Fauquier ENT Blog

T&A Helps with Pediatric Obstructive Sleep Apnea (But Watchful Monitoring OK Too!)

noreply@blogger.com (Fauquier ENT) — Wed, 22 May 2013 03:35:28 PDT

Researchers published in the New England Journal of Medicine that removal of the tonsils and adenoids absolutely helps with sleep apnea in kids along with improvements in behavior, quality-of-life, overall well-being as well as significantly greater reduction in symptoms... but apparently putting off surgery does no significant harm as well from a purely cognitive perspective.

464 children ages 5-9 years of age were randomly split into surgery or watchful monitoring groups (children with severe sleep apnea was excluded from the study). Although surgery helped in all measures tested, what surprised the researchers was that nearly half the children (46%) in the watchful monitoring group also spontaneous improved over a 7 month period of time without surgery. Furthermore, there was no difference between groups on a Developmental Neuropsychological Assessment.

Overall, surgery WAS beneficial, but it is notable that even without surgery, cognitive development was found to be no different than not doing surgery and nearly half improved to point surgery was no longer clinically indicated.

More relevant to clinicians and parents... what were the exact factors that led nearly 50% of kids with sleep apnea to improve over 7 months?

Was it a certain medication? Overall head growth? Treatment of allergies?

If there WAS an intervention, can it be replicated to all kids as something to try prior to surgical consideration?

Reference:
A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea. May 21, 2013 DOI: 10.1056/NEJMoa1215881

Pitch Perfect's Vocal Cord Nodules

noreply@blogger.com (Fauquier ENT) — Tue, 21 May 2013 04:20:22 PDT

Becca (played by Anna Kendrick)

In the hilarious movie Pitch Perfect, Becca played by the lovely Anna Kendrick participates in an all-female a capella singing group.

During a critical juncture in the movie, one of the soloist Chloe (played by Brittany Snow) reveals she had been living (and singing) with vocal cord nodules.

The movie implies that Chloe's vocal cord nodules were surgically removed and that perhaps days later, she resumed singing, though not recovered to the degree that she's able to sing a solo.

Couple problems with this scenario which does not reflect reality.

Vocal cord nodules develop due to aggressive voice use, especially with poor talking or singing technique. As such, initial treatment is NOT surgical because if the underlying vocal behavior that led to vocal cord nodules is not corrected, they will just come back... and you can add some scarring as well due to the surgery itself (strict voice rest for a prolonged period of time after surgery is a must to minimize scarring complications).

Strict voice rest is also not the best course of action which will help initially, but again, if voice use resumes without the underlying bad vocal behavior being corrected, the nodules will just come back again.

So what is the correct course of action???

1) Aggressive voice therapy... Given Chloe is a singer, working with an experienced singing voice therapist would be of tremendous benefit. She can continue singing, but use of electronic amplification is a must to minimize increased compensatory volume (people tend to increase their voice in loud surroundings) and her singing should be limited to low impact vocalizations (think Silent Night rather than Ode to Joy).

2) Limit talking if at all possible and avoid being in conditions where there's a lot of noise. NEVER abuse the voice (no screaming, yelling, etc) which may be hard to do in a college setting with loud restaurants and bars.

3) If after a prolonged voice therapy and restricted voice use does not resolve the vocal cord nodules, only than would surgical intervention be considered. There are two flavors of surgical intervention: steroid injections to the nodules or excising the vocal cord nodules. Needless to say, there will be a mandatory prolonged period of strict voice rest after surgical intervention.

Read more about treatment here.

Finally, there's another scene where Chloe's voice was able to achieve an unusually low note. That does NOT happen with vocal cord nodules whether before or after surgery. Chloe's pitch range should remain the same. The only situation where her pitch would drop lower than normal would be if her vocal cords became diffusely swollen. Just like a violin string, the thicker the string or in this case vocal cord, the lower the pitch.

Hospital Charges vs Surgeon Charges

noreply@blogger.com (Fauquier ENT) — Wed, 22 May 2013 03:38:06 PDT

Some of the most bitter complaints I get from patients are their hospital bills. Apparently, this complaint is not unique to me given numerous media articles about perceived outrageous hospital charges for seemingly simple procedures (article #1 and article #2).

The healthcare system as it currently stands establishes 2 separate charges (surgeon and hospital) with any type of procedure performed in a hospital (even if not in an operating room). There is even a 3rd charge if anesthesia is provided.

The ONLY charge a surgeon has any control over is the surgeon's charge which often is the least expensive of the 3 charges. A common misconception is that the surgeon also has control over hospital and even anesthesia charges which is patently false.

Indeed, the surgeon is not even informed what the hospital or anesthesia charges are for any procedures performed. The surgeon also has no influence, say, or authority over what the hospital or anesthesia charges as well.

As such, if knowledge of total costs is desired with any type of procedure performed in the hospital, it is best to speak with a hospital representative of what the anticipated charges will be... not the surgeon because we actually do not know.

I should also mention that hospital charges are often 10 times or more greater than the surgeon's fees.

Read more about surgical fees.

Even for the SAME exact procedure, the charges vary greatly from one hospital to another.

In May 2013, the federal government released information on how a given hospital ranks in their charges for a given diagnosis or procedure (specifically Medicare, but all insurance base their charges on Medicare rates).

Check to see how your hospital ranks compared with other hospitals with respect to how high their charges are. The New York Times created a handy dandy map that illustrates hospitals which are "expensive" and those that are below average in terms of hospital charges.

I should mention that Fauquier Hospital where I have privileges charges at less than the US average.

Let's take an example to see how hospital charges can significantly influence how much you pay for the same exact procedure depending on which hospital you go.

Let's say you have health insurance with a 10% coinsurance and a $1000 deductible (meaning, before insurance pays for anything, you must pay at least $1000 and than an additional 10% of all remaining charges).

Let's say you decide to proceed with a tonsillectomy.

At hospital A, the surgeon's fee is $500, hospital charges are $5000, and anesthesia charges are $1000 for a grand total of $6500.

At hospital B, the surgeon's fee is $500, hospital charges are $10,000, and anesthesia charges are $5000 for a grand total of $15,500.

Clearly, whether you go to hospital A or B, you will pay $1000 deductible first.

