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October 30, 2012

Elbowed by Your Spouse While Sleeping? You May Have Sleep Apnea!

Canadian researchers have determined that if a patient answers in the affirmative to two questions:

1) Do you get elbowed/poked while sleeping for snoring?
2) Do you get elbowed/poked while sleeping for stopping breathing?

There is a significant chance that the patient may have obstructive sleep apnea (OSA) with AHI score  more than 5.

This quiz has been dubbed the "Elbow Test".

Actual diagnosis for OSA is by sleep study.

Should OSA be actually diagnosed on a sleep study, initial treatment includes CPAP machine followed by oral appliance and potential candidacy for surgical interventions.

“Elbow Test” May Predict Sleep Apnea. Chest 10.22.12

October 29, 2012

Why Patients Travel a Long Distance for Care

The decision for a patient to travel hours away for their medical care is a highly personal decision or a matter of necessity, especially if the care is unavailable locally.

Assuming care IS available locally, based on my own personal observations, the reason to travel for medical care ultimately is due to level of anxiety... either the patient or the surgeon.

Patient A:

I recently saw a patient with a small parotid tumor... about 1.5cm in size that was confirmed on needle biopsy to be a pleomorphic adenoma. Ultimately, the decision for surgery was pursued... but the patient wanted to go elsewhere to have the surgery done even though the patient understood I was perfectly competent to perform the resection.

Why? Because of the high anxiety and concern for the risk of facial paralysis associated with the surgery. The patient perceived her risk of this complication would be smaller if she went elsewhere.

Such patients, like Patient A, typically have certain characteristics:

• Type A personality
• Young (20-40s)
• Never had surgery before
• Surgery has a significant risk associated with it

Patient B:

In another patient who I saw a few months prior to patient A, same scenario, but the parotid tumor was 4cm in size and located in the deep lobe. Decision for surgery was also pursued, but this time, I as the surgeon recommended the patient to go elsewhere to have the surgery done.

Why? Because of the high anxiety and concern for the risk of facial paralysis associated with the surgery. I perceived the risk of this complication would be smaller if he went elsewhere where this type of surgery is frequently performed. This particular patient desperately asked and ultimately begged that I perform the surgery. He really did not want to travel to get the surgery done. However, I explained to the patient that based on size and location, the risk for facial paralysis was quite significant. If it was smaller, like in Patient A, I would have felt perfectly comfortable in performing the surgery.

Patient B ultimately did go elsewhere to have the surgery done... and did, unfortunately, suffer from facial paralysis afterwards.

However, I was happy to provide routine post-op follow-up care given it was more geographically convenient for the patient.

Such patients, like Patient B, typically have certain characteristics:

• Older (50+)
• Has had surgery before

Issues With Long-Distance Care

Regardless of innate patient characteristics, having surgery done a long-distance away is a pain for the patient. Think of the travel, expense, missed time from work, etc NOT just for the surgery, but for any post-operative problems that develop. Oftentimes, the patient concern ends up being unfounded and only reassurance is required, but in order to make that determination, the surgeon needs to do an exam. Imagine the frustration of the patient when a surgeon requests a visit before answering a question about a post-surgical concern... hours of driving to the office, waiting in the exam room, being seen by the surgeon for a few minutes only to hear that everything is fine and normal, and finally driving hours back home.

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

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

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

How to Make Long-Distance Care Easier for the Patient

DO see your most appropriate local doctor and discuss your medical case with him/her. If decision to pursue surgery a long-distance away is made, DO keep your local doctor in the loop.

Routine post-operative care can all be provided locally. Suture removal can be done locally. Infection evaluation can be done locally.

The decision to have surgery a long-distance away was due to concern of risks inherent to the surgery itself... not the care afterwards and as such, such post-operative care can all be provided locally by a competent physician.

Of course, if there's significant concern, the patient can always travel back to the original surgeon, but most often, this travel is unnecessary.

October 25, 2012

Alternative Digital Archival System for KayPentax Strobe System

As a long-time user of the chip-on-tip all-digital KayPentax strobe system, I can certainly vouch for its amazing clarity of visualizing vocal cord pathology.

However, it's digital archival system to record, edit, and store video exams is to put it bluntly, subpar.

Which is why I've ditched that system, and put together a different one based on the Macintosh using its free (and included) but extremely powerful iMovie software which puts KayPentax's system to absolute shame. For those who know how to use iMovie, you know what I mean.

Potentially, this same setup can be applied to ANY medical imaging system including Vision Sciences which my office also uses.

What you need...

1) KayPentax Hardware:
  • EPK-1000 Video Processor
  • Strobe Light Hardware
  • Chip-on-Tip Flexible Endoscope
2) Non-KayPentax Hardware (can be purchased on displayed below):
In essence, you connect the KayPentax hardware together first.

