There's Always Someone With a Bigger Mouth

Continuing the spirit of Halloween with semi-relevant ENT random news...

Someone forwarded me this picture of a TEN foot great white shark which was bitten by an even bigger great white shark. Apparently, the poor shark was still alive when it was captured in Australia.

Click here to read the story and watch a video!

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Crazy Pumpkin Carvings Related to ENT

In celebration for Halloween today, I have found a few crazy pumpkin carvings courtesy of Extreme Pumpkins.




Here is the one that I carved, complete with snotty tissues:




If you have another relevant one, please comment and include a link to a picture. Enjoy!

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Nasal Endoscopy to Evaluate Hoarseness on Dr. Oz Show!

On Oct 23, 2009, Dr. Oz (his show) with the assistance of Dr. Jonathan Aviv, demonstrated a procedure called Nasal Endoscopy which is the main method of evaluating a patient with hoarseness. A pretty good and accurate demonstration I may add.

Watch the video clip here.

Of course, I have produced a few video clips of the same of which one can be viewed below. Click here to watch one being performed on a child. Read more about this procedure here as well as what happens when the voice doesn't sound normal here.

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Why Does Brain Freeze Occur With Eating Ice Cream and Other Cold Treats?

Believe it or not, this has been the topic of research in the past and even has a medical diagnosis called "sphenopalatine ganglioneuralgia". To sum it up, there are two theories behind this phenomenon:

1) Blood vessel phenomenon: Blood vessels constrict when any part of the body is exposed to cold temperature and dilates when it gets hot. This simple fact can be applied to the biological cause of brain freeze as well. Upon contact with ice, the blood vessels in the roof of the mouth begin to constrict, making the vessels in the head to expand, and thus creating a headache.

2) Trigeminal nerve factor: The trigeminal nerve, or cranial nerve 5 (CN5), is responsible for facial sensation. As a result of eating cold foods, this nerve in the palate of the mouth becomes overstimulated. Stimulation of the nerve causes neurons to fire pain signals to the brain, producing a headache.

Is there a cure? Avoid the culprit cold treat that triggers the pain or eat is slowly. Should you suffer from a brain freeze or sphenopalatine ganglioneuralgia, drink warm fluid or just wait!

Read the research behind these theories:
• Ice cream headache--site, duration, and relationship to migraine
• Ice cream evoked headaches (ICE-H) study: randomised trial of accelerated versus cautious ice cream eating regimen

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Possible Dystonia (Rare Neurological Condition) After Flu Shot

Desiree Jennings, a former Redskins cheerleader, received a seasonal flu shot on Aug 23, 2009 and has suffered from a possible dystonia reaction from the flu vaccination resulting in difficulties in eating, talking, and walking.

Here is a link to a video where Dr. Stephen Grill (neurologist) is interviewed by Fox News regarding Desiree's condition.

Here is a video/article of the initial story.

This story is a case of a VERY unfortunate EXTREMELY rare side effect (if true) of the flu vaccine. People should still get the flu vaccine, but be aware that it is not 100% benign in all cases.

However, it seems that Desiree's flu shot reaction may have been psychogenic (and not a true side effect of the vaccine at all). Read this blog article which goes into this in more detail.

Regardless, people have developed rare neurological conditions called laryngeal dystonia otherwise known more commonly as spasmodic dysphonia. The way Desiree talks (from what I can hear from the videos) is distinctly different from patients who suffer from classic spasmodic dysphonia. Click here to hear what laryngeal dystonia/spasmodic dysphonia sounds like.

(Of note, I received both the seasonal and the H1N1 vaccine and have encouraged all my friends, family, and patients who inquire to do so as well.)

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Our Office Has Been Renovated!

I have been hard at work all weekend with the generosity of friends as well as services of furniture reupholsters and general contractors. The waiting room as well as Exam Room 1 has been renovated for the better!

It has been a sore point for me that the walls of my waiting room have been drawn upon with crayons by errant kids. Once one kid has drawn upon it, the other squiggles soon followed (Same kid or different kids? I have no idea).

In any case, they are no more. The walls of the waiting room have been repainted in a two-tone color (sandstone/taupe) giving it a much warmer appearance than before. Furthermore, the waiting room chairs have been reupholstered with pleather to make it easier for cleaning.

Exam Room #1 has also been redone by reducing the space required by the built-in desk to half the size allowing for more free space for movement. The broken electrical outlet has also been fixed eliminating the need for an extension cord for the computer (a real eye-sore).

For those curious, the waiting room chair reupholstering was done by Miller Restorations and the exam room renovations by Cornerstone & Son Construction, LLC. Highly recommend both for pleasant services, being on-time, good price, prompt email correspondence, and excellent job.

Hopefully in the next 6-12 months, further office renovations will be pursued to take advantage of additional office space freed up by the disappearance of paper chart racks now that we've been using EMR the past 2 years.

