ENT Practices and Physicians Who Twitter...

Did you know Fauquier ENT maintains one of the most comprehensive list of ENT physicians who twitter and are otherwise involved with social media not only in the United States, but in the world?

Check out the full list here. There are 76 and growing!

If you are an ENT practice or ENT physician not on the list, please let me know by DM @FauquierENT and I'll add you!

If you are a resident in otolaryngology, feel free to let me know as well.

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At Home Laser Hair Removal That Works

Without going into TOO much detail of how I know this... I have personally observed that the TRIA Laser Home Removal System does work after observing its use and its effects over a 6 month period of time. And before anybody asks... no... I was not paid to write this nor did I get a free one to try. Rather, someone I am close to bought it off Amazon.com and I was a skeptic on-looker.

In any case, the caveat being that I know it works (admittedly anecdotal) as long as the hair is dark (ideally black or brown) on very light colored skin (ideally white).

The way laser hair removal works is that the laser beam is selectively absorbed by the hair follicle causing its death and destruction while preserving other skin structures. As such, the hair follicle needs to be as "different" a color to the skin around it in order for the laser to work. Otherwise, you end up burning the skin as well as the follicle. Depending on the laser used, different colored hair can be targeted on different colored skin. Because of this, the same laser can NOT be used for everybody.

In any case... back to the TRIA. This laser system ideally works best on dark colored hair on light colored skin. The greater the difference, the better it works; the best being black hair on white skin. In fact, the TRIA can't be used at all if you don't have the right hair/skin color combination (TRIA requires a skin check every time before use... unless you "pass," the device will not work).

There are only a few real differences between this laser system and that used in medical offices. 

The TRIA's head is about 1/4 inch in size. The medical-grade laser head can be one inch or larger in size. What that means practically is that if you are using the TRIA for your leg, it'll take a long time and a lot of zaps due to the large surface area.

Also, the TRIA can only be used for about 15 minutes on the highest power before it shuts off for 2 reasons: It "overheats" and needs to cool down or runs out of battery and needs to be recharged. On that last point, you can only use it on battery power (which I suspect is due to safety reasons). After letting it cool/recharge overnight, it is ready to use again by the next day.

Medical-grade lasers do not have these limitations.

Finally, for those technically inclined, the TRIA uses a pulsed diode laser (same as a medical grade laser) with five intensity settings. The highest fluence available is 22 with a wavelength of 810nm, which is lower than what is available from a laser used in the clinic.

Regardless of medical-grade laser hair removal or TRIA, it does require repetitive sessions as the laser only kills follicles that are in the growth phase. Unfortunately, hair are in different phases at any given moment (there are 3 phases) and as such, it may take numerous sessions spaced 1-2 weeks apart over a few months before all hair follicles have entered into the growth phase and thus be able to be amenable to death by laser.

And unlike brain cells... hair follicles CAN come back from the dead and start producing hair again. Hard to say when or why this happens, but is likely due to hormonal factors. 

Overall, however, the TRIA can save you a lot of money (compared to getting it done by a physician) if you have the following characteristics:

1) Dark hair

2) Light skin

3) Patience (small laser head on large surface area takes a long time as well as the fact that a single session may need to be broken up over a few days due to device needing to recharge or cool overnight after about 15 minutes of use)

4) High pain threshold (even with a small head... it does hurt. And because it is a small head, there's a lot more zaps to cover the same surface area)

You can buy it on Amazon.com here.

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American Idol Laryngitis Scare for Lauren Alaina

On May 24, 2011, US Magazine reported that American Idol Finalist Lauren Alaina "blew a vocal cord during afternoon rehearsal" and apparently completely lost her voice (aphonia).

Apparently, a doctor on set and ordered Lauren not to sing or speak which brought a very real possibility that she would not be able to perform that evening. Fortunately, "emergency" care was provided along with resting the voice and apparently sang quite well that night.

Without benefit of having examined Lauren's voice or being told what the exact emergency care that was provided, I have an idea of what might have happened and what care might have been provided.

Usually in the event of a sudden loss of voice during extreme voice use, it does suggest a blood vessel that might have ruptured. Blood vessel formation in the vocal cords is not unusual in the setting of heavy vocal use as shown in the picture to the left (normal is shown above for comparison). However, vasculature presence in the vocal cords is not a great situation as it does lead to a bit of unpredictability of how the vocal cords will perform in any given moment. Why? Because the vessel(s) may fluctuate in size leading to unintended pitch variation and at worst, raspiness. If you consider the vocal cord analagous to a violin string, a blood vessel is like adding the ability of the violin string to fluctuate in size.

