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December 31, 2011

Stabbing Headache Around Eye or Cheek

Do you suffer from a stabbing headache in the areas denoted in red? Do these headaches seemingly come out of nowhere one day? Perhaps started after a viral upper respiratory infection?

You may be suffering from a condition known as contact point headache. This type of headache is also known as:

• Sluder's neuralgia
• Anterior ethmoid neuralgia
• Sphenopalatine ganglion neuralgia
• Pterygopalatine ganglion neuralgia

This type of headache has often been confused with cluster headache, migraine without aura, sinusitis, or other undefinable pathology especially since CT scans and MRI scans that are obtained often do not reveal any tumor or presence of infection.

Click here for more information.

New Treatment for Sore Throat

Well according to American singer-songwriter Suzi Quatro, "I used to get a lot of sore throats and then one of my sisters told me that all illnesses start in the colon. I started taking a daily colon cleanser powder mixed with fresh juice every morning and it made an enormous difference," Quatro told the Daily Mail newspaper.

It is unclear how many ounces of juice, what type of juice, and grams of colon cleansing powder was required to obtain this beneficial effect.

For her outstanding contribution to pseudo-science, she was awarded the prestigious 2011 SAS.

(If you haven't figured it out already, daily colon cleanser powder does NOT help with sore throats. However, there are rare situations where colon diseases like Crohn's Disease can cause throat problems including soreness and swallowing problems.)

Whale sperm, orgasmic feet top 2011 bad science list. Reuters 12/28/11

December 26, 2011

What Makes a Successful Hospital - Where Are the Tweakers???

First off, I don't have a business degree (in fact, I'm a MBA drop-out) nor a degree in hospital administration (does chairing a hospital committee count?), but I do have an opinion (don't we all) in light of having co-founded a bioinformatics company (iCORD, LLC) in the past based on a patent developed during my surgical residency... But I also admit that the company was ultimately unsuccessful if one measures success in terms of monetary profits, but I can say I succeeded in that my now defunct company's "product" still lives on at Duke University Medical Center.

It is perhaps my mixed bag background of a few victories and even more failures that I learned a thing or two about what it means to become better... it is what I call evolutionary tweaking or to put it more bluntly... whining and doing something about it. But let's stick with the "tweaker" euphemism.

Tweakers are annoying and may be a thorn in any administrator's side, but they produce results. They tinker and tinker in an attempt to improve and better a situation they consider a problem whether it be an engine, a computer program, or an entire production system.

Based on Isaacson's biography about Steve Jobs, he had it in abundance... even on medical care and devices during his last days.

Apparently, in his very last days of life, he went through 67 nurses before he found 3 he liked. He also refused to wear an oxygen mask due to a perceived poor design until he personally reviewed 5 different mask options and picked the one he liked best.

I'm certainly not promoting a culture where every patient, nurse, doctor, and administrator should start whining and complaining about everything. The hospital would shut-down.

BUT, there should be a culture where incremental tweaks are not only allowed, but encouraged with the expectation that many ideas will fail with monetary setbacks. However, just like survival of the fittest, the cumulative evolutionary cycles of keeping successful ideas and tossing ones that aren't will lead to a better organization over time... continuously and cheaply.

Home run ideas should not be the goal. Batting consistent singles (or tweaks) are...

There are systems to describe this process: PDSA (Plan Do Study Act), Toyota Production System, Just-In-Time Production, Deming Wheel, Shewhart Cycle, Control Circle, etc.

Now I certainly am not the first to suggest this concept to hospital settings. In fact, I've seen PDSA posters tacked on a wall in hospital physician lounges in the past.

However, I have observed great variances in how different hospital systems incorporate this "controlled whining" into their culture and administration.

Some embrace this process wholeheartedly and have succeeded in abundance. Others give lip service and designate the "tweakers" as whiners to be shut-up with bureaucratic red-tape, offensiveness requiring peer-review, or worse.

Employees and staff are a hospital's greatest assets both in terms of knowledge and production services. A hospital can either embrace trying to unlock the knowledge of what it already possesses or it can stifle them by punishing those who try to "tweak" thereby sending the message to everybody else to stay in the background... passivity being the rule... or voluntarily leave (or get fired).

The long-term success of a hospital system depends on how well it utilizes ALL its resources including not only encouraging an idea a hospitalist physician may have about telephone communication (allowing for faster patient care), but also trying to discover the knowledge trapped in a janitor's head who just might know how to thoroughly clean a hospital floor in half the time (saving time and money), but is too afraid to say anything.

Adapt or perish. History is replete with immensely successful companies that failed to adapt and are now either bankrupt or nearing death... Eastman Kodak, Tower Records, Borders Bookstores, etc.

