Fauquier ENT Blog

Def Leppard's Guitarist Vivian Campbell's Chronic Cough Due to Lung Cancer

noreply@blogger.com (Fauquier ENT) — Thu, 13 Jun 2013 05:00:18 PDT

A chronic cough that's been going on for months to years is an extremely tough problem to figure out due to the many possible triggers including reflux, reactive airway disease, post-nasal drip, allergies, etc.

For Def Leppard's guitarist Vivian Campbell, his chronic cough was ultimately found to be due to Hodgkin's Lymphoma in his chest around his windpipe. In his own word's that he posted on the band's Facebook page (June 10, 2013 post):

“I feel fortunate that my cancer sent me an alarm call in the form of ‘the cough that wouldn’t quit’. Otherwise, how would I have known? After several months of trying every inhaler known to man, my doctor finally had me X-rayed. A further CAT scan revealed that enlarged lymph nodes were doing wrestling manoeuvres on my windpipe – hence the cough. What was causing the enlarged lymph nodes, however, was yet to be determined, so I underwent a surgical biopsy on March 11th, the first day of Leppard rehearsals for our Viva Las Vegas shows. Obviously, I didn’t make it to rehearsal that day, but it’s okay; I know the songs by now…"

Fortunately, compared to other types of lung cancer, Hodgkin's Lymphoma is more indolent leading to vague symptoms like a chronic cough that goes on for months if not years. It is also highly curable.

Just goes to show you that for patients suffering from chronic cough, more needs to be done than just a chest x-ray, breathing tests, and trying out different inhalers.

Sometimes, a CT scan of the chest and even bronchoscopy may need to be performed to fully evaluate pulmonary etiologies for a chronic cough.

And if nothing is found wrong with the lungs... further testing to check out other disease processes that may lead to a chronic cough is required and may include barium swallow, allergy testing, methacholine testing, 24 hour impedance testing, etc, etc, etc.

Media Report:
Def Leppard's Vivian Campbell battling Hodgkin's. USAToday 6/10/13

OSA is a Risk for Sudden Cardiac Death

noreply@blogger.com (Fauquier ENT) — Wed, 12 Jun 2013 04:03:03 PDT

Mayo Clinic researchers have determined that not only does OSA (obstructive sleep apnea) lead to increased risk of stroke, cardiac arrest, hypertension, vascular disease, etc but it can also increase the risk of sudden cardiac death, usually due to a fatal cardiac arrhythmia. This conclusion was reached after tracking thousands of men and women with sleep apnea for up to 15 years of whom 142 had sudden cardiac deaths or arrests who were resuscitated.

These sudden cardiac arrests occurred mainly at night, 60 years of age or older, with AHI scores of 20 or greater, and having low blood levels of oxygen. When oxygen saturation was 78% or less, the risk of sudden cardiac arrest increased by 80%. Normal oxygen saturation is 95-100%.

Unfortunately, the study failed to address whether those who used a CPAP machine (continuous positive airway pressure) or underwent surgical intervention to correct the OSA had a reduced risk of sudden cardiac death.

Such surgical intervention to treat OSA include UPPP and base of tongue reduction. Sedated endoscopy may be required to determine where the obstruction occurs anatomically before deciding on a surgical course of action.

Source:
Sleep Apnea May Boost Risk of Sudden Cardiac Death. WebMD 6/11/13

Reference:
Published online June 11 in the Journal of the American College of Cardiology. Link pending...

Google Search Now Provides Nutritional Information

noreply@blogger.com (Fauquier ENT) — Tue, 11 Jun 2013 14:00:04 PDT

It is not uncommon for me to recommend a patient to avoid certain dietary things like salt and caffeine, especially when dealing with tinnitus or Meniere's disease among other problems.

The next few questions I often get is "What can I eat than?" What foods contain low salt? etc etc.

Though I can refer a patient to a dietitian who knows the answer to many of these questions off the top of the head, Google may now be the next step to take in the future.

As of June 10, 2013, Google now provides fast and accurate information regarding nutritional information on all sorts of foods. With time, the already large database of foods will increase.

