Distributed Botox Injection for Spasmodic Dysphonia (Rather than Single Injection)

For many patients with spasmodic dysphonia, botox injections to the vocal cords are a regular right of passage every few months towards a clearer voice. Spasmodic dysphonia characterized by spastic or breathy voice breaks while talking causes much problems socially as well as misunderstandings.

For many physicians who perform botox injections for spasmodic dysphonia, a single injection is performed to either one or both vocal cords.

However a few and perhaps growing number of physicians are now using a more sophisticated method of injection where not only one, but multiple "mini"- injections are performed to the vocal cord during an injection.

Why would multiple injections be performed when one will do?

For that, I would like to take the reader to the world of cosmetic botox injections for facial wrinkles.

For the millions more sufferers of facial wrinkles, patients know that from the point of injection, there is a limited region of affect... typically no more than a dime to nickle area in size depending on the volume used. SO... in order to get rid of forehead wrinkles, 5 or more injections are required as shown here by the "x" marks.

The point is... in order for a great outcome in forehead wrinkles... multiple injections are performed. Not one single injection.

The same holds true for the vocal cord muscles. Rather than a single large injection to one spot in the vocal cord muscle, there is a growing belief that multiple "mini"-injections should be performed throughout the vocal cord muscle in order to produce a better outcome... a distributed injection. No specific research to prove this, but rather anecdotal.

Here is a video of botox being injected in a patient with spasmodic dysphonia.

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Making Twitter Work for a Specialty Medical Practice (Like ENT)

I've been asked by a few ENT colleagues how I got Twitter to work for my practice and how in the world I managed to get more than a few dozen followers.

I've been at it for about 1 year now (up to 355 followers @FauquierENT) and here are a few tips to making it work for a medical practice... Just an opinion... And it may not apply to everyone...

• When you tweet something, always back it up with a useful link to a webpage using a link shortner like bit.ly or goo.gl.
• Tweet about topics that the LAY-PERSON would find interesting. Twittering about "Outcomes of Vascularized Bone Graft Reconstruction of the Mandible in Bisphosphonate-Related Osteonecrosis of the Jaws" is NOT going to garner you fans even if you personally as an ENT find it riveting reading. An example of a good tweet I recently posted is "Do Cell Phone Makers Secretly Know Cell Phones May Cause Health Problems? http://ht.ly/3bBUZ"
• Follow people you find interesting. They will follow you back typically and their followers will slowly start to follow you. Given I twitter about ENT topics, I make it a point to follow ALL otolaryngologists, respected medical journalists, and health related newspapers.
• Write a blog and use twitter to "advertise" your blog article.
• ADVERTISE on your website that you have a twitter account.
• Be active with tweets. Potential followers will not be that excited to follow you if you have something interesting to say only once every few weeks.
• IF you come across something interesting in a medical journal, tweet it, and support it with a link.

So there you have it... Now go sign up with twitter and don't forget to follow my tweets!

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"Sinus Lift" Procedure - The Return of Intra-Oral Sinus Surgery

I saw a patient today who informed me that she underwent a "sinus lift" procedure in the past.

This statement made me realize that though ENTs are generally considered the sinus surgery experts, dentists and oral surgeons perform some sinus surgery as well like the "sinus lift" procedure. As far as I know, there is no ENT surgeon that does that specific sinus operation.

In essence, the "sinus lift" procedure is when the floor of the maxillary (cheek) sinus cavity is raised with bone graft material in order to accommodate a dental implant. Though there are many approaches to accomplish this task, most require entering into the maxillary sinus cavity. See image below:

It is somewhat strange when considering that back in the old days (like a few decades ago), ENTs routinely performed a similar intra-oral approach (Caldwell-Luc) in order to enter into the maxillary sinus cavity when performing sinus surgery for chronic sinus infections. However, with the advent of endoscopic techniques, this approach is now very rarely performed. Indeed, we try to avoid any incisions if at all possible.

So while ENTs have significantly decreased the use of intra-oral approaches for maxillary sinus surgery, the dental world has brought this approach back!