So, at hospital A, the total charges (minus your deductible) billed to insurance will be $5,500 and at hospital B that cost will be $14,500.

Insurance pays 90% of these charges and you pay the remaining 10% (the 10% coinsurance as per the policy you have).

As such, having a tonsillectomy at hospital A will cost an additional $550 whereas at hospital B, you will have to pay an additional $1,450.

Now, it may seem the charge differences are extreme in the example, but sadly, hospital charges can truly be that dramatically different. Read this New York Times article for more information.

Of course, do keep in mind that the above example is over-simplified as reality does include things like fee schedules, allowable charges, etc.

Source:
Hospital Billing Varies Wildly, Government Data Shows. NYT 5/8/13

How Much Hospitals Charge For the Same Procedures. NYT 5/8/13

Gwyneth Paltrow's Dad Had Throat Cancer

noreply@blogger.com (Fauquier ENT) — Mon, 20 May 2013 09:17:04 PDT

Image from Wikipedia

Gwyneth Paltrow recently divulged that her father was diagnosed with throat cancer in 1998 and eventually passed away in 2002 due to pneumonia complications.

It is unclear exactly what type of throat cancer Mr. Paltrow had, but it could have been anything from tonsil cancer to vocal cord cancer.

Depending on the location, symptoms and physical signs (ie, neck mass) may have been present which ultimately would have required a biopsy. Once the type of cancer has been determined after biopsy, treatment would have included surgery, radiation therapy, and/or chemotherapy.

In any case, the actress credits her dad's cancer diagnosis as a wake-up call to a healthier lifestyle.

Source:
Gwyneth Paltrow; Father's Throat Cancer Diagnosis Encouraged Healthier Diet. Medical Daily 5/20/13

Gwyneth Paltrow Reveals Dad's Cancer Diagnosis Got Her on Healthy-Eating Track. Eonline 5/17/13

Beyonce Cancels Concert Due to Dehydration (and Exhaustion)

noreply@blogger.com (Fauquier ENT) — Thu, 16 May 2013 14:17:59 PDT

Image from Wikipedia

Media has reported the superstar pop singer Beyonce cancelled her May 14, 2013 concert in Belgium on the advice of her doctors "due to dehydration and exhaustion".

Though the rumor mill is churning with the possibility of a pregnancy, I was more interested that a concert was cancelled due to dehydration concerns.

Why is hydration so important for voice production, especially in as athletic activity as singing?

With hydration, the glands that line the throat and voicebox produce nice thin secretions. With dehydration, the secretions become thicker and stickier and can adversely affect the voice.

Keep in mind that hydration with its associated thin secretions is like the oil that makes an engine run smooth. When a person talks or sings, the vocal cords vibrate very quickly. Hydration with its thin secretions allows the vibration to occur smoothly and consistently. If dryness is present, the vibrations will not occur as easily.

Watch the video below. You can see the secretions "dancing" on the vocal cords as it should with smooth, even vibrations producing clarity in voice production.

Regardless of what may have prompted Beyonce to cancel her concert, fans hope her recovery will be speedy!

Source:
Is Beyonce Pregnant? Singer Cancels Show; Rumor Mill Reignites. Huffington Post 5/14/13

Hearing Loss May be Caused by Aspirin, Tylenol, and NSAIDS

noreply@blogger.com (Fauquier ENT) — Thu, 16 May 2013 04:01:00 PDT

Researchers from Harvard and Vanderbilt reported that men who regularly take aspirin, tylenol, or NSAIDS (like ibuprofen) are at increased risk of hearing loss. This increased risk of hearing loss is significantly higher the longer the duration of regular use (defined as 2 or more times per week) and if regular use starts under the age of 50 years.

For women, however, only tylenol and NSAIDS were found harmful to hearing (not aspirin).

Indeed, the conclusion is that regular over-the-counter pain killers may in fact be mildly ototoxic and that such overuse be avoided if possible and would not adversely affect health in other more important aspects (ie, especially in the absence of heart or vascular disease for which daily aspirin is often recommended).

Just goes to show you that too much of any medication is harmful.

Not only does tylenol lead to hearing loss, but it can also cause liver failure and accounts for 400 deaths in the US every year. [more info]

Ibuprofen is even worse leading to bleeding problems and 15,000 to 20,000 deaths in the US every year. [more info]

References:
Analgesic Use and the Risk of Hearing Loss in Women. Am J Epidemiol. 2012 Sep 15;176(6):544-54. Epub 2012 Aug 29. [full text]

Analgesic use and the risk of hearing loss in men. Am J Med. 2010 Mar;123(3):231-7. doi: 10.1016/j.amjmed.2009.08.006. [full text]

Woman Drinks Beer Through Her Ear

noreply@blogger.com (Fauquier ENT) — Wed, 15 May 2013 02:51:10 PDT

Now I am not sure if this woman is actually drinking beer through her right ear at a Czech beer festival as reported by Huffington Post, but is it anatomically even possible?

Well the answer is that it IS theoretically possible though highly improbable.

In order for this to occur, there must first be a hole in the eardrum. Given an eardrum hole, beer can be sucked up into the ear canal (1), through the hole in the eardrum (2), into the middle ear space (3), through the eustachian tube (4), and down into the throat.

Now why would it be highly unlikely that the women is drinking beer through her ear?

1) The eustachian tube opening is VERY small (< 2mm). Trying to suck beer through the eustachian tube would be even harder than trying to suck beer into the mouth through a coffee stirrer.

2) The video would have been more believable if she pinched her nose up when drinking beer into the ear. The fact that she is not makes it unlikely adequate negative pressure can build up in the back of the nose to the point that it would suck beer up into the ear. Not pinching the nose is equivalent to trying to drink something up into the mouth WITHOUT making a tight lip seal around the straw.

Even if you could drink beer through the ear, you really shouldn't because...

1) Beer contains alcohol and if this touches the middle ear region which is very sensitive, there would be quite a bit of pain akin to alcohol touching an open skin wound.

2) Alcohol can also potentially lead to permanent hearing loss if drawn into the middle ear. It's the same reason why earwax removal drops specifically caution against using it whenever there's a hole in the eardrum.

3) Beer in the ear could lead to an ear infection.

