Thyroidectomy (Thyroid Surgery) Risks

Thyroid removal (either total or only one side) is a common surgery performed by general surgeons as well as ENTs for thyroid cancer or masses suspicious for cancer.

Though I no longer perform this surgery, I often get asked for my opinion regarding this surgery. Rationale for why surgery should be done or not, I leave to others as it would literally take a textbook, especially given the controversy regarding when to observe and when to surgically remove. Back when I WAS performing thyroidectomy, I should state my bias was towards removal... and belief that a needle biopsy is not 100% accurate. Indeed, in certain situations, a needle biopsy (FNA) is at best no better than flip of a coin whether cancer is present (it is wrong 50% of the time!).

In any case, there are several risks involved when this surgery is performed. Other than the typical risks common to all surgeries like infection and the ho-hum bleeding, there are several unique risks specific to thyroid surgery. Let's go over each one:

Windpipe
Given the thyroid is located over the windpipe, the surgeon may accidentally (or deliberately if thyroid cancer is invading the windpipe's wall) enter into the airway. Why may this be a problem? Well, it may cause air to leak into the neck causing it to suddenly swell up and potentially lead to a pneumothorax (collapsed lung) if severe enough. The scary thing is that it could potentially occur days after the surgery though if it is going to happen, it usually occurs within hours after surgery.

Bleeding
Bleeding is ALWAYS a risk of surgery causing a hematoma to form. What makes this particular complication especially concerning is that it often occurs DAYS after surgery. Even more worrisome is that it could lead to death as the hematoma formation can cause significant swelling with resulting airway compression (remember that the thyroid is located over the windpipe). This particular complication unfortunately occurs not uncommonly... and often leads the patient to obtain emergency care in the local ER by a local surgeon to drain/remove the hematoma and stop the bleeding even if the surgery was done by surgeon located an hour or more away. A tracheostomy (a hole in the neck to the windpipe) may need to be performed at this time as well.

Recurrent Laryngeal Nerve Damage
The nerve that allows you to talk is called the recurrent laryngeal nerve. This nerve is RIGHT NEXT to your thyroid gland. As such, it can be damaged or cut resulting in a very breathy sounding voice. Oftentimes, it is temporary. Rarely, BOTH nerves can get cut if undergoing total thyroidectomy causing stridor or airway problems mandating a tracheostomy.

In the event that a patient suffers a vocal cord paralysis from recurrent laryngeal nerve damage, it can be corrected surgically resulting in an almost normal sounding voice. If BOTH vocal cords are paralyzed... well... breathing and talking will be a problem and options are quite limited if this unfortunate complication occurs.

Superior Laryngeal Nerve Damage
With this type of nerve damage, you can talk just fine... but you lose your upper range and falsetto.

Parathyroid Gland Loss

The parathyroid glands are located behind the thyroid gland in the 4 corners as depicted by the golden nuggets seen in the diagram to the right. These glands are very important regulating the calcium levels in the blood. In the devastating event that all 4 parathyroid glands get damaged or removed (as might occur during total or completion thyroidectomy), the patient loses the ability to maintain calcium levels in the blood resulting in cardiac and neurologic problems that could lead to death if not immediately addressed. Even if the parathyroid glands are preserved, if the blood supply to the 4 glands get cut off or damaged by the thyroid surgery, blood calcium levels may deteriorate.

Summary
Thyroid surgery has risks and should be performed by a well-qualified surgeon. However, keep in mind that the best person to take care of you should you experience any surgical complication is the surgeon who actually did the surgery (one of many factors to take into consideration when considering having the surgery done far from home).

References:
Mediastinal emphysema and pneumothorax following thyroidectomy. The Journal of Clinical Endocrinology Vol. 9, No. 10 987-998 doi:10.1210/jcem-9-10-987

Complications of Thyroid Surgery. EMedicine

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ENT Problem at the Biblical Wall of Jericho

Many people may be aware of the Sunday School story regarding the Wall of Jericho in the Bible. In this story, seven priests blew 7 trumpets of rams' horns resulting in the collapse of the wall of Jericho (Joshua 6:4-5) allowing the Israelites to conquer the city.

