the otolaryngology department at Johns Hopkins University, George Washington University, and University of Virginia are the only locations in the mid-Atlantic region with access to such robotic technology and the otolaryngology-head and neck surgeons who know how to use it that I'm aware of.

January 16, 2011

U.S. Rep. Gabrielle Gifford Gets a Tracheostomy After 7 Days of Intubation

U.S. Rep. Gabrielle Gifford who is recovering from a gunshot wound to the head 7 days earlier had her breathing tube removed and a tracheostomy tube placed on January 15, 2011.

Many people will wonder why a tracheostomy tube was placed when she's been intubated for only 7 days and even though she has been able to breath on her own since Tuesday. Along with the trach tube, a stomach feeding tube was also placed.

A tracheostomy tube is a small tube placed through an opening in the neck allowing for airway protection, improved ease of breathing, and improved pulmonary care.

It is unusual to keep a patient intubated for greater than 7 days due to risk of tracheal stenosis due to mucosal ulcerations that occur with prolonged intubation. Such ulcerations not only occur in the airway and throat, but also the mouth and lip regions. The exact timing to trach is still controversial however.

However, a tracheostomy tube does appear to speed overall recovery and decrease the number of days of hospitalization.

Though many family members (and patients) may be appalled by the cosmetic appearance of a trach tube, everyone needs to remember a trach tube is TEMPORARY and can be removed without much fuss once the patient regains strength.

Read more about trach here.

Read the Reuters article here.

Watch a video of a trach.

Tracheostomy: why, when, and how? Respir Care. 2010 Aug;55(8):1056-68.

Early versus late tracheostomy in patients with acute severe brain injury. J Bras Pneumol. 2010 Feb;36(1):84-91.

Early tracheostomy in intensive care unit: a retrospective study of 506 cases of video-guided Ciaglia Blue Rhino tracheostomies. J Trauma. 2010 Feb;68(2):367-72.

The impact of time to tracheostomy on mechanical ventilation duration, length of stay, and mortality in intensive care unit patients. J Crit Care. 2009 Sep;24(3):435-40. Epub 2009 Jan 17.

What is the Perfect Tablet Computer for Healthcare?

Many would argue (as I have) that the Apple iPad is THE perfect tablet computer for healthcare professionals. And for many of the mundane tasks of looking up or inputting information into an electronic medical records, that may be true. (Watch a video using the iPad to access MediTech as well as PACS here.)

However, there is a vast area of healthcare that the iPad just does not work at all.

That area is connecting to surgical equipment. Especially in the ENT world, there is a lot of microscopic and endoscopic work that is done. The software that records imagery from such devices are ALL based on the windows platform. Yes... we can record on to a CD, DVD, USB Memory Drive, etc and transfer the file to the iPad for viewing, but there's a lot of steps involved with that:

1) Record the video/image
2) Transfer to media of choice (CD, DVD, USB memory stick, etc)
3) Transfer file to PC/Mac
4) Move it iTunes/iPhoto
5) Synch with iPad

Geez louise!!!

I am currently aching for a highly portable tablet computer to connect to my JedMed Digicam in order to video-record fiberoptic endoscopy, ear work under the microscope, etc. The software the Digicam works with is only Windows compatible (and from my conversations with JedMed, there's no plans to make it work on any other platform in the foreseeable future).

As such, at this time, the Windows (and not iPad) world is the current way to go to address this deficiency. Not Google Android, iPad, Blackberry, etc.

In my mind, the best tablet for video work in the healthcare setting must have the following properties:

1) Windows 7 operating system for compatibility with surgical hardware
2) USB port
3) 10" Tablet for portability
4) Cheap (comparable to iPad)
5) Fast boot (SSD drive)

And WOW... I was amazed at the plethora of tablets introduced at the 2011 CES Convention Jan 6-9, 2011 in Las Vegas.

There were over 80 tablets that were introduced from big name companies to nobodies. Surely, there will a be a few which fits the bill?

Sadly, there were only a few that may fit my needs.

These include:

1) Samsung Note PC Series 7
2) Motion CL900 Windows Tablet

The Dell Inspiron Duo may possibly work, but the swinging screen just looks way too fragile.