In any case, once blood vessels are significantly present, the singer often has to continuously adjust the voice to achieve consistency in vocal quality. Often this leads to changes in vocal technique and even increased exertion in order to produce a consistent "good" voice.

However, with increased exertion to achieve that "good" voice, further irritation of the vocal cord vasculature may occur to the point it may rupture leading to a sudden loss of voice which is often accompanied with some transient pain. Here is a picture of what her vocal cord might have looked like after vessel rupture.

At this point, a few things can be done to try and resolve this situation as quickly as possible. By resting the voice, you reduce the repetitive trauma to the vocal cords that may further exacerbate bleeding into the vocal cord.

High dose steroids can be administered to reduce the inflammatory reaction to the vocal cord lining as well as swelling that is bound to happen.

Improvement can happen within hours... HOWEVER, injury is still present and vocal rest is mandatory to complete the healing process. Otherwise there is potential for permanent vocal cord injury that may require surgical intervention.



If you listen carefully to Lauren Alaina's voice right before her performance in this video, you can hear a slight rasp to her voice especially when saying the word "fine" indicative of a persistent vocal cord injury. I believe that if she sang a song containing  passages requiring a very quiet upper-range pitch, her voice would have sounded quite bad. As it is... by singing loudly, she would be able to "power" past any vocal cord imperfections. Indeed, she "beat" her laryngitis, though she'll have to be careful in the days to weeks after her performance.

Read the US Magazine article here.

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The Vocal Problems of Professional Singers

The Washington Post on May 20, 2011 published a great article on the travails of opera singers regarding their vocal cords and the stresses placed on them (the singers and their vocal cords).

The opera singer (as well as any other professional singer) are the Olympic athletes of the voice.  As such, peak performance is mandatory in order to sustain a successful career. Just as an Olympic sprinter measures their success in milliseconds... the professional singer is judged by the most minute inflections, variances, irregularities of their voice. Never mind the back-biting and gossip.

99.9% is not good enough in this cut-throat world when anything less than 100% perfection is considered failure.

As such, the demands placed on the vocal cords are tremendous and rather than pulled hamstrings of a world-class sprinter, vocal cord swelling let alone nodules or muscle tension dysphonia can cut a career short.

Push the voice too hard... and they can get damaged, especially when vocal technique gets sacrificed to perform pieces beyond appropriate range (and even ability). Even professional opera singers have vocal instructors and coaches... a point I regularly make with amateur singers with injured vocal cords when they argue against the necessity of voice therapy and singing lessons ("I already know how to sing!").

Read the Washington Post story here.

I did want to point out that there was one error in the story...

Near the end of the story, it is stated that Giuseppe Filanoti had thyroid surgery. Although this can affect the voice, it is NOT vocal cord surgery as reported.

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Saline Nasal Flush - Mayo Clinic Video

Ever since our office produced one of the first videos on saline nasal flushes back in December 5, 2007, there have a been a number of additional videos created by medical offices and companies ever since.

The most recent is Mayo Clinic which you can watch here.



Here's our video we made back in 2007.

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Patients with Iodine or Seafood Allergy CAN Receive Contrast During CT Scans

It is a prevalent belief out in the medical (and lay public) community that patients with iodine or seafood allergy can not receive contrast when undergoing certain radiological tests like CT or MRI scans. The concern is that contrast contains minute amounts of free iodide and as such, IV administration of this material puts the patient at risk of a life-threatening anaphylactic reaction.

Contrast is often given in these tests as it traces out bloodflow enabling the physician to see organ and mass architecture much more clearly allowing for improved accuracy in seeing anything abnormal.

Well... rest assured that patients with iodine and seafood allergy CAN receive contrast without any significant increased risk of an allergic reaction as compared to other allergies.

In a large study encompassing 112,003 patients, only 5% had a reaction. The relative risk of a reaction in patients with seafood allergy was 3.0 compared with 2.9 for those with allergy to eggs, milk, or chocolate; 2.6 for those with allergy to fruit and strawberries; and 2.2 for those with asthma [7]. In other words, a seafood allergy increases the risk of a contrast reaction by about the same factor as does any other allergy. At least 85% of patients with seafood allergy receiving IV contrast material will not have an adverse reaction.

Reference:
Formation of potential antigens from radiographic contrast media. Acta Radiol 1987; 28:473-77
Immunologic basis for adverse reactions to radiographic contrast media. Acta Radial 1990; 31:605-612
Contrast media reactions: experimental evidence against the allergy theory. Br J Radiol 1984;57: 469-173
Adverse reactions to intravascularly administered contrast media. AJR 1975;24: 145-152

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Burning Tongue or Mouth Syndrome Due to Magnesium Deficiency?