And how does a hospital adapt to avoid non-existence? Continuously tweak... even when things are going well. USE all your assets with all guns blazing rather than smothering them.

Celebrate the tweakers!!!

December 24, 2011

Toddlers Unable to Tell If They Mispronounce a Word (Thereby Can't Auto-Correct)

Older children and adults constantly monitor what they say and automatically correct or self-adjust when they hear a peach error... oops, sorry I meant to say "speech" error.

Such auditory feedback error correction however is not something we are born with. Rather it seems to be a skill that develops sometime between ages 2 and 4 years according to a new study.
"Researchers had adults, four-year-olds, and two-year-olds say “bed” repeatedly. But scientists filtered the sound so that the subjects heard themselves through headphones pronouncing it as “bad.” Adults spontaneously compensated, and changed so that the word sounded correct to their own ears. They wound up saying “bid.”

Four-year olds also adjusted their speech.

But the two-year olds kept saying “bed” even though they kept hearing “bad.”"
So, how do young children learn to speak correctly if they can't even hear themselves say something incorrectly?

The answer to this question has great import, especially to speech therapists whose job is to "fix" this problem. ENTs are often consulted as well to ensure a child does not have a tongue tie or hearing loss that can also lead to speech difficulties in a young child.

It's possible that young children depend on their parents to correct them when they say something incorrectly.

However, nobody quite knows for sure.

A follow-up study (not sure if will pass muster with an IRB) would be to have 2 sets of 2 year olds... one group where the parent constantly corrects any speech errors the child makes immediately. The other set would have parents NEVER correct a child's speech errors and let the child learn on their own.

Two possible outcomes... By the age of 5 years, there may be no difference in speech skills between the two groups OR there is a big difference and all the parental anxiety over their 3 years old child's inability to say "pizza" may be unnecessary (along with speech therapy sessions)... after all, they will "grow" or "learn" out of it with time.

Toddlers Don't Monitor Their Own Speech. Scientific American 12/24/11

Children's Development of Self-Regulation in Speech Production. Current Biology, 10.1016/j.cub.2011.11.052

Santa Claus Cigarette Ad Blast From the Past

Given the holidays, take a look at this cigarette ad from the past... Times truly have changed (for the better)!

December 23, 2011

Singer George Michael With Tracheostomy

Reuters reported today that singer George Michael suffered from severe pneumonia and underwent a tracheostomy during his hospitalization. A tracheostomy is when a hole is made in the throat for a patient to breath through.

Here is a video of what his trach surgery may have looked like.

Michael apparently was in the middle of a tour when he became ill requiring him to cancel upcoming shows.

A tracheostomy is often performed whenever a patient has been intubated (tube down the throat) on a breathing machine for a prolonged period of time.

For more information on trachs, click here. Watch a video of a trach being performed here.

Gaunt George Michael says "fortunate to be here" Reuters 12/23/11

Robotic Surgery for Obstructive Sleep Apnea

I came across this article the other day regarding use of the daVinci robot to perform base of tongue surgery for obstructive sleep apnea.

For those who don't know, the daVinci robot system made by Intuitive Surgical is a robotic system whereby the surgeon directs the arms of the robot to perform surgery in difficult-to-access areas of the body.

My feeling is that using a robot to perform sleep apnea surgery is way overkill akin to using a $50,000 sniper rifle to kill an ant on the wall.

Everything the daVinci robot can do can also be done without the robot with equivalent patient outcomes. In fact, without the robot, the surgery can be performed more quickly, efficiently, and with less anesthesia than with the robot.

The article also describes sedated (sleep) endoscopy to determine WHERE the obstruction occurs during sleep. The areas of obstruction can than be precisely addressed surgically. Again, this does not require a robot. In fact, I would hazard to say that even the surgeons quoted in the article does not use the robot to perform this procedure.

There are occasions where the robot may be helpful with ENT surgical procedures, but this is not one of them.

N.J. surgeons on the cutting edge in fight against sleep apnea.

December 22, 2011

Amoeba Deaths from Neti-Pot Use and How to Minimize Risk

In the past few weeks, there have been numerous stories about the 2nd death in Louisiana from Neti-Pot use leading to an amoeba infection of the brain. The culprit organism Naegleria fowleri causes a life-threatening encephalitis after passing thru the nose and up into the brain where the organism eats neurons for food.

As such, recommendations have been issued to use water as instructed with the Neti-Pot packaging... water should be boiled, distilled, or filtered.

