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February 28, 2011

Septal Stapler for Septoplasty Surgery

Septoplasty is a surgical procedure whereby the septum, which is the wall that separates the right and left nasal cavities, is straightened out. Read more details of the surgery here.

During this surgical procedure, it is not uncommon for ENT surgeons to place splints and/or packing to bring the septum back together after the procedure is performed. Other surgeons avoid placing splints/packing by suturing the septum together.

A relatively new device called the ENTact Septal Stapler is yet another way to get the septum back together after straightening. I tried this device a few years ago, but stopped due to some instrument shortcomings. However, the company has made a few improvements that has made me reconsider trying it.

Check out this video animation on how this device works.

Watch how septoplasty is performed.

February 27, 2011

The Doctors TV Show Does the Mouth

The Doctors TV actually got something totally right!

Actually there are two segments here... One on the mouth followed by another on what happens when food/liquids go down the wrong way causing a reflexive cough.


February 26, 2011

Baby Shampoo Used to Treat Chronic Sinusitis

Yes... It's absolutely true! There's even research on this (limited).

The mixture ratio is 1/2 teaspoon of Johnsons No-Tears Baby Shampoo in 8 ounces of saltwater rinsed into the nose using a sinus rinse bottle can help with chronic sinusitis, especially when there's a lot of crusting present and to which all other therapies have failed to resolve.

The shampoo appears to work via several mechanisms theoretically:

1) It is directly toxic to germs
2) The soap action helps break apart crusting (similarly to the way detergent gets rid of mud from a kid's shirt in the washer)
3) The soap also helps break down and remove biofilms in the sinus cavities which tends to resist antibiotics and cause recurrent sinus infections (just like dishwasher fluid gets filmy food residue off plates)

For saline flushes, the NeilMed Sinus Rinse bottle is recommended for two reasons.

The black cap of the bottle is about 1 teaspoon... and the bottle itself is 8 ounces.

So, for the particularly difficult chronic sinusitis infection patient who has tons of crusting for which all other treatments have failed, the saltwater is made up as per routine using the NeilMed Sinus Rinse bottle, but than to also add 1/2 capful of the Johnson's No-Tears Baby Shampoo as well before use.

They are to flush their nose twice a day for a few weeks.

Baby shampoo nasal irrigations for the symptomatic post-functional endoscopic sinus surgery patient. Am J Rhinol. 2008 Jan-Feb;22(1):34-7.

Miscarriage During Pregnancy Is Murder Committed by the Mother (According to One Lawmaker)

I know... I know... I'm an ENT, so why am I doing a post on miscarriages? Well, I could not help myself given how outlandish this is... And I did put a picture of a pregnant woman who is smoking and smoking is an ENT problem!

In any case...

So most people in the United States would not bat an eye regarding how abortion can potentially be considered murder.

Most people also would agree with the idea of involuntary manslaughter if a person died due to acts of recklessness or criminal negligence committed by another individual.

Which now goes to the title of this post...

If miscarriage can be shown to be due to "recklessness" or "criminal negligence" of the mother committed against her unborn fetus, is that involuntary manslaughter? For example, if the mom decides to get up to go to the bathroom when told to be on bedrest and a miscarriage occurs, is that manslaughter?

Or what if an uninsured pregnant woman forgoes appropriate prenatal care or is caught smoking during pregnancy (reckless behavior) and miscarries, is that manslaughter?

Such actions can even potentially be considered voluntary manslaughter if it can be proven the mother deliberately committed acts that she knew may potentially by harmful to the fetus. Even if no harm ultimately came to the fetus, it could potentially be considered attempted "assault" and "battery" with the appropriate criminal charges dependent on the degree.

Well, Georgia State Rep. Bobby Franklin, a Republican from Marietta, Georgia, has introduced a 10-page bill (HB 1) earlier this year, that would criminalize miscarriages, making abortion and miscarriage ("prenatal murder" in the language of the bill) potentially punishable by death.

In essence, according to this bill, women who miscarry could become felons if they cannot prove that there was "no human involvement whatsoever in the causation" of their miscarriage. The burden of proof is on the mother.

Furthermore, the bill holds women responsible for protecting their fetuses from "the moment of conception" even though I do believe pregnancy tests aren't accurate until at least 3 weeks after conception.

Now, I'm not an obstetrician, but I do believe most miscarriages occur because the fetus is not developing normally from inherent factors and not external acts.

I'm not exactly sure how the State of Georgia will enforce this legislation if it passes (which I hope won't happen).

The USA is in the midst of spiraling healthcare costs due to defensive medicine being practice by doctors to prevent lawsuits against them. Now think about what would happen if this legislation passes...

Read news article about this here.

Do Cell Phones Pose a Health Hazard? Do Cell Phone Companies Know About Them?