Patients with burning mouth syndrome (BMS) have two major findings: one, burning sensations in their mouth and two, no anatomical changes present in their mouth to relate to this burning.

Dr. Henkin and colleagues at the Center for Molecular Nutrition and Sensory Disorders have clinically distinguished two major groups of patients with BMS. One group has burning limited only to their tongue – called GLOSSOPYROSIS. The other group has burning in their entire mouth, including their tongue, lips, palette, gums and pharynx – called OROPYROSIS. They have recently been able to distinguish these two patient groups biochemically.

Patients with GLOSSOPYROSIS have lower levels of magnesium in their red blood cells (erythrocytes) than do patients with OROPYROSIS or normal subjects.

Patients with GLOSSOPYROSIS have lower levels of magnesium in their parotid saliva than do patients with OROPYROSIS or normal subjects.

However, serum levels of magnesium and serum erythrocyte and saliva levels of calcium are similar in patients with GLOSSOPYROSIS, OROPYROSIS or in normal subjects.

These results suggest that patients with GLOSSOPYROSIS are magnesium deficient.

These findings does suggest magnesium supplementation to reverse the magnesium deficiency may be of benefit in patients with GLOSSOPYROSIS.

Courtesy of Dr. Robert Henkin of the Center for Molecular Nutrition and Sensory Disorders.

Reference:
Biochemical differences in parotid saliva distinguish patients with glossopyrosis from those with oropyrosis: Are there also neurochemical differences? The FASEB Journal. 2011;25:857.4

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Study Suggests (Incorrectly?) Steroid Nasal Spray Use Does Not Help with Eustachian Tube Dysfunction

In the May 2011 edition of Archives of Otolaryngology-Head & Neck Surgery, a study was published on a randomized, placebo-controlled, double-blind prospective clinical trial (the best kind of research) to determine whether Nasacort AQ steroid nasal spray can resolve eustachian tube dysfunction as well as ear symptoms related to this disorder. Eustachian tube dysfunction at its mildest would cause symptoms of ear clogging much akin to the way the ears fill up when flying or driving up the mountain. At its worst, can lead to fluid buildup in the ear as well as chronic ear infections.

In the study population of 91 patients, they found that use of a steroid nasal spray did NOT help...

HOWEVER, after reading the paper, there is a major flaw to how the study was conducted which would significantly affect study outcomes. Mainly, how the nasal spray is used would strongly affect whether it will help or not.

According to the paper, patients were instructed to simply administer "2 metered sprays in each nostril once daily (55 µg per spray)..."

Nothing else.

Unfortunately, this type of administration is bound to fail, mainly because using a nasal spray in this manner is inadequate when addressing eustachian tube dysfunction.

First of all, the eustachian tube openings are at 90 degrees to the face, so the steroid nasal spray bottle needs to be directed towards the back of the head and not towards the eye. This needs to be specifically mentioned/demonstrated as it is not intuitive for most patients (and even doctors). The first picture is INCORRECT! The second picture is correct use. Read more here why directionality is important.

Second, a valsalva maneuver (blow air out the nose while keeping the nares pinched) must be performed after nasal spray administration in order to force the nasal spray medicine up into the eustachian tubes in order for the medication to affect the region of concern. Without a valsalva, the nasal spray medicine sits in the nasal cavity which would help with sinus problems, but not the ears which is the area of complaint. Valsalva needs to be done regularly throughout the day during treatment.

Why is this maneuver important? It's like pouring draino (steroid nasal spray) into a clogged toilet, but than not using a plunger (valsalva maneuver).

In any case, there are other studies that have found steroid nasal sprays to be helpful for eustachian tube dysfunction as listed under references.

Read more about eustachian tube dysfunction here.

References:
Management of Eustachian Tube Dysfunction With Nasal Steroid Spray. Arch Otolaryngol Head Neck Surg. 2011;137(5):449-455. doi:10.1001/archoto.2011.56

The role of topical nasal steroids in the treatment of children with otitis media with effusion and/or adenoid hypertrophy. Int J Pediatr Otorhinolaryngol. 2006;70(4):639-645.

Oral or topical nasal steroids for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev. 2006 Jul 19;3:CD001935.

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What is Considered a Normal Number of Reflux Episodes?

Depending on whether one is talking about GERD (gastroesophageal reflux disease) or LPR (layrngopharyngeal reflux), I believe the answer is completely different.

As it pertains to GERD and what literature, doctor, or testing equipment is used, 73 plus or minus some change is what is considered a normal number of reflux episodes a typical adult may experience in a 24 hour period of time.

What exactly does this number mean? This number describes how many times stuff in the stomach regurgitates up into the esophagus which is the tube that carries food down to the stomach after food is swallowed.