However, before the millions of people who may have elected to simply use tap-water change their daily routine, consider that more commonly, swimming in warm lakes or rivers causes 2-3 amoeba related deaths per year... and swimming in and of itself leads to thousands of drownings per year. So far, there have been only TWO amoeba-related deaths linked with Neti-Pot usage that we know of so far.

In any case, lets talk about boiled, distilled, or filtered water and what a Neti-Pot user can do to keep their daily routine simple. After all, it is so simple to simply fill the container with running tap-water. The additional step to keep things safe can become annoying.

Boiled Water: Naegleria fowleri can not survive in temperatures above 47°C. As such, by boiling water, you guarantee death if any are present in the water. Typically, boil for for 3-5 minutes and cool to lukewarm before storage.

Save time by boiling a large amount of water and storing in 1+ gallon containers for daily use.

Distilled Water: By definition, distillation involves boiling the water and then condensing the steam into a clean container. It's a slow process, but it not only kills any micro-organisms much like simple boiling does, but also removes any inorganic "impurities" that may be harmful like mercury as well as beneficial minerals including calcium, magnesium, and sodium. Distillation does not discriminate.

It is not feasible for most individuals to set up a home water distillation process just so they can use the Neti-Pot. Though can get expensive over the years, save time by purchasing large volumes of distilled water to have at home. But, there are portable water distilling machines you can purchase as well.

Filtered Water: Water that is filtered is cleaned by means of a fine physical barrier, a chemical process or a biological process. In most homes, filtered water is almost universally achieved by a physical barrier. There are numerous vendors out there that sell devices to filter the water including Pur Water and Brita.

Alternative filters should contain pores at least 1 micron in size or smaller.

Save time by purchasing a faucet attachment that automatically filters water into your Neti-Pot when you need it.

December 20, 2011

Doctor Distraction Happens... It's Mandatory!

I admittedly snorted out loud when I read a New York Times article  earlier last week regarding increased physician distraction due to electronic devices, especially with the advent of the smartphone with its emails, text messages, calls, and other alerts that ping intermittently throughout a typical work day.

There is no question that electronic devices distract physicians as the article pointed out... But that's like complaining about a leaky faucet when there's a flooded basement and a hole in the roof.

The bigger problem that should be mentioned is hospital bureaucracy which probably creates just as much if not more unintended distractions for physicians and nurses.

What many patients and lay public may not realize is that there is a TON of paperwork that goes into the care of a patient. Regulatory bodies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that accredits hospitals have made it mandatory in many cases though I suspect hospital administration often carries it a step above and beyond what is truly necessary.

What all this "mandatory" paperwork means is that nurses are calling physicians all the time just so they can check a box on a form... and there are a LOT of boxes to check.

Take a simple ear tube placement. A procedure that takes about 1-2 minutes to perform under sedation in the pediatric population.

It takes about 15-20 minutes to fill out all the nursing and physician forms (whether paper or electronic medical records). When the surgery actually begins, the nurse is too busy filling out even more forms rather than paying attention to the surgery... and often the surgery is already over... and the nurse is still busy filling out forms.

Talk about distraction... a registered nurse has been relegated to being a mere secretary rather than helping (or paying attention) in the care of a patient.

I recently asked a nurse how much time they spent on actual patient care versus how much time filling out forms during a typical shift.

It saddened my heart when I was told 60-70% of a nurse's time is spent on filling out forms (whether notes, chart documentation, medication reconciliation, etc) and only 30-40% on actual patient care. This time disparity was not always true in years past.

OR... ask any physician how many times they get called during a typical day because some form or paperwork was not completed or needs completion or just remind to get it completed by nurses who themselves are the main individuals who suffer under the crush of mandatory documentation in a hospital setting.

It is irritating to say the least to get a phone call during the middle of an operation, say dissecting a tumor off the facial nerve during a parotid cancer resection, by someone who wanted to remind me to sign off on a medication list on a patient I've already provided prescriptions for.

Another classic experience of mine was when the anesthesiologist had trouble intubating a patient who started to suffer a severe lack of oxygen. I was immediately called to the bedside and performed an emergency tracheostomy.

Of course, the nurse (well indoctrinated in form completion) involved in the case immediately instructed me to STOP performing the trach and to get consent as per the regulations... which is true 99% of the time... but never mind that. Heaven forbid we now can't check that little box that states "consent obtained prior to surgery." But in the interest of patient care, I did suggest that it would be better if the patient lived with an unconsented trach rather than died due to time spent obtaining consent.

Though electronic devices may be considered a "distraction" analogous to a mosquito buzz that comes and goes, one must not forget the avalanche of paperwork which is a much more pervasive and insidious distraction that DELIBERATELY takes attention away from the care of the patient. I understand the need for documentation, but at some point when the documentation itself dominates the majority of heathcare rather than the actual administration of care, there's something fundamentally wrong going on.

