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January 24, 2012

Bacon Can Stop Nosebleeds! No joke...

When I saw this research, I had to re-read it to believe it... Nasal packing with good-old fashioned bacon stops nosebleeds!!!

Yes... you heard me correctly... and it was actually published in a reputable ENT journal in Nov 2011. AND, it was conducted here in the USA (Detroit, Michigan).
"Cured salted pork crafted as a nasal tampon and packed within the nasal vaults successfully stopped nasal hemorrhage promptly, effectively, and without sequelae … To our knowledge, this represents the first description of nasal packing with strips of cured pork for treatment of life-threatening hemorrhage in a patient with Glanzmann thrombasthenia."
The current standard of care for nasal packing to treat nosebleeds is using synthetic hemostatic products that appear similar to tampons used for menstruation.

However, this publication in 2011 wasn't the first to document use of bacon for nosebleeds.

There have been reports on use of bacon since 1940 sporadically (see references below).

In this day and age of cost-cutting and finding cheaper alternatives, bacon is pretty much as cheap as one can go to address nosebleeds. Compare this to synthetic nasal packing which costs on upwards of $50 or more.

Although bacon may work to stop nosebleeds, I personally have no plans to use bacon in this manner other than to eat.

This research has even been portrayed (teased) on the Colbert Report. Watch video below.

Read more about nosebleed management.

Another unusual nosebleed management includes the application of female hormone estrogen (vaginal premarin cream) to the nasal mucosa.

Traditional nosebleed treatment includes nasal emollient application, humidification, nasal cauterization, septoplasty, and eventually nasal packing.

Nasal Packing With Strips of Cured Pork as Treatment for Uncontrollable Epistaxis in a Patient With Glanzmann Thrombasthenia. Ann Otol Rhinol Laryngol 2011;120:732-736.

Rendu-Osler-Weber Disease— Is Embolization Beneficial? Arch Otolaryngol. 1976;102(6):385.


USE OF SALT PORK IN CASES OF HEMORRHAGE. Arch Otolaryngol. 1940;32(5):941-946.

Sleep Apnea Surgery Malpractice Lawsuit

In November 2009, a patient underwent multi-level surgery to treat her mild-moderate obstructive sleep apnea by a Houston, TX otolaryngologist.

The surgery included:

Uvulopalatopharyngoplasty (UPPP)
Tonsillectomy (typically considered part of UPPP)
• Hyoid Myotomy
• Genioglossus Advancement

She unfortunately experienced some unspecified complications stemming from this surgery which apparently has not helped with her obstructive sleep apnea either. A malpractice lawsuit commenced and final judgement is still pending.

Let's take a closer look at the incomplete information provided.

The patient suffered from mild-moderate obstructive sleep apnea which typically means a AHI score of around 15 (< 5 is normal).

For this level of severity, simultaneous multi-level surgery is not typically performed. Rather such extensive surgery is reserved for severe obstructive sleep apnea.

Also unclear is whether any objective studies were performed prior to surgery to try and localize the levels of obstruction that required correction. Such preoperative studies include a sedated endoscopy as well as trial of CPAP usage.

Assuming patient tried and failed to use CPAP and had objective evidence for multi-level obstruction, what did each of the surgical procedures do?

UPPP, tonsillectomy, adenoidectomy address mouth-level obstruction.

Hyoid myotomy and genioglossus advancement address tongue-level obstruction (the tongue can fall backward while sleeping causing obstruction).

Complications can occur for each of these procedures mainly dealing with bleeding, hematoma, infection, or abscess formation. Swallowing problems can also occur with the hyoid myotomy and genioglossus advancement.

Read more information on obstructive sleep apnea.

Sleep apnea surgery leads to malpractice lawsuit. Southeast Texas Record. 1/23/12

January 23, 2012

Dr. Chang a Northern Virginia Top Doctor for 2012

Northern Virginia Magazine published their annual list of Top Doctors for 2012 in their February 2012 edition. Dr. Chang was listed as one of Northern Virginia's Top Doctor in the field of Otolaryngology (page 72).

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

January 22, 2012

Northern Virginia Balloon Sinuplasty for Chronic Sinusitis

In the past month, local residents of Northern Virginia may have received a magazine newsletter from Prince William Hospital (Manassas, Virginia) that contained a feature story about sinus surgery and about balloon sinuplasty specifically.

