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August 30, 2012

Actor Larry Hagman Treated for Throat Cancer

Image by Toglenn from Wikipedia
In June 2011, actor Larry Hagman was diagnosed with stage 2 throat cancer. It is unclear exactly where the throat cancer was localized to (tongue, tonsil, supraglottis, hypopharynx, oropharynx, etc), but it was treated medically with radiation and chemotherapy.

Larry Hagman is a well-known actor playing oil baron J.R. Ewing in the soap opera Dallas (1980s as well as 2012) as well as Major Nelson in  the TV sitcom I Dream of Jeannie. Most impressive was the fact that he continued to act while undergoing cancer treatment for the Dallas remake.

Yesterday, Aug 29, 2012, media reported that the actor is now "cancer free."


Throat cancer, especially stage 2, has the potential to come back. Though there may be no detectable signs of cancer currently, there is the possibility of cancer coming back in the future.

The risk of cancer recurrence is highest within the first 2-3 years after treatment completion, and markedly decreases after 5 years.

Typically if cancer has not come back after 5 years, the word "cure" may than be used, but even than, such patients are seen yearly for the rest of their life for cancer monitoring.

Given the high risk of cancer recurrence, patients are seen frequently for the first 2-3 years after treatment.

Every 2 months for the first year. Every 3-4 months in the 2nd year. Every 4 months in the 3rd year. Every 6 months in the 4th year. Yearly starting at 5 years after treatment.

This type of follow-up applies to all head and neck cancer.

Larry Hagman is cancer-free. SFGate 8/29/12

Larry Hagman. Wikipedia

Should Gloves Be Worn When Giving Allergy Shots?

A common question patients ask is whether nurses and or other medical staff be wearing gloves when giving allergy shots (or other forms of immunization).

According to the CDC:
"Gloves are not required when administering vaccinations, unless persons administering vaccinations are likely to come into contact with potentially infectious body fluids or have open lesions on their hands." [link]
 As such, the practice of wearing gloves is left up to the discretion of the person administering the shot.

Some offices/hospitals may have a policy in place that makes it mandatory, but technically it is not required.

Of course, many individuals will point out a conflicting policy based on "Universal Precautions" which can potentially be interpreted as mandatory use of barrier protection (like gloves) whenever there is the possibility of bloodborne pathogen transference (which some may interpret as risk is always present).

However, if one actually reads the Universal Precautions put out by the CDC as it relates to blood drawing (considered higher risk than immunizations),
"In universal precautions, all blood is assumed to be potentially infective for bloodborne pathogens, but in certain settings (e.g., volunteer blood-donation centers) the prevalence of infection with some bloodborne pathogens (e.g., HIV, HBV) is known to be very low. Some institutions have relaxed recommendations for using gloves for phlebotomy procedures by skilled phlebotomists in settings where the prevalence of bloodborne pathogens is known to be very low. Institutions that judge that routine gloving for all phlebotomies is not necessary should periodically reevaluate their policy. Gloves should always be available to health-care workers who wish to use them for phlebotomy." [link]
Not quite the "mandatory" use of gloves some people stipulate when quoting Universal Precautions policy.

General Recommendations on Immunization. CDC 2/8/02

Perspectives in Disease Prevention and Health Promotion Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings. CDC 6/24/88

August 29, 2012

Allergies May Prevent Heart Attacks???

Research has been published suggesting an inverse relationship between serum IgE and heart attacks in the US population independent of coronary risk factors.

No kidding...

This conclusion was reached based analyzing 4002 participants between 2005-2006. They also detected that of the 7 "data-driven, prespecified allergen clusters," house dust mite was the only allergen cluster for which serum IgE is associated with reduced risk for heart attack.

For those wondering, serum IgE is a rough measure of how allergic a patient is generally speaking without any specification of what the patient may be allergic to. It is obtained by bloodwork (RAST or immunoCAP).

The higher the IgE levels, the more allergic a patient is generally speaking. However, one must keep in mind that it may still be possible to be allergic even if IgE is low or vice versa.