"4: And seven priests shall bear before the ark seven trumpets of rams' horns: and the seventh day ye shall compass the city seven times, and the priests shall blow with the trumpets. 5: And it shall come to pass, that when they make a long blast with the ram's horn, and when ye hear the sound of the trumpet, all the people shall shout with a great shout; and the wall of the city shall fall down flat, and the people shall ascend up every man straight before him."

Now... from an ENT standpoint, I can imagine the mayhem this weaponized horn sound must have caused not only to the wall of Jericho, but also to the surrounding soldiers and people.

Back than, city walls were constructed of brick and mud. It is entirely possible that a loud enough sound can certainly cause the collapse of this wall, but it would have to be very loud... at least 180dB (decibels) loud.
 
Just how loud is this sound? Well, a motorcycle is 100dB; a jet engine is 140dB. From a human ear standpoint, ear pain starts at 125dB. Permanent hearing loss due to ear tissue death occurs at 180dB... but before ear tissue death occurs, the eardrums will rupture at 160db.
 
Even if the Israelites wore ear plugs and ear muffs (like airplane workers do), it only decreases the sound intensity by 15-45dB. So, the rams' horn sound blast at 180dB would still result in the Israelite soldiers being exposed to 140dB of sound with its attendant ear pain and temporary threshold shift (temporary hearing loss).
 
So... though not expressly reported in the Bible, I'm sure not only did God supply the device causing the fall of Jericho's walls... but also appropriate ear & hearing protection for Joshua and his army.
 
In fact... even if the walls did not fall, its inhabitants certainly would be deaf from ruptured eardrums and hearing nerve death. And if Jericho's army is unable to talk and hear each other, its fighting effectiveness would be pretty much severely compromised.
 
Of note... the United States military utilizes weaponized acoustic devices that produce only 155dB.
 
Lung rupture and presumably embolism due to air blast occur at 200 decibels which can lead to death.
 
If you want to read more about acoustic weapons, click here which will probably provide more info than you ever wanted on this subject.

Of note, I can't take full credit for the idea of this blog post which is based on an episode on NPR Radiolab. The NPR Radiolab episode purely focused on the acoustic physics whereas I've taken the extra step of how it can cause health problems.

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How Does Coblation Work?

Coblation is a unique technology that cuts and stops bleeding simultaneously using radiofrequency plasma technology. This technology is used in many ENT procedures including turbinate reduction, tonsillectomy, adenoidectomy, respiratory papilloma excision, cryptolysis, etc.

The benefit of this technology over cauterization which does the same thing is that coblation occurs near room temperature opposed to cauterization which may produce temperatures exceeding 400 degrees celsius. Such high temperatures with cauterization can cause thermal damage to surrounding normal tissue leading to prolonged healing and swelling.

Watch a video of coblation being used for tonsillectomy and turbinate reduction.

Here's a video I shot using coblation on a piece of chicken to illustrate closely what is happening.

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Pacemaker To Cure Obstructive Sleep Apnea (OSA)?

The Huffington Post on Dec 27, 2010 published a story about a potential new treatment whose goal is  obstructive sleep apnea cure (OSA) cure using a pacemaker made by Inspire Medical... for the tongue. The New York Times also published a similar story more recently about the same device on 1/8/2014.

The device works by stimulating the nerve going to the tongue (hypoglossal nerve) to contract with every breath a person takes while sleeping.

Why would this help? In some patients with severe obstructive sleep apnea, the tongue falls backward against the throat's back wall (tongue prolapse) causing airway obstruction. By stimulating the tongue's nerve, the tongue is stimulated to move forward when a patient takes a breath preventing obstruction.

Of course, this treatment works ONLY if the obstruction is due to tongue prolapse.

There are other treatments that also accomplish the same thing including:

• Base of tongue coblation/reduction
• Geniohyoid advancement
• Repose procedure
• Oral appliance

At least in our office, we only offer the base of tongue reduction to address tongue prolapse that may lead to obstructive sleep apnea.

This pacemaker for the tongue is currently experimental and not available for the general public yet.