Who knows? Perhaps ENT and oral surgery will join forces at some point in the future in order to perform an endoscopic "sinus lift" procedure in order to avoid making any incisions in the mouth!

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Fauquier ENT Blog Now Published on the Kindle

We are pleased to report that our blog is now published on the Kindle! As many readers may already be aware, the Kindle is the top-selling e-book reader sold by Amazon.com. Click hereto subscribe to our blog on the Kindle!

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Zenker's Diverticulum Endoscopic Treatment Confusion

Having treated many patients with Zenker's Diverticulum using the endoscopic approach, I've had many confused patients ask me how the diverticulum is treated if it is not removed.

For those unfamiliar with this disorder, click here for more information.

The basic concept of treating this rare disorder is that there is a common wall that divides the esophagus from the diverticulum pouch. This common wall is endoscopically divided such that the pouch now becomes the new back wall of the esophagus. So when the patient swallows, food/liquids can no longer get "trapped" causing symptoms.

Still confused? Here are some picture illustrations...

When endoscopically exposed, the pouch is denoted by the arrow.

When looking through the scope placed into the mouth down into the throat, there is a common wall that is between the pouch (blue arrow) and esophagus (green arrow).

Endoscopically, whether using a stapler or laser, this wall is divided down the middle. This picture shown below is when a stapler is used.

Here is the side view before and after common wall division:

After the procedure, any food/liquid substances that are swallowed can't be trapped in the pouch. Therefore, even though nothing is surgically removed, the patient's swallowing symptoms completely disappear.

Hopefully, this explanation helps clear up any confusion of what exactly happens!

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Teaching Dr. Oz About Nosebleeds (Re-Published on KevinMD)

One of Dr. Chang's blog article on nosebleeds has been re-published on KevinMD, an internationally recognized medical blog and contributor to MedPageToday.

The original blog article by Dr. Chang can be read here.

The blog article re-published on KevinMD can be read here.

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Do Cell Phone Makers Secretly Know Cell Phones May Cause Health Problems?

Recently, there has been much speculation on whether cell phones pose a health risk. Wikipedia has a nice summary of those concerns.

What I find interesting is that the cell phone makers may actually know more about these risks than they are letting on or even have evidence for them.

If you look in the small print booklet that comes with your cell phone, cell phone makers state that phones should not be in contact with your body or skin and should be kept a certain distance away when in use or when carrying around. The picture here is exactly how you are NOT supposed to use the cell phone.

For example, in the iPhone 4 small print booklet that comes in the box with the phone, go to page 5 under the section "Exposure to Radio Frequency Energy." I quote:

"When using iPhone near your body for voice calls or for wireless data transmission over a cellular network, keep iPhone at least 15 mm (5/8 inch) away from the body, and only use carrying cases, belt clips, or holders that do not have metal parts and that maintain at least 15 mm (5/8 inch) separation between iPhone and the body."

Now, when I use a phone and answer a call, I have the phone right up against my ear as shown in the picture here. I do not keep it 5/8 inch away from my ear/head.

Now why would a cell phone maker care whether the phone is right up against the ear (so you can hear better) or not unless there is some concern that there may be a danger due to proximity/contact?

Perhaps they are protecting themselves from any possible lawsuit that may occur in the future due to health problems that will occur with phone use over time?

Kind of reminds me of the tobacco industry who for years denied that smoking posed any health risk. Now we know better.

Something to think about...

I should add that most studies to date do not show any definitive long-term harm from using cell phones, though studies following patients for more than 10 years do show an association with brain tumors. The greatest consistent risk is more from contact allergy.

BUT, to be on the safe side, it is recommended to talk on speakerphone or use a wired headset.

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Does the Nose Appearance Change After Septoplasty? (Answer: No)

Septoplasty is a surgical procedure to straighten out a deviated septum causing problems with nasal obstruction/congestion.

A common question I get asked is whether the nose appearance will change after this surgery. The answer is no (if correctly done). In fact, if the nasal appearance DID change afterwards, you would also have undergone rhinoplasty nosejob.

The explanation for why the nasal appearance does not change after septoplasty 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.