Also, although there appears to be a relationship between IgE and heart attacks, it is doubtful it reaches clinical significance for any given patient. Rather, such conclusions may apply to a general population. This study was also retrospective and as such, it would be nice if a new study now looked at a group of allergic patients and see how many suffer heart attacks in the future.

Such un-intuitive relationships just goes to show how complex the human body is where one thing doesn't cause one problem, but rather one thing may affect multiple different aspects of human health.

Now why would IgE and/or allergies in general influence heart attack risk?

Well heart attacks are due to vascular disease (blockage of the coronary artery). Vascular disease is thought to be influenced by how much inflammation is present in the body. The more inflammation present, the higher the risk of vascular disease which in turn increases heart attack rates.

One factor thought to influence the degree of inflammation present in the body is the immune system, and allergies is one part of the immune system.

As such, allergies could be a reflection of what the immune system is doing which in turn influences the degree of inflammation present in the body which in turn affects vascular disease which plays a role in heart attacks.

Relation between objective measures of atopy and myocardial infarction in the United States. Journal of Allergy and Clinical Immunology. In Press Aug 27, 2012.


August 27, 2012

Same Doctor Visit, Double The Cost

On August 26, 2012, the Wall Street Journal published a story describing a situation whereby a patient who sees a physician employed by a hospital essentially pays double out-of-pocket what they would have paid for the same exact office visit with a physician NOT employed by the hospital.

I actually wrote about this situation in January 21, 2012.

Beyond what the Wall Street Journal reported, what's going on?

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 government-established 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 Congress is considering abolishing the outpatient prospective payment system for clinic visits only. Click here for more info.

Same Doctor Visit, Double the Cost. WSJ 8/26/12

Hospital-Based Practice Versus Physician Private Practice. Fauquier ENT Blog 1/21/12.

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

August 24, 2012

Healthcare Websites and Blogs Worth Anything?

I wrote in the past that healthcare blogging was in some ways a losing proposition when compared to entertainment news in terms of web traffic and search queries.

However, when it comes to ad revenue and how much a website is worth to potential buyers, healthcare topics (as well as sports) are king in monetary generation.

Flippa is a website that mediates the buying and selling of websites. They also produced a handy visual aid infographic based on their internal statistics.

As you can see, health websites are worth a premium. Furthermore, websites that generate revenue based on ads are also worth more.  Why? Because on average, health niches also get a pretty good cost-per-click (amount a website owner is paid every time someone clicks on an ad on their site).

August 22, 2012

Bi-Lobed Zenker's Diverticulum

In the not so distant past, I saw a patient who suffered from a bi-lobed Zenker's Diverticulum. Zenker's diverticulum for those who don't know is the abnormal development of a pouch in the throat causing symptoms of phlegm in the throat, food regurgitation, swallowing difficulties, and aspiration.

Most Zenker's Diverticulum is composed of a single central pouch. However, there are more rare varieties such as this bi-lobed pouch seen on barium swallow.

However, at time of surgery (endoscopic staple diverticulostomy), the bi-lobed nature of the pouch essentially disappeared.

Video of how the surgery is performed:

Bacteremia IS Present During Tonsillectomy!

@ENTHouse brought to my attention a very interesting research regarding the presence of bacteria in the bloodstream during tonsillectomy, both elective and quinsy. Elective tonsillectomy is when the tonsils are removed in the absence of any significant infection. Quinsy tonsillectomy is when the tonsils are removed in the setting of a peritonsillar abscess.

The research involved obtaining blood cultures, tonsillar swabs, core tissue, and pus aspirates during the operation on 80 patients undergoing elective surgery and 36 undergoing quinsy surgery.

What they found was,
"Bacteremia was detected in 73% of patients during elective tonsillectomy compared to 56% during quinsy tonsillectomy. Significantly more blood culture bottles were positive for each isolate obtained from elective tonsillectomy cases compared to quinsy tonsillectomy cases. In all, 59% and 42% of electively and acutely tonsillectomized patients, respectively, had bacteremia with microorganisms that are predominant in bacterial endocarditis. Ninety-three percent of the isolated strains were sensitive to amoxicillin, and all were sensitive to amoxicillin with clavulanic acid." [link]
Amoxicillin with clavulanic acid is also known as Augmentin.