4) Lastly, if the beer is not at body temperature, it could lead to severe dizziness due to a phenomenon known as caloric vestibular stimulation.

So... don't do it... even if you could!

Source:
Woman Drinks Beer Though Her Ear? Czech Clip Appears To Show Crazy, Dangerous Stunt (VIDEO). Huffington Post 5/14/13

Google CEO Larry Page Suffers from Bilateral Vocal Cord Paralysis

noreply@blogger.com (Fauquier ENT) — Fri, 17 May 2013 03:55:02 PDT

Image from Wikipedia

Over the past year, there has been concern over the health of Google CEO Larry Page after missing a few important meetings and having a hoarse voice that is unusually soft and prolonged.

Apparently, it's because he suffers from bilateral vocal cord paralysis. [link]

He initially suffered from a unilateral vocal cord paralysis at the age of 14 years old. At that time, his left vocal cord became paralyzed after a viral URI. Beyond a viral infection of the nerve, no other specific cause was identified.

Than during the summer of 2012, he suffered another viral URI followed by the unfortunate paralysis of his opposite right side resulting in bilateral vocal cord paralysis. It is EXTREMELY rare that both vocal cords become paralyzed in this manner in the same individual.

With bilateral vocal cord paralysis, he now suffers from an even weaker voice along with reduced ability to exercise.

Now, why is that?

First, a basic anatomy lesson...

Briefly, the voicebox is composed of a right and left vocal cord that is attached on one end, much like a "V". When the vocal cords are apart, air moves in between the vocal cords into your windpipe that allows one to breathe. When a person wants to sing/talk or say "eee," the vocal cords come together and vibrate very quickly creating the voice. The vocal cords and their movement can be visualized on fiberoptic laryngoscopy (watch movie of this exam).

A "paralyzed" vocal cord is when one or both of the vocal cords do not move resulting in voice changes as well as difficulty breathing easily. Specifically, when both vocal cords are paralyzed, the vocal cords do not come together as tightly resulting in a weaker than normal voice. At the same time, given the vocal cords are not able to move apart, there is a smaller than normal opening thru which to breath resulting in shortness of breath, especially with exercise. Here are two video examples of when both vocal cords are paralyzed. Compare this to a normal example. Note the difference in how wide the vocal cords move apart.

Why would the vocal cords both become paralyzed in the first place? The MOST common cause of bilateral vocal cord paralysis is surgery, especially thyroidectomy. Other less common causes include neck trauma, traumatic intubation, and cancer (especially lung or thyroid cancer). Regardless of cause, if the paralysis is permanent, the options are quite limited and require the sacrifice of either breathing or talking. You can't have both good breathing and a good voice. Please note that a patient may have bilateral vocal cord fixation and NOT paralysis which is treated completely differently.

Why can't you have both good breathing and a good voice when both vocal cords are paralyzed? Because in order to have a good voice, the vocal cords need to come tightly together... but given they are paralyzed, they will not come together to allow for a good strong voice.

In order to have good breathing, the vocal cords need to be widely apart... but given they are paralyzed, they will not be able to move apart to allow for good breathing. Which in essence means you can't have both good breathing and strong voice.

One or the other needs to be sacrificed... or a compromise of both is required resulting in so-so breathing and a so-so vocal quality... which seems to be the option Larry Page has gone with.

Well... there is ONE option in order to have good breathing and a good voice... and that's a tracheostomy with a one-way valve. The vocal cords could be fixated together to allow for good voice. To allow for good breathing, airway is achieved through the tracheostomy (hole in the neck that goes directly into the airway). A one-way valve is placed with the tracheostomy such that when breathing in, the valve opens up to allow air passage thru the tracheostomy, but when breathing out, the valve will close to force air up thru the vocal cords to allow for talking.

BUT, if tracheostomy is out-of-the-question.. than a patient with bilateral vocal cord paralysis is stuck with a compromise between the voice and breathing.

To explain this compromise of voice and breathing further, normally, when the vocal cords are both moving fine, the voice is at 100% and breathing is at 100%. However, with bilateral paralysis, the voice and breathing are now linked to each other and collectively can not exceed 100%. As such, a patient with new onset bilateral vocal cord paralysis may start with a 40% of normal vocal quality and 60% of normal breathing ability for a total of 100%. If a patient desires to improve the vocal quality from 40% to 100% (an improvement of 60%), then the breathing WILL correspondingly decrease 60% down to 0% (or vice-versa). The total percentage of vocal and breathing quality can never be more than 100%. If a patient wants the best possibly voice and breathing, than the compromise would be to increase the vocal quality 10% from 40% to 50%, but understanding that this 10% improvement in vocal quality WILL mean a corresponding 10% decrease in breathing ability from 60% to 50%. This 10% change means that in the end, the voice and breathing would both end up at 50% of normal.

Wondering what kind of workup is required as well as surgery to adjust the voice when both vocal cords are paralyzed? Click here to read more...

Source:
Larry Page Explains Why He Lost His Voice. Businessweek 5/14/13

Nice ICD10 Booklet for ENTs

noreply@blogger.com (Fauquier ENT) — Thu, 09 May 2013 13:57:31 PDT

The American Academy of Otolaryngology (AAO-HNS) has put out a sample ICD10 booklet of sorts which may come very handy once ICD10 usage becomes mandatory in 2014. ICD stands for "International Classification of Diseases" and is the way physicians code for a given medical problem. It also is one way health insurance determines what tests or surgeries will be approved or not.

The current ICD system being used is called ICD9.

Within ICD9, an acute ear infection (whether right or left side) would be coded as 382.9.

With ICD10, more detail is contained. For example, ICD10 code H66.002 is left acute ear infection without rupture.

Although ICD10 will contain much more detail about the medical condition being described, with increased detail brings more headaches as one ICD9 condition may now have 10 other related ICD10 codes that need to be specified.

Which means ENT related ICD codes which used to all potentially fit on a one page cheat sheet may now take over 10+ pages booklet.

The AAO-HNS was nice enough to compile a booklet of the most common medical diagnosis with their ICD10 codes for the otolaryngology specialty.

You can download the pdf or MS Word doc here.