Sources:
Sleep Apnea: Experiments Test If Implant Can Block Sleep Problem. Huffington Post 12/27/10

For Sleep Apnea Patients, a Possible Alternative to Masks. NYT 1/8/14

Reference:
Upper-Airway Stimulation for Obstructive Sleep Apnea. New England Journal of Medicine. January 9, 2014DOI: 10.1056/NEJMoa1308659

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Santa Claus, A Sick Patient Needing Medical Care

ENT Journal published in December 2003, a humorous paper on Santa Claus as a patient with numerous medical problems. Given it is Christmas Eve, it is probably worth revisiting the article which lists among his many medical problems:

• Allergies to woodwork (sawdust and varnish) and materials used in preparing teddy bears, dolls, and other gilts.
• Asthma exacerbated by reindeer exposure as well as the hay and straw in the stable which makes his nose run
• His symptoms get worse when he leaves the North Pole where there is no pollen to regions of the Earth where vegetation and pollen are plentiful, especially in the Southern Hemisphere where it is summer.
• Going down chimney's irritates the eyes and his nose resulting in sneezing fits. Probably carcinogenic as well.
• Santa is considerably overweight, and his cheeks appear quite ruddy suggesting high blood pressure.
• Probably has type 2 diabetes exacerbated by milk and cookies left for him in millions of homes.
• He smokes a pipe putting him at increased risk of oral, throat, and lung cancer

Merry Christmas!

Suggest you leave for Santa a glass of water and a low-calorie, low-salt granola bar instead of milk and cookies tonight!

Read the full article here.

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Can Placebo Be Used to Help People Instead of Drugs?

On my way to work On December 23, 2010, I heard a great story on NPR regarding how placebos can potentially be used to help people... EVEN if they know it's a placebo!

Based on research done at Harvard, they found that a placebo helped patients with irritable bowel syndrome 59% of the time compared to a similar group that received nothing. Of greater significance... the treatment group with placebo KNEW they were getting a placebo.

Given that many medications have similar (and even lower) improvement rates, that's quite amazing.

Why does placebo work?

My own personal belief is that this is truly a case of mind over matter.

The human body is literally a pharmaceutical manufacturing company able to naturally produce all sorts of chemical compounds. Pretty much every drug that you can take in pill form, the human body already produces within to some degree. Drugs in essence augments what the body is already able to naturally produce.

The placebo effect is (in my opinion) when the human mind is able to boost the production of the appropriate drugs the body is already able to naturally produce.

The REAL key to improving the human health condition and avoid all the drugs and their potential for side effects is to somehow figure out how to enable the placebo effect on command.

Read the NPR story here.

Reference:
Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome. PLoS One. 2010

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Can Humming Ease Sinus Problems?

Well... according to a recent New York Times article published Dec 20, 2010, the answer is yes...

Apparently, humming can keep air moving through the sinuses and nasal cavity which suggests improved ventilation. Good sinus ventilation means healthy sinuses.

Their conclusion is based on two studies listed under the references below. Unfortunately, the conclusion can't extend to stating humming prevents sinus infections. The only way to evaluate that hypothesis is to do a study comparing two groups of patients with chronic sinus infections and instruct one to hum and the other not to and see if there's any difference in the intervention group over time. Even better would be to do a prospective double-blinded study, but not sure how one can perform a double-blinded study in this case.

Read the NYT article here.

References:
Humming greatly increases nasal nitric oxide. Am J Respir Crit Care Med. 2002 Jul 15;166(2):144-5.

Assessment of nasal and sinus nitric oxide output using single-breath humming exhalations. Eur Respir J. 2003 Aug;22(2):323-9.

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ICD-10 Coding Primer for Otolaryngologists

If you are a physician... you probably already know what I am talking about...

ICD is the "International Statistical Classification of Diseases and Related Health Problems" used by physicians to code a given medical problem whenever a patient sees a doctor. This "code" is what is submitted to insurance companies along with medical charges.

Periodically, ICD undergoes an update and in the United States, it is about to undergo a MAJOR update come October 1, 2013 to version ICD-10-CM. The current ICD being used in the Unites States is ICD-9-CM.