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Zyrtec (OTC) and Xyzal (Rx) Contain the SAME Active Ingredient? Prilosec (OTC) and Nexium (Rx) Too!

If zyrtec and xyzal (allergy medications) both contain the same active ingredient (cetirizine), why are they "different" and one is sold over-the-counter (zyrtec) and the other available only by prescription (xyzal)? This is also true for reflux medication prilosec (OTC) and nexium (prescription) which contain the same active ingredient omeprazole.

It's because of mirror images of the same active ingredient molecule... with one being biologically active and the other inactive.

In nature, there is a "doppelganger" of sorts for every protein, compound, molecule, and even drug ingredients. This doppelganger is what is known as a stereoisomer and is an exact mirror image copy of the original. As such, they look the same, but are actually very different, just like a pair of hands. Though both hands appear to be an exact copy of the other, one is left and the other is right and that's why you can't wear a right glove with a left hand.

Still confused? Take a look at the picture below...

The two structures are an EXACT replica of each other with the colored balls in the exact same location relative to each other.

NOW... take a look at this picture below:

The two structures are an exact MIRROR image of each other and though they appear to be the same, the colored balls cannot be overlain on top of each other due to different relative locations.

What does this have to do with medications? Well in nature... ALL living things contain and utilize only the LEFT-handed structure (also known as L-isomer). The right-handed structure (or R-isomer) either is inactive biologically or in some cases, even poisonous. (Rarely, the R-isomer is the biologically effective structure.)

ZYRTEC contains the active ingredient cetirizine, but both the L and R-isomers.
XYZAL also contains the active ingredient cetirizine, but only the biologically active L-isomer.

Same goes for PRILOSEC which contains the active ingredient omeprazole, but both isomer shapes. NEXIUM contains only the L-isomer shape.

Now wait a minute... if you look at the box for NEXIUM, the active ingredient is esomeprazole and not omeprazole. Note that depending on the convention used, L-isomer may be called S-isomer; R-isomer may be called D-isomer. SO... "S"-isomer omeprazole is Nexium. "S"omeprazole sounds like esomeprazole.

Same goes for xyzal which has as it's active ingredient levocetirizine and not cetirizine. "Levo" is latin for left (from laevus). So L-ceterizine when not abbreviated turns into levo-cetirizine.

Sneaky...

Now why in the world would a drug company sell a product that contains an inactive stereoisomer when it is a known fact that only the L-isomers are biologically active?

It's because of money...

A patent on a drug only lasts 10 years. After that, it goes off patent (generic) and other companies can start making and selling it. However, by making and selling a "dirty" version first (containing both L and R-isomers), they can reserve for a later time the "purified" version (L-isomer only) and get another 10 years of patent protection after the dirty version goes off-patent.

So when you see a commercial, read literature, or talk with a sales representative that xyzal is more effective than zyrtec, that nexium is more effective than prilosec... it IS true... but only because xyzal and nexium contain only the purified mirror-image of the active ingredient.

This story is played out over and over again... sometimes with horrific consequences. Most notoriously, there was the drug thalidomide sold in the 1950s...

Thalidomide was a widely prescribed sedative drug which was later found to cause horrible birth defects... well... only the S-isomer caused the birth defects. The R-isomer did not... But guess what? The thalidomide that was sold contained both isomers.

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Are Doctors Required to Obtain Patient Permission For Posting Non-Identifiable X-Rays, CT Scans, Etc Online?

The blunt answer is no... as long as there is no way the patient can be identified by looking at the image. (in other words, anonymous).

Dr. Ves Dimov at CasesBlog has written a very good article regarding this very question and the guidelines used to determine whether patient permission is required or not.

Read his blog article here.

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Bilateral Lateral Hypopharyngocele (Cervical Esophageal Diverticulum)

I recently was asked to review this interesting (and rare) disorder in which a diverticulum or pouch has formed on both sides of a patient's upper esophagus. This condition which I'll call bilateral lateral "hypopharyngocele" is even more rare than Zenker's Diverticulum which is also not very common.

Check out the barium swallow which shows a barbell like image. The "barbell" part is the abnormal pouch and is found on both sides.