With all the recent news about increased glucose metabolism in the area of the brain in proximity to cell phone antennas (study abstract here), I thought it worth re-printing this blog article I wrote back in November 2010 regarding the possibility that cell phone makers may know more about health risks associated with cell phone use than they may be letting on. There's another blog article I wrote regarding what studies ARE already out there regarding risk of developing brain tumors that I felt worth re-printing below as well.

It is true that some people may find this recent research good news for some young people as it may be the only stimulation their brain gets (joking!), but it does bring some additional concerns that may merit limiting cell phone use as well as how it is used.

I quote (myself)...

Recently, there has been much speculation on whether cell phones pose a health risk.

What I find interesting is that the cell phone makers may actually know more about these risks than they are letting on or even have evidence for them.

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. The picture of how the Verizon ad guy is using the cell phone is exactly how you are NOT supposed to use the cell phone (cell phone pressed against the face).

For example, in the iPhone 4 small print booklet that comes in the box with the phone, go to page 5 under the section "Exposure to Radio Frequency Energy." I quote:
"When using iPhone near your body for voice calls or for wireless data transmission over a cellular network, keep iPhone at least 15 mm (5/8 inch) away from the body, and only use carrying cases, belt clips, or holders that do not have metal parts and that maintain at least 15 mm (5/8 inch) separation between iPhone and the body."
Now, when I use a phone and answer a call, I have the phone right up against my ear just like the Verizon ad guy. I do not keep it 5/8 inch away from my ear/head.

Now why would a cell phone maker care whether the phone is right up against the ear (so you can hear better) or not unless there is some concern that there may be a danger due to proximity/contact?

Perhaps they are protecting themselves from any possible lawsuit that may occur in the future due to health problems that will occur with phone use over time?

Kind of reminds me of the tobacco industry who for years denied that smoking posed any health risk. Now we know better.

It would be ironic if Paul Marcarelli, the actor of the "Verizon Guy" character, develops a brain tumor due to cell phone use and sues the wireless industry just like the family of David McLean, the actor of the "Malboro Man," sued the tobacco industry for wrongful death when he developed and died from lung cancer caused by smoking.

Something to think about...

So are there studies out there suggesting that cell phones and wireless phones can lead to brain tumors like astrocytoma, malignant gliomas, and benign acoustic neuromas? Several 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 should be noted that 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 (which it seems to be nearly all kids nowadays).

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, especially in children.

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

Effects of cell phone radiofrequency signal exposure on brain glucose metabolism. JAMA. 2011 Feb 23;305(8):808-13.

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.

February 22, 2011

Diagnosing Smell and Taste Disorders

This article is reprinted with kind permission from Dr. Robert Henkin of the Smell and Taste Clinic located in Washington DC.

Answers to the Four Questions Required to Determine Cause of Smell and Taste Disorders: 

Question 1. DETECTION THRESHOLD – Can you detect the least concentrated stimulus from among three presented stimuli – two of which are either water (tastants) or neutral (odorants) and one of which is different?

This answer tells us of the presence and character of functioning taste and/or smell receptors. If this threshold number is higher (less sensitive) than normal then the patient requires more tastant or odorant than normal to stimulate taste and/or smell receptors. If the number is higher than normal then the patient has lost sensory receptor function due to some pathology.

Question 2. RECOGNITION THRESHOLD – Can you recognize correctly the different stimulus you just detected?

This answer tells us of the interaction between taste and/or smell receptors and the brain which processes this information. If the threshold number is higher (less sensitive) than normal then the patient requires more tastant or odorant than normal both to stimulate receptors and for the brain to process the sensory information correctly. This means that the patient has either lost sensory receptor sensitivity and/or has brain impairment which inhibits processing of the sensory stimulus due to some pathology.

Question 3. MAGNITUDE ESTIMATION – Can you judge the intensity of the correct recognition you just made using a scale from 0-100?

This answer tells us of the number of functioning taste and/or smell receptors. Taste and smell receptor activation involves a “field effect”; the larger the field, the more functioning receptors, the higher the magnitude estimation number. Thus, if the magnitude estimation number is lower than normal then the receptor number (taste and/or smell) is diminished and indicates pathology of the sensory system related to decreased receptor number.

Question 4. HEDONIC ESTIMATION – Can you judge the unpleasantness on a scale of -100 – 0, or pleasantness on a scale from 0 – +100, of the stimulus you just correctly recognized?

This answer tells us of the interaction between sensory receptor and the brain with respect to intensity of distortions of the sensory stimulus. This test uses a scale from 0 - −100 to indicate unpleasantness and a scale from 0 - +100 to indicate pleasantness. If a sweet tastant stimulus is considered unpleasant (e.g., -50% at a moderate concentration of sucrose, 300mM) then this response indicates a sensory distortion and thereby pathology of the taste system. Similarly, if the fruity odorant stimulus of amyl acetate is considered unpleasant (e.g., -50% at a moderate concentration of 10-1M) then the response indicates a sensory distortion and thereby pathology of the smell system.