What is fascinating is the high rate of bacteria presence in the bloodstream during a routine elective tonsillectomy... even higher rates than tonsils which are actively and terribly infected. Perhaps because those with an active infection are already on antibiotics thereby suppressing bacteria in the bloodstream? Also, with an abscess, the pus pocket is already walled off by inflammatory tissue thereby preventing further leaching of bacteria into the bloodstream?

Regardless, these findings are especially interesting in light of the fact that antibiotics are not routinely recommended before, during, or after surgery!

Bacteremia during quinsy and elective tonsillectomy: an evaluation of antibiotic prophylaxis recommendations for patients undergoing tonsillectomy. J Cardiovasc Pharmacol Ther. 2012 Sep;17(3):298-302. Epub 2011 Oct 24.

FDA Approves New Epinephrine Injector That Talks

Sanofi US has introduced a new epinephrine injector (competitor to the more commonly known EpiPen made by Dey Pharma LP) that is equipped with audio and visual cues that helps a patient or care-giver administer epinephrine in cases of a severe allergic reaction (anaphylaxis).

Known as Auvi-Q, it was FDA approved Aug 13, 2012, and should soon become available for purchase by prescription.

Just like EpiPen, Auvi-Q comes in two different dosages of epinephrine... 0.3mg for patients who weigh more than 66 pounds and 0.15mg for those who weigh between 33 and 66 pounds. Each pack contains two devices with active drug plus a non-active training device.

During a life-threatening allergic reaction, Auvi-Q talks the patient or care-giver through each step of the injection process. If more time is needed, it can repeat the instructions step-by-step. The device also comes with written instructions printed on the side. In addition, there are visual cues with an alert light to signal when the injection is complete. Watch video.

Auvi-Q is about the size and shape of a credit card, the thickness of a cell phone and fits comfortably in a pocket or small purse. This size and shape is in contrast to the EpiPen which looks like a fat marker. Being compact and easy to carry should remove one obstacle that could be a reason why as many as two-thirds of patients do not carry their epinephrine injector device.

Like the EpiPen, the device also has an automatic retractable needle mechanism to prevent accidental needle sticks.

FDA Approves Auvi-Q Voice Activated Epinephrine Injector. EmaxHealth 8/13/12

August 19, 2012

Singer Nicki Minaj with Strained Vocal Cords

Media has reported that pop star Nicki Minaj had to cancel upcoming concerts in England due to injured vocal cords.

She apparently saw a doctor who diagnosed "strained vocal cords" after an x-ray and recommended voice rest for a few days.

The singer apparently ignored this advice and sang in New York City on Aug 18 causing her voice to substantially worsen resulting in her decision to cancel her concerts this weekend.

Details of her vocal cord condition are sparse. However, based on the limited information provided, there's a few things I can guess at.

First off, an x-ray can NOT diagnose any type of vocal cord condition. The singer must have undergone a trans-nasal endoscopic procedure which is the ONLY way to visualize the vocal cord and diagnose any vocal problems.

Given the singer was instructed to rest her voice for "a few days," she most likely suffered from a mild acute laryngitis causing inflamed vocal cords. By ignoring advice to rest her voice, she potentially turned a mild laryngitis into a more severe laryngitis. She probably did not suffer from any physical problems on her vocal cords like nodules or polyps which would take weeks if not months to recover (not days) as happened to singers Adele and John Mayer.

Really, at this point, strict voice rest, hydration, acid reflux control, and steroids (ie, prednisone) would enable her to recover her normal voice ASAP.

Here's a picture of a severe laryngitis (left) compared a normal appearing vocal cords (right). Note that the vocal cords are swollen and red compared to normal pearly white and thin appearance.


Nicki Minaj cancels U.K. concerts due to strained vocal cords. NBC News 8/18/12

Financial Issues with Emergency Room Specialist Care

Imagine this scenario... A young child is playing in the yard when her pet dog bites her face. Bleeding, the child is rushed to the emergency room and the emergency room doctor offers to suture up the child's face.

