Vocal Cord Botox Injections to Treat Asthma???

Yup... It's true...

A clinical trial is under way in Australia to see if botox injections to the vocal cords can improve the shortness of breath some asthmatics have. Though nobody disputes that asthma is a pulmonary problem, it is not uncommon that the vocal cords in asthmatics may be dysfunctional exacerbating the breathing problem.

What is meant by dysfunctional? It's when the vocal cords come together when the person is trying to breath. It is also known as paradoxical vocal cord motion, vocal cord dysfunction, or laryngospasm at its worst. Read more here.

Botox injections will paralyze the vocal cord muscles preventing the vocal cords from coming together thereby allowing easier airflow into the lungs... or at least that's the hope. This procedure is commonly performed in patients suffering from spasmodic dysphonia and the technique used to treat these patients would be the same as that proposed for asthmatics. Watch a video here on how this is performed.

What's the downside? Aspiration, breathy voice, and trouble swallowing are common but temporary side effects. Problem is if aspiration occurs in a patient with significant pulmonary compromise, it can potentially be devastating leading to asthma exacerbation and even pneumonia.

Read a news article regarding this clinical trial here.

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Miss USA Beauty Pageant's Take on the Theory of Evolution

I was quite disheartened to see only a small minority of contestants fully supportive of evolution. In fact some outright stated evolution is wrong.

The Miss USA pageant was recently held on June 19, 2011.

Hear the answers...

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Xylitol (Natural Compound) to Prevent Recurrent Sinus and Ear Infections?

Image by Lauri Andler from Wikipedia

I only recently became aware of a natural sugar compound called "Xylitol" from a colleague's blog, BoogorDoctor, managed by Dr. Russell Faust. I certainly have never heard of it during medical school or surgical training.

This naturally-occurring sugar substitute apparently has all sorts of anti-bacterial as well as anti-fungal properties and has been known to doctors and scientists but hardly marketed or promoted in any fashion.

However, the importance of this compound is that it DOES appear to significantly decrease the incidence of ear infections and sinus infections when used regularly (in essence, xylitol mixed in with salt-water sprayed into the nose several times a day). See references below for links to research papers.

It's cheap, over-the-counter and at least from the studies I've reviewed, does seem to work. However, to be fair, it only works when given regularly even if healthy. If given when sick, it does not work (see this study). Also to be fair, there are some studies that suggest that xylitol does NOT work at all.

However, given there are minimal (if any) side effects and safe for kids, it is certainly something worth trying before surgical consideration, especially in children.

Why is this compound not more well-known?

Probably because it's cheap and therefore not a money-maker... which means not a lot of dollars goes into marketing the product whether directly to patients or doctors.

In any case, you can get it on Amazon.com here (or possibly at a local pharmacy).

I should also mention that Xlear is the only product series that uses the optimal concentration xylitol (others use only the bare minimum concentration to meet ingredient inclusion).




References:
A Story About a Sugar: The X-Factor. Blog by Dr. Faust

Xylitol as a prophylaxis for acute otitis media: systematic review. Int J Audiol. 2010 Oct;49(10):754-61.

A novel use of xylitol sugar in preventing acute otitis media. Pediatrics. 1998 Oct;102(4 Pt 1):879-84.

Xylitol chewing gum in prevention of acute otitis media: double blind randomised trial. BMJ. 1996 Nov 9;313(7066):1180-4.

Failure of xylitol given three times a day for preventing acute otitis media. Pediatr Infect Dis J. 2007 May;26(5):423-7.

Xylitol administered only during respiratory infections failed to prevent acute otitis media. Pediatrics. 2002 Feb;109(2):E19.

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Why Are You Looking in My Mouth When It's My Ear Hurting?

One June 20, 2011, NPR aired a great story about how a person may not "see" a person getting beat up on the side of a jogging path when they are focused on a task (pursuing another jogger)... even if they pass RIGHT BY THE FIGHT!!!