By use of answers to these four questions it is possible to determine the nature and character of the pathology affecting taste and smell dysfunction. Answers to each of these questions are essential to determine this pathology.

These tests are used at The Taste and Smell Clinic in Washington, DC to determine the nature and character of sensory abnormalities of patients with taste and smell dysfunction. Only by use of this entire test battery can the nature and character of sensory dysfunction be determined. Simpler tests cannot fulfill this requirement.

Dr. Robert Henken
The Taste and Smell Clinic
Phone: (202) 364-4180

An open label controlled trial of theophylline for treatment of patients with hyposmia. American Journal of the Medical Sciences. Vol. 337, pp. 396-406, 2009.

New Video of Phlegmy Throat

In this video, the patient suffered from a severe phlegmy throat after suffering from a stroke. His secretions did not pass down to his stomach, but rather collected in his throat causing constant throat-clearing and coughing up clear phlegm.

As you can see in the video, there is a tremendous amount of mucus pooling present.

Treatment was geared toward improving his swallowing function so that his secretions would not collect in his throat.

If you are not sure what normal is supposed to look like, click here.

February 21, 2011

Oral Sex Causes More Oral Cancer Than Smoking!

HPV may now be overtaking tobacco as the leading cause of oral cancers in America in people under age 50.

And HPV, otherwise known as Human Papilloma Virus responsible for gential warts and cervical cancer, finds it way into the mouth via oral sex.

The latest data suggest that 64% of oral cancers are caused by HPV, which is more than tobacco causes. Furthermore, as the number of partners on whom you have performed oral sex goes up, the risk of oral cancer goes up.

These findings were presented by scientists this past Sunday at the American Association for the Advancement of Science annual meeting.

Hopefully, these results will be formally published soon, but you can read the story on CNN for now here.

Read more about oral masses in general here.

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

Related References:
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.

February 20, 2011

The King's Speech and Those With Spasmodic Dysphonia

The film "The King's Speech," nominated for Oscars in 12 categories for the 83rd Annual Academy Awards hits home for many who suffer from stuttering. However, I am sure this story also has empathetically affected those patients who suffer from spasmodic dysphonia.

What is spasmodic dysphonia?

Think of it as stuttering of the voicebox where the words get stuck in the throat level rather than the mouth level.

Both conditions result in patients severely limiting their social engagements and cause tremendous stress when communicating with others.

Many people know what stuttering sounds like... Now listen to what spasmodic dysphonia sounds like here in this video. This video also shows how spasmodic dysphonia is treated with botox injections to the vocal cord. Such injections calm the spasms down so that the person is able to speak almost completely normally for at least 3 months until the botox wears off and it needs to be repeated.

Botox injections for spasmodic dysphonia as well as other conditions are performed by Dr. Chang every week.

How a Grizzly Bear Can Help Patients

Scientists recently figured out exactly what happens to a bear when they hibernate... For SIX to SEVEN MONTHS...

- Their metabolism decreases by 75%. The breathing and heart-rate also decreases
- Their body temperature stays the same
- They do not produce urine or feces
- They do not eat or drink
- Bone strength remains the same
- Their muscle mass and strength remains the same

Now, lets take a look at humans, especially those who are bedridden in a hospital in the intensive care unit. Over a matter of days:

- Muscle mass and strength starts to decrease
- We still produce urine and feces
- We develop bed-sores
- We still require water and food
- Our bones start to weaken
- Our metabolism also decreases, but at the detriment of all other body functions

If somehow we can translate what a hibernating bear does to human beings, that would be amazing in terms of healthcare cost savings AND patient well-being. Imagine being put into a hibernating state while doctors cure your cancer or you recover from surgery or a major illness. Imagine paramedics inducing a hibernating state in a major trauma victim of a motor vehicle accident.

Once your illness, surgery, cancer, or whatever has been cured, you "wake" from your hibernation fully functional without any deterioration in muscle/bone mass or strength. You would literally be able to wake up and go home as if you just woke from a nice long sleep.

From a hospital standpoint, the cost-savings would be enormous. No need for feeding such hibernating patients. The entire field of physical therapy and orthopedics would be dramatically reduced given bones would be stronger with less risk of fractures.

Hibernation would be a natural sleep as opposed to anesthesia which is more akin to a coma.

In terms of ENT, adults can theoretically elect to go into a hibernating state after a tonsillectomy so they would not have to experience the horrible pain that lasts for 2-3 weeks.

Read more about the amazing hibernating bear on NPR news here.

February 19, 2011

Boy With Missing Cerebellum & Pons Learning to Walk!

First off... the cerebellum and pons are part of the brain that is responsible for some very important things like balance, breathing, regulating blood pressure, heartbeat, etc.

So one would think that without a cerebellum or pons, life would not be possible.