It's probably why medical missions are so gratifying to participating nurses and physicians where 90%+ of the time is in actual patient care.


December 18, 2011

Carpenter Shoots Himself in the Neck with Nail Gun

According to Boston News, in early December 2011, a carpenter accidentally discharged a nail gun and embedded a 3.5 inch nail in the bottom of his neck. Based on the CT scan included here, it appears the nail entered the neck dead center given the clear appearance of the windpipe.

Based on the location, the anatomic sequence of nail piercing is as follows:

Skin --> Thyroid Gland --> Trachea --> Esophagus Back Wall --> Cervical Vertebral Body

The damage to skin, thyroid, and trachea is not a big deal... In fact, one can consider this a mini-tracheostomy. Minimal bleeding would be expected.

However, the hole between the trachea and esophagus is another matter which may heal well... or not. The esophagus is the swallow tube which transports food from the mouth to the stomach. A hole in the esophagus to the trachea (tracheo-esophageal fistula) would allow swallowed food/liquid to pass from the esophagus over to the trachea and into the lungs leading to pneumonia and bronchitis. This uncontrollable aspiration can potentially be life threatening as the hole could also allow food to pass BETWEEN the trachea and esophagus right down to the heart leading to possible mediastinitis (inflammation/infection of the heart lining).

Treatment initially would be placement of a feeding tube and a long course of IV antibiotics. If the hole does not spontaneously close, it would require surgical closure, typically with a flap of some kind.

The easiest test to perform to determine whether the hole has closed up or not is a swallow study using gastrografin or barium. Watch a video of how this test is performed.

As the news story mentioned, he was VERY lucky the nail went in where it did. If it went in a little further to the right or left, it could have punctured his carotid or jugular vein and he would have bled to death.

Carpenter Shoots Himself In Neck With Nail Gun. WCVB Boston News

December 17, 2011

NY Yankees Mariano Rivera Undergoes Vocal Cord Surgery

NY Yankees pitcher Mariano Rivera may have a fabulous right arm, but his voice was not exactly golden. He apparently had vocal cord polyps that resulted in a progressively raspy voice. Read the NY Post article.

On Dec 2, 2011, he underwent surgery to get them removed and if he now sticks to an appropriate voice therapy program, his voice should essentially revert completely back to normal! Watch the video to see what vocal cord surgery looks like.

There are MANY theories as to how vocal cord polyps as well as other similar vocal abnormalities like cysts and nodules form. However, one theory that seems to make the most sense to me deals with how the vocal cord heals after a phono-traumatic event like screaming or yelling... something I'm sure Mr. Rivera routinely performs during baseball games.

To differentiate among the various benign vocal cord masses, consider a cyst which is formed when the mucosal vocal cord lining breaks down and during the healing process a cyst develops due to entrapped cells meant for creating lining. A polyp, however, is in essence a blistering of the vocal cord lining. Vocal cord nodule for comparison's sake is just callous thickening of the vocal cord lining that occurs over time.

To use human skin as an analogy...

vocal cord cyst is like a sebaceous cyst that commonly occurs under the skin of the face or neck (a pimple, but no opening to the surface).

vocal cord polyp is like a blister that forms on the hand if you shovel dirt too much.

vocal cord nodule is like a callous that forms after prolonged repetitive skin trauma (like callous on the hands after shoveling dirt for years).

Read more about vocal cord cystspolyps, and nodules!

How to Make Xylitol Nasal Flush at Home

Given the unusually large reader response to my last blog regarding xylitol nasal rinses regarding the "recipe," I thought it easier to write a blog about it!!!

To be brief, xylitol is a naturally-occurring plant-based sugar substitute that apparently has all sorts of anti-bacterial as well as anti-fungal properties. Given these properties, daily xylitol gum chewing or xylitol nasal spray use has been shown to help prevent recurrent acute ear infections and sinus infections... safe for use even in infants.

When used as part of nasal flushes to the nose, it seems to work even better than traditional saline flushes to the nose (read more about this here).

So, I have provided below a few different recipes to make xylitol nasal flushes at home. One may be more comfortable than the other, but it is user dependent. Obviously, convenience will play a role as well.