For example...

As it relates to decreasing salt intake, I often recommend somebody with Meniere's or tinnitus to ingest no more than 1000mg of sodium per day.

Given I'm Asian, I happen to use a lot of soy sauce. If I'm curious as to how much sodium is in soy sauce, just google search "How much sodium is in soy sauce?" and you will get the following answer:

Note that you can also specify what type of soy sauce as well as quantity to get a more specific answer.

Cool!

Taking Too Much Vitamins May Even Cause Cancer

noreply@blogger.com (Fauquier ENT) — Tue, 11 Jun 2013 03:59:49 PDT

Image from Wikipedia

Too much of anything can be harmful... even vitamins which people seem to consider benign regardless of how much is taken. In fact, taking regular large doses of vitamins (greater than 150% of what is recommended per day) actually INCREASES the risk of cancer.

To be clear, vitamins and supplements are great, but only when taking the recommended daily amount in a normal, healthy individual. Supplements may be necessary only if there's a deficiency, but not when you are a healthy individual.

The New York Times wrote a nice expose regarding this issue along with why the FDA doesn't say anything about it (vitamin lobbyists passed a law in 1976 prohibiting the FDA from saying anything).

So, let's take a look at the studies mentioned in the NYT documenting the adverse affects of too much vitamins:

The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. N Engl J Med. 1994 Apr 14;330(15):1029-35.

"Unexpectedly, we observed a higher incidence of lung cancer among the men who received beta carotene than among those who did not (change in incidence, 18 percent; 95 percent confidence interval, 3 to 36 percent)... more deaths from hemorrhagic stroke were observed among the men who received this supplement than among those who did not. Total mortality was 8 percent higher (95 percent confidence interval, 1 to 16 percent) among the participants who received beta carotene than among those who did not, primarily because there were more deaths from lung cancer and ischemic heart disease."

Effects of a combination of beta carotene and vitamin A on lung cancer and cardiovascular disease. N Engl J Med. 1996 May 2;334(18):1150-5.

"After an average of four years of supplementation, the combination of beta carotene and vitamin A had no benefit and may have had an adverse effect on the incidence of lung cancer and on the risk of death from lung cancer, cardiovascular disease."

Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality. Ann Intern Med. 2005 Jan 4;142(1):37-46. Epub 2004 Nov 10.

A dose-response analysis showed a statistically significant relationship between vitamin E dosage and all-cause mortality, with increased risk of dosages greater than 150 IU/d.

Antioxidant supplements for preventing gastrointestinal cancers. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004183.

We could not find evidence that antioxidant supplements prevent gastrointestinal cancers. On the contrary, they seem to increase overall mortality.

Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev. 2012 Mar 14;3:CD007176. doi: 10.1002/14651858.CD007176.pub2.

We found no evidence to support antioxidant supplements for primary or secondary prevention. Beta-carotene and vitamin E seem to increase mortality, and so may higher doses of vitamin A. Antioxidant supplements need to be considered as medicinal products and should undergo sufficient evaluation before marketing.

There are many more studies that show the adverse affects of taking mega-vitamins as well as additional studies that show that taking mega-vitamins makes absolutely no difference. Of course, with any medical issue, there are also studies that support the consumption of mega-vitamins, but the studies are not as rigorous nor as conclusive.

What to do?

I would suggest taking a regular multi-vitamin daily. No more or less unless a deficiency is present.

What are the Most Common Severe Drug-Induced Anaphylaxis?

noreply@blogger.com (Fauquier ENT) — Sat, 08 Jun 2013 07:58:40 PDT

Image from Wikipedia

Interesting paper came out listing the most common severe drug-induced anaphylaxis. From a database of 333 patients who suffered from anaphylaxis,

• Anaphylactic shock (76.6%)
• Severe systemic reactions (10.5%)
• Acute laryngeal edema (9%)
• Severe bronchospasm (2.1%)
• Fatal in 6 cases (1.8%)

There were 270 cases (81.1%) of ambulatory anaphylaxis. Sixty-three cases (18.9%) occurred during anesthesia.