Well... it seems that may not be quite true.

You see, there's a young boy missing those parts of the brain who not only is living without mechanical assistance, but eventually managed to sit up on his own, something he shouldn't have been able to do without a cerebellum to provide balance. Next he learned to crawl, first dragging himself military-style, then pushing himself upright. Now, he's learning to walk.

A true medical mystery.

Read more here.

How is Love Like Dizziness? Medically Speaking...

I watched this touching video of what it is like to fall in love... that very moment when you see the love of your life for the first time... and the world falls away. Time slows down. That feeling of elation, passion, love overwhelms. Time stands still. Everything else blurs out except for him/her...

Now from a medical perspective, how can we test this? If "love" is considered a disease, how can we positively "diagnose" this? How can a doctor touch, see, feel, measure "love" and the severity of this affliction when all the symptoms are felt on the inside?

The simple answer is you can't. Similarly, dizziness is a problem that like love, can't be seen, touched, measured by the doctor very easily. Unlike tonsillitis where all a doctor has to do is look in the mouth and "see" the infection, we can't do the same for dizziness.

The way a physician approaches a sensation that is only felt by the patient, but no other is via several steps.

A good history. That's why when a patient with dizziness comes to a doctor's office, we ask a lot of really picky questions as it helps narrow down the possibilities. This step is just like when a friend asks exactly what you felt when you first saw the love of your life.

- What does the dizziness exactly feel like? Spinning, fainting, rocking, drunk, etc???
- Exactly how long does an episode last for? Seconds, minutes, hours, days, weeks, months???
- Can it be triggered? Turning, bending, walking, etc???

Click here for a dizziness flowchart based on answers to these and other similar questions.

Based on the history, additional testing may or may not be required. If a doctor was trying to decide if a patient was afflicted with "love", a good history may be all that is required. However, if the doctor is not quite sure, he/she may want to get an EKG to measure the pulse to ensure no supraventricular tachycardia arrhythmia ("When I see John, my heart races"), MRI scan to ensure no brain tumor (causing symptom of time standing still), ophthalmology exam ("Everything else seems to blur out except for John"), etc.

Just like for "love", a similar type workup needs to be pursued for dizziness depending on how the dizziness exactly felt like and may include audiogram, EKG, bloodwork, ENG, cardiac ECHO, 24 hour holter, 30 day cardiac event monitoring, pulmonary function tests, carotid ultrasounds, MRI/CT scans, EEG, chest-x-rays, allergy testing, tilt-table test, etc. As such, one may need to have an evaluation by a neurologist, cardiologist, ENT, pulmonologist, endocrinologist, etc to uncover the cause of your specific dizziness.

Once the cause is determined, treatment is based on addressing that specific diagnosis. As one can see, the human body's sense of balance is actually extremely complex making dizziness one of the most difficult symptom to diagnose and treat.

"Love" would be similarly difficult to diagnose with absolutely certainty if it was considered a disease as well. Based on symptoms alone (without history), love could potentially be confused with fear, anger, hate, etc.

February 18, 2011

Stabbing Headaches??? Maybe It's A Knife in the Head...

At least it was for one patient who suffered stabbing headaches for 4 years after being mugged... and another due to a nailgun accident who complained mainly of a toothache...

As unbelievable as it sounds, neither patients realized they had a knife/nail in their head until an x-ray was done showing the culprit.

Read more in the LA Times story here.

Read the MSNBC story here.

February 17, 2011

U.S. Marshals Seize Auralgan Otic Solution (Unapproved FDA Medication)

Auralgan Otic Solution, a prescription drug used to treat pain and inflammation associated with ear infections, was being distributed in violation of federal law because the product does not have FDA approval and its labeling does not include adequate directions for use.

On Feb. 5, 2010, the FDA issued a Warning Letter to Deston, the maker of Auralgan, citing the company for distributing unapproved new drugs and misbranded drugs.

As such, on Feb 15, 2011, US Marshals seized all lots of Auralgan Otic Solution warehoused at Integrated Commercialization Solutions Inc. (ICS) in Brooks, KY.

Read the FDA notice here.

February 16, 2011

Ear Pain Due to Tooth... In the Ear Canal!

The Daily Mail published a story about a patient who suffered from right ear pain since the age of 14 that ultimately was found to be due to a tooth in the ear at the age of 47 years!

Removal of the tooth resolved his long-standing ear pain. It was also the last tooth to get removed as he had all his teeth inside his mouth removed years ago.

Based on the size, it is conjectured to be a baby mandibular front incisor.

My theory? Either he or some other kid put the tooth there and than forgot about it... It happens!

Read this interesting story here.

Read about other causes of ear pain here.

New Anti-Snoring Device... aveoTSD

I received in the mail today a new device called aveoTSD anti-snoring aid by Glidewell Laboratories.