In fact, only a third of the subjects reported seeing this mock fight when the experiment was conducted at night. Even more surprisingly, broad daylight didn't improve the statistics (only 40% noticed the fight).

Though the situation and circumstances do not exactly correspond, there is a lesson to be learned here that applies to a medical visit.

As an ENT, I often see patients for a very specific complaint...

"My right ear hurts."
"I have a bad cough."

No matter what the complaint, unless it is for a specific task (there is earwax... can you remove it), I most always still do a complete ear, nose, and throat exam no matter the complaint.

Why???

Because often the symptoms are "the jogger" in the example above which is noticed to all exclusion when "the fight" is the more important event that should have been noticed.

Let's go to the examples stated above...

"My right ear hurts."

Though a patient may wonder why the heck I look in the mouth when their ear is the main complaint, it's mainly because there are other things that can cause ear pain... some of it life-threatening.

Tonsil cancer can cause ear pain (without any other symptoms) as well as a base of tongue abscess. Obviously, giving antibiotics to treat the right ear pain totally misses the fact that there was tonsil cancer that got missed or the tongue abscess which requires an emergency trip to the operating room followed by a few days in the intensive care unit.

"I have a bad cough."

This statement is pretty self-explanatory. Why bother looking in the ears??? A loose hair in the ear canal can cause a persistent dry cough. Why look in the nose if the cough is coming from the throat? Severe allergies and nasal polyps can lead to post-nasal drainage leading to a chronic cough. Why would an ENT than ask about my blood pressure medications? Because ACE inhibitors like lisinopril cause a chronic dry cough as a side effect.

The point being with these examples is that medical doctors are trained to not just focus in the exact symptom the patient is complaining of, but the entire picture. It doesn't do the patient any good if a doctor gets tunnel-visioned to the point where they don't notice what may be a very obvious thyroid mass or the large nasal polyp.

SO... next time you see a doctor for a specific complaint, humor us, and answer fully all questions about your medical history, surgical history, medications you are taking, and the physical exam we will perform on you... even if you are there for just a "simple" earache.

Read the NPR story here and the police beating that triggered this inattention experiment.

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Dr. Chang Quoted in Nationally Circulated Monthly Magazine

In the June 2011 edition of the American Academy of Otolaryngology-Head & Neck Surgery monthly magazine (AAO-HNS Bulletin) delivered nationally to otolaryngologists, Dr. Chris Chang was quoted for a story published on page 43 in an article titled "Technology Offers Physicians Opportunity, Peril".

In the article, Dr. Chang discusses use of social media including Twitter, Facebook, Blog, and YouTube.

Click on the image to read the article.

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Spit Analysis Can Reveal Person's Age

There are certain compounds in a person's spit that can reveal their age to within 5 years. No kidding. There are certain things we know about DNA. We know that DNA gets methylated (like ornaments on a Christmas tree). We also know that the methylation pattern on the DNA changes with age. So the hypothesis was whether looking at the methylation pattern of the DNA can reveal a person's age? And guess what... it does according to a recently published study.

In this study published on PLoS ONE, researchers studied the saliva of identical twins to figure out what sites appeared to correlate best with age. They narrowed it down to 88 DNA methylation sites that seemed to correlate with age. Based on these 88 sites, they than verified it in 60 men and women, ages 18 to 70, and found that two genes in particular had the strongest age correlation to within 5 years. Amazing!

This finding can certainly help with crime-fighting, but also has potential for spit being a marker for all sorts of other biological problems that have yet to be discovered (perhaps even replace painful needle sticks for blood draws). After all, if a person's spit can reveal their age, who knows what else it can reveal about the person!

Reference:
Epigenetic Predictor of Age. PLoS ONE 6(6): e14821. doi:10.1371/journal.pone.0014821

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Steroid and Anti-Histamine All-In-One Nasal Spray!