Than add in the non-KayPentax hardware. The key most important piece of hardware that makes this all work is the ADVC55 Converter box.

This converter box essentially brings in the separate video and audio feeds from the KayPentax hardware and spits out a single AV signal that is transmitted to the Mac Mini via FireWire which iMovie interprets as a single audio-visual digital signal.

The video signal is obtained from the EPK-1000 Video Processor using one of its S-video out ports. The audio signal, which is amplified using the Mic PreAmp, is recorded from a microphone and split to the Stroboscope and another to the converter box.

Finally, the DIP switches on the converter box needs to be set as follows:

3 ON
4 ON
5 ON

That's it!

iMovie videos are than recorded, edited, and saved just like any other movie file taken from a camcorder.

Movie files can be saved by iMovie in any one of a variety of standard video formats that can be read by any computer. Super nice as a copy of the video file can be simply copied to a thumb drive and given to the patient. On the other hand, the KayPentax system records videos in a proprietary video format which first has to be converted to a standard video format before anybody else can play it. Annoying and time-consuming if a patient wants a copy.

Keeping the saved iMovie files secure is another story, but briefly, I would suggest encrypting the hard drive using Apple's built-in FileVault. Use WPA-2 Enterprise or 802.1x for WiFi connectivity, but best to just turn WiFi off completely. For those more advanced users, a secure networked RAID hard-drive can be used as a central storage repository for all saved video files which can be accessed by only those computers authorized.

Best to talk to your local IT expert to get the networking all set up and ensure it's all secure.


October 24, 2012

"Mother's Kiss" to Remove Nasal Foreign Bodies

In 1965, a general practitioner Vladimir Ctibor described the "Mother's Kiss" technique of removing nasal foreign bodies in a child.

Essentially, a trusted adult (like a mother) places her mouth over the child's mouth as if to perform mouth-to-mouth resuscitation. While pinching off the unaffected nostril, the adult than blows gently into the child's mouth until resistance is felt caused by the child closing the glottis. At that moment, the adult gives a sharp explosive exhalation to deliver a strong puff of air that passes up into the nose and out the unblocked nostril. If successful, this air puff will also blow the foreign body out the nose as well.

If the adult blow's air when the child's glottis is open, air will just go into the lungs rather than up the nose.

Prior to the procedure, the child is informed that the mom will give the child a "big kiss," hence the name of this procedure.

Now... does this technique actually work?

According to one meta-analysis, it works about 59.9% of the time.

The way I consider it... it can't hurt to try before using instruments to manually remove the nasal foreign body. A "mother's kiss" is certainly a more comfortable and familiar approach for a child versus the alternative.

However, one warning point... the child should be calmly breathing during this procedure. If the child becomes hysterical during the procedure, the child might strongly inhale through the unblocked nostril and potentially suck the foreign body (if small enough) down into the lungs making an unlucky situation into a medical emergency.

Another point for those uninformed... do NOT use this procedure on ear foreign bodies. It will NOT work. The ear canal is a closed container with no inlet or outlet for any air pressure produced by a "Mother's Kiss." In fact, trying to perform this procedure on the ear may cause a ruptured eardrum and even permanent hearing loss.

Removal of Foreign Bodies from the Nose. NEJM 1985; 312:725.

Efficacy and safety of of the "Mother's Kiss" technique: A systematic review of case reports and case series. CMAJ 2012. DOI:10.1503/cmaj.111864 (full length pdf)

October 23, 2012

What do Earthquakes Have to do with Thyroid Masses?

I'm not sure what is going on within the Italian Court system, but in October 2012, the Italian Court convicted 7 scientists to jail terms for not accurately predicting the 2009 L'Aquila earthquake that ended up killing over 300 people.

Also in October 2012, the Italian Supreme Court ruled that cell phones caused one man's brain tumor.

Since when does the Court decide on matters of scientific validity?

And even more importantly, what does this have to do with ENT???

I'm sure people here and there will shake their heads and say how ridiculous. "Unbelievable" that the Italians Courts have made such a stupid decision.

I hate to break it to you all... but it happens ALL THE TIME, especially in the field of medicine. The Court and Lawyers have profoundly influenced how medicine (and now seismology) is practiced whether scientifically valid or not. No matter how ridiculous it may be seen in hindsight or not.

Let's go back to those poor convicted earthquake scientists...

At least in Italy, it's likely that these Court decisions will having a chilling influence over how scientists will behave in the future whether scientifically valid or not. For every single minor tremor, scientists will now have to weigh potential for jail-term if they are inaccurate with their predictions (even though everybody knows predicting major earthquakes accurately is impossible).

I can imagine them to report in the future every single minor tremor as a potential threat of a major earthquake and as such, citizens of Italy are warned to take precautions and evacuate the area for 1 month.

I wonder how Californians will react to such predictions.