The next question a parent will probably ask (or demand) is the desire for a plastic surgeon to suture the face instead of the emergency room doctor.

As such, the plastic surgeon is called in and sutures up the face beautifully.

The child and family goes home and that's when the financial nightmare begins...

The plastic surgeon bills the family for $2,000 for services rendered in the emergency room. The plastic surgeon does NOT participate with their health insurance plan and being a non-participating provider, the bill for care provided is directly sent to the child's family.

Here is a New York Times article describing this situation.


Unfortunately, it is not unusual... and there are lawsuits now pending among insurance companies, specialist physicians, as well as even against patients regarding who pays the medical bills.

Here is an article portraying a hand surgeon who has sued numerous patients regarding just this scenario. Most specialists will either write-off or accept any amount after being sent to collection.


If a patient has a medical problem, a call to the medical office is made to see the doctor. However, before the appointment is made, both the patient and office checks to ensure the visit will be covered by insurance. If not, a call to a different medical office is made until one that participates with the patient's insurance is found. However, if the patient decides to see a physician who does NOT participate with his health insurance company, he will be responsible for the entire bill (the office visit will not be covered by insurance).

The same is true for outside specialists called into the emergency room. These outside medical specialists participate only with certain insurances. As such, if they perform services on a patient whose health insurance does not cover that particular medical specialist, the patient will get the entire bill.

Emergency room care IS covered by insurance... because it is an "emergency," but services performed ONLY by the emergency room staff applies. NOT services by outside specialists called in.

What to Do?

So what is a patient to do in order to avoid a surprising large bill?

Ideally, have all services performed by emergency room staff and avoid services by outside specialists. If it is not life-threatening (like a facial dog-bite... ugly, but not life-threatening), have the emergency room doctor do all he can. Than follow-up as an outpatient with a specialist who participates with your health insurance plan.

If an outside specialist MUST be called in, ask whether this specialist participates with your health insurance plan. If not, ask how much the specialist will charge for services rendered. Be aware, if the outside specialist actually comes into the hospital, a consultation fee will be charged (typically around $100-$200). If a procedure is performed, a procedure charge will be present (hundreds to thousands of dollars).

A patient can request whether there is a different doctor who can be contacted should the specialist on-call not participate with his/her health insurance plan. However, be aware that typically only ONE doctor per specialty is on-call to the emergency room at any given time and as such, an alternative doctor may not be available.

Once you are aware of the charges, you as the patient needs to decide whether to proceed with specialist care or not.

Be aware that the insurance coverage issues also applies for specialist consultations during a hospitalization and not just in the emergency room.

Bottom Line

Simply going to the emergency room does not mean all medical services will be covered by insurance, especially services provided by a medical specialist.

If specialist care is required in the emergency room, just ask whether the specialist participates with your health insurance plan, because if not, be aware that you directly will get a bill.

That's just how the medical system is set up currently.

Congressman Putney with Vocal Cord Cancer

Media has reported that Congressman Lacey Putney, chairman of the powerful Appropriations Committee in the House of Delegates, has early stage vocal cord cancer.

He is currently undergoing radiation therapy which has a high chance of cure with relatively minimal side effects along with voice preservation.

My suspicion is that he is suffering from squamous cell carcinoma which is the most common type of vocal cord cancer. Though radiation therapy is a common form of treatment for this type of early stage cancer, surgical excision without the need for radiation is also possible. No chemotherapy is necessary for early stage vocal cord cancer.

Below is a picture of an early stage right vocal cord squamous cell carcinoma.

Compare to normal:

Putney undergoing treatment for throat cancer. WSLS10 8/15/12

August 17, 2012

CPAP + Oral Appliance (All-In-One) Device for OSA

A dentist colleague of mine informed me of a new device that combines CPAP mask with an oral appliance for patients with obstructive sleep apnea (CPAP Pro + Mandibular Advancement).

The unique benefits of this combo device are several-fold:

• No straps
• Keeps mouth closed
• Addresses tongue collapse that obstruct the airway by bringing jaw forward
• Can sleep in any position

This device does need to be fitted by a dentist. (For Virginia residents, Dr. Jason Woodside is familiar with this product.)