Just as an FYI, you can also purchase pre-packaged packets that contain xylitol for the ultimate convenience. Just open one packet and mix it in with water inside your nasal flush kit of choice (Nasopure, Neti Pot, Neilmed, etc)

Recipe #1 (Complex):
1 cup of water (8 ounces)
1/4 tsp salt
1/2 tsp of xylitol crystals
1/4 tsp baking soda
4 drops of grapefruit seed extract

Recipe #2:
1 cup of water (8 ounces)
1/4 - 1/2 tsp salt
1/2 tsp of xylitol crystals

Recipe #3:
1 cup of water (8 ounces)
1/4 - 1/2 tsp of xylitol crystals

December 16, 2011

Nasal Dripologist

I always thought that pediatricians, primary care physicians, allergists, and ENTs were the true nasal dripologists, but I guess I'm wrong...

Saw this ad by Target promoting their pharmacists...

Xylitol Nasal Flushes Helps Prevent Chronic Sinusitis

Image by Aikhan from German Wikipedia
Over the years, there has been much about how beneficial a safe food additive called xylitol is in preventing infections. This naturally-occurring plant-based sugar substitute apparently has all sorts of anti-bacterial as well as anti-fungal properties. Given these properties, daily xylitol gum chewing or xylitol nasal spray use has been shown to help prevent recurrent acute ear infections and sinus infections... safe for use even in infants.

How may this occur? Toronto researchers figured out that xylitol inhibits the adherence of germs (burkholderia in the study) to airway linings thereby helping to prevent recurrent infections.

Another beneficial practice found to be helpful in preventing sinus infections are saline flushes to the nose. For those who don't realize the difference, saline flushes are different from saline nasal sprays in the volume of irrigation performed (think garden hose versus squirt bottle). Nasopure nasal flushes is being shown in the picture above (there are many different styles but all basically do the same thing).

Now what if we combine saline flushes with xylitol for those who suffer from particularly difficult chronic sinus infections???

Stanford University researchers conducted a small study (20 subjects) to see whether xylitol flushes (rather than nasal spray) to nose works even better than plain saline flushes to the nose. In spite of its small size, it was a prospective, randomized, double-blinded, controlled crossover pilot study.

What they found, at least in the short term, is that xylitol nasal irrigations resulted in greater improvement of chronic rhinosinusitis symptoms as compared to saline irrigations.

Xylitol nasal irrigation in the management of chronic rhinosinusitis: A pilot study. The Laryngoscope Volume 121, Issue 11, pages 2468–2472, November 2011

A novel model to study bacterial adherence to the transplanted airway: inhibition of Burkholderia cepacia adherence to human airway by dextran and xylitol. J Heart Lung Transplant. 2004 Dec;23(12):1382-91.

A novel use of xylitol sugar in preventing acute otitis media. Pediatrics. 1998 Oct;102(4 Pt 1):879-84.

December 11, 2011

For a Physician, When is the Best Time To Tweet or Publish a Blog?

According to professional bloggers and tweeters, timing of content publication is important in order to maximize getting noticed and shared. From a general topics viewpoint (not healthcare specific; data taken from here):
  • 4PM Eastern is the best time to Tweet
  • Friday is the best day to Tweet
  • 9AM Eastern is the best time to Facebook share
  • Saturday and Sunday are the best days to Facebook share
  • In the morning is the best time to blog
  • Publishing a different blog article multiple times throughout the day is better than once per day
However, I've always wondered if such "rules" similarly apply to healthcare content as by their very nature, people tend to search a problem after seeing their doctor or seeing/reading it on the news.

Ever since I've been monitoring my website statistics starting in 2005, I've noticed some undeniable trends of "when" website activity occurs which presumably reflects "when" healthcare keyword searches occur.

For any given 24 hour period of time (graph shown below is for Nov 14-15, 2011), my ENT practice website got THE most activity between noon and midnight; peak activity being from noon - 3PM.

On a weekly basis (graph shown below is for Mon Nov 14 - Sun Nov 20, 2011), the greatest activity is Monday thru Wednesday after which web traffic drops off almost 50% by Saturday before bouncing back up 100% on Monday.

Such statistical fluctuations have been true for the past 5 years I've been tracking this stuff.

Now I certainly can't explain the "why" this phenomenon happens without more google analytics data from more healthcare websites, but I certainly can take advantage of this knowledge as it pertains to ENT problems (though I suspect that what is true for ENT is true of other health problems when it comes to web traffic).

How can I take advantage of this knowledge?

People are CONSTANTLY adding to the content found on the web, all vying for the attention of eyeballs. Being the first is important as it seems to me that google values original content (not copies that appear later), but just as important is "when" the content first appears as one would like to ride the wave of when healthcare keyword searches occur.

Overall, the holy grail is to come up with great original content, be the first to publish it, but publish it at the right time.

Great, Original Content

Good content is king and #1 in the priority of getting noticed. If your content stinks, being first and when you publish won't matter.