According to the literature, the way it works is by advancing the tongue forward thereby preventing the tongue from falling backward and vibrating against the throat's back wall causing snoring as well as obstructive sleep apnea.

The way the device moves the tongue forward is by literally suctioning the tongue tip into the device and holding it in place by vacuum seal.

The theory behind how this device works is sound and mimics what an oral appliance does as well as several surgical procedures including base of tongue reduction, hyoid advancement, and Repose procedure.

The one caveat I have with this device is that it only resolves snoring due to the tongue. It would not necessarily address snoring that comes from the nose or palate. There are other devices/surgeries that would address those areas (breath-rite strips, Pillar procedure, UPPP, septoplasty, etc).

I lied... there's another caveat... Will the suction vacuum hold all night for a patient??? It does come in several different sizes... but still...

Read more about the aveoTSD here.

Read more about snoring here.

1 Out of 5 Kids With Viral URI Develop Ear Infections

According to a study published in 2011, more than 20 percent of young children with colds or other respiratory viral infections will develop middle ear infections of varying severity-including some mild infections.

This finding is not really that surprising. Even adults have ear symptoms with a viral URI including ear fullness and difficulty popping the ear. Though adults do what they can to keep the ears clear by valsalva, swallowing, chewing gum, yawning, or proactive ear popping, kids may not even know what to do when their ear feels full or otherwise abnormal let alone blow their nose.

When the ears are not ventilating properly whether in adults or kids, it leads to ear problems including fluid buildup and even infections.

Why does this occur?

With a viral URI, the mucosal lining of the nose gets swollen leading to symptoms of runny nose, nasal congestion, and even nasal obstruction. However, this mucosal swelling does not just occur in the nose, but the eustachian tube as well which connects the back of the nose to the middle ear space. When the ear "pops", what one is doing is opening up the eustachian tube to allow pressure and fluid to drain from the ear into the back of the nose. That's why yawning, swallowing, or nose-blowing causes an ear pop normally.

When the eustachian tube mucosal lining swells up, it utterly blocks the tube preventing ear popping leading to symptoms of persistent ear pressure, clogging, fullness, fluid buildup and eventually even ear infections.

Read more about eustachian tube dysfunction here.

Clinical Spectrum of Acute Otitis Media Complicating Upper Respiratory Tract Viral Infection. Pediatric Infectious Disease Journal: February 2011 - Volume 30 - Issue 2 - pp 95-99 doi: 10.1097/INF.0b013e3181f253d5

February 15, 2011

Not All Facial Fractures Require Repair... Ask Anaheim Duck's Getzlaf

Anaheim Ducks forward Ryan Getzlaf suffered multiple nasal and sinus fractures when he took a puck to the forehead during a win over Phoenix on December 28, 2010.

He visited a maxillofacial surgeon and had a CT scan which revealed those fractures were non-displaced and stable. A further evaluation determined that the bone breaks remained stable and that surgery was not be required.

This case illustrates that most facial fractures do NOT require surgical repair.

The key elements that lead towards a decision for surgery are the following (not all-inclusive, but general pointers):

- Any functional deficit including inability to open and close the jaw.
- Change in your occlusion (the way your teeth come together).
- Double vision (blurry vision does not count).
- Cosmetic deformity due to facial fracture (bruising and swelling does not count).
- Change in your ability to breath.

The two main specialties able to assess whether surgery is required or not is ENT and Plastic Surgery as well as some oral surgeons.

Read more about Ryan Getzlaf's injuries here.

February 13, 2011

Fauquier Hearing Aid and Hearing Testing Services Offered at Fauquier ENT

Even though our office has been offering hearing tests and hearing aid services in Fauquier County for over a decade, many people are still surprised when they learn they can get hearing tests, hearing aids, ear plugs, and other ear & hearing services in our office. The additional benefit is having a ENT specialist also present in the same office.

Furthermore, we offer a comprehensive suite of other related services including non-sedated ABR (auditory brainstem response) hearing testing to specialized custom ear plugs for hunters and musicians.

We evaluate all different ages from 1 day old infants to the 99 year old hearing impaired patient.

The full list of Fauquier Hearing services we provide include:

Comprehensive Hearing & Audiometric Evaluations
  • Hearing Testing from Birth to Adult
  • Newborn Hearing Screening and Follow-up
  • Otoacoustic Emmission Testing (OAE)
  • Auditory Brainstem Response Testing (ABR)
  • Tone Burst Auditory Brainstem Response (TB-ABR)
  • Bone Conduction ABR Auditory Brainstem Response (BC-ABR)
  • Auditory Steady State Response (ASSR)
  • Electrocochleography (ECoG)
  • Central Auditory Processing Evaluations (CAPD)
  • Hearing Aid Evaluations and Consultation
  • Hearing Aid Dispensing
  • Advanced Digital and Wireless Hearing Aid Technology
  • Aural Rehabilitation Counseling
  • Hearing Aid Service and Repair
  • Hearing Aid Accessories and Batteries
  • Resources for Parents of Deaf and Hard of Hearing Children
  • Electronystagmography (ENG)
  • Vestibular Evoked Myogenic Potentials (VEMP) for Meniere's Disease
  • Vestibular Rehabilitation Counseling
  • Canalith Repositioning 
  • Custom Swim Plugs
  • Custom Hearing Protection
  • Musicians Filtered Earplugs
  • Earplugs for Hunters
  • Custom Earmolds for iPods, Cell phones, Headsets
  • Assistive Listening Devices and Technology 

For more information, please go to our webpage here.