Does Milk Cause Increased Phlegm or Mucus Production?

noreply@blogger.com (Fauquier ENT) — Wed, 08 May 2013 07:00:46 PDT

For many individuals, milk and associated dairy products definitely seem to cause an increased production or thickening of mucus in the mouth and throat... the phlegmy throat. It certainly happens to me...

Of course, perception is not always supported by research...

"Milk and dairy product intake was not associated with an increase in upper or lower respiratory tract symptoms of congestion or nasal secretion weight. [...] We conclude that no statistically significant overall association can be detected between milk and dairy product intake and symptoms of mucus production in healthy adults, either asymptomatic or symptomatic, with rhinovirus infection." [link]

However, other research support the possibility that dairy products might increase mucus production only if the milk contains beta-CM-7 protein (not all milk contains this protein). [link]

I have a different hypothesis for why milk may cause the perception of increased mucus production. I should preface that I have no research study to quote to prove this hypothesis. Might be a good research project for a medical student???

In any case, milk contains a protein called casein. When the milk is not refrigerated, it causes bacteria to metabolize lactose within the milk leading to lactic acid production as a byproduct. When acidity is present, the casein congregate in a process called curdling. That's the "chunks of milk" seen in milk gone bad.

Now, bacteria certainly will not be playing a role in lactic acid production after fresh milk is consumed, BUT, there IS acid present in the stomach which can initiate curdling.

Now what if a patient suffers from acid reflux... and what if some of the reflux episodes reach the throat level?

So, hypothetically speaking, if somebody who suffers from acid reflux drinks a lot of milk, two things might hypothetically happen (or drinks orange juice followed by milk):

1) Milk temperature goes up from body heat (which assists in curdling)
2) Acid present from the reflux will initiate curdling

If acid is present in the mouth and throat from reflux or secondary source (like recently drunk orange juice), curdling to some degree may occur from milk residue mixing with acid residue present leading to perception of mucus production.

Now does this actually happen???

I don't know and I hope some researcher looks into this hypothesis further!

However, in the end, if dairy avoidance helps with a phlegmy throat, than it can't hurt to avoid it! I should also point out that egg and wheat does cause a similar phlegmy problem in some patients.

Reference:
Relationship between milk intake and mucus production in adult volunteers challenged with rhinovirus-2. Am Rev Respir Dis. 1990 Feb;141(2):352-6.

Does milk increase mucus production? Med Hypotheses. 2010 Apr;74(4):732-4. doi: 10.1016/j.mehy.2009.10.044. Epub 2009 Nov 25.

What is the BEST Way to Disinfect a Toothbrush?

noreply@blogger.com (Fauquier ENT) — Sun, 05 May 2013 04:56:36 PDT

In my previous blog article, I discussed the debate over whether a toothbrush becomes "contaminated" leading to the practice of throwing them out after a strep throat infection. Although the answer is still ambiguous whether it helps or not, the fact that even NEW toothbrushes contain harmful bacteria brings even more confusion on what to do.

Going on the assumption that bacteria on a toothbrush is harmful and if a new or old toothbrush contain such bacteria, perhaps the best practice would be to disinfect toothbrushes on a regular basis.

Would toothbrush disinfection work best by..

• Microwave
• Ultraviolet light (examples in this list from Amazon)
• Dishwasher
• Listerine
• Crest Pro-Health
• Air dry
• 3% Hydrogen Peroxide

Although the ultraviolet sanitization method is perhaps getting the most attention due to the high-tech nature, researchers have found that though this method did significantly decrease bacteria load, they also have found this method to be the least effective compared to other measures.

Rather, the best way to disinfect a toothbrush is by rinsing the toothbrush with Crest Pro-Healthmouthwash for 20 minutes OR having it go through a normal dishwasher cleaning cycle. 3% Hydrogen Peroxide was also found helpful.

Interestingly, Listerine didn't work much better than air-dry alone and ultraviolet light didn't do much better.

Bottom line?

Don't waste your money on ultraviolet light toothbrush treatments.

Rather, if you already use a dishwasher regularly, stick the toothbrush in there. If you already like gargling with mouthwash, get Crest Pro-Health which can also disinfect toothbrushes effectively.

References:
Disinfection of toothbrushes contaminated with Streptococcus mutans. Am J Dent. 2011 Jun;24(3):155-8.

Germicidal activity of antimicrobials and VIOlight Personal Travel Toothbrush sanitizer: an in vitro study. J Dent. 2010 Aug;38(8):621-5. doi: 10.1016/j.jdent.2009.08.011. Epub 2009 Sep 23.

Should Toothbrushes be Thrown Out After Strep Throat?

noreply@blogger.com (Fauquier ENT) — Sun, 05 May 2013 04:58:46 PDT

As with so many things with medicine, this question which sounds so straightforward unfortunately has no straightforward answer.

After all, there have only been a few studies that have specifically looked to answer this question.

And the answer is decidedly ambiguous as the few studies done so far either support or disprove this practice.

Two studies have found no difference in recurrent infections whether one keeps using an old toothbrush or replaces it with a new one after a strep throat. In one study, even NEW toothbrushes contained harmful bacteria.

Of course, there are several studies that support this practice.

In fact, environmental hygiene in general is also disputed with studies supporting for as well as against this practice after an illness.

Check out a few references below to add more mud to the confusion.

Of course, with multiple recurrent episodes of strep throat, tonsillectomy surgery is quite helpful.

Also given the confusion, perhaps the safe course would be to disinfect a toothbrush regularly.

References Against Throwing Toothbrushes Out:
Recurrence rate of streptococcal pharyngitis related to hygienic measures. Scand J Prim Health Care. 1998 Mar;16(1):8-12.

How dirty is your toothbrush? Answer: Not as much as you think. NBC News 5/4/13

References in Support:
Contamination of toothpaste and toothbrush by Streptococcus mutans. Scand J Dent Res. 1978 Sep;86(5):412-4.

Persistence of group A beta-hemolytic streptococci in toothbrushes and removable orthodontic appliances following treatment of pharyngotonsillitis. Arch Otolaryngol Head Neck Surg. 1998 Sep;124(9):993-5.