Of course, it is relatively new and we'll see if patients love this combo CPAP mask more than the traditional masks that have been on the market.

For those patients who do NOT have a problem with tongue collapse, but prefer the no-straps solution of the oral appliance, the company does make a mouthguard that fits only the upper teeth.

August 16, 2012

Squid Ejaculates Into Woman's Mouth

It happened in June 2012...

A South Korean woman was eating a half-cooked squid when the squid apparently ejected its sperm bag into her tongue causing...
"pricking and foreign-body sensation in the oral cavity. Twelve small, white spindle-shaped, bug-like organisms stuck in the mucous membrane of the tongue, cheek, and gingiva..." [link]
Of course, she immediately spat the squid portion out, but required surgical excision of affected mucosa.

Bizarre but true...

Squid Injects Woman's Tongue With Sperm Bag As She Eats In Korea. Huffington Post 6/15/12

Penetration of the oral mucosa by parasite-like sperm bags of squid: a case report in a Korean woman. J Parasitol. 2012 Feb;98(1):222-3. Epub 2011 Aug 11.

August 14, 2012

Mouth "Oil Pulling"

The other day, I had a patient ask me about "oil pulling." For those who don't know what oil pulling is:
"Oil pulling or oil swishing is a traditional Indian folk remedy that involves swishing oil in the mouth. It is mentioned in the Ayurvedic text Charaka Samhita, where it is called Kavala Gandoosha or Kavala Graha. Ayurvedic literature describes oil pulling as capable of both improving oral health and treating systemic diseases such as diabetes mellitus or asthma. While scientific evidence is lacking to support any systemic benefits of oil pulling, some studies have suggested that it may reduce oral plaque, halitosis, and gingivitis." [Wikipedia]
The oil used to swish the mouth is typically vegetable based like sesame or sunflower and is performed for 15-20 minutes before being spit out (or swallowed depending on what you want to accomplish).

Though there are plenty of testimonials on the internet and explanations for its amazing effects including the oil's alleged ability to suck plaque off teeth, absorb germs into the oil, make teeth whiter, etc I feel the oil's effects are more mundane in nature.

Just as chapstick is an oil-based compound that treats dried and chapped lips by coating the surface allowing the lip mucosa to heal, oil pulling may just provide a protective barrier to provide a similar function. Oils are essential to skin and mucosal health and when such oils are stripped, problems occur (ask anybody who washes their hand with soap multiple times a day).

As such, I personally don't think it can hurt if someone wants to give oil pulling a try to address oral problems. But I would not recommend this type of unproven treatment to address systemic disorders like diabetes or asthma over more established medical management.

Of note, the references listed below are studies published in less-than-authoratative journals.

Tooth brushing, oil pulling and tissue regeneration: A review of holistic approaches to oral health. J Ayurveda Integr Med 2 (2): 64–8. doi:10.4103/0975-9476.82525.

Effect of oil pulling on Streptococcus mutans count in plaque and saliva using Dentocult SM Strip mutans test: a randomized, controlled, triple-blind study. J Indian Soc Pedod Prev Dent 26 (1): 12–7.

Mechanism of oil-pulling therapy - in vitro study. Indian J Dent Res 22 (1): 34–7. doi:10.4103/0970-9290.79971.

Effect of oil pulling on plaque induced gingivitis: a randomized, controlled, triple-blind study. Indian J Dent Res 20 (1): 47–51. PMID 19336860.

Effect of oil pulling on halitosis and microorganisms causing halitosis: a randomized controlled pilot trial. J Indian Soc Pedod Prev Dent 29 (2): 90–4. doi:10.4103/0970-4388.84678.

Intra-Nasal Trigger Point Injections for Facial Headache

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 or a type of neuralgia involving one of the nerve plexuses found inside the nose:

• Anterior ethmoid neuralgia (Sluder's 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.

In the event of a contact point headache, surgical removal of the offending anatomic abnormality is curative.