84 drugs were identified as being responsible for these cases of anaphylaxis.

• Antibiotics (49.6%)
• Muscle relaxants, latex and anesthetics (15%)
• NSAIDS (10.2%)
• Tylenol (3.9%)
• Iodinated or magnetic resonance imaging contrast media (4.2%)
• Allergy shots and vaccines (3.9%)
• Other drugs (13%)

Among antibiotics, amoxicillin (97 cases), other penicillins (four cases), cephalosporins (41 cases), quinolones (15 cases), and pristinamycin (seven cases) were the most common.

Reference:
Severe drug-induced anaphylaxis: analysis of 333 cases recorded by the Allergy Vigilance Network from 2002 to 2010. Allergy. 2013 Jun 6. doi: 10.1111/all.12168. [Epub ahead of print]

At Home Allergy Testing

noreply@blogger.com (Fauquier ENT) — Sat, 08 Jun 2013 07:45:08 PDT

Recently, a new at-home allergy test can be found on store shelves throughout the United States as well as Amazon.com. It is called "MyAllergyTest" produced by ImmuneTech Corporation and it is FDA approved. The way it works is that you place a few drops of blood into the collection kit which is than mailed to a lab in a pre-paid, pre-addressed envelope.

Results are than obtained via internet or by certified mail in about one week.

What's tested? Only ten things (IgE only):

• Timothy Grass
• Bermuda Grass
• Mountain Cedar
• Short Ragweed
• Alternaria Mold
• Cat Dander
• Mite pternoyssinus
• Egg White
• Wheat
• Milk

As such, if testing comes back normal, it does not mean you do not have allergies... It just means that you do not have allergies to these 10 things only... You could be allergic to other non-tested substances.

A report is produced listing what you are allergic to and how badly:

How accurate is the testing? Apparently, it is comparable to Pharmacia CAP system (specific IgE FEIA).

In terms of actual numbers, the test has a sensitivity 88%, specificity 94%, and accuracy 91%.

Source:
FDA.gov

Company Website

Sinus Headache [video]

noreply@blogger.com (Fauquier ENT) — Thu, 06 Jun 2013 11:08:12 PDT

I could describe it... but I think it's better if you just watch the video...

Dangerous Tongue Patch Procedure for Weight Loss

noreply@blogger.com (Fauquier ENT) — Thu, 06 Jun 2013 04:34:15 PDT

Image from Wikipedia

There is a clinic in Beverly Hills who has been offering a risky "tongue patch" procedure in order to achieve weight loss of about 30 pounds in a single month. Although this clinic is currently the only one providing this "service" in the United States, it has been performed in Venezuela for quite some time.

In essence, a mesh made of marlex typically used for hernia repair is surgically sutured to the back area of the tongue and left in place for up to one month. While in place, this postage-stamp sized patch causes extreme discomfort if not pain whenever eating leading to a decrease in food ingestion and therefore weight loss. This non-FDA approved procedure is paired with a 800 calorie liquid diet.

In a normal swallow, the back of the tongue is required to help propel food down into the throat. With a patch in place, this step of the swallow becomes disrupted. Watch video to see how swallowing works here.

Does the concept work? In theory yes via starvation (hurts too much to swallow)...

Are there problems with it?

Absolutely and may even be considered highly unethical.

This procedure is associated with substantial risk including difficulty talking (you do need a tongue that moves well to enunciate words), infection, swelling, tissue overgrowth, and potential to dislodge leading to possible airway obstruction.

Why would somebody even consider this procedure? Well, if diet and exercise just doesn't work and financially, a desperate patient can't afford gastric lap band or bypass surgery... that's why some patients have pursued it.

Source:
Tongue Patch Surgery: Risky Weight Loss Procedure Draws Criticism. Yahoo News 6/5/13

New Movie Trailer for Fauquier ENT YouTube

noreply@blogger.com (Fauquier ENT) — Wed, 05 Jun 2013 01:38:01 PDT

It has been an amazing experience with how successful our videos have been on YouTube. We now have 60+ different videos of ENT procedures that has been viewed over 247 million times since 2007. We also now have over 12,300 subscribers to our video channel.