What are these changes as it relates to otolaryngolgists?

First the basics:

Differences in organization & structure, code composition, and level of detail.
ICD-9-CM	ICD-10-CM
Consists of three to five characters First digit is numeric or alpha (E or V) Second, third, fourth, and fifth digits are numeric Always at least three digits Decimal placed after the first three characters	Consists of three to seven characters First digit is alpha All letters used except U Second and third digits are numeric Fourth, fifth, sixth, and seventh digits can be alpha or numeric Decimal placed after the first three characters

ICD-10-CM codes may consist of up to seven digits, with the seventh digit extensions representing visit encounter or sequelae for injuries and external causes.

ICD-9-CM Code Format	ICD-10-CM Code Format

SO... here are some examples of how the code changes from ICD-9-CM to ICD-10-CM:

Diagnosis	ICD-9-CM	ICD-10-CM
Right Earwax	380.4	H61.21
Left Earwax	380.4	H61.22
Bilateral Earwax	380.4	H61.23
Unspec Earwax	380.4	H61.20
Right Acute Otitis Externa	380.1	H60.311
Left Acute Otitis Externa	380.1	H60.312
Bilateral Acute Otitis Externa	380.1	H60.313
Unspec Acute Otitis Externa	380.1	H60.319

As you can see, what used to be a single code like 380.4 for earwax is now split into as many as 4 different codes based on side. Such increased specificity goes across the board for pretty much every diagnosis.

ICD-10-CM has numerous other new features allowing for a greater level of specificity and clinical detail.

• Combination codes for conditions and common symptoms or manifestations
• Combination codes for poisonings and external causes
• Added laterality
• Added extensions for episode of care
• Expanded codes (injury, postoperative complications)
• Expanded detail relevant to ambulatory and managed care encounters
• Changes in timeframes specified in certain codes
• External cause codes no longer a supplementary classification

ICD-10-CM also includes added standard definitions for two types of excludes notes. Excludes1 indicates not coded here. The code being excluded is never used with the code. The two conditions cannot occur together. For example, B06 Rubella [German measles] has an Excludes1 of congenital rubella (P35.0).

Excludes2 indicates not included here. The excluded condition is not part of the condition represented by the code. It is acceptable to use both codes together if the patient has both conditions. For example, J04.0, Acute laryngitis has an Excludes2 of chronic laryngitis (J37.0).

An additional feature is the expansion of codes for certain conditions like postoperative complication codes. Here's one if you accidentally leave behind a neuro paddy in the nose after sinus surgery causing nasal obstruction:

• T81.524 codes for "obstruction due to foreign body accidently left in body following endoscopic examination"

Code extensions (seventh character) have been added for injuries and external causes to identify the encounter: initial, subsequent, or sequela. The extensions are:

• A Initial encounter
• D Subsequent encounter
• S Sequelae

So that's a primer on how ICD-10-CM coding WILL affect otolaryngologists. A lot more time will be spent on coding than now.

The American Academy of Family Physicians has produced a superbill comparing ICD-9 and ICD-10. What took only 2 pages with ICD-9 will take up 9 pages once ICD-10 goes into effect. Sigh!

Click for ICD-9 and ICD-10 Superbill

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Google Body Browser (Google Maps of the Human Body)

Google released a new "map" so to speak of the human body. In the same spirit and controls as the venerable Google Earth, Google Body Browser allows a user to zoom in and out as well as pan across the human body. Here is a window capture of a session when I was checking it out.

Currently, this internet-based program only works with Google Chrome which you can download for free here.

Access Body Browser here after you have Google Chrome installed.

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Robotic Surgery for Oral Cancer

I encountered these amazing pictures in the Archives of Otolaryngology-Head & Neck Surgery Dec 2010 edition in an article titled "Transoral Robotic-Assisted Surgery for Head and Neck Squamous Cell Carcinoma". This surgery was performed at Mayo Clinic as well as University of Alabama.

Of note, there are also some YouTube videos of robotic surgery for thyroidectomy you can watch below or here.