What do others think? I'm pinning my hope on the Samsung model as the Motion tablet price is a bit much. The Samsung tablet is suppose to go on sale in March 2011 with a price tag around $699.

Watch a video the demonstrates the Samsung Note PC:

Tongue Piercing Infections

It seems that tongue piercing is slowly becoming more popular than ever... and correspondingly, there seems to be even more tongue infections than ever before due to the piercing.

If tongue piercing MUST happen, it is recommended that you avoid studs made of metal which increases the risk of infection, at least according to a recent study in the Journal of Adolescent Health.

The study demonstrated that studs made of steel might promote the development of a bacterial biofilm leading to increased risk of infection whereas those made of polytetrafluoroethylene or polypropylene are inert to such bacterial colonization.

I should also add that metal studs may cause an allergic reaction leading to painful tongue swelling/itching, especially in those with metal allergies. This is similar to the skin reactions that some people experience with cheap metal jewelry.

Tongue piercing: the impact of material on microbiological findings. J Adol Health online, 2011

Fauquier ENT Is Now Searchable on!

What in the world is

It is in essence a search engine for links shared on Twitter (or Facebook or Blog, etc). At least for us, we have elected to share on only our Twitter account for now. At current count as of January 16, 2011, we have tweeted over 1081 links of interest on a variety of topics related to ENT.

Even we can't remember all the interesting links we have shared with the world on Twitter. allows anyone to find that one interesting link that we shared 1 or even 3 years ago on a certain topic.

WHAT was that link we shared about a leech in the nose causing nosebleeds? Search for it on and find it!

WHAT was that link we shared about cancer being contagious? Search for it on and find it!

Search all our Tweeted shared links on!

Truly, as's catchphrase states, "Never Forget a Link Again"!

January 15, 2011

Chronic Hives Due to Vitamin D Deficiency

It seems that there is more and more research being published indicating that vitamin D deficiency leads to allergy exacerbation (and by supplementation, the severity can be reduced). Particularly problematic given so many people are vitamin D deficient as a possible byproduct of working indoors for so many of us (including physicians).

The most recent research out of Nebraska suggests that chronic urticaria in adults may be due to reduced vitamin D levels. In the small study, researchers compared 25 patients with chronic hives to 25 patients with nasal allergies. Researchers found patients with hives had significantly reduced levels of vitamin D, with nearly half of them considered to be vitamin D deficient.

Reduced vitamin D levels in adult subjects with chronic urticaria. J Allergy Clin Immunol. 2010 Aug;126(2):413; author reply 413-4.

Low vitamin D status despite abundant sun exposure. J Clin Endocrinol Metab. 2007 Jun;92(6):2130-5. Epub 2007 Apr 10.

Serum vitamin D levels and severe asthma exacerbations in the Childhood Asthma Management Program study. J Allergy Clin Immunol. 2010 Jul;126(1):52-8.e5. Epub 2010 Jun 9.

Vitamin D in atopic dermatitis, asthma and allergic diseases. Immunol Allergy Clin North Am. 2010 Aug;30(3):397-409.

Serum vitamin D levels and severe asthma exacerbations in the Childhood Asthma Management Program study. J Allergy Clin Immunol. 2010 Jul;126(1):52-8.e5. Epub 2010 Jun 9.

Vitamin D in atopic dermatitis, asthma and allergic diseases. Immunol Allergy Clin North Am. 2010 Aug;30(3):397-409.

January 13, 2011

Dr. Chang Receives Patients' Choice Award for 2010

For the year 2010, Dr. Christopher Chang was given a Patients' Choice Award. Apparently, only a handful of physicians receive this honor (less than 6% out of 720,000 active physicians). This honor is determined based on ratings provided by actual patient ratings.

Read more about Dr. Chang here.

January 11, 2011

Dr. Chevalier Jackson, Laryngologist Extraordinaire

On Jan 10, 2011, the New York Times published an article on Dr. Chevalier Jackson, a pioneer in the field of laryngology, who is perhaps best known for his extensive collection of foreign bodies he removed from patients, young and old, with little or no anesthesia. His genius is documented in a new biography called "Swallow" by Mary Cappello.