However, for neuralgia, trigger point injections may be helpful according to a recent study. Using a 1:1 mixture of 0.5% bupivacaine and Kenalog-40, either the sphenopalatine ganglion or the anterior ethmoid neurovascular bundle or even both are injected. For the sphenopalatine ganglion, the injection is where the middle turbinate inserts into the lateral nasal wall. For anterior ethmoid injection, identify the arch where the middle turbinate inserts superiorly to the lateral nasal wall and inject 5mm above this site.

In a total of 882 nerve blocks in 147 patients, 99.3% had no complications. 2 patients reported visual changes that resolved within 2 days. More importantly, 81.3% claimed improvement in their headache, 17.9% reported no change and 0.79% reported worse pain after the injection.

The typical duration of pain relief was 3-4 weeks. As such, for continued pain relief, the injection needs to be repeated monthly on average.

Endoscopic neural blockade for rhinogenic headache and facial pain: 2011 update. Int Forum Allergy Rhinol. 2012 Apr 5. doi: 10.1002/alr.21035. [Epub ahead of print]

August 11, 2012

Honey Helps Relieve Coughing in Kids

Ever since the FDA has withdrawn in 2008 common over-the-counter medications to treat cough in kids, there has been a conundrum among pediatricians and their young patient charges on how to address the cough that occurs with viral upper respiratory infections (common cold). Beyond humidified mist, hydration, vapor baths, saline spray, and sleep, there are still some other effective options to try...

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.

There was a 2007 study published in the Archives of Pediatrics and Adolescent Medicine by Hershey Penn State Medical Center revealing the benefit of buckwheat honeyto help with pediatric cough. In fact, it was found to work even BETTER than over-the-counter cough suppressants. This study has been picked up by the general news media as well.

In a more recent 2012 study (randomized, double-blinded, placebo-controlled) comparing 3 different honey products (eucalyptus honey, citrus honey, or labiatae honey) against placebo, the cough improvement was greater in the honey groups for all the main outcome measures. (media report)

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.

Any further questions or concerns should be directed to your pediatrician. Be aware that honey should not be given to infants less than 1 year old due to risk of botulism.

Of note, the reason why cough syrups were removed from sale in 2008 was because 5 children died from overdoses.

You can purchase buckwheat honeyon

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.

Effect of Honey on Nocturnal Cough and Sleep Quality: A Double-blind, Randomized, Placebo-Controlled Study. Pediatrics. Published online August 6, 2012 (doi: 10.1542/peds.2011-3075)

August 10, 2012

Child's Allergy Risk Higher If Same Sex Parent Has It

British researchers reported this month their findings that a child is at higher risk of allergies if the same sex parent has allergies. In other words, if a father has bad allergies, his sons are at higher risk for them and if a mother has bad allergies, than her daughters are at higher risk for allergy problems.

They based their findings following 1456 children examined at 1, 2, 4, 10, and 18 years of age. History of asthma, eczema, rhinitis, and environmental factors was obtained and skin prick tests were carried out at ages 4, 10, and 18 years, and total IgE measurement was carried out at 10 and 18 years. Parental history of allergic disease was assessed soon after the birth of the child, when maternal IgE levels were also measured.

Keep in mind that the appearance of allergy in a child is not wholly based on genetics but does have some environmental basis as well.

However, the association of gender is a new twist on whether a child will develop allergies or not.

The effect of parental allergy on childhood allergic diseases depends on the sex of the child. The Journal of Allergy and Clinical Immunology Volume 130, Issue 2 , Pages 427-434.e6, August 2012


Spider Found Living in Woman's Ear for 5 Days

Thanks to @beubank for alerting me to this story about a spider who lived in a woman's ear for 5 days before being removed. As an aside, in typical media blunder of factual error, in the Huffington Post, a picture is shown of the spider stating an "x-ray photo"... COME ON!!! The picture is NOT an x-ray in any way shape and form!!! It's just a regular ordinary picture one takes with a camera.

On that note, August 9, 2012 must be the time for all media to report on all sorts of things found in people's ears and noses.

Fox News reported on a story about a lego being stuck inside a kid's nose for 3 years.