It was a great story about how far sinus surgery has come compared to even just 5-10 years ago and great patient experiences after this type of surgery is not uncommon now.

A few key features of sinus surgery of the 21st century that is provided at Fauquier ENT include:

• Nasal packing rarely occurs
• Most patients are surprised by how little pain there is
• No facial swelling or bruising... your best friend won't be able to tell you just had sinus surgery
• Fast recovery
• No incisions on the face or in the mouth
GPS-like image guidance to make sinus surgery even safer is available
• In select patients, can even be performed in the office without sedation using local anesthesia only

Balloon sinuplasty is a relatively new innovation that allows sinus surgery to even be performed even more comfortably in the office without any sedation (not all patients are candidates).

Such advanced sinus surgery techniques have been available at Fauquier ENT since 2005.

Read more about sinus surgery and balloon sinuplasty.

Balloon Sinuplasty. Perspectives Winter 2011 Pages 2-3.

January 21, 2012

Hospital-Based Practice Versus Physician Private Practice

The other day, an astute patient of mine asked what the difference is between a physician who works for a hospital (hospital-based practice) versus a physician run private practice.

After all, a patient still sees a physician in either case...

Is there an actual difference from a patient's perspective???

Assuming all things equal whereby a private practice physician and a hospital-based physician are equally competent and the supporting staff for each are both equally good (such assumptions are debatable in some circles, but will be ignored here), it all comes down to money.

When a patient sees a private practice physician, the fee schedule only incorporates payments to the physician.

When a patient sees a hospital-based physician, the fee schedule not only incorporates physician payments, but also additional payments to the hospital.

Now, the patient doesn't pay what insurance covers in either scenario, but typically there is a copay or coinsurance payment that the patient is responsible for that typically is 20% of the total charges.

Here's an example using the Medicare fee schedule from 2002. I elected to provide "old" 2002 data as this information can be found easily and corroborated, but rest assured, the numbers are starkly different and perhaps more lopsided today. Medicare was selected as it is the bar to which all other insurance plans are typically based on.

In a physician run private practice, the only charges that are incurred is from the "Physician Fee Schedule". In a hospital-based practice, a patient incurs not only the physician fee schedule, but also additional charges based on the "Outpatient Prospective Payment System".

As you can see, the physician fees are slightly higher in the private practice setting compared to hospital-based practice... BUT, given the additional hospital charges involved with a hospital-based practice, the patient ends up being charged more per service for a simple clinic visit ($16.48) than if they had been seen in the private practice office ($10.06).

The cost differential for the patient is far worse with any procedures ($62.62 versus $342.47).

For the same exact procedure or service, a patient automatically ends up paying more to be seen in a hospital-based practice.

This payment system is the same whether you go to a tertiary care teaching hospital like Massachusetts General Hospital or a tiny 98-bed community hospital.

As an aside... for any physicians employed by a hospital, it behooves you to consider this differential payment in terms of how a hospital determines your salary and productivity. Do they consider ONLY the physician fee schedule or do they also take into account the outpatient prospective payment system?

I should also mention that for 2012, Congress is considering abolishing the outpatient prospective payment system for clinic visits only. Click here for more info.

Elimination of Differential in Medicare Payment for Clinic E&M Services Furnished in Hospital-Based Outpatient Departments Proposed. Martinedale 12/10/11

Medicare rules for hospital-based clinics. American College of Surgeons. Vol 87, No 4

Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System. Congressional Research Service. 8/6/2010

January 15, 2012

A Beauty Product GUARANTEED to Work!

I have seen it, used it, and it works! AND best of all, you don't need plastic surgery!

Watch the video commercial below...

For those you who actually thought this infomercial was real... it isn't... but the product it is describing is certainly real.

Photoshop by Adobe is a computer program that does everything the commercial stated it would, but only for pictures.

Miss America, SLP-CCC

Miss Wisconsin Laura Kaeppeler won the Miss America title for 2012 this past weekend.

This news co-mingled with all the other news of the day, except for one key fact that caught my attention...

Miss Kaeppelar majored in music and vocal performance and plans to obtain a Master's degree in speech and language pathology (SLP).

A voice major with a Master's in SLP is a rare combination that is in great demand in the world of laryngology where singers with vocal injury are common. A SLP who specializes in the injured voice is rare. A SLP who knows and understands opera intimately is exceedingly rare.

The vast majority of SLP are specialists in speech production... not voice.