The reason why heartburn is not initially experienced is because the lining of the esophagus has a protective layer preventing acid damage. However, once the number of reflux episodes goes higher than 80, the protective layer breaks down and acid damage starts to occur leading to typical symptoms of heartburn and/or chest pain.

Now what about laryngopharyngeal reflux (LPR)?

I would argue that even ONE episode is not normal if symptomatic. (Also see references below.)

LPR is when stomach contents regurgitate up to the level of the voicebox. At its most basic limited definition, LPR is a near-vomit (vomit being stomach contents that reach the mouth level and beyond). The only difference between LPR and vomit is the volume of regurgitation and location it reaches.

When such regurgitation reaches the voicebox level, a number of symptoms occur, even if it happens one single time.

First, when LPR occurs, the throat feels phlegmy leading the patient to throat-clear the mucus up and out or to re-swallow.

Second, when enough LPR episodes occur, the mucosal lining of the voicebox region starts to get irritated that may lead to a chronic cough. At its worst, it may lead to vocal cord dysfunction and even laryngospasm. Some episodes may even be aspirated into the lungs leading to bronchitis and reactive airway disease.

Third, the sphincter (upper esophageal sphincter) that separates the esophagus from the voicebox may start to tighten which is the body's way of attempting to prevent further reflux from reaching the voicebox. Such muscle tightening may lead to symptoms of difficulty swallowing with food getting stuck at the voicebox level as well as lump in throat sensation (globus).

Heartburn is not very common with LPR (though it may occur) as one needs to remember that there is a protective barrier preventing acid damage to the mucosal lining.

Also, non-acid reflux may be present rather than acid reflux. With non-acid reflux, heartburn symptoms are not as common due to lack of acid presence that would lead to damage (though other factors are present including bile, enzymes, etc).

Given even a single episode of LPR can be considered abnormal if symptomatic, many studies will come back NORMAL due to timing. A barium swallow typically does not take more than a few minutes to perform done during business hours. Same goes for upper endoscopy. BUT... what if the few episodes of LPR occur in the evening or early morning NOT when the studies are performed?

As such, what I consider the BEST study to evaluate for LPR is a 24 hour multi-channel pH and impedance testing. This test looks for reflux during a continuous 24 hour period of time. If it sees reflux, it records what time, how long it lasts for, how high does the reflux go up, what the pH level is, etc. BRAVO or single or dual-probe pH studies are inadequate as they measure ONLY whether acid GERD is occurring or not. These alternative tests can not evaluate for LPR or non-acid reflux.

BOTTOM LINE

With GERD, up to around 73 episodes of reflux is considered normal.

With LPR, even a single episode can be considered abnormal if symptomatic. Check out references below.

Watch a video I made below showing a patient who is experiencing a non-acid LPR episode during an examination. This patient had a normal upper endoscopy, normal pH study, and normal barium swallow. Look at all the frothy mucus that is bubbling up to and around his voicebox leading to his complaint of phelgmy throat and chronic cough/throat-clearing. Treatment was surgery (nissen fundoplication).

References:

How much pharyngeal exposure is "normal"? Normative data for laryngopharyngeal reflux events using hypopharyngeal multichannel intraluminal impedance (HMII). J Gastrointest Surg. 2012 Jan;16(1):16-24; discussion 24-5. Epub 2011 Oct 28.

Gastroesophageal and laryngopharyngeal reflux detected by 24-hour combined impedance and pH monitoring in healthy Chinese volunteers. J Dig Dis. 2011 Jun;12(3):173-80. doi: 10.1111/j.1751-2980.2011.00502.x.

The importance of the number of reflux episodes in the diagnosis of laryngopharyngeal reflux disease. Otolaryngol Head Neck Surg. 2013 Feb;148(2):261-6. doi: 10.1177/0194599812466534. Epub 2012 Nov 2.

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New and Only Over-The-Counter Anti-Histamine Nasal Spray

Up until now, there has been three anti-histamine nasal sprays in the United States market available only by prescription... Astelin, Astepro, and Patanase.

However, in May 2011, Meda Pharma announced a new anti-histamine nasal spray Rhinolast Allergy that is available over-the-counter.

The active ingredient is azelastine, the same one as found in the prescription nasal spray Astelin and Astepro.

Azelastine has a triple mode of action: anti-histamine effect, m,ast-cell stabilizing effect, and anti-inflammatory effect. Azelastine has a rapid onset of action of 15 minutes.

It can be used from the age of 5 years.

This nasal spray can be used in combination with other over-the-counter anti-histamines medications taken orally like zyrtec, claritin, allegra, and benadryl.

Read more about this new nasal spray here.

Read more about allergy medications in general here.

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