In the past year, I must have removed several cockroaches, ticks, rocks, pebbles, play-doe, paper, cotton, and even one moth. Never a spider however.

In perhaps one of the most impressive arrays of foreign objects removed from the ear, nose and throat (I believe in the thousands) is on display at the Mutter Museum in Philadelphia. All objects were removed by a single ENT (Dr. Chevalier Jackson). If you are ever in Philadelphia, this museum is a must see.

August 08, 2012

Nasal Congestion or Obstruction During Pregnancy

When a woman becomes pregnant, it is not unusual for the nose to become quite congested... uncomfortably so, even to the point of being unable to breath through the nose.

This condition known as "rhinitis of pregnancy" affects as many as 30% of pregnant women and can start in the second month of pregnancy; it tends to worsen later in pregnancy. The nasal congestion should ease up soon after giving birth and be gone completely within two weeks after delivery.

The nasal congestion occurs due to elevated amounts of estrogen causing swelling of nasal mucous membranes. Furthermore, there is a marked increased in circulating blood in the body which also leads to swelling of the tiny blood vessels lining the nose. Bloodflow causing nasal obstruction (turbinate hypertrophy) is not unusual and even occurs in men (laying down on one side causes nasal obstruction that than switches when laying down on the other side; improves when sitting/standing).

On exam, a common finding are large inferior turbinates. Inferior turbinates are soft tissue outpouchings within the nose that warm and humidify the air as nasal breathing occurs. Normally, they are quite small, but with rhinitis of pregnancy, they can become enormous... even quadrupling in size.

Inferior Turbinates Seen on Exam

Generally speaking, my approach to treating this uncomfortable condition is as follows (assuming all other causes are ruled out and no medical contraindications):

1) Regular HYPER-tonic saltwater nasal irrigations to the nose 3-4x per day. I recommend HYPER-tonic saltwater rather than regular strength saltwater. Why? Salt sucks moisture out of the nose. With regular strength saltwater (aka, normal saline), the saltwater concentration is equal to that found within the body and minimal if any moisture displacement (osmosis) occurs. With HYPER-tonic saltwater, given the increased salt concentration compared to that found within the body, moisture leaves the nose allowing for decongestion to occur.

Nasal irrigations can be performed with Neti Pot or NeilMed Sinus Rinse Bottle. Hypertonic salt packets can be purchased and mixed with 8 ounces distilled water. Or, if you want to make it yourself, 1/2 to 3/4 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of distilled water.

2) Rhinocort AQ steroid nasal spray 2 sprays on each side daily. Steroids help to decrease swelling, especially the large inferior turbinates. This steroid nasal spray is the ONLY steroid nasal spray that is Class B for pregnancy.

3) Keep the head elevated when you lie down. This reduces the blood flow to the nose which exacerbates the nasal congestion.

Of course, steps 1 and 2 assume that there is SOME room for the treatment to occur. If the nose is 100% blocked up, use over-the-counter Afrin nasal spray a few times to get things to open up (never more than 3 days). Once opened up some, immediately start #1 and 2. It is not healthy nor wise to use afrin too much. Ideally, it may need to be used for 1 day only and no more thereafter. There is also some concern that decongestant use during only the first trimester may cause some birth defects (read more). Even in non-pregnant individuals, afrin should never be used more than a few consecutive days otherwise risk addiction!

Response to treatment typically occurs within 2 weeks.

Oral Steroids No Help in Sinus Infections?

Media outlets such as Fox News reported yesterday that oral steroids do not help with sinus infections. This claim is based on a small study of 174 patients with clinical symptoms of an acute sinus infection and given either 30 milligrams per day of prednisolone or placebo pills for one week. Of note, antibiotics were not given.

No significant difference in symptom resolution was found.

Now why would one even think to give oral steroids for sinusitis in the first place?

Steroids decrease inflammation and swelling which theoretically would allow for the sinuses to drain more easily and effectively therefore expediting sinusitis resolution.

Also, there have been studies that suggest steroid nasal sprays do help with resolve sinusitis to a certain extent.

Keep in mind that steroids are NOT antibiotics and do not kill the germs that cause an infection. Furthermore, many viral upper respiratory infections are misdiagnosed as sinus infections.