Reference:
Transoral Robotic-Assisted Surgery for Head and Neck Squamous Cell Carcinoma. Archives of Otolaryngol Head Neck Surg 136(12):1248-1252; 2010

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Patient Experience Just As Important As Clinical Expertise

I read with great interest an article in the New York Times "How Does Your Hospital Room Make You Feel?" regarding how a patient room... how a hospital appears... private rooms... may play just as important a role in where a patient goes for treatment as the clinical expertise of its doctors.

Indeed, amenities are a critical part of the patient experience and possibly even a more valuable component of patient-centered care as reported in the New England Journal of Medicine. A patient’s nonclinical experience inspires clinical productivity, drives improved clinical outcomes, and improves overall patient satisfaction.

Not that such reports are a big surprise. It's something I think all major non-healthcare corporations have already realized for decades. Just walk into any Abercrombie & Fitch or Toyota car showroom. Such businesses hit all of our senses to the 10th degree... There's the visual stimulation of models (human or otherwise). Popular music playing in the background to stimulate the ears. Lovely perfume smells in a clothing store or fresh leather in a car showroom to stimulate the nose. And oh yes... freshly baked cookies or candies to bring some zing to the taste buds.

How can you NOT like what you see/hear/taste/smell??? And, buy some things along the way given you have been stimulated into such a good mood?

Indeed, it's surprising why hospitals weren't the FIRST institutions to maximize the senses to bring peace to mind/body/soul and... to also provide medical treatment.

SO... it is with great satisfaction that our practice is affiliated with a hospital that subscribes to the importance of these non-clinical factors. Fauquier Hospital has:

• Private patient hospital rooms
• Family and friends can drop by any time, day or middle of the night
• Food that's actually good
• Patient friendly architectural features including:

• built-in sleeping accommodations for family members
• carpeted corridors and additional windows
• lamps have replaced overhead lighting
• halls have been carpeted to keep down noise or are finished in faux wood for a warmer feel
• community artwork hangs on the walls
• barriers between patients and staff, such as those sliding-glass windows that close nurses off from patients and the public, have been removed
• elevators for patients and the public are separate
• no constant paging over the intercom system, either; instead, unobtrusive music plays all the time.

• Also, a culture fostering patient care is presented.

Come check out Fauquier Hospital here!

Read the NYT article here.

Read the New England Journal of Medicine Article here.

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Dr. Chris Chang Mentioned in a Medical Blog

Dr. Chris Chang and his blog was mentioned in an article in another medical blog "Dr. John M" on December 14, 2010.

"---One of the best ways to know something well is to teach it. Dr Chris Chang from the blog of the Fauquir ENT Consultants of Virginia writes about why he keeps a blog. His first reason is that it keeps him highly informed. No doubt about that. Could we bloggers get some CME credit, please?"

 Click here to read the whole story!

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New Video on Septoplasty to Correct Nasal Obstruction Due to a Deviated Septum

A new video has been created and uploaded onto our YouTube channel depicting how a deviated septum causing nasal obstruction is corrected by a septoplasty surgery.

Watch the video below or on our YouTube channel.

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Has Evidence-Based Medicine Gone Too Far?

Although there is no question that evidence-based medicine is a very important development in the evolution towards higher quality healthcare, the demand for evidence for a given treatment can go too far.
The following abstract is an ACTUAL published article in the British Medical Journal describing the lack of evidence that parachutes are effective when falling out of a plane.

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.Smith GC, Pell JP (2003) BMJ. 327 (7429), 1459-61.

Objectives To determine whether parachutes are effective in preventing major trauma related to gravitational challenge.
Design Systematic review of randomised controlled trials.
Data sources: Medline, Web of Science, Embase, and the Cochrane Library databases; appropriate internet sites and citation lists.
Study selection:  Studies showing the effects of using a parachute during free fall.
Main outcome measure: Death or major trauma, defined as an injury severity score > 15.
Results We were unable to identify any randomised controlled trials of parachute intervention.
Conclusions As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.

Read the full text article here.