In medicine, especially in the field of radiology and pathology, diagnostic dilemmas equivalent to what Italian seismologists go through are common. For fear of the Court and Lawyers, radiologists and pathologists commonly overcall grey areas leading to further testing and even surgery for ultimately reasons that were totally unnecessary.

For example, thyroid masses are one particularly thorny area for both radiologists and pathologists.

In radiology, they will report every single nodule and cyst no matter how small for fear of Court and Lawyers. In the huge majority of the time, such thyroid masses are benign and no intervention is needed. However, should one of those nodules/cysts actually end up being thyroid cancer, the radiologist may end up being sued if he did NOT report them. As such, they are all reported and the burden of lawsuit than falls upon the doctor who ordered the CT scan or ultrasound in the first place.

What does this mean for the patient? For fear of Court and Lawyers, patients will end up getting more tests done and even undergo surgical removal "just to make sure" that it is not cancerous.

Which leads to the next diagnostic dilemma...

In pathology, fine needle biopsies of such thyroid masses is common. However, making a pathological diagnosis is sometimes quite difficult, especially if cancer is on everybody's mind. So what is the pathologist to do if he is uncertain whether cancer is present or not? For fear of Court and Lawyers, he makes an ambiguous statement:
There are some atypic cells suggestive but not definitive of cancer. Clinical correlation recommended.
Now the legal burden is on the surgeon. The surgeon, for fear of Court and Lawyers, will now suggest to the patient that to be absolutely sure there is no cancer present, it is perhaps best to remove the thyroid gland.

Low and behold, many patients who undergo thyroid removal for such ambiguous findings on radiology and pathology reports end up with no cancer found in the thyroid gland. All that testing and surgery was, in the end, totally unnecessary.

The judgements of four physicians have been consecutively affected and compounded with each other for fear of Court and Lawyers:
  • Primary Care Doctor who ordered the CT scan or Ultrasound of the thyroid gland
  • Radiologist who reported the thyroid nodules/cysts
  • Pathologist who interpreted the needle biopsies of those nodules/cysts
  • Surgeon who ends up removing the thyroid gland based on the pathology and radiology results
Does this actually happen???

Absolutely. All the time.

In fact, it happened to the President of Argentina who had her entire thyroid gland removed for fear of cancer, but ended up that no cancer was found. Read more.

Read more about the surgery here or watch the video!

October 22, 2012

Cheerleading A Dangerous Sport from an ENT Perspective

The American Academy of Pediatrics (AAP) published its first policy statement regarding cheerleading due to the increasing rate of injuries found in this increasingly competitive sport.

Who knew that although the overall risk of injury is lower than other sports, it has one of the highest rates of catastrophic injuries including closed-head injury, skull fractures, cervical spine injuries, paralysis, and even death.

After all, cheerleaders do not wear protective gear and safety is utterly dependent on external factors such as spotters and floor protection.

From an ENT perspective of a solo private practice, cheerleading is one of the leading causes of facial fractures in a student population.

Such fractures include nasal bone and orbital blow-out fractures sustained from elbows and other flying limbs.

Although AAP made 12 recommendation to make this sport safer, I was going to suggest that all cheerleaders should wear face-guards to minimize risk of facial trauma.

Here's one called Mueller Nose Guard. Available for purchase on
Cheerleading Injuries: Epidemiology and Recommendations for Prevention. Pediatrics 2012;130:966-971.

October 19, 2012

Cell Phones Caused Brain Tumor Rules Supreme Court

On October 12, 2012, the Italian Supreme Court ruled that cell phones caused one man's brain tumor. The Court felt that there was a causal link between businessman Innocente Marcolini's brain tumor diagnosis and his phone use which he used up to 6 hours per day for over a decade. Although the brain tumor was a benign trigeminal neuroma, it required surgery and badly affected his quality of life.

This "causal link" between cell phones and brain tumors has been described in a previous blog post.

Though definitive scientific proof that links cell phones with brain tumors (benign or cancerous) is still under debate, apparently this court ruling has set a precedent for possible future lawsuits whether there is a true scientific basis present or not.

Indeed, this court ruling should NOT be confused as conclusive scientific evidence which is still lacking.

However, I forsee that this court ruling will be used in place of scientific evidence.

This association has also been claimed by singer Sheryl Crow who has a brain meningioma.

I'm not sure what is going on within the Italian Court system, but they also recently convicted 7 scientists to jail terms for not accurately predicting the 2009 L'Aquila earthquake. Since when does the Court decide on matters of scientific validity?

Cell Phones Caused Man's Brain Tumor, Italian Supreme Court Rules. Medical Daily 10/19/12.

October 16, 2012

Periodic Fevers in a Child - PFAPA

Fever in a child is not uncommon. After all, they get a lot of infections whether it be ear infections, tonsillitis, viral syndromes, etc.