February 12, 2011

New Video Produced on Non-Sedated ABR/OAE Testing

Our office has produced a new video on non-sedated ABR/OAE hearing testing. Such testing traditionally required sedation as the patient was required to be absolutely still and quiet in order to obtain accurate test results. However, new technology now enables such testing to be performed without sedation. Furthermore, given the testing can be performed wirelessly, the patient can stand and walk around. Absolute quiet is also no longer necessary and the patient can actively play and even eat while testing is going on.

Read more about non-sedated ABR/OAE testing here.

Watch the video here.

How to Unclog a Clogged Ear

First, one needs to know what is causing the clog before proper treatment can be initiated. There's a few assumptions here before proceeding.

• You have no ear problems typically
• There is no "pain" per se other than perhaps a pressure type pain. If there's actual PAIN present, you most likely have an ear infection and this article does not apply to you.
• You currently have no other symptoms (ie, sinus or nasal problems). An upper respiratory infection or sino-nasal problem may have triggered your ear problem, but you no longer have those symptoms anymore.
• You are older than 8 years of age.

Step 1:
Examine the ear canal with an otoscope. Look for any blockage like earwax or fluid.

If earwax is found, the first step is to get the earwax out! Although your doctor or an ENT specialist can do this for you, some rather try it at home by attempting to flush the earwax out. My personal at-home earwax flush kit favorite can be found here on

Step 2:
Assuming no earwax is present, the next step is to get a hearing test. Why? The hearing nerve can become damaged causing a sense of fullness or clogged sensation. Click here to read a Washington Post article about this. Treatment must be urgently pursued as there is only a short window of time when medications can reverse the nerve damage (around 4 weeks). After this period of time, there's not much that can be done other than wait and cross-the-fingers.

Step 3:
Assuming there is no earwax and a hearing test revealed no nerve damage, you either have fluid in the middle ear (serous otitis media) or pressure (eustachian tube dysfunction).

Regardless of fluid or pressure presence, the treatment is the same. Click here to read the protocol to fix this problem.

Remember that pressure/fluid buildup in the ear is just like water/pressure contained inside an inflated (water) balloon. It needs to be "released" in a physical manner. There is no "pill" that can automatically do this for you. Watch video explanation. Read more about this here.

Mythical Treatments:
There are a couple key points to make if you have reached Step #3.

You do NOT have an ear infection and antibiotics will make little if any difference. Antibiotics help with infections and only infections. It does not get rid of pressure or fluid (ie, throwing antibiotics into a swimming pool will not make the water disappear). Other common myths also need to be dispelled:

• Sudafed and other oral decongestants do not help unless you have nasal congestion and/or runny nose.
• Antihistamines like zyrtec, benadryl, allegra, claritin, etc do not help unless you have other allergy symptoms affecting the nose.
Saline flushes or nasal sprays also do not help unless there are associated nasal symptoms.

Products That Help Pop the Ear Due to Eustachian Tube Dysfunction or Fluid in the Middle Ear:


February 09, 2011

Dr. Chang to Guest Lecture at Shenandoah University

Dr. Christopher Chang will be a guest lecturer at Shenandoah University for a course on Anatomy and Function of the Singing Voice (MUPP 533) on February 9, 2011. The lecture will be held during normally scheduled hours at 5:00 - 6:40PM in Ruebush R209. This particular lecture will focus on Video Laryngoscopy.

The second lecture he will give for the same course will be held on March 23 at 5PM and will focus on Vocal Abuse and Misuse.

February 07, 2011

Is Whispering Bad for Your Vocal Cords???

For most people, the answer is yes according to research publicized in a New York Times article on Feb 7, 2011.

In the mentioned study, out of a group of 100 patients, 69% exhibited increased supraglottic hyperfunction with whispered voice (ie, it was bad for the voice). 18% had no change and 13% had less severe hyperfunction.

As such, though whispering is not bad for everybody, it is for most people and as such, the safest thing to do if the vocal cords are damaged whether by infection or trauma is to rest your voice. If you have to talk, do not whisper, but rather talk in a soft voice.