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Dr. House Video Clip Illustrating Doctor-Patient Communication Problems

In this classic video clip, Dr. House interviews a patient with asthma. Their interaction illustrates the problem of communication between doctor and patient that unfortunately too often occurs.

Errors in doctor-patient communication as shown by this video clip:

• Doctors assume that patients know how to use medications (or understand treatments) when they don't.
• Patients assume that they know how to use medications (or understand treatments) even if they don't.
• Doctors can be intimidated by patients who appear to know/understand their medical treatments when they truly don't.
• Patients can feel insulted when a doctor assumes they don't know how to use medications (or understand treatments) when they shouldn't because they really don't.

I feel Dr. House perfectly handled this particular situation... though it is unclear what he said AFTER the patient demonstrated how she uses inhalers.

Watch the video on YouTube here.

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Different Types of Immunotherapy for Allergy Cure

Most people are already familiar with allergy shots and even sublingual (under the tongue) allergy drops as treatment to try and achieve cure (or tolerance) to the things they are allergic to.

However, there are other forms of immunotherapy that may one day provide just as good if not better allergy cure rates. These include (most currently under research):

- Intra-Lymphatic Injections (ILIT): Rather than weekly shots in the arm, one research paper reported only 3 injections into a groin lymph node over 2 months provided equivalent results to allergy shots in the arm after 3 years!

- Allergy Tablets: Potentially in the next year or 2, tablets may become available to treat certain allergies. Grazax by Merck which treats grass allergy is the first which is currently undergoing FDA approval.

- Epicutaneous immunotherapy (EPIT) involves lightly scraping a patient’s skin and then applying a patch that delivers the allergens through the bloodstream.

- Intra-Nasal Spray: Declared effective and safe by WHO.

- Bronchial Inhalers: Marginal effectiveness and risky.

At this time, our office only provides allergy shots and allergy drops.

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Can A Person Have Allergies Even if Allergy Testing Comes Back Negative?

YES!!! But how can that be?!! Well, here is the simplified answer. When allergy testing is performed whether by skin prick or blood testing (RAST), one is testing to certain specific proteins known to cause allergic reactions in majority but not all patients (these are called major allergen).

Patients need to remember that for a given allergy like CAT (or tree, mold, dust, etc)... there are millions of proteins (minor allergen) that have the potential to cause an allergic reaction in people. Allergy testing to cat ONLY tests for ONE of these proteins called Fel d1 as well as a few other minor allergens. As such, if a patient is CAT allergic, but not to the Fel d1 protein, then the allergy testing will come back normal!

Given this information, that's why skin testing is a bit more "accurate" when it comes to determining whether a patient has allergies or not as there are more "proteins" for a given allergen like CAT being tested than the blood test like RAST which STRICTLY tests for a single protein.

Of course, it is possible that a patient may TRULY not have any allergies. So, how can a person tell? Look at the total IgE serum levels. If it is high, than you most likely have allergies even if everything comes back negative.

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Will.i.am Suffers From Tinnitus

And yet another celebrity reports suffering from bad tinnitus or ringing of the ears. Black Eyed Peas' Will.i.am spoke with Britain's the Sun stating that the only time it doesn't bother him is when there's loud music. Read the news report here.

Prevention is by far the best way to avoid suffering from this debilitating condition. How does one prevent this problem? Protect your ears from loud noises!!! Wear ear plugs if loud noise exposure is unavoidable.

Unfortunately for Will.i.am who is a hip-hop star with the Black Eyed Peas, his tinnitus is likely due to loud noise exposure from his music... an unfortunate job hazard of his profession.

If you are a musician and loud noise exposure is unavoidable, get Musician's Ear Plugs through our office which can help reduce noise exposure while maintaining music fidelity.

If you already have tinnitus, click here for more info on treatment options.

Read the news report here.

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Extremely Discounted Blood Tests for Cash-Paying or Uninsured Patients

Through the cooperation of Summit County Medical Society, LabCorp, and PrePaidLab, patients are now able to get lab tests done for a small fraction of the normal cost via the medial society website. Anyone near a LabCorp location nationwide is able to use this website to obtain the same low-cost blood tests.