A paper was actually written about this condition by Dr. Chang.

Reference:
Bilateral Pharyngoceles (versus Branchial Cleft Anomalies?) and Endoscopic Surgical Considerations. Annals of Otology, Rhinology, & Laryngology. 114(7):529-532, 2005.

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Hotels Offering Hypoallergenic Rooms

Recently, a few hotel chains including Hyatt, Wyndham, and NYLO have introduced hypoallergenic rooms for those suffering from asthma, allergies, or just want a room with a clean breathing environment.

At least for Hyatt, the rooms are called "Respire" and as per their website:

"Respire by Hyatt rooms undergo an additional six-step process to reduce airborne particles and minimize the presence of potential irritants. This process includes installation of a state-of-the-art air purification system and treatment of all fabrics and surfaces in the guestroom. All Respire by Hyatt rooms are installed and maintained on an ongoing basis by PURE Solutions NA.

The Respire by Hyatt – Hypo-Allergenic Rooms purification process includes:

• Application of PURE Shield and PURE Clean to minimize presence of allergens on carpet, upholstery and other surfaces in the room.
• One-time shock treatment to minimize irritants.
• Complete disinfection of Air Handling Unit and Installation of removable tea tree oil cartridge to maintain these conditions.
• Installation of hypo-allergenic mattress & pillow encasings.
• Installation of a powerful air purifier by Healthway, listed as a Class II Medical device by the F.D.A.
• Recertification every six months."

These rooms (regardless of the hotel) are implemented by New York–based company Pure Solutions.

Read more about what exactly is done to these rooms here.

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Large Metal Hook In Person's Head (No Kidding)

An ENT colleague brought this x-ray to my attention. Apparently, there was an accident during which a large hook got embedded in this patient's head.

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Wearable Camcorders for Video-Recording Surgeries From the Surgeon's Viewpoint?

An avid snow-boarder, I had the bright idea of using the ContourHD wearable camcorder I purchased to record snow-boarding runs... to instead video-record surgical cases. This wearable type of video-recording has many advantages over traditional camcorders which requires an assistant to shoot the video.

First, the angle of a wearable camcorder is from the surgeon's viewpoint and has minimal distraction impact. Having an assistant video-recording over the surgeon's shoulder during a surgical case is not ideal on both these points.

Second, the surgeon has complete control over what is being recorded rather than depending on a 3rd party making that decision.

Third, when these wearable cameras are attached... it is incredibly secure. It will NOT fall off accidentally or otherwise. When an assistant is doing the recording... there is always the chance they may drop the camera into a sterile surgical field which would be a disaster. Here is a picture of me with the camcorder attached:

There is also the cost factor... These consumer wearable camcorders are around $275 or less on Amazon.com. Compare that with dedicated surgical headlight camera systems like the MicroLux® DLX by Integra which cost way more.

SO... how well did the ContourHD camcorder work? Not too good...

Unfortunately, the focal length of these camcorders are set to 2 feet to infinity resulting in blurry videos when shooting at closer distances, like dissecting out a parotid tumor (believe me... I tried). These wearable camcorders also are not focus-adjustable.

Hopefully, a manufacturer will address this key shortcoming and make one with either an adjustable focus OR enable the user to swap out the lens set to different focal lengths OR designing an adapter over the built-in lens that would adjust the focal length. Here is a concept of what I have in mind:

It would be pretty cool to record surgical cases with as much "pop" and detail as this snowboarding video (not mine).

Wearable camcorders I am monitoring (hoping) for such innovation that is usable in the operating room theater include ContourHD and GoPro Camera.

There are other wearable camcorders such as the Looxcie which is not as well-suited for recording surgical fields. The main problem with such "social" camcorders like the Looxcie is that it can only record (the previous) 30 second video snippets and is not in HD quality. Read more about Looxcie here.

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Allergy Shots in Britain Require a LONG Waiting Period Afterwards

I recently heard that one reason why allergy shots are rare in England (and why sublingual "under-the-tongue" drops aka SLIT, are so common) is that British patients are required to wait under observation for anaphylaxis as long as ONE HOUR after each and every injection!!!