However, what can be particularly vexing and confusing for both physicians and families is a child who keeps getting recurring fevers every few weeks out of nowhere for seemingly no reason and no obvious infectious source.

The typical scenario is a child with abrupt onset of fevers to ~102 degrees F or higher that lasts 3-7 days and just as inexplicably disappears... only to come back again 3-6 weeks later. This cycle may be repeated numerous times. In between these fever episodes, the child is completely fine.

This fever cycle may be associated with one or more of the following:
  • Aphthous stomatitis (inflammation of the mouth mucosa)
  • Pharyngitis (inflammation of the throat mucosa)
  • Cervical Adenopathy (large lymph nodes in the neck)
Though a specific finding of aphthous stomatitis or pharyngitis may not be made (child may be uncooperative with a full oral exam), the child will usually complain of a sore throat, swallowing difficulties, or may suffer from poor appetite.

Numerous tests can be obtained during a fever episode without any positive findings. Strep cultures are negative. Bloodwork is unrevealing.

Trial courses of antibiotics make no difference.

What can this be???

It is most likely due to a syndrome called PFAPA (Periodic Fevers, Aphthous stomatitis, Pharyngitis, cervical Adenitis). The hallmark feature of this syndrome is the cyclical almost clockwork regularity of acute-onset high fevers.

What is the treatment?

Tonsillectomy and adenoidectomy (T&A) is almost always curative.


Given we have no idea what even really causes this syndrome, we also don't really know why T&A works either,  but just know from studies (see references below) that it does work.

Long-term Surgical Outcomes of Adenotonsillectomy for PFAPA Syndrome. Arch Otolaryngol Head Neck Surg. 2012;138(10):902-906. doi:10.1001/2013.jamaoto.313

Effectiveness of adenotonsillectomy in PFAPA syndrome: a randomized study. Journal of Pediatrics 2009 Aug; 155 (2) : 250-3.

October 15, 2012

Why Are Some Patients Sensitive to Narcotics and Others are Not?

Blame cytochrome P450 2D6, also known as CYP2D6.

Found in the liver, it is responsible for metabolizing drugs including many narcotics.

It also determines how "sensitive" a patient is to these drugs.

For example, codeine is not bioactive until it is metabolized by CYP2D6 into morphine, the bioactive form that helps with pain.

As such, how "sensitive" a patient is to codeine is determined by how active their CYP2D6 is. The more active, the more quickly codeine is converted into morphine. The less active it is, the less morphine is created and the less pain control a patient will have when taking codeine as prescribed.

Due to the wide variability in its expression in the liver among patient populations, there will be a correspondingly large variation in how sensitive patients are to such drugs depending on how active CYP2D6 is expressed in the liver.

Such variability accounts for normal, reduced, and non-existent CYP2D6 function in patients.
  • Poor Metabolizers – These patients have little or no CYP2D6 function. (Codeine will provide poor pain control.)
  • Intermediate Metabolizers – These patients metabolize drugs at a rate somewhere between the poor and extensive metabolizers. (Codeine will provide some pain control.)
  • Extensive (Normal) Metabolizers – These patients have normal CYP2D6 function . (Codeine will provide safe and appropriate pain control.)
  • Ultra-Rapid Metabolizers – These patients have multiple copies CYP2D6 and therefore greater-than-normal CYP2D6 function. (Codeine will provide dangerous levels of pain control.)
Additionally, certain genetic variations of CYP2D6 will result in normal, decreased, or no CYP2D6 function.

Additionally, certain medications can inhibit or induce CYP2D6 functionality [read more]. Most importantly to ENT surgeons, decadron which is a steroid commonly given during or after tonsillectomy surgery increases CYP2D6 function.

This CYP2D6 variability and in particular the existence of ultra-rapid metabolizers is the reason why narcotics are strongly discouraged in the pediatric population after surgery. There have been deaths associated with codeine due to respiratory depression in those patients who have a super-active CYP2D6 resulting in too-high morphine production. High morphine levels can potentially lead a patient to stop breathing which ultimately can lead to anoxic brain injury and even death.

There is ethnic variability with CYP2D6 functionality as well. Poor metabolizers are found in less than 10% of whites, asians, and blacks. However, Middle Eastern and North African populations have a relatively higher occurrence of ultra-rapid metabolizers.

More codeine fatalities after tonsillectomy in North American children. Pediatrics. 2012 May;129(5):e1343-7. Epub 2012 Apr 9.

Preventing opioid-related deaths in children undergoing surgery. Pain Med. 2012 Jul;13(7):982-3; author reply 984. doi: 10.1111/j.1526-4637.2012.01419.x. Epub 2012 Jun 13.

Unique CYP2D6 activity distribution and genotype-phenotype discordance in black Americans. Clin Pharmacol Ther. 2002 Jul;72(1):76-89.