Why is this distinction important?

Speech is basically sound that is produced by a person after modification by the lips, teeth, tongue, palate, and throat of a person. As such, speech issues are related to problems stemming from these anatomical parts.

Voice is basically the sound that is produced by the voicebox. Basically, it is the noisemaker upon which the sound produced is modified to ultimately produce speech. In another words, "voice" is created prior to "speech". Voice problems are limited to anatomical or functional abnormalities of the voicebox resulting in a raspy/hoarse/breathy sounding voice. Such problems include vocal cord nodules, vocal cord polyps, spasmodic dysphonia, paralyzed vocal cords, etc.

Depending on whether a patient is suffering from a speech problem or a voice problem determines what type of SLP is appropriate.

Miss Kaeppelar would (hopefully) be classified into a special (and rare) category of SLP who specializes not just in voice therapy, but voice therapy for singers with an injured voice.

Read more about voice versus speech therapy here.

Miss America confronted family pain with pageant. FoxNews 1/14/12

January 14, 2012

Nasal Hair Removal and Nasal Sores

It is not unusual that I encounter a patient who develops crusting and sores around the entrance to the nose where coincidentally nasal hair is found... in both men and women.

Other complaints/symptoms beyond crusting and sores include:

• Skin Splitting
• Pimple/Acne Formation
• Scabbing
• Ulcers

People often try applying lotion, neosporin, or cortisone cream... which does help, but not completely with recurrent flareups.

The most common triggers I find that lead to such recurrent sores are nose-picking and nasal hair removal.

The best thing is to avoid doing either... but... if one must...

Nose picking is pretty self-explanatory, but nasal hair removal does require some clarification.

People often use tweezers or even their fingers to pull the offending long nasal hair out for either cosmetic or annoyance reasons.

Yanking nasal hair out is not a good idea beyond the watery eyes it may bring. It causes micro-trauma to the surrounding skin and hair follicle that may lead to infection. Furthermore, just like any other place on the body where hair is removed, ingrown hair growth can also occur.

Aha! one might say... Use an electric nasal hair cutter! That's a good idea, but make sure it does not cut down to the skin for the same reasons as stated above. Also, ensure the blades are kept sharp to prevent hair pulling.

There are good nasal hair cutters and there are bad ones...

From personal testing of a variety of nasal hair cutters, I like the Groom Mate Platinum XL.

I'm sure there are other good ones, but it may also come down to personal preference.

Now, if there's an active recurrent nasal sore that's not healing, the best way to treat it is with prescription cortisporin ointment.

However, best to have a doctor to check it out as there are other more malicious reasons for a nasal sore including skin cancer.

January 10, 2012

Woman Coughs Out Her Throat Cancer

It was reported today a woman literally coughed out a previously undiagnosed throat cancer... and cured herself of it.

She apparently felt a tickle in her throat forcing her to cough... and spat out a 2 cm large mass. No kidding...

The mass was sent to pathology and was diagnosed to be malignant and was told she only had a 50% chance of survival.

To ensure no cancer was left behind, she underwent radiological scans as well as additional biopsies in the base of tongue region where the mass probably originated from and no further trace of cancer was found.

She is very lucky as most base of tongue cancers that's 2 cm large usually requires not only surgery, but also chemotherapy and radiation treatment.

As the report stated, the cancer was probably on a thin stalk (like a lollipop) that allowed her to cough the entire cancer out!

Woman in clear after coughing up a cancerous throat tumour. 1/11/2012

January 08, 2012

Food Allergy Reaction Video

So the other day, I was watching the movie Hitch starring Will Smith and Eva Mendes during which there is this one scene where Hitch suffers an allergic reaction from a food he ate during a dinner date. Watch video.

It's actually a pretty good depiction of a reaction due to a food allergy.

However, given the throat-clearing suggesting airway swelling which extends to his face, he really should have called 911 as this not uncommonly leads to death if the airway swelling is severe enough to obstruct his breathing. Along with facial and airway swelling, his blood pressure probably dropped and his heart rate increased to point he could have passed out due to insufficient blood flow to the brain. Of course, it was a movie and none of that happened, but don't think for a second that benadryl alone is adequate.

It is a little unusual for an adult to have a previously unknown food allergy with this severe a reaction in someone as old as Hitch, but not impossible.

Treatment was appropriately given with benadrylin the movie, but in reality Hitch additionally should have gone to the ER where epinephrine and steroids also would have been administered followed by several hours of observation.