To celebrate, a movie trailer of sorts has been created to introduce new viewers to the sort of videos they will see and will continue to see from us.

Check it out! And... if you haven't yet subscribed to our video channel, please do so!

Former Bills QB Jim Kelly Diagnosed with Jaw Cancer

noreply@blogger.com (Fauquier ENT) — Thu, 06 Jun 2013 04:35:31 PDT

Image from Wikipedia

Former QB for the Buffalo Bills, Jim Kelly, announced that he has a squamous cell carcinoma of his upper jawbone.

He had been experiencing jaw pain since Dec 2012. When the pain failed to resolve with antibiotics, follow-up testing which probably included a CT scan revealed a cystic mass of the maxillary bone. Removal of this nickel-sized cyst in March 2013 revealed cancer.

Additional testing reported by Jim Kelly showed that the cancer has not spread elsewhere. Such testing may have included bloodwork and a PET/CT scan.

This Friday, a complete cancer resection operation will be performed. Given what information was provided, he will likely have his maxillary bone removed along with a rim of soft tissue until no pathological evidence for cancer is present. A limited neck dissection which entails removal of all the lymph nodes in the neck may also be performed.

Of course, after removal of his upper jawbone, there will be a big hole present. As such, he will likely also undergo simultaneous reconstruction to replace what was removed. Bone, muscle, and soft tissue will likely be obtained from either the leg or arm to reconstruct Mr. Kelly's jawbone.

It is also not unusual to have a feeding tube placed for some time to allow healing before oral intake is allowed.

This operation takes a LONG time... typically anywhere from 4-12+ hours depending on what is found during the operation.

Depending on final pathology which may take up to one week for results, Mr. Kelly may need to undergo further cancer treatment with radiation therapy with or without chemotherapy.

I wish him the best of luck!

Source:
Former Bills QB Kelly battling cancer of the jaw. Boston.com 6/3/13

Can HPV be Caught by Kissing Someone with HPV Throat Cancer?

noreply@blogger.com (Fauquier ENT) — Sun, 02 Jun 2013 10:03:51 PDT

HPV transmitted by oral sex is the leading cause of oral and throat cancer now. And for spouses/partners of patients diagnosed with HPV throat cancer, the main concern is whether it is "contagious".

After all, if HPV is transmittable by oral sex, than it would seem that kissing can also transfer HPV to the partner as well.

Well, a small Johns Hopkins study suggests that kissing someone who has HPV oropharyngeal cancer does NOT lead to a new HPV infection in the mouth or throat in the partner. Among 94 partners of 166 patients, prevalence of HPV infection in the throat was no higher than would have been expected. Specifically, about 5% had HPV which is equivalent to what one would find in couples without history of HPV throat cancer. There were only six male partners, none of whom had oral infection with HPV.

Please keep in mind that this study is far from definitive and further study is required before one can say with absolute certainty that kissing is totally safe. After all, oral sex leading to HPV infection of the mouth is a relatively recent discovery. Who is to say that with time and enough study, even kissing may eventually be found to do the same.

The study was presented at the 2013 annual meeting of the American Society for Clinical Oncology.

Source:
Wives of Men With HPV Throat Tumors Need Not Worry About Catching HPV. Forbes 6/1/13

Why Is a Nosejob Sometimes Necessary to Resolve Nasal Obstruction?

noreply@blogger.com (Fauquier ENT) — Sun, 02 Jun 2013 13:35:42 PDT

A very common complaint for a patient to see an ENT surgeon is to resolve nasal obstruction. The most common surgeries to resolve nasal obstruction include septoplasty, adenoidectomy, and turbinate reduction. All of theses procedure are performed within the nasal cavity and does not affect appearance.