What this study suggests is that at least for acute sinusitis, oral steroids alone do not help resolve an acute sinus infection.

HOWEVER, keep in mind that oral steroids have been shown to help with nasal polyps and chronic sinus infections when given in the setting of antibiotics and sinus surgery.

Oral steroid doesn't clear up sinus infections. Fox News 8/7/12

Systemic corticosteroid monotherapy for clinically diagnosed acute rhinosinusitis: a randomized controlled trial. CMAJ August 7, 2012 First published August 7, 2012, doi: 10.1503/cmaj.120430

Chronic rhinosinusitis: epidemiology and medical management. J Allergy Clin Immunol. 2011 Oct;128(4):693-707; quiz 708-9. Epub 2011 Sep 3.

Treatment outcomes and predictors for systemic steroids in nasal polyposis. Acta Otolaryngol. 2012 Jun;132 Suppl 1:S82-7.

Intranasal Corticosteroids in Management of Acute Sinusitis: A Systematic Review and Meta-Analysis Ann Fam Med May/June 2012 vol. 10 no. 3 241-249

August 07, 2012

Singulair May Help Cure Mild Sleep Apnea in Children

Singulair (generic montelukast as of Aug 2012) is a medication often prescribed for asthma as well as allergies and works by blocking the leukotriene receptor. This mechanism is different than that found in common allergy medications like claritin and benadryl which work by blocking the histamine receptor (anti-histamine).

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

Recent research published in Sept 2012 suggests that singulair may lessen symptoms in children with non-severe apnea and potentially allow them to skip the surgery.

In the study, 46 children with non-severe sleep apnea received singulair or a placebo for 12 weeks. The kids who received the drug showed improvements in their sleep apnea, their sleep-related symptoms, and the size of their adenoids compared to the placebo group. There were no side effects seen among kids who took the study drug.

Another larger study conducted in 57 children in 2016 confirmed these findings. This study was also double-blinded, randomized, and placebo-controlled.

Beyond singulair, steroid nasal sprays have also been found helpful to reduce adenoid size.

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

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

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

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

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

Montelukast for Children with Obstructive Sleep Apnea: Results of a Double-Blind, Randomized, Placebo-Controlled Trial. Annals of the American Thoracic Society, Vol. 13, No. 10 (2016), pp. 1736-1741.

August 02, 2012

Benign Stridor Often Mistaken for Laryngospasm

Laryngospasm causes a high-pitched squeak or wheezing sound when a person is trying to breath due to abnormal vocal cord movement. Watch video regarding this condition.

Larygnospasm (the most severe form of vocal cord dysfunction) is commonly misdiagnosed as asthma and patients may go for years labelled as asthmatic even though they may not have it at all.

However, though laryngospasm is often the victim of misdiagnosis, there is a condition known as non-organic stridor which is often misdiagnosed as laryngospasm (culprit as well as victim of misdiagnosis).

Here is a video example (watch the movie clip all the way to the end) of a patient with non-organic stridor who was initially misdiagnosed with asthma, than misdiagnosed as having vocal cord dysfunction/laryngospasm before being finally correctly diagnosed with having non-organic stridor.

As you can see, the vocal cords remain apart which immediately rules out the diagnosis of laryngospasm.

What is also apparent is the wheeze or stridor noise is due to vocal cord vibration while they are apart.

The fast moving inhalation/exhalation literally rattles the vocal cord membranes just like a strong wind flaps around an American flag resulting in "noise". No need for the vocal cords to come together to create the noise. The fast moving air does it all by itself.

The existence of non-organic stridor is one of the main reasons why laryngoscopy during a "breathing attack" suspected to be due laryngospasm is so important.

It's also why I have my patients run around my office until they become symptomatic before I perform this exam. Why do an exam when breathing is completely normal???

What is the treatment? Just reassurance... Given it is the fast-moving air that is causing the noise, one simply has to slow the breathing down. No inhalers, no epinephrine, no medications are needed.

For whatever reason, by far the most common patient who suffers from non-organic stridor is a female high school athlete.

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