Among other achievements by Dr. Jackson was passage of the Federal Caustic Poison Act of 1927, esophageal dilatation in kids, and treatment of many poor children without pay.

Perhaps the one thing Dr. Jackson was mistaken on was the discouragement of high tracheostomies or cricothyrodotomies back in 1921.

Of note, Dr. Jackson's foreign body collection (2000+ items) is now owned by the Mütter Museum of the College of Physicians of Philadelphia... a fantastic museum I may add.

Read the NYT article here.

January 09, 2011

Cigarette Ad Blast From the Past

A reader forwarded this ad to me... My how times have changed...

Singulair May Help Reduce Tonsil and Adenoid Enlargement

Singulair is a medication often prescribed for asthma as well as allergies and works by blocking the leukotriene receptor. This mechanism is different than that found in common allergy medications like claritin and benadryl which work by blocking the histamine receptor (anti-histamine).

Singulair has also incidentally been found to possibly help reduce the size of tonsils and adenoids. Given this beneficial affect, singulair may be a helpful intervention in those kids with mild obstructive sleep apnea or nasal obstruction due to adenoid hypertrophy avoid surgical intervention (tonsillectomy and adenoidectomy).

Steroid nasal sprays have also been found helpful to reduce adenoid size.

However, only an association between singulair use and reduction in adenoid/tonsil size has been found. Double-blind, placebo-controlled studies are required for determination of true benefit.

Singulair can be given from the age of 1 year old.

Leukotriene modifier therapy for mild sleep-disordered breathing in children. Am J Respir Crit Care Med. 2005 Aug 1;172(3):364-70. Epub 2005 May 5.

Leukotriene pathways and in vitro adenotonsillar cell proliferation in children with obstructive sleep apnea. Chest. 2009 May;135(5):1142-9. Epub 2008 Dec 31.

The role of mometasone furoate aqueous nasal spray in the treatment of adenoidal hypertrophy in the pediatric age group: preliminary results of a prospective, randomized study. Pediatrics. 2007 Jun;119(6):e1392-7. Epub 2007 May 28.

Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006286.

January 08, 2011

Twins Die after Tonsillectomy and Adenoidectomy

Twin Ohio boys, 3 years old, both died on April 19, 2006 after both kids underwent tonsillectomy & adenoidectomy (T&A) less than 48 hour earlier. Both children were discharged home on the same day of surgery. Read the story here.

On Aug 6, 2010, a malpractice suit was found against the otolaryngologist who performed the surgery, based on the assertion that if the surgeon "kept the children in the hospital overnight - something within his power and a standard practice for children under 3 and for those with a history of breathing trouble - their low oxygen levels could have been detected. Maybe they could have been saved..."

Tonsillectomy and adenoidectomy (T&A) is a very common surgery done on children for a variety of problems. However, this surgery does carry risks, especially as it relates to airway swelling that almost always occur to some degree after surgery, especially uvular swelling (see picture).

Due to this swelling and risk of airway problems, most (but not all) otolaryngologists are reluctant to perform this surgery on very young children (less than age 2 for adenoids and less than 3 years old for tonsil removal) unless absolutely essential. And when performed on such young children, most (but not all), otolaryngologists will admit into the hospital for overnight observation.

I personally take the extra step of warning parents of very young children undergoing T&A that given this airway risk, it is not unreasonable to not only be admitted overnight after surgery, but to also have the surgery done in a facility that has an ICU just in case airway loss occurs. Otherwise, if done in a community hospital without pediatric ICU capabilities, an airway loss event would require emergency intubation followed by helicopter life-flight transportation to a hospital that does have one.

Certainly by the age of 4 for tonsillectomy and 2 for adenoidectomy, the airway risk for most children becomes negligible and it is safe to discharge home same day of surgery unless other medical problems/concerns are present.

Why at those particular ages is it fine? It is mainly because the child would be much bigger with a correspondingly larger airway that can accomodate the swelling. Furthermore, a child who is older can communicate what they are feeling better which leads to the other risk that is present in very young children.