After recovery, he should ALWAYS carry an epipen with him. He should also probably see an allergist to determine what it was he reacted to so that he can avoid it in the future.

On another note, in the movie, Hitch literally chugs down an entire bottle of liquid benadryl and acts drunk from it. That usually wouldn't have happened... rather, he would have gotten extremely drowsy and fallen asleep fairly quickly. However, in some individuals, it might occur.

Revolutionary Camera Takes "Living" Pictures

Lytro has introduced a new type of camera that may have tremendous implications in medical photography.

It is a camera that takes a "living" picture. What does that mean?

In essence, it is a camera that takes a picture taking ALL the light information that is present such that the picture can be manipulated as if you haven't taken the picture yet.

It sounds confusing, but practically speaking, it means that one can literally refocus any part of a picture AFTER it has been taken. We are not talking about photoshopping using the blur or sharpen filter. It is literally refocussing a picture AFTER it has been taken!!!

You need to see it to believe it...

Click here to view some sample pictures. Touch (click) to refocus any part of the picture; pinch (double-click) to zoom.

I can't wait to see some medical photography done with this camera which starts at $399.

Purchase through the company's website.

New Webpage Describing Surgery to Treat Reflux

Given how often we see patients for reflux-triggered ENT problems and the questions we often get regarding surgical options, we have created a new webpage to discuss procedures used to try and cure reflux-triggered ENT symptoms.

Such symptoms may include:

Chronic cough
Phlegmy throat (lots of throat mucus)
Chronic throat-clearing
• Burning throat
Lump in throat sensation

Heartburn or any burning sensation may not be present at all!

Surgical options include not only the standard laparoscopic Nissen Fundoplication which requires multiple small incisions over the belly, but trans-oral incisionless fundoplication whereby the surgery is all accomplished through the mouth.

Click here to read more!

Head MRI and CT Scans Explained!

@ENTHouse brought to my attention a FANTASTIC website that literally identifies and goes through all anatomic structures on every slice of a CT or MRI scan of the head.

Sinus cavities, blood vessels, nerves, bone, suture lines, etc...

Wish I thought of doing it first...

It may be a bit confusing for a layperson, but if you have a copy of your CT/MRI scan and wonder where the maxillary sinus or optic nerve is located on your scan, check this website out and you probably can figure it out!
Check it out!

January 07, 2012

Argentine President Had Surgery for Wrongly Diagnosed Thyroid Cancer

On Jan 4, 2012, Argentine President Cristina Kirchner underwent a total thyroid gland removal for papillary thyroid cancer.

On Jan 7, 2012, it was announced that she never had thyroid cancer in the first place! See news report.

Why did this happen? And it does happen unfortunately to not only President of a nation, but to ordinary citizens.

Without benefit of having access to her medical records, I suspect her medical course went something like this which is what happens in the vast majority of patients with a thyroid mass...

She probably had a full medical evaluation including an ultrasound of her thyroid gland which revealed a nodule or mass.

She underwent an ultrasound guided needle biopsy in order to obtain some cells for pathology review. I suspect that the pathologist reported suspicion for papillary thyroid carcinoma. She may even have undergone a thyroid scan which revealed a cold nodule (increasing the likelihood but does not confirm cancer).

Based on a diagnosis obtained on a needle biopsy, standard of care treatment is complete thyroid removal followed by radioactive iodine treatment.

I suspect the surgeon who did the surgery did discuss with the patient the option of removing only half the thyroid gland (side with the mass) and waiting on final pathology to confirm presence of cancer before removing the rest of the thyroid gland. However, this would mean TWO separate operations on different days as it does require time for final pathology results to become available.

Given I'm sure President Kirchner is a VERY busy person, she probably elected to have the whole thyroid gland removed rather than undergoing the possibility of two operations. The risk being she may ultimately have a total thyroidectomy done when no cancer was actually present at all!

SO... was there a mistake made (if any)?

Was it the pathologist who reported cancer in the needle biopsy?

Was it the surgeon who did not confirm cancer by removing only half the thyroid first?

Let's look into the mind of the pathologist...