However, sometimes in order to resolve nasal obstruction, the appearance of the nose MUST change especially if the nostril openings are very narrow. By looking at these example pictures of the nostril openings, it's pretty obvious that breathing would be an issue. So even though a nosejob is typically performed for cosmetic reasons, it may also be recommended for medical reasons should nasal breathing be inadequate.

For both these patients, the nasal columella is crooked to one side resulting in one nostril opening being larger than the other which causes nasal obstruction on the more narrow side.

Correction of this crooked nasal columella into a straight and midline appearance would result in improved nasal breathing as well as a change in appearance.

Sometimes the nasal columella may be straight, but the nostril openings are both too narrow leading to nasal obstruction. Correction would require enlarging the nasal opening by use of alar batten and spreader grafts which would result in not only improved nasal breathing, but also a wider nasal appearance overall.

The explanation for why the nasal appearance does not change especially after septoplasty which requires cartilage and bones removal is actually quite simple. The analogy would be a house where the appearance on the outside would not change even though you may knock down a wall between two rooms inside the home.

SO... Here is a side view of the septum. The blue arrow is pointing to the nostril opening and the red arrow is pointing to the lip.

In this picture below, the septum has been removed.

As you can see, the outside appearance of the nose remains unchanged as the rim of the nose is kept intact as shown by the red arrows here:

So that in a nutshell is the explanation for why deviated septum surgery does not change the outside nasal appearance.

Read more about the septoplasty surgery here.

Medical Translator Commercial...

noreply@blogger.com (Fauquier ENT) — Sat, 01 Jun 2013 10:59:45 PDT

I'm sure many patients would like a medical translator like this one shown in this humorous commercial. In case you haven't seen it yet...

Do Nosebleeds Cause Stool Blood Tests to Become Positive?

noreply@blogger.com (Fauquier ENT) — Fri, 31 May 2013 05:42:53 PDT

As a general rule, an ordinary nosebleed will not cause a screening stool blood test (hemoccult or guaiac) to come back positive.

However, if the nosebleed is bad enough to consider going to the emergency room... and you are swallowing a lot of it... only than will it be likely that such stool tests will come back positive for blood.

To be precise, such stool tests turn positive only if there's at least 2+ teaspoons of blood leaking into the digestive system everyday (or swallowed from a very bad nosebleed).

Of course, there are MUCH more sensitive tests out there to determine if there's blood in the stool including heme-porphyrin or immunochemical tests, but have a high false-positive rate.

From an ENT perspective, immunochemical testing is interesting because this test uses antibodies to detect human globin epitopes which get digested in the stomach... so if there's a question of whether a patient's anemia is due to nosebleed or a lower GI tract bleed (ie, colon), immunochemical stool testing can answer the question.

Just as an FYI, if the nosebleed is severe, it is likely that you will end up getting your nose packed.

New Video on Awake Tonsil Cryptolysis to Address Tonsil Stones

noreply@blogger.com (Fauquier ENT) — Thu, 30 May 2013 15:59:45 PDT

A new video has been uploaded describing a minimally invasive technique to address tonsil stones called tonsil cryptolysis.

This technique accomplishes the same thing as laser cryptolysis but at lower cost and increased safety. Just like laser cryptolysis, this procedure can be done awake without any sedation using only local anesthesia (the caveat being that the patient must have minimal/no gag reflex with easy visualization of the tonsils).

Watch the video below or on YouTube. Read more about this procedure here.

Dr. Chang's 2013 Lecture Circuit

noreply@blogger.com (Fauquier ENT) — Thu, 30 May 2013 04:42:21 PDT

After numerous inquiries regarding conferences I will be presenting at (as well as other venues), I thought to list them all here for the year 2013...

So.. for the year 2013, here you go! There's a few national conferences and even an international conference. If you happen to be present during one of my talks, give a shout-out!

(Full list can be found on my CV.)

• Upcoming: Christopher Y. Chang, Wei J, Eisenberg L, Simon LM. Utilization of Social Media in Medicine. Presented at the 2013 AAO-HNS Miniseminar Presentation in Vancouver, BC. October 2, 2013.