The other risk involved is over-administration of narcotics which are prescribed after surgery which probably played a role with these twins coupled with their age. When the child is too young to communicate their feelings, any signs of discomfort could be erroneously misinterpreted as pain by the parents. And with suspicion of pain, parents often will give prescription narcotics. If too much is given when the child is not truly in pain, the narcotics can suppress breathing resulting in respiratory arrest.

Due to this risk, narcotics are no longer routinely prescribed after this surgery for kids under 7 years of age. Read more.

Read the full story here.

Surgical management of obstructive sleep apnea in infants and young toddlers. Otolaryngol Head Neck Surg. 2009 Jun;140(6):912-6. Epub 2009 Mar 9.

Ambulatory pediatric otolaryngologic procedures in the United States: characteristics and perioperative safety. Laryngoscope. 2010 Apr;120(4):821-5.

Postoperative respiratory complications of adenotonsillectomy for obstructive sleep apnea syndrome in older children: prevalence, risk factors, and impact on clinical outcome. J Otolaryngol Head Neck Surg. 2009 Feb;38(1):49-58.

Avoiding airway obstruction after pediatric adenotonsillectomy. Int J Pediatr Otorhinolaryngol. 2009 Jun;73(6):803-6. Epub 2009 Mar 14.

January 05, 2011

How to Use an EpiPen??? There's An App for That!

No kidding...

The makers of the EpiPen have created an app that works on the iPhone, iPad, and iPod Touch called MyEpiPenApp.

Within this app, you’ll find:

• A video demonstrating how to use an EpiPen Auto-Injector
• A quick slideshow (User Guide) to help you visually walk someone through the three steps of an EpiPen injection
• The ability for you and your healthcare professional to create multiple allergy profiles listing allergens to avoid and symptoms that may indicate an allergic emergency
• The ability to share the User Guide and your allergy profile(s) with anyone via Email

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Clinical Guidelines For Tonsillectomy in Children Published

This month, the American Academy of Otolaryngology-Head & Neck Surgery published clinical guidelines for tonsillectomy in kids. No big surprises in the guidelines, but everything is nicely summarized in one document.

In summary:
• Strong recommendation that clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.
• Strong recommendation against clinicians routinely administering or prescribing perioperative antibiotics to children undergoing tonsillectomy.
• Recommendations for:
  1. watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years
  2. assessing the child with recurrent throat infection who does not meet criteria in statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance; PFAPA (periodic fever, aphthous stomatitis, pharyngitis and adenitis); or history of peritonsillar abscess
  3. asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy
  4. counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing
  5. counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management
  6. advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain
  7. clinicians who perform tonsillectomy should determine their rate of primary and secondary post-tonsillectomy hemorrhage at least annually.

Clinical Practice Guideline: Tonsillectomy in Children. Otolaryngology– Head and Neck Surgery 144(1S) S1–S30

January 03, 2011

Avoidable Pediatric Radiation Exposure

Children and teens often get diagnostic tests that expose them to radiation, increasing the risk of cancer later in life. Over just a 3 year span, 42.5% of kids got some form of ionizing radiation from a diagnostic medical procedure whether it be a chest x-ray, CT scan, dental scan, etc. Click here to calculate the cumulative risk of cancer with each type of test.

It also estimated that 1/3 of CT scans are unnecessary and that by limiting CT scans to when it is truly needed would reduce the number of cancers by 43%.

From an ENT standpoint, common diagnostic tests that expose patients to radiation include CT scans of the head, facial x-rays, and neck x-rays.

Why would kids get such scans done?

CT scans are often performed to evaluate for sinusitis as well as to figure out what is causing chronic headaches. Neck x-rays are often done to evaluate for adenoid hypertrophy while facial x-rays are done after facial trauma to look for a nasal fracture.

It is my personal bias to avoid such diagnostics tests if at all possible, ESPECIALLY because there are alternative options.

Nasal endoscopy can be performed to evaluate for sinusitis as well as adenoid hypertrophy thereby making unnecessary the need for neck x-rays as well as CT scans. X-rays to evaluate sinusitis is NEVER indicated as it is wrong 50% of the time (click here for more info on this).