Actress Sofia Vergara Underwent Total Thyroidectomy for Thyroid Cancer

noreply@blogger.com (Fauquier ENT) — Sat, 04 May 2013 06:30:04 PDT

Image from Wikipedia

Actress Sofia Vergara, best known for her role in the TV hit comedy Modern Family, had her entire thyroid removed for thyroid cancer when she was 28 in 2000. This was followed by radioactive iodine therapy and now takes a daily thyroid hormone replacement for her hypothyroidism.

Thyroid cancer is typically first suspected on a routine examination if a neck mass consistent with a thyroid nodule is palpated. An ultrasound of the neck is typically performed to characterize the thyroid mass further which is than followed by a biopsy. Should the biopsy come back malignant, thyroid removal surgery is performed. Even if the biopsy comes back indeterminate, surgery may still be pursued to be on the safe side.

Other studies may be pursued including CT scan and a thyroid nuclear scan.

Although the type of thyroid cancer Sofia Vergara had was never revealed, she most likely had papillary thyroid carcinoma which is the most common form of thyroid cancer and is highly curable (which is where the comment of being a "good" cancer comes from).

Other less common thyroid cancers include follicular thyroid carcinoma and medullary thyroid carcinoma.

It should be mentioned that until the thyroid is removed, one can NOT be absolutely sure that thyroid cancer actually truly is present. Indeed, the president of Argentina announced that she had thyroid cancer only to find out after her thyroid was removed that no cancer was actually present. Read blog post about this "mistake".

Read more about the surgery here or watch the video below of what Sofia's thyroid surgery might have looked like.

Source:
The Workout: Sofia Vergara Hates to Exercise. NYT 5/3/13

How is a Pollen Forecast Made?

noreply@blogger.com (Fauquier ENT) — Sat, 04 May 2013 03:56:39 PDT

Pollen Trap from Burkard

Unlike weather forecasting which utilizes high technology, satellites, complex computer models, etc, pollen forecasting seems downright archaic, though just can be just as complex and unpredictable.

So, here's what happens...

The main "equipment" to enable pollen forecasting is a simple air trap in order to capture and ultimately count what pollen is currently circulating in the environment. This equipment known as a "Volumetric Spore Trap" is placed in an open area and sucks in a specific volume of air through a narrow slit. Within the spore trap is a rotating drum covered with sticky tape upon which pollen gets stuck on.

Spore Trap. Image from Burkard

Every morning, an aerobiologist removes the sticky tape and places it on a glass slide to look at it under 400x magnification.

Pollen spores are identified and counted by the aerobiologist.

Based on this pollen count information in combination with the weather forecast, precipitation, wind direction, etc a pollen forecast can be provided for a region.

However, a pollen forecast may not accurately reflect local conditions. For example, grass counts may be very elevated all year round where timothy grass is present as feed for horses whereas regional pollen forecast may show elevated grass pollen only during the summer.

More obviously, mold spores would be elevated inside a damp old home all year round that is not reflected in a regional pollen forecast.

In any case, allergies can be treated with medications.

What's That Yellow Pollen Coating My Car Windows?

noreply@blogger.com (Fauquier ENT) — Fri, 03 May 2013 04:34:23 PDT

Every spring, a yellow coating of pollen covers everything, most noticeably car windows. For many people with allergies, this yellow pollen is the cause of all their sinus and nasal misery triggering bouts of sneezing, sniffling, water eyes, etc.

However, this yellow pollen produced by pine trees is NOT a significant allergy trigger. When it comes to allergy, the biggest culprits are the pollen you can not see. Such springtime microscopic pollen that IS the culprit for allergies come from trees (non-pine) and grasses.

So don't demonize the yellow pollen! Unless, of course, you are upset that the car now needs to be washed/cleaned.

If you are curious what you may be allergic to, you can get allergy tested. Or, try an over-the-counter anti-histamine, many of which used to be prescriptions.

Here's a complete list of allergy medications and how they work.

Fecal Transplantation Administered Through the NOSE!

noreply@blogger.com (Fauquier ENT) — Thu, 02 May 2013 14:16:19 PDT

Fecal transplant is nothing new as it has been around since the 1950's... It is used to treat multi-drug resistant clostridium dificile infection by replacing the "bad" gut bacteria with normal "good" bacteria. However, what is new is the fact that such fecal transplantation is being administered through the nose using a tube threaded into the small bowel. [Thanks to @GuildfordENT who brought this to my attention!]

Historically, such fecal transplantation (aka fecal bacteriotherapy) was performed via multiple infusions via enema (uncomfortable for both the physician as well as the patient) or via colonoscope. Although first described being done in humans in 1958, it was never really seriously studied until the mid-1980's. Even before humans, it had been performed in animals by veterinarians for centuries.

In any case, there has been new literature supporting the use of nasoduodenal tubes to administer poop via the nose. With nasoduodenal tubes, a tube is threaded through the nose, past the stomach, and into the small bowel.

Now keep in mind that the stool actually NEVER comes into contact with the nose. It is contained within an impermeable tube at all times, so it is not quite as gross as you might think (though mentally, there may still be an emotional ick factor present).

Another approach being considered is encapsulating the poop inside enteric-coated capsules so a patient can theoretically swallow the pill-containing poop.

Media Mention:
Doctors save patient from deadly superbug by transplanting faeces through his NOSE. MailOnline

Reference:
Duodenal infusion of donor feces for recurrent Clostridium difficile. New England Journal of Medicine. 2013 Jan 31;368(5):407-15. doi: 10.1056/NEJMoa1205037. Epub 2013 Jan 16.

Same poop, different gut. The Scientist 11/3/105/2/13

What Makes a Voice Sound Attractive?

noreply@blogger.com (Fauquier ENT) — Wed, 01 May 2013 11:05:58 PDT

Ever hear a voice that sounded sexy or attractive? Ever build a mental image of what a stranger on the phone may look like purely based on the sound of the voice???

Well, according to researchers, an attractive voice reflects an attractive perceived body size.

A group of human subjects listened to the same sentence that was manipulated by altering pitch, acoustic resonance, and voice quality based on body size projections reported for animal calls and emotional human vocal expressions.

For example, a rough, low-frequency animal call suggests the vocalizer is large and aggressive whereas a more clear, higher frequency animal call suggests a small, non-threatening animal.

Not surprisingly, male listeners preferred a female voice that suggested a small body size (relatively high pitch, wide acoustic resonance range, and breathy voice). Think Marilyn Monroe...