From the pathologist perspective, it is better to be safe and over-call things... because it is FAR worse to miss a cancer diagnosis. Imagine if the pathologist stated NO thyroid cancer was seen on the needle biopsy... only to be wrong and the Argentine president dying of thyroid cancer at some point in the future due to this misdiagnosis. The medical-legal liability and fear of being sued forces not only pathologists but also radiologists to report slight abnormal findings just to be on the safe side. Such reports will often state:
 "Cells [or CT scan] have some features suggestive of cancer. Clinical correlation recommended."
This vague statement can be interpreted in two ways... The pathologist is NOT saying there is cancer present. He is stating it might be present, but he's not sure. Which means the burden of liability now passes to the surgeon...

From the surgeon's perspective, he now has to deal with whether to operate or not based on an equivocal diagnosis on needle biopsy. What if he does NOT operate and cancer WAS present? There was than a delay in cancer treatment and theoretical decrease in survival.

OR... take the safe route and operate, but acknowledge that there is the possibility that no cancer was present and that surgery was actually not truly needed in the end. Complicating this course of action is that surgery has risks (and what a bummer if "unnecessary" surgery was performed and complications happened).

The compromise solution would have been to remove just the side where the thyroid nodule was present, but than a 2nd operation would have been needed if cancer WAS found.

So, was there "malpractice" committed by any physician in the care of President Kirchner?

Probably not because the decision making by various physicians in her care probably tended towards being safe rather than sorry (for not only the patient, but also the physicians).

There are many variations on this theme... Other courses of action that could have occurred or been taken include:

1) Monitoring with repeat ultrasounds and needle biopsies
2) Getting multiple 2nd opinions
3) Repeating radiological scans

Danger is what if some say do it and some say don't do it. Some scans or needle biopsies suggestive for cancer and others that aren't?

As the old saying goes, too many cooks ruin the soup. OR, you see five doctors, you may get 5 different opinions.

At some point, YOU as the patient needs to decide what to do and live with the consequences of your decision.

Why does this even occur???

Because NO test is 100% accurate.

Read more about the surgery here or watch the video!

Argentine President Cristina Kirchner wrongly diagnosed with cancer. The Telegraph Jan 7, 2012.

January 06, 2012

Laryngospasm and Vocal Cord Dysfunction Video

A new video has been uploaded showing what happens inside the throat when a patient suffering from laryngospasm or vocal cord dysfunction suffers from a breathing attack.

For more information on this condition, click here.

If you are unable to watch the video below, click here to watch it on YouTube.

January 04, 2012

Argentine President Undergoes Thyroid Surgery

BBC News reported today that popular Argentine President Cristina Fernandez de Kirchner underwent total thyroidectomy for papillary thyroid carcinoma, a highly curable form of thyroid cancer.

Thankfully, there were no complications and she is expected to be discharged from the hospital in the next 2 days.

Thyroidectomy is when the entire thyroid gland is removed which is necessary whenever thyroid cancer is present.

What are some of the complications that could have occurred?

Vocal cord paralysis, either one or both vocal cords
• Calcium level problems which can lead to heart arrhythmias
• Bleeding which can compress the airway necessitating a tracheostomy

Read more about thyroid surgery here. Watch video of a thyroid being removed.

Argentine President Fernandez undergoes cancer surgery. BBC News Jan 4, 2012.

January 02, 2012

Misleading FoxNews Report: Laryngitis for 30 Years

On Dec 23, 2011, Fox News reported on a woman who supposedly had laryngitis for 30 years.

The story reported that the woman had a viral URI in 1982 which resulted in laryngitis and a paralyzed vocal cord.

What people should be aware of is that a paralyzed vocal cord is NOT laryngitis. Laryngitis is an infection of the larynx or voicebox. Stating that a paralyzed vocal cord is akin to laryngitis is like claiming a person who has a paralyzed arm/leg from a stroke has an arm/leg infection.

Now it is true that a viral laryngitis can cause a paralyzed vocal cord, but they should not be considered synonymous.

Patients with a paralyzed vocal cord have a very breathy sounding weak voice and a weak cough. They may also suffer from aspiration where liquids/foods go down the wrong way more easily than normal.

Typically, the first way to treat a paralyzed vocal cord is voice therapy. If voice therapy does not make much improvement, surgical intervention can be considered.

Typically, a vocal cord injection is performed if the paralysis onset was within one year. After one year, an implant can be placed as the Fox News report mentioned.

Read more about paralyzed vocal cords as well as watch a video here.

Woman Gets Voice Back After Suffering From Laryngitis for 30 Years. FoxNews 12/23/11

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