• Upcoming: Invited Lecturer. Social Media for the Busy Surgeon. American Society of General Surgeons Annual Meeting. National Harbor, MD. August 17, 2013.

• Upcoming: Invited Lecturer. Laryngo-Pharyngeal Reflux: Collaborative Treatment Between General Surgeon and ENT. American Society of General Surgeons Annual Meeting. National Harbor, MD. August 17, 2013.

• Lecturer. Botulinum Toxin Injections for Spasmodic Dysphonia. National Spasmodic Dysphonia Association Symposium. Arlington, VA. May 18, 2013.

• Christopher Y. Chang, Payne SC, Stern W. Social Media for the Otolaryngologist. Presented at the AAO-HNS BOG Spring Meeting & OTO Advocacy Summit in Alexandria, VA. May 5, 2013.

• Lecturer, “Vocal Assessment.” Performing Art Medicine Certificate Program. Shenandoah University. Winchester, VA. April 7, 2013.

• Guest Lecturer, "Vocal Abuse and Misuse." Anatomy and Function of the Singing Voice Course at Shenandoah University. Winchester, VA. March 27, 2013.

• Guest Lecturer, "Video Laryngoscopy." Anatomy and Function of the Singing Voice Course at Shenandoah University. Winchester, VA. February 13, 2013.

How Does Neuropathy Lead to Lump in Throat or Phlegmy Throat Sensation?

noreply@blogger.com (Fauquier ENT) — Thu, 30 May 2013 03:27:24 PDT

To preface, have you ever been to the dentist and received a novacaine injection prior to a dental procedure? Did you notice that where the injection is performed, it feels as if the area feels really swollen and also you feel like you are drooling... but than when you look in the mirror, there's no drooling and there's no swelling either?

In this dental situation where novacaine got injected leading to a temporary induced neuropathy... a similar phenomenon can also occur in the throat region due to neuropathy most commonly triggered by a virus or throat-level reflux (LPR). This condition is called laryngeal sensory neuropathy (LSN).

And because the neuropathy occurs in the throat region... a sensation of swollen or lump feeling in the throat (globus) may occur just like the sensation in the face/jaw after getting numbed up for a dental procedure.

Similarly, a mucus phlegmy throat sensation may also occur just like a drooling sensation of the face/jaw after being injected with novacaine.

Such a swollen throat or phlegmy throat sensation can also be temporarily induced in normal patients when the throat gets numbed up with lidocaine or other anesthetic for a surgical procedure.

How is this condition treated?

First and foremost, other non-neurologic etiologies must first be ruled out with medications and extensive testing. Also, triggers that may have led to this neuropathy must be thoroughly addressed as well. Such testing may include allergy testing, specific food avoidance, 24 hour multichannel pH impedance, manometry, etc, etc.

Once laryngeal sensory neuropathy is confirmed, medications like amitriptyline, neurontin, and tramadol can be tried.

For more information, click here for globus and here for phlegmy throat.

Why Would a Zenker's Diverticulum Recur After Surgical Treatment?

noreply@blogger.com (Fauquier ENT) — Wed, 29 May 2013 05:01:26 PDT

Zenker's diverticulum is an extremely rare disorder whereby a pouch develops in the throat leading to food and liquids getting caught causing symptoms of swallowing difficulties and food regurgitation. One of the best ways to address this rare condition is a procedure called endoscopic staple diverticulostomy (ESD).

Unfortunately, with any Zenker's treatment including ESD, there is a small percentage (~10%) that the Zenker's diverticulum recurs typically within one year of treatment (average 8.5 months).

Why might that be?