Be the FIRST to Publish

I can't prove it and I don't have supporting evidence for it, but it seems that google does prefer content that appears "first" over copies that appear later. The prime example is Associated Press articles that are syndicated and re-published over a wide variety of different newspaper websites throughout the world.

If google encounters the same exact article 100 times, how does it rank one over the other?

I suspect, it ranks based on two factors:

1) "Popularity" of the website publishing the content
2) Being the first to publish

Obviously, an individual only has control over timing. Take advantage of it.

WHEN to Publish

Though being the first to publish is important, the timing of when to publish is also extremely important. It's almost like surfing... You want to be the first to stake out a place to ride a wave... but you need to be where the waves are.

Given the dramatic... but consistent... fluctuations in healthcare web activity, it is better to wait and publish when people are actively searching. It is more likely to get noticed and hopefully shared, emailed, liked on facebook, tweeted, etc. Going viral is the goal all content publishers dream of.

So, WHEN is the golden moment to publish?

It is around 11AM on Mon, Tues, and Wed based on my limited data.


Now, do I even follow my own advice?

Not necessarily... I tend to go with the "be the first" rule regardless of the time, not because I feel it more important than the timing of publication, but it's just that I have so much other things to do (like taking care of patients), that if I come up with an idea to write about, I just publish it and not worry too much about timing.

BUT, if I do have a moment, I WILL tend to publish things timed between 11AM and 3PM during the week.

Natural Remedies for a Sore Throat, Cough, and Viral Infections

Homeopathy and alternative medicine often get a bum rap, but they have come up with some treatments for sore throats and upper respiratory viral illnesses that actually have been proven to work.

Here's a few...

1) Honey

Sore throats (and coughing) can be soothed by swallowing honey straight-up or slightly diluted with warm water with honey to make it easier to swallow. The best time to do this is at bedtime given it will stick around for awhile (eating/drinking will wash away the coating). The purpose of honey is to create a throat barrier to ease the discomfort.

Think of it like chapstick to coat irritated lips, but meant for the throat.

Use of honey is also recommended by the World Health Organization which has also published a monogram on viral colds and the various treatments explained. Pay particular close attention to Annex 3 (Page 11) which gives various recipes to treat pediatric cough including the use of honey.

Effect of Honey, Dextromethorphan, and No Treatment on Nocturnal Cough and Sleep Quality for Coughing Children and Their Parents. Arch Pediatr Adolesc Med. 2007;161(12):1140-1146.

2) Humidification

Dry cool air increases risk of viral infections as well as giving it to others. As such, add room humidification to a bedroom and keep the door closed (small room humidifiers can't humidify an entire house... so keep door closed!).

Why does this help? Increased humidification inactivates viruses!

Humidification also helps minimize a persistent dry cough worse at night often due to reactive airway disease triggered by breathing in dry air.

However, keep in mind that if you actively have a viral illness, it is too late for humidity to help. It is best used as a preventative measure.

Dynamics of airborne influenza A viruses indoors and dependence on humidity. PLoS One. 2011;6(6):e21481. Epub 2011 Jun 24. Influenza virus transmission is dependent on relative humidity and temperature. PLoS Pathog. 2007;3:e151.

Heated, humidified air for the common cold. Cochrane Database Syst Rev. 2011 May 11;(5):CD001728.

3) Gargling and Saline Flushes

Gargle with saline water... or even just tap-water on a daily basis. Why does this help prevent viral infections? It washes away the viral particles before it gets a chance to cause problems.

It's also probably why drinking lots of fluids also helps since the viruses get deactivated in the stomach from the acidic digestion.

Unfortunately, gargling only helps with the throat... saline flushes are required to help with sino-nasal problems.

Can we prevent influenza-like illnesses by gargling? Intern Med. 2007;46(18):1623-4. Epub 2007 Sep 14.

4) Xylitol

This naturally-occurring sugar substitute apparently has all sorts of anti-bacterial as well as anti-fungal properties and has been known to doctors and scientists but hardly marketed or promoted in any fashion.

However, the importance of this compound is that it DOES appear to significantly decrease the incidence of ear infections and sinus infections when used regularly. It comes in nasal spray form as well as gum.


A novel use of xylitol sugar in preventing acute otitis media. Pediatrics. 1998 Oct;102(4 Pt 1):879-84.


Sometimes the BEST medicine are things you can do at home without need for a physician visit... and is based on fact rather than anecdotal evidence.

December 09, 2011

New Webpage on Cochlear Hydrops

Sense of ear fullness or clogging is one of the most common reasons to see an ENT. Common causes of such a symptom include eustachian tube dysfunction, sudden sensorineural hearing loss, or fluid in the middle ear. However, cochlear hydrops is another potential, but rare cause for ear fullness.