In fact, initially the waiting period was as long as TWO HOURS when the British Committee for Safety of Medicines became alarmed with some deaths that followed allergy injections in 1986. Subsequently, the safety committee decreed that these injections could only be administered when full equipment to cope with any emergency was at hand and further required that the patient must remain under supervision in the clinic for two hours after the injection. This had the effect of stopping this method of treatment completely, mainly because of the long waiting period.

That's quite a pity especially when considering that allergy shots were first "invented" in 1911 by two British physicians, Drs. Leonard Noon and John Freeman.

Read more about the history of allergy desensitization in England here.

Of note, our clinic provides allergy testing, allergy shots, and under-the-tongue allergy drops. And no... we do not make patients wait 1 hour after an injection.

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Nosebleeds... It's That Time of Year Again!

With the fall season, the air becomes cooler and dryer... Families start turning on the heat which further dries the air leading to a potent environmental situation ideal for nosebleeds.

What can you do to minimize nosebleeds?

Use a humidifier in the bedroom and keep the door closed to prevent the humidity from escaping.

Use a nasal emollient like ponaris. Ponaris is a wonderful product to alleviate the dry, irritated, and sometimes burning sensation in the nose. It is also a great product to treat nosebleeds and nasal crusting. I like to think of Ponaris as chapstick, but made for the nose. To apply, it already comes with an eye-dropper. Just place 1-2 drops for each side of the nose and let it ooze down and coat the entire nasal cavity. Just like chapstick, one can feel the protective barrier for several hours after application. This can be applied up to 4 times a day as needed (just like chapstick). Alternatively, one can convert Ponaris into a nasal spray form instead of using the eye-dropper. Just purchase a saltwater nasal spray bottle over the counter (ie, Ocean Nasal Spray, Ayr Nasal Spray, etc). Empty the saltwater and clean out the nasal spray bottle thoroughly. Than pour the Ponaris bottle into the nasal spray bottle. That's it!

Should nosebleeds persist, make an appointment with an ENT for nasal cauterization consideration. In essence, cauterization burns the culprit bleeding areas inducing scar formation which is less prone to bleeding. Watch the video below on how this is performed.

What should you do if you have a nosebleed? Use PRESSURE!!! In other words, pinch the fleshy bottom part of the nose together firmly for 10 minutes. Not where the bone is. See picture below:

All other methods that your mom may have told you won't really work such as using ice packs, tilting the head in one direction or another, etc. Think of a stab wound... To stop bleeding from a stab wound, you apply direct pressure. You don't add ice packs or raise the wound a certain direction to stop the bleeding.

If all else fails, go to the ER where nasal packing may be performed.

In rare cases, even nasal packing may not work in which case surgery or embolization may be required.

Read more about nosebleeds here.

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Teenager Dies From Tonsillitis

A teenager in the United Kingdom died from an unfortunate missed diagnosis of tonsillitis. Apparently, her primary care doctor thought she had swine flu and was prescribed tamiflu... an anti-viral medication.

For bacterial tonsillitis, treatment is with anti-bacterial antibiotics like amoxicillin, penicillin, etc.

The tonsil infection spread into her blood, seeded her lungs, and eventually caused multi-organ failure and death.

Read the full story here.

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Gaviscon Advance by Reckitt Benckiser

Our office has received a number of inquiries on where one can purchase Gaviscon Advance made by Reckitt Benckiser (not available in the US which only carries the plain Gaviscon without the "advance").

This product, sold in the United Kingdom, is only available through online pharmacies.

The Gaviscon Advance made by Reckitt Benckiser actually maintains a list of online pharmacies that carry this product here:

http://www.gaviscon.co.uk/resources/useful_links.php

Specifically, these online pharmacies are listed:

ExpressChemist
ChemistDirect.co.uk
Pharmacy2U
MyPharmacy.co.uk

Amazon.com occasionally will have some in stock as well.

Please note that this information is provided for patient convenience. Our office does not vouch for nor has confirmed the legitimacy of these online pharmacies. Purchase at your own risk!

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