There are some known (and unknown) issues that may lead to recurrence including:

• Incomplete division of the cricopharyngeus muscle: If the pouch is small, the cricopharyngeus muscle may not be completely divided using the ESD method. It is a shortcoming inherent to the method itself and not a lapse on the surgeon's part. The only way to completely address the muscle when the pouch is small (less than 1 .5cm) is via external approach or use of a laser with its associated increased risk of complications.
• Unaddressed or persistent laryngopharyngeal reflux: Proton pump inhibitor medications are ALWAYS prescribed before and after surgery... even if heartburn symptoms are absent. However, even with such medications, there may be a certain sub-population that suffer from persistent throat-level reflux that may trigger the Zenker's diverticulum to reform. This factor is probably the single most important reason why recurrence may occur within months.
• Loose staples: After surgery is performed, all loose staples are removed to minimize recurrence from this factor.
• Idiopathic scarring of the common wall: Some unindentified inflammatory process leads to restenosis of the common wall.
• Unknown: Whatever factor lead to the Zenker's formation in the first place may cause it to happen again. Indeed, we actually don't precisely know what causes the Zenker's pouch to occur in the first place.

As such, if recurrence occurs years after treatment, it usually will suggest an incomplete cricopharyngeus muscle division. Repeat ESD can be performed with good results.

If recurrence occurs within one year of treatment, I typically will consider the possibility of persistent throat-level reflux (laryngopharyngeal reflux) that was not or incompletely addressed with reflux medications. Before performing ESD again after a recurrence, I will obtain a few studies to determine how significant throat-level reflux may be present.

That typically entails getting a 24 hour multi-channel pH and impedance testing with manometry. The most important result from this study is the frequency of proximal esophageal reflux events and as such, any other type of reflux study that does not include proximal esophageal or hypopharyngeal sensors would be considered inadequate. Ideally, it should be as close to zero as possible. If proximal esophageal reflux events are present, this needs to be thoroughly eliminated prior to revision Zenker's surgery... otherwise, the Zenker's pouch may yet again recur.

Manometry is performed to ensure the cricopharyngeus muscle (if present) is adequately "loose".

Of course, the barium swallow needs to be repeated as well.

Reflux Increases Risk of Throat Cancer by 78%

noreply@blogger.com (Fauquier ENT) — Sat, 25 May 2013 11:11:08 PDT

Brown University researchers found that frequent heartburn was an independent risk factor for not only esophageal cancer but also cancer of the throat and vocal cords. This conclusion was based on a large population study involving 631 patients with throat cancer and 1,234 without throat cancer as a control group.

The study group also did not heavily smoke, drink, or have HPV (other independent risk factors for throat cancer).

Individuals with frequent heartburn were found to have a 78% increased risk of developing throat cancer. What researchers also found was that taking antacids for reflux (but not proton pump inhibitors or H2 blockers) seemed to protect against the development of throat cancer by 41% in patients with frequent heartburn.

The explanation for how reflux can cause throat cancer is similar to how it can also cause esophageal cancer. With repetitive mucosal injury by gastric juices to the delicate lining of the throat, there is a cycle of healing and injury that may eventually trigger cancer development. Patients with reflux that reaches the throat level have a condition called LPR or laryngopharyngeal reflux. Although symptoms may be similar to the more common GERD, it is not unusual for patients to experience only throat symptoms without the heartburn. Such atypical symptoms include:

• Chronic cough
• Phlegmy throat
• Chronic throat clearing
• Vocal cord dysfunction
• Globus pharyngeus

It is also notable that it takes far less reflux episodes in the throat region compared to the esophagus in order to trigger mucosal damage... it takes fewer than THREE episodes per WEEK! [link]

In any case, more research is needed to determine at what point cancer risk increases in individuals with LPR, what type of reflux (acid?, non-acid?, pepsin?, bile?) triggers cancer concern, to what degree of reflux prevention is required to protect against cancer development.

Also more needs to be done to figure out why antacids help reduce cancer risk, but not other types of reflux medications.

References:
Gastric Reflux Is an Independent Risk Factor for Laryngopharyngeal Carcinoma. Cancer Epidemiology Biomarkers & Prevention. Published Online First May 23, 2013; doi: 10.1158/1055-9965.EPI-13-0183

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991 Apr;101(4 Pt 2 Suppl 53):1-78.

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) — Sat, 25 May 2013 16:45:10 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. See video clip below.

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, 06 Jun 2013 04:39:53 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]