Other symptoms that a patient with cochlear hydrops may exhibit include:
  • roaring sound in the ear
  • fluctuating hearing loss
  • noise sensitivity
  • speech/sound distortion
A new webpage has been written regarding this problem and treatment for it.

Check it out here!

December 07, 2011

Dr. Chang a Castle Connolly Top Doctor in America

In November 2011, Dr. Christopher Chang was added to Castle Connolly's list of Top Doctors in America. Apparently, he is the only Top Doctor in the field of otolaryngology within a 30 mile radius.

It's no surprise given patients travel from as far away as California and even the Philippines to be treated by Dr. Chang.

You can check out his listing here or on US News and World Report of Top Doctors.

December 06, 2011

Healthcare Blogging a Losing Proposition?

An interesting blog article from the folks at Compete came to my attention recently. Compete for those who don't know is a fantastic analytics site to see how ANY website is doing in terms of popularity (number of visitors in a given time period). The basic data is free. For more in depth information, there's a charge.

For example, for our practice's website, here is the Compete data I pulled which is "relatively" accurate based on my own analytics information:

My nearest local competitor in terms of website popularity is the hospital, Fauquier Health System:

Though I may smile that my solo private practice website is getting nearly 30X the number of visitors as a community hospital, such numbers PALE in comparison to what truly is driving website searches by the lay-population... celebrity, entertainment, and political topics which collectively garner more than 80X the search volume compared to searches related to healthcare. Here is the graph by Compete.

Healthcare is the purple line WAY down at the bottom.

Assuming people ARE searching for healthcare topics, what might those topics be?

They are pregnancy and cancer related by a vast margin (chart taken from here).

What is the take-home message?

Healthcare blogging is truly a niche market... and a small one at that...

BUT, if one wants to become a successful healthcare blogger, it should be slanted towards pregnancy and cancer topics.

"Thyroid" made the top 20 list, but beyond that, ENT healthcare topics are left out in the dust... perhaps  even smaller than dust.

Take a look at the stats for, a website dedicated to celebrity and entertainment news:

December 03, 2011

The Doctors TV Show Does Adenoidectomy

Dr. Nina Shapiro was the featured otolaryngologist when The Doctors television show discussed nasal congestion as well as large adenoids. A sanitized view of adenoid removal surgery was also shown.

For a more detailed view of the surgery, click here.

For more info on adenoids and its surgical removal, click here.

Portable CT Scanner

Portable X-ray machines are commonplace... but a portable CT scanner?!!

I saw this article by MedGadget about a portable CT scanner introduced earlier this year that can be wheeled around in the hospital made by NeuroLogica.

When looking up more details, the company makes not just one portable CT scanner, but FOUR different portable machines:

BodyTom: Portable whole-body CT Scanner
CereTom: Portable CT Head scanner
OTOscan: Portable CT Sinus scanner
inSPira HD SPECT: Portable SPECT scanner

Pretty amazing.

Though the whole-body CT scanner seems a bit big to be easily moved from hospital room to hospital room, it is comparable in size to portable fluoroscopy equipment currently in use. The other models are quite a bit smaller.

Realistically, I think the CereTOM will be the big winner as CT scans of the head is probably the most ordered CT scan in the hospital, often ordered to evaluate for stroke, head injury after a fall, sinusitis, facial fractures, brain tumor, seizures, etc, etc, etc. In many of these situations, the patient is fairly immobile and it just may be easier and faster if the CT scanner is brought to the patient rather than patient wheeled to a stationary CT scanner.

Dr. House of TV Fame Would Never Survive in Real World

Would YOU as the patient see a doctor who is a well-known jerk, abuses drugs, gives the wrong diagnosis more often than not, and is known to like ordering very invasive tests??? Be honest...

The other week, a patient with a chronic cough exclaimed to me that she wished the fictional character Dr. House of TV fame actually existed in real life, because he was somebody who can diagnose anything.

I looked her straight in the eye and told her that somebody like Dr. House in the real world would be a physician nobody would want to see for many reasons:
  1. In the real world, patients expect doctors to have the correct diagnosis from the beginning (might forgive one wrong diagnosis). Dr. House seems to always get things wrong multiple times before he gets it right. I seriously doubt most patients would have stuck around as long as they do on the TV shows before going elsewhere.
  2. In order to achieve that correct diagnosis, Dr. House seems to pursue invasive tests which in reality is something patients rarely like to pursue... and often get second opinions to determine if really needed.
  3. Dr. House is fairly abrasive with his colleagues and even with his own patients which pretty much guarantees one star ratings on physician rating websites like and
  4. Dr. House is addicted to vicodin, morphine, and cocaine... That pretty much guarantees loss of hospital privileges and perhaps even his medical license to practice in the real world. Furthermore, what would you do as a patient if you found out that your doctor abuses drugs??? Most will go elsewhere.
So given what I know patients want in reality, it boggles my mind why patients in the real world think Dr. House is so great and wish a fictional character like him truly existed.