Nasal fractures are easily appreciated on exam thereby making unnecessary facial x-rays. In cases of trauma, an x-ray can be considered from a purely medico-legal documentation standpoint, but is not really necessary from a medical standpoint. Read more here why.

Read a story about this in Reuters and in the LA Times.

The Use of Computed Tomography in Pediatrics and the Associated Radiation Exposure and Estimated Cancer Risk. JAMA Pediatr. 2013;():1-8. doi:10.1001/jamapediatrics.2013.311.

Computed Tomography — An Increasing Source of Radiation Exposure. N Engl J Med 2007; 357:2277-2284November 29, 2007DOI: 10.1056/NEJMra072149

Children, computed tomography radiation dose, and the As Low As Reasonably Achievable (ALARA) concept. Pediatrics. 2003 Oct;112(4):971-2.

Surgery Costs for Self-Pay Patients

Surgery is expensive... there are no doubts about that. However, there are a few things a patient without insurance who desires surgery can do to minimize the costs as much as possible. Before going into cost-cutting measures, you first need to understand where the costs come from.

In rank order, the costs of surgery come from (highest to lowest):

• Hospital Charges (MOST expensive charges)
    a) Use of OR Room
    b) Paying the Circulating Nurse
    c) Paying the Scrub Nurse
    d) Paying for the medications used during surgery including anesthesia
    e) Paying for the OR room cleaning
    f) Paying for administrative overhead
    g) Use of surgical instruments including cleaning/sterilization after use
    h) All disposable used for the surgery (ie, masks, drapes, wires, IV tubing, gauze, etc)
• Anesthesiologist Fees (excluding anesthesia medications)
• Surgeon's Fees (LEAST expensive charges)

The hospital charges run into the many thousands of dollars (typically charges start at around $3000 and goes up from there). The surgeon's fees can be as low as $100 to around $1000 depending on the surgery. The anesthesia's fees are between the hospital charges and the surgeon's fees (yes... anesthesiologists are paid similarly or more than the surgeons per case).

So now that you know where the costs come from, what are some ways to reduce them? Please be aware that the surgeon has no control/authority/influence over the anesthesia and hospital charges which the patient needs to individually deal with each separately.

• Have the surgery done in an Ambulatory Surgery Center if possible. Oftentimes, the costs are almost 50% lower than the same surgery done in a hospital. If possible, the hospital charges can be completely avoided if the surgery is done in the surgeon's office.
• Ask the hospital about self-pay discounts/payment plans.
• Ask the surgeon about self-pay discounts/payment plans.
• Ask about further fee discounts if the total cost is paid all at once up front in cash rather than a payment plan.
• DO get referred by a free clinic if your income level qualifies you. Free clinic referral pretty much means (for most patients), the care including surgery will be provided completely for free. Fauquier County residents have one here.
• If possible, request only local anesthesia which is cheaper than MAC anesthesia (twilight anesthesia) which is cheaper than general anesthesia which is the most expensive.
• Request medication samples (ie, antibiotics for after surgery).

January 02, 2011

Cocaine the Soft Drink Being Sold in the United States

It was a little bit disturbing to me when I found out there is a soft drink being sold in the United States called "Cocaine". Made by Redux Beverages, LLC, they have a very aggressive marketing campaign using the tagline "Cocaine is a hell of a drug!" with a website, YouTube channel, Twitter feed, and a Facebook page (over 3500 fans).

It is marketed as an energy drink high on caffeine and packs 750 grams of taurine like most energy drinks. Unlike Four Loko (pulled off the market), it contains no alcohol.

Even in spite of the warning label on the can:

"WARNING: This message is for the people who are too stupid to recognize the obvious. This product does not contain cocaine(duh). This product is not intended to be an alternative to an illicit street drug, and anyone who thinks otherwise is an idiot."

What's next?

An orange juice called "Marijuana"?

Bottled water called "Roofie"?

Labeling benign food/drink items with illicit drug names is a travesty and should be banned. In essence, such illicit drugs are receiving free advertisement and can desensitize children to how dangerous these drugs are given the sugar-coating and flippant warning and potentially lead them to become users later in life.