The best way to think about injured vocal cords is to talk in an analogy. Laryngitis is like a badly sprained ankle. In this scenario, talking is like walking and screaming is like running. So just like you would rest the sprained ankle and not walk on it in order for it to recover as quickly as possible, you should refrain from talking in order for the laryngitis to recover as quickly as possible. Where does whispering fall in this analogy? Probably equivalent to running on a sprained ankle.

Read the NYT article here.

Read more about voice problems here.

Laryngeal hyperfunction during whispering: reality or myth? J Voice. 2006 Mar;20(1):121-7.

February 06, 2011

Video of Monkey Behaving Like a ENT Doctor

All I can say is look at time 0:41 - 1:25 in the video clip below. If you can't see the video below, click here.

Coming soon to an otolaryngology office near you...

“The Who" Roger Daltrey Underwent Vocal Cord Surgery

A story was published in December 2010 about Roger Daltrey's experience with losing his voice and requiring vocal cord surgery literally 6 weeks before he was to sing at the Superbowl February 2010.

Fortunately, under the expert care of Dr. Zeitels at Massachusetts General Voice Center, he was successfully treated and recovered his voice in time to sing during the 2010 Superbowl half-time show in Miami.

Read the story here.

Homeless Man With the Golden Voice

video of Ted Williams, a homeless man with a golden radio voice, has gone viral taking him from the streets of Columbus, Ohio, to the national airwaves in just three days.

If unable to view the video, click here.

Miley Cyrus "I Cut My Uvula"! ...NOT!

I was recently made aware of this video Miley Cyrus made in January 2009 when she reported that she cut her uvula (according to a nurse) after swallowing a slippery piece of chicken causing her voice to sound quite hoarse. Watch the video here:

However, based on how her voice sounds, I seriously doubt that her hoarseness is due to a cut uvula. When the uvula gets cut, or swollen, or gets injured one way or another, it would cause her voice to sound muffled... NOT raspy like her voice sounds. Though it is possible that her uvula may have been injured, it certainly is not the cause of her poor vocal quality.

Rather, I suspect that her voice sounds bad the way it does due to a vocal cord injury. Often, when people swallow a piece of food (like a chicken) that either gets stuck or goes the wrong way, the person automatically coughs severely in order to expel it.

If the cough is severe enough, it'll cause traumatic injury to the vocal cord resulting in a hoarse voice. The injury itself may not be that bad (usually a mild vocal cord submucosal hemorrhage), but the voice does sound bad. Here are two mild examples of laryngitis due to blood accumulation here and here. A more severe example of traumatic laryngitis can be found here.

In this situation, if the person persists and tries (forces) to talk and sound normal in a setting where the vocal cord is injured, compensatory behavior sets in whereby the vocal quality will fluctuate and go in and out as Miley's voice does in the video (listen to an audio of another patient with this problem here). This condition is called "compensatory muscle tension dysphonia," and in her case, secondary to acute traumatic laryngitis.

This diagnosis can be confirmed on fiberoptic laryngoscopy. Treatment is high dose steroids that will bring the swelling down as well as strict voice rest for a few days (depending on severity of the injury). Resolution of her voice would be expected within 1 week with this treatment. Voice therapy may be required, though usually not.

Read more about traumatic laryngitis here.

Read more about muscle tension dysphonia here.

February 05, 2011

New Video on Uvula Excision for Snoring (and Other Problems)

Our office has created a new video on how a uvulectomy (or uvula excision) is performed to treat not only snoring, but chronic cough, throat-clearing, and even gagging due to an extremely long uvula.

Though the procedure can be performed awake without sedation in adult patients without a severe gag reflex, for those with a bad gag reflex, it must be performed under general anesthesia as shown in this video.

For more info on this procedure, click here.

Check it out here!

February 04, 2011

Xyzal and Clarinex Generics Now Available

Xyzal and Clarinex are both anti-histamines used to treat allergies. Both medications are now available as generics by prescription since December 2010. The active ingredient for both xyzal and clarinex are the active stereoisomer of the over-the-counter zyrtec and claritin respectively.

In other words, zyrtec and claritin available over-the-counter contain the same active ingredient found in xyzal and clarinex, but in an "un-purified" state. Still confused? Read this article which probably contains more information than you ever wanted on this subject.

February 02, 2011

Non-Sedated ABR & OAE Now Offered at Fauquier ENT

What is ABR/OAE? ABR (Auditory Brainstem Response) as well as OAE (Oto-Acoustic Emission) are specialized hearing tests that can evaluate whether a child/infant/newborn can hear without requiring them to respond.

These tests are completely non-invasive. Just like an EKG measures a heart's electrical activity using little stickers, ABR/OAE testing checks out the electrical activity from the ear to the brain. Special stickers on the head enable us to "see" whether the brain "hears" any sounds introduced into the ear.

If the ABR/OAE testing comes back normal, rest assured your child's hearing in both ears is normal.