Frequent occurrence of CYP2D6 gene duplication in Saudi Arabians. Pharmacogenetics. 1997 Jun;7(3):187-91.

Morphine or Ibuprofen for Post-Tonsillectomy Analgesia: A Randomized Trial. Published online January 26, 2015 (doi: 10.1542/peds.2014-1906)

October 14, 2012

Deaths Associated with Codeine Usage in Young Kids

For decades, surgeons have provided young children with prescriptions for pain control after tonsillectomy and/or adenoidectomy surgery, most commonly tylenol with codeine (otherwise known as tylenol #3), but also related narcotics including morphine, lortab, hydrocodone, etc. Millions upon millions of such prescriptions have been filled and taken without any problems, but there is now a growing concern that such narcotics may be causing more harm than good in a small percentage of kids and perhaps an even greater percentage where it absolutely does nothing. Furthermore, it has now become the subject of an FDA investigation.

Why the sudden concern?

There has been a small but increasing number of children who have suffered anoxic brain damage and even fatalities due to respiratory suppression associated with codeine use. This association was not figured out until recently as such unfortunate incidences were initially felt to be due to medication overdosage, poor care, and/or surgical error.

But now, it is felt that such adverse events were probably due to the administration of codeine itself.

What's going on?

All of the children who died following codeine administration had extra copies of the liver enzyme CYP2D6 which metabolizes codeine to its more potent form morphine [study]. Referred to as ultra-rapid metabolizers, these children metabolize codeine so rapidly to morphine that it leads to respiratory depression or arrest. Substituting codeine for hydrocodone, oxycodone, or other opioids is also unsafe as such narcotics are also metabolized by CYP2D6 and cause even more problems because the CYP2D6 metabolites of hydrocodone and oxycodone are even more potent than morphine. (Of course, on the flip side, there are patients who have minimal CYP2D6 functionality which leads to minimal if any pain relief with codeine.)

Although rare, there has been an increasing number of case reports describing children who have died after receiving codeine for post-operative pain, particularly after tonsillectomy. The most recent report published in 2012 documented the cases of three children who died after receiving standard treatment with tylenol with codeine after tonsillectomy between 2010 and 2011. However, these are only the known documented cases.

Given how rare, changing prescribing patterns may not be warranted... BUT...

What about the possibility that there may be numerous other cases which are not documented or close-calls? As we all know, for every documented case, there's probably numerous other undocumented cases.

To investigate this possibility, a close proxy would be to look at malpractice lawsuits after tonsillectomy. This report did just that looking closely at lawsuits stemming from tonsillectomy complications between 1984 and 2010 and found that the incidence of codeine-related deaths was much higher than the researchers expected. They found that 18 percent of death claims and 5 percent of injury claims resulted from the use of opioids, largely codeine. Indeed, after bleeding, opioid usage was the second most common cause of death in patients after tonsillectomy.

Additionally, death and anoxic brain injury claims associated with narcotic usage were associated with the greatest indemnity with a median payment of more than $900,000 per case.

Though likely impossible to do retrospectively, it would have been interesting to see whether all these children in these lawsuits had multiple CYP2D6 copies or not.

Alternatives to Narcotics

First, there is the question whether tylenol with codeine even helps with pain. Apparently not according to one study. In fact, children who took tylenol alone resumed a normal diet more quickly than kids who received codeine.

In fact, tylenol with codeine is associated with adverse side effects (nausea, dizziness, vomiting, etc) in up to 79% of children who take it [link].

Ibuprofen may also be given for pain control. Though ibuprofen theoretically can increase risk of bleeding due to its anti-platelet activity, numerous studies have not found this to be true.

Given codeine helps minimally with pain and tylenol alone seems to provide adequate pain control, why even given narcotics, especially given the small but significant risk of death associated with this drug?

Pain Control Protocol

Based on all these findings, we feel that narcotics for pain control after tonsillectomy for kids under 7 years of age is not recommended.

Rather, the following protocol is what we will now be implementing:

Tylenol and Ibuprofen over-the-counter as needed to help with pain control. The dosing is weight-based and exact dosing for a given child can be found on the bottle. These medications can be given alternating between Tylenol and ibuprofen every 3-4 hours (Tylenol first, followed by ibuprofen 3-4 hours later, followed by Tylenol 3-4 hours after that, etc). A prescription for a single dose of steroids is also provided which is meant as a one-time dose that can be given anytime 3 days after surgery if the child suddenly seems to have significantly more pain that is not controlled with Tylenol and ibuprofen. Pain in this scenario is often due to inflamed tissues that can be quickly minimized with steroids.

FDA Drug Safety Communication: Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life-threatening adverse events or death. FDA 8/15/12

Post-Operative Pain in Children Undergoing Tonsillectomy. ENT Today. Sept 2012.