Female listeners preferred a male voice that suggested a large body size (low pitch and narrow acoustic resonance range) akin to actor James Earl Jones. However, female listeners interestingly also preferred some breathiness in the male voice which may signal a perceived decrease in the aggressiveness associated with a large body size.

Another reason why patients undergo voice therapy, even if there's nothing medically wrong...

It is not unusual for a male lawyer to undergo voice therapy to try and achieve a lower and more aggressive vocal quality as it does correlate with success. (Read more about this link between voice pitch and success).

Similarly, women in positions of authority in the political and corporate world do the same. Margaret Thatcher underwent voice therapy for this very reason [link].

However, women with a low raspy voice often pursue treatment to try and achieve a more feminine voice (high-pitched and breathy).

Indeed, when voice therapy fails, there are even surgical procedures to try and alter a person's voice.

Source:
Voices Considered Attractive Send Body Cues. Scientific American. 4/30/13

Reference:
Human Vocal Attractiveness as Signaled by Body Size Projection. PLoS ONE 8(4): e62397. doi:10.1371/journal.pone.0062397

Pop Singer Nathan Sykes Undergoes Vocal Cord Surgery

noreply@blogger.com (Fauquier ENT) — Mon, 29 Apr 2013 18:33:11 PDT

Nathan Sykes, singer for the boy band The Wanted, underwent vocal cord surgery on April 18, 2013 for a "hemorrhaged nodule" according to media reports.

Rather than a nodule, I am suspecting he actually suffered from a hemorrhagic polyp which makes more medical sense. And along with surgery... he is now on voice rest for an indefinite period of time.

This condition is the same reason Adele underwent vocal cord surgery in 2011 which mandated a several month period of voice rest leading to cancelled concerts.

Typically, a hemorrhagic polyp is treated with strict voice rest followed by extensive voice therapy prior to surgical consideration. However, this (safe) course of action takes time and as such, much more aggressive approaches can be pursued in order to recover the voice as quickly as possible.

For professional singers like Nathan Sykes and Adele, the desire to have a restored voice as soon as possible is understandable. However, there are always downsides.

To explain, a lesson in some basic anatomy first...

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

When there is a hemorrhagic polyp with a blood vessel as in Nathan's case (presumably), the vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to phono-trauma or even hormones especially in females. When a polyp is present, the vocal changes are even more dramatic. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice very unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. There may even be mild pain associated with this occurrence.

It is unknown what exactly happened in Nathan Syke's case.

But, in Adele's case, she remembers the very moment this occurred during a radio interview when she "felt a pop" and her vocal pitch suddenly dropped into the bass range.

This makes perfect sense... To use the analogy of a violin string, the thicker the violin string the deeper the pitch. When hemorrhage occurs, the vocal cord becomes thicker due to blood pooling resulting in a deeper voice instantly.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially, during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in the development or exacerbation of a vocal cord polyp. With repetitive cycles of healing and trauma, vocal cord scarring may even develop. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel and associated polyp.

For that, surgical intervention is required.

One option is to precisely cut out the polyp and cauterize the feeding blood vessel at the same time. This approach was the course that Adele pursued and probably what happened with Nathan Sykes as well. Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. This latter approach is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision and vessel obliteration with a laser at the same time (though not zero). Furthermore, a smaller polyp also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Adele, that was strict voice rest for nearly two months (Nov and Dec 2011). Why? Because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won't heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

The vocal cord surgical wound MUST heal prior to talking let alone singing for normal recovery. That means strict voice rest. Strict voice rest means no talking, no singing, no whispering, no mouthing words, no throat-clearing, no humming, etc.

Read more about vocal cord polyps here.

Source:
The Wanted's Nathan Sykes Taking 'Unforeseen Hiatus'. MTV News 4/17/13

The Wanted say they 'fear' for Nathan Sykes' voice. BBC News 4/29/13

How the Voice Anatomically Reverberates to Produce Speech

noreply@blogger.com (Fauquier ENT) — Fri, 26 Apr 2013 04:40:14 PDT

Came across this old school animation showing how sound produced in the voicebox reverberates in the upper airway, mouth, and nasal cavity to produce speech that everybody else hears.

To watch what it looks like from the inside, check this video out.

Source:

FFFFound! 5/23/11

ENT Sued for Wrongful Death from Airway Closure

noreply@blogger.com (Fauquier ENT) — Tue, 23 Apr 2013 04:43:38 PDT

Media reported on a malpractice case whereby in October 2010, a woman presented to the emergency room at Ochsner Medical Center (Louisiana) with symptoms of sore throat, neck pain, and painful swallowing.

A CT neck performed at that time revealed "swelling in her neck and a narrowing at the top of the throat" [link]. Patient was given a strong pain medication to help with her discomfort (presumably a narcotic), admitted into the hospital, and ENT consulted for further evaluation and management. Unfortunately, the patient's airway completely closed early the next morning resulting in a massive brain injury due to oxygen deprivation with eventual withdrawal of life support four days later.

Lawsuit against the hospital and ENT among others pending.

What could have happened?

Based on the limited information provided, it seems that the airway swelling noted on the CT scan could have been due to a large peritonsillar abscess, throat tumor, or epiglottitis.

A peritonsillar abscess is basically a tonsillitis gone real bad with pus collecting under the tonsil causing it to swell. This condition could have been treated quickly with an incision and drainage.

Epiglottitis is when the "throat flap" becomes infected resulting in massive swelling which can lead to airway closure. Typical management would include IV antibiotics, IV steroids, and close observation. If airway truly becomes critical, an awake tracheostomy should be pursued. However, medical management is most always tried first if airway is still patent (albeit narrowed).

Throat tumor (ie, cancer) is pretty much a large growth in the throat causing airway narrowing. Treatment is an emergent awake tracheostomy followed by biopsies to determine what type of cancer is present so that treatment can be pursued as quickly as possible.

It is unclear from media reports exactly what was causing the airway narrowing and whether ENT had even seen the patient until the airway closed off. Also unclear was whether the ENT was made aware just how critical the airway was.

A tragedy...