For example, a lipid panel (cholesterol test) can cost as much as $148 for an uninsured person. The same test is available for less than $18 through the site.

Here are the steps to take:
1) Click here and choose the tests your doctor says you need.
2) Give the doctor's fax number, pay with a credit card, and print out the order.
3) Take the order to any LabCorp location in 47 states and have the work done.
4) Results are sent securely to the patient and the doctor, often within 24 hours.

Sound too good to be true? It really is true.

Read about this amazing offer on a news report from CNN here.

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Physician Marketing Using Groupon

For those not in the know, Groupon is a website that offers coupons and other savings on local merchandise and services. Groupon also has recently rejected a takeover bid by Google.

I recently encountered this amazing deal on Groupon offered by an ENT colleague, Dr. Ghaheri:

"$149 for Four Laser Hair-Removal Treatments at The Center for Aesthetic Medicine at The Oregon Clinic (Up to $1,000 Value)"

I wonder if such marketing and medical discount offerings like this will become the future. Clearly, procedures and other types of medical treatments that are not covered by insurance will be applicable.

For example... here are some medical treatments/services I am considering to discount on Groupon:

1) Injection snoreplasty for snoring
2) Botox injections for facial wrinkles
3) Hearing services and products including hearing aids
etc

Click here to check out Groupon and create an account!

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Strange But True Allergies People Suffer From (Sex, Kissing, Water, etc)

As shown on CBS news here, these things can cause an allergic reaction in the rare unfortunate individual:

1) Water can cause hives in some people (aquagenic urticaria)
2) Sunlight
3) Kissing (a person has recently eaten a food substance that the person being kissed is allergic too)
4) Sex (some women are allergic to seminal fluid)
5) Hops and barley can cause an allergic reaction
6) Low temperatures
7) Cell phones (due to Nickle content)
8) Pressure (too tight a belt, necktie, bra, etc)
9) Chocolate
10) Exercise (cholinergic urticaria)
11) Vibration (dental drill, lawn-mower, jackhammer, etc)
12) Allergy medications (or more precisely, the additives found within allergy medications)

See your local allergist if you suspect you have this!

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What Makes A Great Surgeon or Doctor?

Or for that matter, a great violinist? As many psychologists suggest (regardless of whether one is talking about sports, music, painting, astronomy, physics, etc), it entails:

1. Focused practice (at least 10,000 hours according to many)
2. Good coaching
3. Great role model to provide motivation

Does this apply to surgeons or doctors? I believe it absolutely does. 

Any person who puts in enough good training hours under the tutelage of a great teacher with a great role model to aspire to can become a more than competent physician. And as any highly trained professional can attest to, it requires continued training and practice to stay on top of one's game. As Vladimir Horowitz, a premiere concert pianist, once said, "If I skip practice for one day, I notice. If I skip practice for two days, my wife notices. If I skip practice for three days, the world notices."

How does this compare to a surgeon's training and professional career? To use myself as an example, while at Duke where I received 5 years of training to become a head and neck surgeon, I averaged about 110 hours of work training per week during my first 2 out of 5 years. In the last 3 years, I probably averaged around 90 hours a week for a grand total of 25,480 hours of training before I graduated and came to Northern Virginia to be in private practice. During that 5 years of training, I performed nearly 3,000 surgical cases under a master surgeon before graduating. Furthermore, I had plenty of role models at Duke for me to try to aspire towards. A "goal" so to speak, of the kind of surgeon I wanted to become.

A similar experience can be found for all physicians and doctors who go through the American medical training system.

Even after training, physician education is not completed... In fact, it never ends. Indeed, physicians are required to continue to receive education from master instructors, journals, or other text every year (Continuing Medical Education or CME) as well as undergo regular testing to ensure their knowledge is current and comprehensive.

(NOTE: Enforced around year 2005, physicians in training are now required to work no more than 80 hours per week. The number of years of training has remained the same. At this time, it is unclear whether this decrease in training hours has significantly impacted physician training in the United States or not.)

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New Video On Performing a Tracheostomy

A new video on performing a surgical tracheostomy has been created by our office and uploaded onto our YouTube channel. Watch the video here or below!

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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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