FDA Investigates Codeine Safety After Children’s Deaths. ABC News. 8/15/12

Ibuprofen with Acetaminophen for Postoperative Pain Control following Tonsillectomy Does Not Increase Emergency Department Utilization. Otolaryngol Head Neck Surg. 2014 Sep 9. pii: 0194599814549732. [Epub ahead of print]

More codeine fatalities after tonsillectomy in North American children. Pediatrics. 2012 May;129(5):e1343-7. Epub 2012 Apr 9.

Preventing opioid-related deaths in children undergoing surgery. Pain Med. 2012 Jul;13(7):982-3; author reply 984. doi: 10.1111/j.1526-4637.2012.01419.x. Epub 2012 Jun 13.

Complications and legal outcomes of tonsillectomy malpractice claims. Laryngoscope. 2012 Jan;122(1):71-4. doi: 10.1002/lary.22438. Epub 2011 Nov 10.

Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy. Laryngoscope. 2000 Nov;110(11):1824-7.

Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003591.

Morphine or Ibuprofen for Post-Tonsillectomy Analgesia: A Randomized Trial. Published online January 26, 2015 (doi: 10.1542/peds.2014-1906)

Outcomes of an Alternating Ibuprofen and Acetaminophen Regimen for Pain Relief After Tonsillectomy in Children. Ann Otol Rhinol Laryngol. 2015 Apr 22. pii: 0003489415583685. [Epub ahead of print]

October 13, 2012

Nasal Spray to Help Motion Sickness

Over the years, many NASA initiated research has resulted in new products and treatments geared towards advancing the space-program, but has eventually led to benefits to us earth-bound mortals including:

NASA publication Spinoff highlights these research innovations that has benefitted the general public.

Well, you can now add dizziness treatment to another NASA innovation to help motion sickness.

Born of the need to quickly treat motion sickness which astronauts can suffer from up in space (imagine vomiting in zero-gravity), NASA developed a super fast-acting nasal spray to eliminate dizziness.

Called INSCOP, it is essentially scopolamine which already is found in injectable, patch, and pill form. But, this new NASA nasal spray formulation acts faster and more reliably than the oral tablet.

Under a joint agreement with pharmaceutical company Epiomed Therapeutics, it will hopefully soon become available to the public.

This is not the only NASA dizzy research either...

Earlier, they also figured out what movements triggered the worst motion sickness as well as what at-the-time currently available medication combination(s) worked best to combat it. Read more.

The efficacy of low-dose intranasal scopolamine for motion sickness. Aviat Space Environ Med. 2010 Apr;81(4):405-12.

October 12, 2012

"Bitter" Taste Sense Contributes to Immune Defense

As children, we all learned about the 4 different taste qualities the human tongue can appreciate: salty, sugar, bitter, and sour. Savory or umami was added in 1985. "Calcium" has been proposed in 2008 as well as more recently, "fatty" taste.

However, we are slowly learning that "taste" is much more complex than simply the ability to perceive the taste qualities associated with food.

That tongue map we all memorized in elementary school? It's a lie... Read more here.

But even cooler... the "bitter" taste may actually help fight infections!

University of Pennsylvania researchers have discovered that the bitter taste receptor T2R38 also participates in upper airway immune defense.

They demonstrated that the T2R38 receptor was expressed in the upper respiratory tract lining and could be activated by molecules (acyl-homoserine lactone) secreted by Pseudomonas aeruginosa and other gram-negative bacteria (staph and strep are gram-positive bacteria). When the receptor is activated, it stimulates muco-ciliary clearance and initiates direct cellular antibacterial effects.

Furthermore, small mutations in the T2R38 gene had a direct influence on the frequency of bacterial sinus infections.

These findings may explain WHY some patients are more prone to getting infections versus another patient... It's because of their bitter taste receptor!

T2R38 taste receptor polymorphisms underlie susceptibility to upper respiratory infection. J Clin Invest. doi:10.1172/JCI64240.

October 11, 2012

Pacifier Use Increases Risk of Ear Infections in Infants

There are many reasons why an infant may suffer from ear infections... parental smoking, not breast-feeding, daycare, etc.

However, what many parents may not realize is that pacifier use is also an additional well-known independent risk factor for causing ear infections as well.

Numerous studies have documented this association and depending on what study you look at, the risk can be quite significant.

Furthermore, the longer and more frequently the pacifier is used, the more ear infections a child can have.

As such, it is suggested that pacifiers should be used only during the first 10 months of life and only when need for sucking is strongest.

Of course, pacifier do have benefits including analgesic effects, shorter hospital stays for preterm infants, and a reduction in the risk of sudden infant death syndrome.

A pacifier increases the risk of recurrent acute otitis media in children in day care centers. Pediatrics. 1995 Nov;96(5 Pt 1):884-8.