Given the restrictions on cigarette ads imposed by law, I shudder to think when cigarette companies get wind of this marketing ploy and start producing water called "Malboro" and a candy bar called "Camels" as a form of indirect advertisement to get around the restrictions.

Remember the cigarette candies of the 1970s - 1990s now banned in many countries?

Illicit drug names should go the way of the Dodo as well...

Simple Rubber Device Mimics Complex Birdsongs & Implications for Human Voice

A team of US researchers at Harvard has developed a simple rubber device composed of two pieces of rubber replicating the 'vocal tract' and a motor that replicates the action of a contracting muscle. With this device, the researchers have been able to EXACTLY mimic the birdsong of a variety of species including the bengalese finches and vireos.

Given complex birdsongs have been faithfully reproduced with such a rudimentary device as shown here, it does suggest that complex neurologically processes are NOT required. In reality, physics is all that is needed with just a little brain power.

You can listen to samples of birdsongs produced by the device here (halfway down the page).

If birdsongs can be replicated with such a simple device, just maybe, better vocal cord devices can be created for humans who have lost the ability to produce a clear voice.

Humans can lose the ability to talk/sing clearly due to cancer, papillomas, scarring, paralysis, etc. Although research on vocal cords is active, I'm not aware of any projects pursuing complete replacement with a biological equivalent of the rubber band. In fact... I'm not aware of any research project being pursued to create the biologic rubber band in the first place.

If you read any textbooks describing the vocal cords, it does seem mind-numbingly complex which perhaps explains why researchers have been discouraged from pursuing this line of inquiry.

But, if it can be done for birdsongs whose vocal cords are anatomically similar to humans, than theoretically, a simple rubber band device can also be created mimic-ing the human voice. This does sound like a fun high school science project the more I think about it.

Once that has been achieved, the physical characteristics of this rubber band can be broken down and than replicated by biochemists to create a biologic equivalent (or biologically inert) rubber band which can than be transplanted into a human with a damaged vocal cord.

Even to just more faithfully replicate a human voice would be a boom for those whose voiceboxes have been completely removed due to cancer (laryngectomy). Current replacement talking devices sound like a robot using state-of-the-art electrolarynx. Watch video below:

Just a thought that I am sure is easier said than done.

Read the full article in the BBC here. Research paper on this topic to be published in near future.

Anesthesia Sleep is Actually a Coma and Implications for Snoring Evaluations

On December 30, 2010, the New England Journal of Medicine published a paper titled "General anesthesia, sleep, and coma". The article goes on to describe normal sleep as well as sleep induced by anesthesia at time of surgery. What researchers have found is that anesthesia-induced sleep actually is more like a deeply unconscious coma patient than someone sleeping.

This actually makes sense to me... When a person sleeps, they can be aroused if noxious stimuli is introduced causing the person to wake up... and most likely yell at the person trying to wake them up. However, in a coma patient, the person does not "wake" up no matter what is being done to them.

During surgery, the last thing you want is for the person to wake up. As such, a coma-state would be preferred rather than a true sleep state.

This finding does have implications for snoring research as there have been several papers (see references below) in the recent past that proposed the use of anesthesia in order to pinpoint where a person's snore is coming from.

Why would this exam be helpful at all? Because one could perform a variety of endoscopic evaluations while a patient is sleeping (or rather coma) to find the culprit tissue vibration causing the snore. Is it the soft palate or nose or tongue or voicebox or a combination of factors? Such an exam is not possible if the person is "sleeping" as they would just wake up.

Without knowing where the snoring is coming from, treatment is at best a good guess.

This sleep research does potentially cause one to pause and wonder whether an exam of snoring during anesthesia is an accurate portrayal of snoring during sleep.

After all... a coma is not the same as regular sleep. It does follow that potentially, snoring during a coma is not the same as that found in regular sleep which would invalidate any exam findings regarding snoring localization.

In fact... I wouldn't be surprised if snoring sources found during anesthesia-induced coma is more severe (and potentially different) than that found during regular sleep and may needlessly lead the surgeon to pursue more aggressive snoring surgery than truly required.

Clearly, more research is needed. Indeed, in one paper published back in 1998, snoring was produced during anesthesia in 45.3% of non-snorers and could not even be produced in 18.1% of snorers!!!