Source:
Daughter of woman who died from brain damage after airway swollen shut sues hospital. The Louisiana Record 4/15/13

Men with Deeper Voices are More Successful

noreply@blogger.com (Fauquier ENT) — Sun, 21 Apr 2013 15:43:59 PDT

A Duke University study has found that men with deeper voices not only are more successful, but also make significantly more money. How much more money? $187,000 per year more than men with higher-pitched voices.

How much deeper does the voice need to be to make a difference? Apparently 22.1 hertz which is approximately 1/6 the difference between the pitch of James Earl Jones (low-pitch) and Mike Tyson (high-pitch).

Other research (see below) have found that a deeper voice also makes a candidate more likely to win, are more desirable to women, mate more frequently, and father more children.

How can a man with a relatively higher-pitched voice achieve a natural-sounding deeper voice? The first and perhaps best way to accomplish this is through voice therapy. Think of it like singing where a person learns to achieve a greater vocal range through intensive instruction... but in this case, focusing on the lower range.

Of course, there are surgical interventions that may also be helpful should voice therapy be unsuccessful including:

1) Vocal cord bulking through injection
2) Cricothyroid muscle dennervation through botox or lysis
3) Thyroid cartilage framework surgery (Isshiki Thyroplasty Type 3)

I should point out that surgical intervention is NOT recommended as a first step and usually does not achieve the profound improvement that most men desire... in other words, there is no simple, quick, and easy way to deepen the voice.

References:
Voice pitch and the labor market success of male chief executive officers. http://dx.doi.org/10.1016/j.evolhumbehav.2013.03.001, How to Cite or Link Using DOI

"Sounds like a winner: Voice pitch influences perception of leadership capacity," Proc Biol Sci. 2012 Jul 7;279(1738):2698-704. doi: 10.1098/rspb.2012.0311. Epub 2012 Mar 14.

Preferences for very low and very high voice pitch in humans. PLoS One. 2012;7(3):e32719. doi: 10.1371/journal.pone.0032719. Epub 2012 Mar 5.

Sources:
Voters 'like low-pitched voices'. BBC 11/14/11

Your Voice Could Be Costing You Hundreds Of Thousands Of Dollars, Study Shows. Forbes 4/18/13

Scam Tracheostomy in Hospital Leading to Arrests

noreply@blogger.com (Fauquier ENT) — Thu, 18 Apr 2013 04:53:19 PDT

Image from Wikipedia

A Chicago hospital owner and a few doctors were arrested in a horrific scandal involving deliberately over-sedating patients thereby ensuring a patient will not be able to come off the breathing machine leading to the excuse needed to perform a tracheostomy [link]. All done in the name for greater profits.

This scandal is particularly notable given it has come right at the heels of a New York Times story which reported that hospitals often profit from surgical errors, though in this criminal case, it was deliberate rather than unintentional errors.

Tracheostomy is typically performed whenever a patient is on a breathing machine for a prolonged period of time and there is a low likelihood of recovery.

However, prior to tracheostomy consideration, sedation is turned off so that the patient is allowed to wake up and try to breath on their own. If able to breath on their own with machine assistance, the breathing tube may be removed thereby avoiding a tracheostomy.

However, according to the lawsuit, the hospital and physician colluded to over-sedate patients thereby ensuring the patient is "ventilator-dependent" for which a tracheostomy is (erroneously) "justified".

Furthermore, patients who have undergone tracheostomy were intentionally made to stay in the hospital longer than required ("28 days") in order to earn as much money as possible in insurance reimbursements for the hospital. [link: paragraphs 123-142]

According to media reports, this scam has so far involved 28 patients... 5 who ultimately died within 2 weeks. The most recent unnecessary tracheostomy was performed on March 1, 2013.

Because of the trach and subsequent prolonged hospitalizations, the hospital received up to $160,000 for each patient from Medicare and Medicaid.

There's more... there was a massive kickback scheme whereby the hospital paid doctors to refer cases to the hospital (clear violation of Stark Laws), doctors ordered unnecessary ER visits, and fraudulently referred patients to nursing homes and ambulance services which the hospital had a relationship with.

This awful scam was brought to light by hospital workers (administrators, physicians, and nurses) who secretly worked with the FBI and other federal investigators.

Sources:
Feds raid Sacred Heart Hospital, arrest owner and doctors. Chicago Sun-Times 4/16/13.

United States of America Criminal Case Record. 4/15/13

Hospitals Profit From Surgical Errors, Study Finds. New York Times 4/16/13

Relationship Between Occurrence of Surgical Complications and Hospital Finances. JAMA. 2013;309(15):1599-1606. doi:10.1001/jama.2013.2773.

Pinterest for the Medical Office

noreply@blogger.com (Fauquier ENT) — Tue, 16 Apr 2013 03:07:32 PDT

For some time now, I've been struggling to figure out how to use Pinterest social media as it applies to a medical practice.

Pinterest is a pinboard-style photo-sharing website that allows users to create and manage theme-based image collections such as events, interests, and hobbies. Users can browse other pinboards for images, 're-pin' images to their own pinboards, or 'like' photos.

Pinterest is also one of the newest and hottest social media platform, especially among women and 20-40 years old demographic. As such, it behooves physicians and hospitals interested in social media to figure out how to incorporate Pinterest to their social media campaign.

For more interesting Pinterest statistics, check this webpage out.

BUT... given its visual and pictoral nature, it has been problematic when incorporating into something as privacy-ridden as healthcare.

How to use Pinterest for a medical practice and be successful without getting into trouble with HIPAA?

Not sure I have the secret, but I've ultimately decided that relevant medical infographics is the best way to go.

We shall see...

Check out our Pinterest page here!

Top 3 Reasons Why Your Child Can't Shake that Cough

noreply@blogger.com (Fauquier ENT) — Sat, 13 Apr 2013 03:47:45 PDT

Guest Blog Post by Dr. Julie Wei

Any parent who has lived with a toddler or preschooler knows the pain of hearing a child’s endless cough, daytime, nighttime, all the time... It seems as if the cough never clears up in a day or two, or after a cold, but may last for weeks. Even if it does clear up, it always seems to return without much warning, and can be more stubborn than your 4 year old about eating vegetables! If you are wondering why cough medications can't stop your child's cough, or for that matter, why inhalers for "asthma", another 10 days of antibiotics, and/or allergy medications are all not working, then continue reading. Have you dragged your child all over town to see yet another specialist to find out why they just keep coughing?