Specifically, OAE is performed by placing an earpiece and playing clicks into the ear. The machine than listens for an echo which indicates that the ear "heard" the clicks.

ABR is performed just like an OAE, but special leads are placed behind the ear and forehead which measures brainwaves (just like an EEG or an EKG) to see if the brain "hear" the clicks produced by the testing machine. There are several different types of ABR (regular, tone burst, bone conduction, ASSR) depending on the age of testing and reason for the testing.

Traditionally, ABR/OAE testing required sedation in order to obtain accurate and reliable results as any muscle activity can lead to false reports. Furthermore, there are a lot of wires going from the patient to the equipment and as such required the patient to stay still. In the case of infants/children, this mandated general anesthesia in a hospital operating room.

Fortunately, new technology that our office possesses eliminates the need for such sedation and still obtain accurate ABR/OAE test results. Our office uses Vivosonic Integrity which incorporates wireless technology and the use of an in-situ bio-amplifier which amplifies biologic electrical activity at the ear source thereby reducing interference from environmental electric, magnetic, and RF field-induced noises. This also dramatically reduces artifacts which result from other muscular and ocular electrical activity.

What does this all mean for a patient?

It means that an ABR/OAE can be obtained in our office on a child/infant who is actively moving and playing around, eating food, chewing gum... all without being attached to wires. No sedation. No medications. No needles. No pain.

Click here for more info.

February 01, 2011

Tonsillectomy Causes Obesity?

MSNBC published a story on Feb 1, 2011 regarding a new study suggesting a link between childhood obesity and tonsillectomy.

What they found was a greater than expected weight gain in both normal weight and overweight children after tonsillectomy over a 6-12 month period of time. In one study, the average body mass index of the kids increased by about 7 percent. In another analysis of 249 children, 50 to 75 percent of kids had weight gain after surgery. While most weight gain happened in the first year after surgery, scientists don't know definitively whether it levels off after that.

What is unclear about this research is whether this common surgery to remove tonsils is contributing to the nationwide "epidemic" of obesity.

Several theories have been proposed:

1) One reason why tonsillectomy is performed is because of difficulty breathing. In this scenario, more calories are expended on trying to breath. After tonsillectomy, all the energy expended on breathing is now being used to gain weight instead.

2) Having difficulty swallowing food due to large tonsils may prevent children from eating very much. In this scenario, after tonsillectomy, the child can now eat without problems leading to eating more and gaining weight.

3) In young and school-age children there's evidence of both a weight gain and a "growth spurt" after tonsillectomy that may be triggered by higher levels of growth factors.

One needs to be careful and realize that this study does NOT prove cause and effect. It suggests a possible association and the only way to know for sure if this common surgery actually causes obesity is to perform a double-blinded, placebo-controlled, prospective study... or at the very least, a prospective study (given it will be near-impossible to have a placebo group and be double-blinded... after all, you can just look to know if the tonsils were removed or not). What will likely end up being true is the fact that obesity is due to a number of factors of which tonsillectomy may play one possible role in certain pediatric populations. In the end, more study is needed.

Regardless of the cause, perhaps the best advice for parents is to have tonsillectomy done for their child only if it is absolutely necessary and if done, keep an eye on how much they are eating and to encourage healthy eating habits.

Read the MSNBC report here.

Pending in Feb 2011 Issue of Otolaryngology-Head & Neck Surgery

The Doctors TV Show Does Surgery for Obstructive Sleep Apnea

The Doctors TV show at some point in the past (not sure when), did a segment on surgery used to treat obstructive sleep apnea. The surgery portrayed was UPPP (uvulopalatopharyngoplasty). Dr. Brian Weeks, the featured otolaryngologist, removed the tonsils and uvula followed by suturing the cut mucosa to reposition the soft tissues of the patient's throat.

This operation is a basic surgical method addressing obstructive sleep apnea. However, prior to considering surgical treatment, I typically recommend trial of CPAP for 3 months.

Some things to keep in mind is that obstructive sleep apnea is often due to multiple levels of obstruction. UPPP only addresses mouth-level problems. Other sleep apnea surgery options need to be considered when obstruction exists at other levels including the back of tongue (below the mouth level). Base of tongue reduction helps in this situation.

Watch the video of the TV show here. Watch the video our office produced on this surgery here.

New Video on UPPP Surgery to Treat Sleep Apnea (Uvulopalatopharyngoplasty)

A new video has been created and uploaded onto our YouTube channel showing how a UPPP (uvulopalatopharyngoplasty) sleep apnea surgery is performed. This surgery is commonly performed to try and improve or even cure obstructive sleep apnea in adults. This surgery rarely is performed in kids.

Read more about UPPP here. More info about obstructive sleep apnea can be found here.

Another operation used to treat obstructive sleep apnea in adults along with UPPP is base of tongue reduction. Read about this operation here as well as watch the video here.

Watch the video here.

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