Pacifier as a risk factor for acute otitis media: A randomized, controlled trial of parental counseling. Pediatrics. 2000 Sep;106(3):483-8.

Is pacifier use a risk factor for acute otitis media? A dynamic cohort study. Fam Pract. 2008 Aug;25(4):233-6. Epub 2008 Jun 17.

Risks and benefits of pacifiers. Am Fam Physician. 2009 Apr 15;79(8):681-5.

October 09, 2012

Is Flu Shot Safe for Patients With Egg Allergy?

It is the season for flu shots... and with that... we invariably get phone calls from patients asking whether it is safe to receive the flu shot if they are egg allergic. Generally speaking, the blunt answer is that it is safe... even if you have a life-threatening egg allergy.

Why the concern? The flu shot vaccine (both H1N1 and seasonal) are grown inside eggs which is where this concern arises. It also doesn't help that the pre-flu shot questionnaire specifically asks about egg allergy. Though egg-based, during vaccine production the egg protein is filtered out such that there should be no egg contaminants in the final vaccine. However, it is theoretically possible that some egg may still be present in the vaccine.

Given the infinitesimal possibility of egg contaminants, is the concern still legitimate?

There has been a recent study by Canadian researchers who followed 367 egg-allergic people, mostly children, who got the flu shot over five years. Almost one-third of these patients had a significant history of anaphylaxis after eating eggs causing serious symptoms like trouble breathing or a drop in blood pressure. However, in this study, NOT ONE of those patients, experienced a serious reaction to the flu vaccine. Only 13 of the 367 had mild "allergy-like" symptoms, like itchy skin or hives, within a day of the shot.

Furthermore, numerous past studies that involved close to 4,000 egg-allergic people who got the flu shot revealed not a single case of a serious allergic reaction.

However, if such studies still do not alleviate anaphylaxis concern if egg-allergic...

You can either get one of the new completely egg-free flu vaccine Flucelvax or Flublock or...

To play it safe, the absolute safest way for a patient with egg allergy to get the flu shot is via a few steps:

1) Get a test dose of the flu vaccine where a small amount (0.025cc typically) of the flu vaccine is administered sub-dermally.
2) Wait 10-20 minutes.
3) If there's no reaction (redness and swelling of the skin), get the shot properly into the muscle.
4) If there's a large wheal reaction, it's probably best not to get the flu shot or see an allergist to get desensitized prior to receiving the injection.
5) If flu shot given, make patient wait 30 minutes to observe for any adverse reaction.

Not all practices may be familiar with these particular steps. If that's the case, request to take the flu vaccine to an allergy office (including ours), and have us administer it. (Please note that we do not provide egg desensitization.)

If you are only IgG allergic and not IgE allergic to egg, no need to worry. Get the flu shot.

For a more in depth discussion, click here to read a document prepared by the American Academy of Allergy Asthma & Immunology.

Egg-allergic patients can be safely vaccinated against influenza. Journal of Allergy and Immunology. In Press. Published Online Oct 1, 2012

October 07, 2012

Why Does Burping after Drinking Soda Burn the Nose?

I do not believe this question has actually been scientifically studied... but I can hazard a guess.

Sodas are those flavored fizzy drinks like Coca-Cola and Pepsi.

The "fizziness" is due to carbonation or carbon dioxide dissolved within the drink. When sodas are made, carbon dioxide is forced into the liquid under pressure so that there's more gas dissolved in the liquid than at regular air pressure. The bubbles you see and feel is caused by the carbon dioxide gas being released back into the air when exposed to back into regular air pressure (a closed can or bottle keeps the carbon dioxide under pressure within the liquid).

Such machines can even be purchased to make sodas at home (see below).

A soda becomes flat when all the carbon dioxide has been released back into the air.

In any case, why the burn?

Carbon dioxide (CO2) and water (H2O) together undergo a chemical reaction to form a very weak acid  called carbonic acid (H2CO3).

CO2 + H2O <--> H2CO3

So, after drinking some soda, the CO2 that is released reacts with the water inside your mouth, throat, and belly. The resulting carbonic acid, some of which is aerosolized, can than be burped up into the nose.

The nasal lining is quite sensitive, and when in contact with carbonic acid, can cause a burning sensation.

Now... does this actually happen?

Well, sounds like a potential neat research project that can potentially even be done by a high school student.

October 06, 2012

Feeds for Fauquier ENT Blog Has Changed

Fauquier ENT blog has recently changed its email subscription service from FeedBurner (run by Google) to FeedBlitz.


Well, it is because Google appears to be shutting the FeedBurner service down.

FeedBurner API will be shut down on October 20, 2012. At that point, feed metrics will be gone, though feedburner itself will continue to work.

• FeedBurner Twitter and Blog accounts were abandoned on July 26, 2012.