To flip things around... the real question is why aren't real world patients more forgiving of physician fallibility like those on TV? I'm the first to admit that physicians (in the real world) are not perfect though the expectation is that we are.

December 02, 2011

In-Office Sinus Surgery Without General Anesthesia

There has been tremendous advances in sinus surgery over the past decade. From the elimination of nasal packing after most routine sinus surgery to the more recent use of balloons to open the sinus cavities, patient comfort has improved greatly after this particular operation. What used to be a several week recovery may now only be a few days.

Balloon sinuplasty in particular has been revolutionary in the surgical treatment of chronic sinusitis. Though sinus surgery normally is performed under general anesthesia, balloon sinuplasty now allows this operation to be performed awake WITHOUT sedation using local anesthesia only.

At its essence, sinus surgery "opens" up blocked sinus cavities to allow drainage and ventilation. Traditional sinus surgery "removes" tissue to accomplish this goal whereas balloon sinuplasty stretches open the sinus cavity without the need for tissue removal.

Given the lack of tissue removal with balloon sinuplasty, there is less pain and faster recovery after the procedure.

What are the steps?

After adequate anesthesia of the nose using both topical and injectable numbing medicine...

Step 1
Under endoscopic guidance, the balloon catheter is introduced into the nasal cavity and guided towards the target sinus cavity opening. Depending on the system used, a sinus guidewire or sinus illumination may be used to help with the guidance. 
Step 2
Once the sinus balloon catheter is correctly positioned across the blocked sinus opening, the balloon is gradually inflated to stretch open the ostia.
Step 3
After several seconds, the sinus balloon catheter is then deflated and removed leaving an enlarged sinus opening allowing for the return of sinus drainage. There is little to no disruption to mucosal lining.

Of course, not all patients are candidates for balloon sinuplasty, let alone this procedure to be done awake with local anesthesia alone.

In particular, balloon sinuplasty can only address blockages involving the frontal, maxillary, and sphenoid sinus cavities. Ethmoid sinus cavities can NOT be corrected using this method.

Also, balloon sinuplasty does not allow for tissue biopsies (by definition, the advantage of balloon sinuplasty is the lack of need to remove any sinus or nasal tissues). As such, if there are any masses present including nasal polyps, traditional sinus surgery is the better way to go.

December 01, 2011

Human Ear Contains a Built-In "Ear Plug"

According to one Australian researcher, by just chewing a gum or singing/talking loudly, one could be protecting your ears from noise-induced hearing damage. How???

It is not common knowledge that the human ear contains two muscles that attach to the middle ear bones called the stapedius and tensor tympani muscles.

The middle ear bones, composed of the malleus, incus, and stapes, are what transmits sounds from the eardrum to the cochlea which allows a person to hear. The stapedius muscle attaches to the stapes and the tensor tympani to the malleus.

If something prevents the middle ear bones from vibrating, that effectively dampens the sound transmission from the eardrum to the cochlea... just like an ear plug or a bad case or earwax dampens sound transmitted through the ear canal to the eardrum.

SO... if the middle ear muscles tighten which are attached to the middle ear bones preventing them from vibrating, less sound is transmitted to the cochlea... just like an ear plug, except it is built-in.

Just how effectively does this reduce sound?

According to the researcher who has been studying this phenomenon, by about 30 decibels (or 1000x fainter).

That's about the same as foam earplugs!

How does one "activate" the middle ear muscle contraction?

By chewing a gum or singing/talking loudly!

Some individuals can sense this contraction if they close their eyes and try to "pull the muscles around the ears together"... a fluttering sensation inside the ear may be heard/felt which is the contraction of the middle ear muscles. In rare patients, this contraction may occur involuntarily and continuously.

SO... if you happen to have forgotten your ear plugs and are attending a very loud rock concert, chew gum and/or sing along with the band loudly! This may actually protect your hearing!

Of course, it's better to wear hearing protection, or better yet, avoid such circumstances altogether.

Read more about this here.

How do middle ear muscles protect the cochlea? Reconsideration of the intralabyrinthine pressure theory. Journal of Hearing Science 2011; 1(2): RA 9 - 23

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