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NYT: How Tongues Taste Carbonation in Soda

The New York Times published a story on Oct 19, 2009 regarding how tongues taste that "carbonation" we all appreciate when drinking soda pop beverages. The story entitled "How Tongues Taste the Carbonation in a Fizzy Beverage" reveals that the carbonation is NOT due to the bubble popping, but rather a taste receptor.

As we all know, there are receptors for five tastes: sweet, sour, salty, bitter and umami (sometimes termed savory).

It is the receptor for sourness that is responsible for the taste of carbonation.

Read the story here.

Read the research here.

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AP: HHS Secretary Had Skin Cancer (BCC) Removed From Forehead

Associated Press reported today (Oct 22, 2009)that Health and Human Services Secretary Kathleen Sebelius had a Basal Cell Carcinoma (BCC) skin cancer removed from her forehead. Read the article here.

BCC is a very common type of skin cancer that is often curable by complete excision. Often, this procedure is done in the office setting.

Of note, our office regularly performs skin cancer excisions of the head and neck regions.

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Nasal Irrigation Beneficial for Pregnant Women With Allergies

Italian researchers have reported in the International Archives of Allergy and Immunology in Sept 2009 that saline nasal rinsing is a safe and effective treatment option for nasal problems in pregnant women with seasonal allergic rhinitis. In their paper titled "Nasal Lavage in Pregnant Women with Seasonal Allergic Rhinitis: A Randomized Study," the researchers instructed the study group to perform hypertonic saline lavages to the nose 3X per day. Of note, HYPERTONIC saline solution was used instead of the more usual isotonic saline solution.

A statistically significant improvement in rhinitis symptoms (rhinorrea, obstruction, nasal itching and sneezing) was found during the observed weeks 2-6. Furthermore, the mean number of daily antihistamines use per patient per week was significantly reduced at weeks 2, 3 and 6. No adverse effect was reported in the active group.

Read the abstract here.

In our office, we recommend the Neilmed Sinus Rinse bottle as the cheapest and most effective way to perform nasal irrigations. Of note, the Neilmed sinus rinse bottle also comes with hypertonic saline version (along with the more common isotonic version). For convenience, irrigation devices (shown below) are also sold, but much more expensive.

Click here to watch a video of how to perform nasal rinses.

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WSJ: FDA Approves Gardasil for Boys (and Girls)!

This was reported by the Wall Street Journal on Oct 16, 2009. Why is this significant from an ENT perspective?

Well, gardasil is supposed to vaccinate people from getting HPV related diseases like genital warts which would help both genders when individuals become sexually active. Of more note, it has been specifically shown to help prevent cervical cancer in females which is a big killer of women.

However, it may potentially prevent other types of HPV related disorders involving the head & neck in both men and women (which has not been studied, but likely to still help), including:

Respiratory Papillomas (benign)
Throat Cancer
Oral ulcers/lesions/warts (benign)

In order to receive the beneficial effect of the vaccine, the vaccine needs to be given in 3 doses (at $130 per dose) between ages 9-26.

Read the WSJ article here.

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Botox Treatment for Vasomotor Rhinitis (Idiopathic or Non-Allergic Rhinitis)

A new research paper has been published Oct 16, 2009 in Head & Face Medicine entitled "Minimally invasive application of botulinum toxin A in patients with idiopathic rhinitis" in which researchers successfully treated patients with a persistent runny nose not due to any known problems like allergy. Such a condition is called vasomotor rhinitis or idiopathic rhinitis or non-allergic rhinitis.

In this new described method of treatment, a sponge soaked with 40 Units of botulinum toxin type A was inserted into a patient's nose and left in place for 30 minutes. Apparently, this did result in a significant reduction in rhinitis (but not congestion) and lasted for as long as 12 weeks.

Read the abstract here.

Of course, this is a non-FDA approved use of Botox.

Historically, this condition is often treated with nasal sprays (ie, astelin) and decongestants with some success in some patients, but not all patients respond.

Surgical treatment include turbinate reduction which reduces (usually about 50%), but does not cure this condition.

Before you ask... NO we do not offer this procedure until further research and data becomes available.

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MRSA Sinusitis

There seems to be an increasing number of patients I see with MRSA sinusitis. Not many, but definitely not rare. These patients are understandably very concerned with how to treat their MRSA sinusitis.

Beyond the usual protocol that applies to any MRSA infection, if the sinusitis is severe, sinus surgery is recommended for 3 main reasons.

1) Get the infection cleaned out surgically (much like draining an abscess of the skin)
2) Enlarge the openings of the sinus cavity to allow good post-op topical treatment in order to potentially avoid oral and IV antibiotics (though they still may be needed)
3) Sinus infection can be carefully followed endoscopically in the future

By opening up the sinuses, topical treatment can be performed that is sometimes more effective that IV or oral routes as higher concentrations of medication can be delivered right to the area of concern (instead of oral or IV routes which go throughout the entire body causing side effects).

Such topical treatment include:

• Saline flushes (Neilmed Sinus Rinse is our preferred method though irrigation devices shown below are also fine)
• Bactroban Cream or Cortisporin Ointment injection directly into the sinus cavity
• Antibiotic flushes to the sinus cavity
• Chemical saline flushes to the sinus cavity (my favorite being No-Tears Johnson's Baby Shampoo - 1 tsp in 250 cc of saline)

Debridement of the sinus cavity can also be easily performed after sinus surgery in the office.