Though Google has not specifically stated they will shut down FeedBurner, such actions (or inactions) stated above does not exactly build confidence in me.

As such, rather than waiting for the complete shutdown to occur before making a move, transition has been made to what I believe is a superior email subscription service for blogs called FeedBlitz.

I do expect a few errors to pop up while all bugs are worked out, so please be patient.

What do current subscribers need to do?

If you have subscribed by email already, there's nothing for you to do. You will continue to receive email updates with new blog entries.

BUT, if you subscribe via RSS reader, you will need to change / resubscribe using the new feed run by FeedBlitz as the FeedBurner feeds will soon be discontinued.

Here are the new RSS feeds:

Feed URL:
Mobile Friendly:

Thank you for all your support and understanding!

October 04, 2012

ENT Surgeons Who Use daVinci Robot

Readers know my skepticism on the practicality of the daVinci robot in ENT head and neck surgeries.

However, that does not mean that I do not doubt its effectiveness in certain unique situations... as well as market forces that use such high (and expensive) technology to market a given hospital's services.

In any case, plenty of patients have asked me if there's any ENT surgeons who use the daVinci robot in the region.

There are... and here are two that I am aware of.

Dr. David Shonka at UVA
Dr. Stan Chia at Georgetown

Does Social Media Advance Medical Knowledge?

According to a recent paper, the answer is absolutely!

A survey was distributed via email to a random sample of 1695 practicing physicians in the United States in March 2011 with responses from 485 physicians (28.61%). Rather than rehashing what was said, I quote from the abstract,
Overall, 117 of 485 (24.1%) of respondents used social media daily or many times daily to scan or explore medical information, whereas 69 of 485 (14.2%) contributed new information via social media on a daily basis. On a weekly basis or more, 296 of 485 (61.0%) scanned and 223 of 485 (46.0%) contributed. In terms of attitudes toward the use of social media, 279 of 485 respondents (57.5%) perceived social media to be beneficial, engaging, and a good way to get current, high-quality information. In terms of usefulness, 281 of 485 (57.9%) of respondents stated that social media enabled them to care for patients more effectively, and 291 of 485 (60.0%) stated it improved the quality of patient care they delivered. 
I should mention that this study was brought to my attention via tweet by Dr. Ves, an allergist who is an active blogger and tweeter.

How medically efficient, relevant, and useful social media is to a practicing physician utterly depends on "who" physicians follow on the variety of social media platforms whether twitter, facebook, linkedin, or blog. Even videos on YouTube.

It also depends on the willingness of physicians to than share interesting medical information they found useful with others who than in turn share with others.

Perhaps one of the most difficult aspects in getting started in medical social media is finding who to follow in the first place who is worth following for useful medical tidbits.

If you are new to medical social media, I would suggest the following to get started. I should also mention that twitter IS the best and most efficient way to get started learning from and sharing information.

KevinMD (Primary Care)
Dr. Ves (Allergist)
Dr. Wes (Cardiologist)
Skeptic Scalpel (General Surgery)

Of course, I should add myself to this list:

Fauquier ENT or Dr. Chris Chang (Otolaryngology)

Understanding the Factors That Influence the Adoption and Meaningful Use of Social Media by Physicians to Share Medical Information. J Med Internet Res 2012;14(5):e117

October 03, 2012

Mozart May Help with Tinnitus

Currently, there is no fast, good, and cheap way of resolving tinnitus. Tinnitus is in essence hearing a ringing or buzzing that does not exist in reality. At best, it may be something you hear, but does not bother.

At worst, it can literally drive a person crazy.

Neuromonics is perhaps one of the very few treatment protocols that has been proven to work resolving/improving tinnitus in 80-90% of patients over a period of months.

However, it is expensive... typically around $6000 out-of-pocket.

In a study out of Italy, a group of patients between 22 and 78 years of age who suffered from tinnitus were told to listen to Mozart's Sonata k448for 1 hour daily for 1 month. This was followed by instruction to listen to Beethoven's Fur Elisesonata for 1 hour daily for another month.

For all the parameters investigated, there was a general significant improvement between the pre- and post-listening evaluation. Significant improvement in several parameters were seen even after a single exposure to Mozart's sonata.

So apparently listening to Mozart may not help only baby's to become smarter (debatable), but it can help adults as well.

It's also cheap... about as much as it takes to download the songs from a music store.

Some other thoughts that may require additional research...

• What if a patient hates classical music?
• Does "how" a patient listens to the music affect results? (Playing the music in background while doing some other activity versus doing nothing other than listening to the music.)
• How long does the improvement last after treatment?
• What about other songs by Mozart?

But... all in all... given it is cheap... it certainly can't hurt to give it a try.

The Mozart effect in patients suffering from tinnitus. Acta Oto-laryngologica. Posted online on October 1, 2012. (doi:10.3109/00016489.2012.684398)

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