Here is what I explain to all families who come to see me about cough. Cough is an involuntary reflex, or protective mechanism the body has to get unwanted particles or irritants out of our airway. So if dust got into our windpipe, or a droplet of liquid goes into the airway accidentally while your child was drinking and trying to talk at the same time, or the phlegm that he/she gets with a viral illness... all of these things can make our children cough. While most children are thankfully not intermittently or continuously inhaling dust, or running around drinking with their head tilted while talking at the same time, the one frustrating thing about young children is the fact that they get 7-10 viral upper respiratory track illnesses, or colds every year. Each one of these “colds” last 7-10 days, and so pretty quickly, you can have a child with cold symptoms for a third of the year!

So... without further ado... the top 3 reasons why the cough is still hanging on...

NUMBER 3: Post-viral neurogenic cough or habitual throat-clearing. Whatever the reason was, your child started out having a bad cold and coughed due to being sick. Even after the fever and acute illness goes away after 7-10 days, their throat and voice box somehow stays irritated and they continue to cough. At some point, your child may not even realize that he/she is "coughing". Often these are children who are throat-clearing and not really coughing (more often in short annoying bursts, as often as every few minutes). If you no longer hear them "coughing" during sleep, but only when they are awake, then this is likely what your child has. These children often show no other signs of illness or discomfort. It's a difficult diagnosis to make and usually after all other reasons have been rules out. I often offer strategies to families to help break these habits such as creating a game (older than 3 or 4 years of age can do this) whereby a kitchen timer is used to help suppress the urge to "cough" starting from 30 seconds and working up to 5 minute intervals. School aged children who do not appear ill but have a “dry” throat clearing do very well with this exercise. Another option is when they get into a coughing fit, to distract them with chewing gum, having them count backwards from 20, hopefully distracting them from this habit.

NUMBER 2: Chronic Rhinosinusitis (CRS). Your child may have developed true chronic rhinosinusitis which means inflammation from thickening of the lining inside their sinus cavities and their sinus "plumbing" is clogged up. Chronic sinus inflammation is NOT a bacterial infection so antibiotics will not make it go away completely, even if it seems to decrease the cough temporarily. This usually occurs in children older than 4, especially if they have underlying test proven allergies to common aero-allergens like trees, pollen, grass, dust-mites, and other environmental allergens. Sometimes this is bad luck and develops after your child has experienced a terrible viral illness, such that the mucous membranes inside the nasal passages were so swollen that the natural drainage points that lead each sinus cavity into the nasal passage are blocked, which then leads to the inflammation inside the sinus. Since there is a built-in mechanism called the "sinopulmonary reflex", children who have inflamed sinus mucous membrane lining will likely continue to cough until the nasal passage and sinus mucous membranes are no longer swollen and healthy again. The only way to truly know if your child has CRS is for him/her to get a CT scan, a special imaging of their sinus cavities which can involve some radiation exposure. These children tend to complain of a stuffy nose all the time along with the cough, and can't blow anything out of their nose even if they try. Mothers always tell me that their child is stuffy and can’t breathe well, leading to snoring, fatigue, sometimes headaches.

NUMBER 1: The Milk and Cookie Disease (MCD). Your child is coughing because day after day, night after night, their larynx (voicebox) is bombarded with stomach content backwash (gastroesophageal reflux and laryngopharyngeal reflux) coming up to and irritating the voicebox. The voicebox which enables humans to talk is also designed to "cough" as a way to keep unwanted materials from entering our airway. If it did not protect itself by coughing, then we would aspirate and possibly get pneumonia. Find out how your child can live and eat in "A Healthier Wei" and fight the Milk and Cookie Disease, by minimizing dairy and sugar in the evenings and then his/her voicebox can rest and not be in "fighting" mode all the time. I have met thousands of children who have chronic cough not because they are sick, but because they were eating a diet or drinking beverages containing too much dairy and sugar, as well as possibly greasy foods and processed foods. All these items increase likelihood of reflux or backwash and assault on the larynx. If the voicebox is always on “alert” and ready to “fight” and protect the body, then it really can’t relax and rest. I believe that when this happens chronically from MCD, and let’s not forget those 7-10 colds and how they also lead to an irritated overreactive cough, then together, this child has no chance and probably will cough, A LOT! By making changes in diet and dietary habits in children, we can decrease the chance of stomach backwash coming up to irritate the voicebox and cause cough, then hopefully your child only coughs when it is truly because of a cold. Don’t take my word for it, try “A Healthier Wei”. You will likely notice at least much less coughing, and coughing ending much sooner after a cold. I also ask parents to stop dairy/milk for up to 1 week during the time their child is sick. This is when digestion is not at its best, and things get sour and gross in the stomach increasing chance for reflux and more cough.

by Julie Wei, MD, FAAP

Cicadas Can Cause Permanent Hearing Loss!

noreply@blogger.com (Fauquier ENT) — Thu, 11 Apr 2013 04:48:21 PDT

Cicadas are pretty darn ugly... But beyond their ugliness and making cars look pretty messed up... the sound they make is not only irritating, but potentially harmful.

Sometime the end of this April 2013, billions of large flying insects called cicadas will make their appearance along with their characteristic stridorous noise. The male cicadas are the ones making this mating noise with "tymbal" soundmakers amplified by large resonance chambers found on body.

Occurring every 17 years, this year's swarm is known as Brood II and has not been seen since 1996. Expected to cover much of the East Coast, the buzz created by these insects can reach 90 decibels... about as loud as a jackhammer. If one is right next to your ear, the sound can reach 120 decibels are equivalent to sandblasting or a loud rock concert. [see noise chart]

At 90 decibels, possible hearing damage may occur if a human ear is exposed to this level noise for more than 8 hours a day. At 120 decibels, less than 15 minutes of exposure can induce possible permanent hearing loss.

So... keep a pair of ear plugs in your purse or pants pocket and use them if the sound starts to get too loud.... or too irritating.

Sources:
17 years in the making, this spring's cicada invasion generates early buzz. NBC News 4/10/13.

Cicada. Wikipedia