Once the active MRSA sinusitis infection has cleared, continued topical treatment with daily saline nasal flushes help prevent future sinus infections.

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Tionne "T-Boz" Watkins Suffered from Acoustic Neuroma (Brain Tumor)

It was revealed in Oct 2009 that celebrity Tionne "T-Boz" Watkins of TLC fame (Celebrity Apprentice), that she was diagnosed with a type of benign brain tumor called acoustic neuroma. She underwent surgery in 2006 to have it removed and experienced a difficult recovery especially with balance.

One of the earliest symptom of this type of brain tumor is an asymmetric sensorineural hearing loss (ASNHL) or a sudden hearing loss only in one ear (SSNHL). This type of unusual hearing loss is when one ear hears much worse than the other and can only be diagnosed on a hearing test audiogram. Should ASNHL be found on audiogram, an MRI scan of the Internal Auditory Canal with gadolinium contrast is often ordered to evaluate further. An ABR (auditory brainstem response) test may also be ordered instead of MRI, but is not considered as good a test.

Should an acoustic neuroma be found, the surgery to remove it is usually performed jointly by a neuro-otologic surgeon as well as neurosurgeon. In our area, there are only a few surgeons able to perform this type of surgery including Drs. Kesser and Hashisaki at University of Virginia as well as Dr. Bryan McKenzie in Fairfax, VA. Our office can evaluate and diagnose, but we are unable to perform this type of surgery.

Read more about Tionne's struggle here.

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Saline Nasal Sinus Irrigation Systems

I must admit... our office is a big fan of the Neilmed Sinus Rinse bottle for patients who suffer from chronic sinusitis and severe allergies as it is cheap, easy to clean, and it works. However, many patients who are already fans of flushing the nose with saline water end up purchasing saline irrigation systems. There's a bunch of these devices sold on Amazon.com. Check them out below, but I would suggest that you first become adept and able to tolerate saline flushes using the Neilmed sinus rinse bottle first prior to paying almost $100 for these devices.

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Egg Allergy and the Flu Shot

Several patients have called our office asking whether it is safe to receive the flu shot if they are egg allergic. Generally speaking, for most patients, the blunt answer is that it is safe.

The flu shot vaccine (both H1N1 and seasonal) are egg-based from which this concern arises. It also doesn't help that the pre-flu shot questionnaire specifically asks about egg allergy. Though egg-based, most of the egg protein is filtered out such that there are no egg contaminants. However, it is possible that some egg is present in a vaccine.

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

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

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

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

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

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New Video Produced on Proper Ear Drop Administration

We have recently produced and uploaded on to our YouTube channel a new video describing how to properly administer ear drops. This video is especially pertinent in patients who have ear tubes.

Watch the video below:

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TWO Ear Canals in the Same Ear!

I recently saw a patient who had a complaint of having two ear canals in each of the ears. To my surprise, the patient had exactly that! You can see the second ear canal in the picture below... it is above the normal one and is about 25% the size.

To those in the know, this is due to a congenital birth defect related to the first branchial cleft.

Read more about this birth defect here. Clearly, the way to correct this is surgical.

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LA Times: Driving a Convertible May Cause Permanent Hearing Loss!

The LA Times published a story on Oct 6, 2009 entitled "Cruising with the top down? Cover your ears" describing research that assessed noise levels in seven different scenarios where the convertible was traveling at speeds of 50, 60 and 70 miles per hour. Researchers found that drivers were consistently exposed to noise levels between 88 and 90 decibels. Even with the windows up, the noise levels were found to be at 82 decibels.

To keep these findings in perspective, repeated exposure to noise over 85 decibels can result in permanent hearing loss.

To make things even worse, because there is surrounding noise from other vehicles especially in traffic, driving more slowly may end up being just as loud as when driving more quickly.

These findings may be a big bummer for those who love to drive convertibles, but driver beware!!! Perhaps these drivers need to wear ear plugs whenever the top is down.

Read the story here.

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NYT: Does Snotty Colored Discharge Require Antibiotics? No!!!

The New York Times published a story on Oct 6, 2009 entitled "The Claim: With a Runny Nose, Green Calls for an Antibiotic." It actually is a pretty good article though I'm not sure how much impact this will have in clinical practice.

The story reports that green discharge from the nose is NOT indicative of a bacterial sinus infection and as such, this symptom should not be the sole reason why antibiotics should be prescribed.

It does reference a research paper that backs this claim up. There are others.

In any case, the last sentence of the story is worth reiterating: "THE BOTTOM LINE: The color of nasal discharge should not dictate the medicine."

Not sure how accepting patients will be of this factoid given how ingrained colored discharge has been equated with sinus infection.

I personally have encouraged saline nasal flushes starting from as early as 5 years old as the main treatment for this issue which some patients have been more accepting than others.

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