General anesthesia, sleep, and coma. N Engl J Med. 2010 Dec 30;363(27):2638-50. Press Release

Validity of sleep nasendoscopy in the investigation of sleep related breathing disorders. Laryngoscope. 2005 Mar;115(3):538-40.

Acoustic parameters of snoring sound to compare natural snores with snores during 'steady-state' propofol sedation. Clin Otolaryngol. 2006 Aug;31(4):341-2; author reply 342.

Propofol-induced sleep: polysomnographic evaluation of patients with obstructive sleep apnea and controls. Otolaryngol Head Neck Surg. 2010 Feb;142(2):218-24.

The value of sedation nasendoscopy: a comparison between snoring and non-snoring patients. Clin Otolaryngol Allied Sci. 1998 Feb;23(1):74-6.

January 01, 2011

Should You Have Surgery Far From Home???

I am in the fortunate position of seeing patients who live locally as well as a handful who travel across one or more state lines to see me on a weekly basis, as well as the sporadic few who come from even other countries.

When patients travel great distances to see a doctor, this puts the physician in a particularly humbling position. However, it also places additional strain on how care can be provided efficiently and reasonably when geography logistically makes it difficult.

To begin, why would a patient even want to travel great distances to see a doctor? The basic answer is due to the perception that they would receive better care than can be obtained locally. If true, such long distance travel is justified. After all, if you have thyroid cancer and there are no surgeons who can remove this cancer, than by all means, travel is merited.

However, too often, I see patients travel great distances to see a surgeon due to the perception that this one particular doctor is better than the one found locally, EVEN if the local surgeon is quite competent. Here is where the decision to travel becomes... well... less logical, especially if the surgery is for a routine problem.

IF there's a local competent surgeon, I feel it is ALWAYS better to get the surgery done locally. Why? Because if there's any problems after the surgery, it can be easily addressed quickly and with minimal fuss. If the surgery was done hours away, think of the travel, expense, missed time from work, etc NOT just for the surgery, but for any post-operative problems that develop. Oftentimes, the patient concern ends up being unfounded and only reassurance is required, but in order to make that determination, the surgeon needs to do an exam. Imagine the frustration of the patient when a surgeon requests a visit before answering a question about a post-surgical concern... hours of driving to the office, waiting in the exam room, being seen by the surgeon for a few minutes only to hear that everything is fine and normal, and finally driving hours back home.

Even in the hands of the BEST surgeon, problems can arise after surgery. Is the surgical wound becoming infected? Where is that fever coming from? There's a little drainage occurring... is that normal? Why is the skin red? There's a lot of pain and his medications aren't working.

To complicate things further, narcotic pain killers can NOT be called in by federal rules. A hardcopy prescription is required. Now, wouldn't that be mighty inconvenient if a patient (who mind you is in pain), needs to drive hours to the surgeon's office just to pick up a hardcopy narcotic prescription.

The logistical difficulties of dealing with post-operative care after patient discharge is tremendous for both the surgeon as well as the patient if the distance between the two is large.

Now when should a patient travel to have their surgery done?

DO travel to see a surgeon when your local surgeon feels it imperative that you do so either due to the complexity of the problem or inexperience. Especially, if the local surgeon is well-respected and honest. This serves two purposes... you get the surgery done by the best possible... AND, if any problems develop after surgery, your local surgeon is in the loop and can probably handle most routine post-surgical concerns.

I should state that I HAVE performed surgery in patients who live hours away (some even an airflight away) but I ALWAYS encourage patients to try and get the surgery done locally if at all possible due to the reasons stated above. If a competent local surgeon is not available, than that's fine. But if competent local surgeons are present... I do my best to steer patients to get the surgery done locally as it IS for the patient's best interest.

I have also referred patients to other surgeons a long drive away due to one reason or another, even if the patient desperately wants me to do the surgery. I'll be the first to admit if I lack experience to address a given problem. I also follow-up in stating to the patient that if there's any problems that occur after the surgery, to please return to see me rather than making a long-distance trip as there's a good chance I'll be able to address the concern. Everyone wins this way.

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