Meda Pharmaceuticals has announced a new nasal spray "Dymista" that contains both a steroid and an anti-histamine active ingredient. Why is this significant? It's because it's the first and only one to do so. Of course, it's not available yet until the FDA approves it, but at least it has shown effectiveness in Phase 3 clinical trials.

At this time, nasal sprays as it relates to nasal allergies come in two separate flavors:

1) Steroid Nasal Spray (flonase, nasonex, nasacort, rhinocort, veramyst, omnaris, etc, etc)
2) Anti-Histamine Nasal Spray (patanase, astepro, astelin)

This new combo nasal spray "Dymista" contains fluticasone and azelastine. Fluticasone is a steroid that is also found in flonase nasal spray whereas azelastine is an anti-histamine also found in astepro and astelin nasal sprays.

Clinical trials in the past have shown that using a steroid nasal spray and an anti-histamine nasal spray was more effective than using one or the other individually.

Similarly, Dymista has also been found to be better than either nasal spray alone, but with the convenience of using a single nasal spray.

Look for it in the near future! Let's just hope insurance will cover it however.

Read the press release here.

Reference:
Onset of Action of MP29-02 in the Treatment of Seasonal Allergic Rhinitis. J Allergy Clin Immunol 2011; 127; 2; Abstracts 199

MP29-02 in the Treatment of Nasal Symptoms of Seasonal Allergic Rhinitis. J Allergy Clin Immunol 2011; 127; 2; Abstracts 199

Combination therapy with azelastine hydrochloride nasal spray and fluticasone propionate nasal spray in the treatment of patients with seasonal allergic rhinitis. Annals of Allergy, Asthma and Immunology, 2008, vol. 100, no. 1, pp. 74 - 81.

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Kids Exposed to Fido or Fluffy in the First Year of Life Decreases Risk of Becoming Allergic to Them

There have been a number of studies in the past investigating whether it is healthy for a baby to be around pets and whether such exposure increases or decreases risk of becoming allergic to them later in life.

In a recent study (published online June 2011), the researchers found that among males, those with an indoor dog during the first year of life had half the risk of becoming allergic to dogs at age 18 compared with those who did not have an indoor dog in the first year of life regardless whether born by C-section or vaginally. Also, teens with an indoor cat in the first year of life also had a decreased risk of becoming allergic to cats. Neither cumulative exposure nor exposure at any other particular age was associated with either outcome. So it appears that the FIRST year of life is key to whether a child develops pet allergies or not.

Although in this study, cat and dog ownership appears to be beneficial in kids, prior studies have suggested that for at least cats, it increases risk of overall allergies in children by 13 times! Dog exposure, however, reduces overall allergy by 4 times.

Reference:
Lifetime dog and cat exposure and dog- and cat-specific sensitization at age 18 years. Clinical & Experimental Allergy Volume 41, Issue 7, pages 979–986, July 2011

Genetic and environmental risk factors for childhood eczema development and allergic sensitization in the CCAAPS cohort. J Invest Dermatol. 2010 Feb;130(2):430-7. Epub 2009 Sep 17

Opposing Effects of Cat and Dog Ownership and Allergic Sensitization on Eczema in an Atopic Birth Cohort. J Pediatr. 2011 Feb;158(2):265-71.e1-5.

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Innovative Research to Treat Tonsil Stones by Dr. Chris Chang Accepted for Publication

There are some unfortunate individuals who suffer from an annoying problem called tonsil stones. This aggravating problem is when the tonsils produce tiny stones that extrude into the mouth resulting in chronic bad breath and throat discomfort. When it does pop out into the mouth, the stone itself tastes terrible. For many individuals, this may occur every few weeks. In others, it can happen on a daily basis causing significant quality of life issues.

In the past, there has been only 3 ways to address this problem:

1) Conservative management with gargles and manual expression (kind of like popping a pimple, but it's the tonsil)

2) Tonsillectomy (no tonsils to produce the stones than)

3) Laser cryptolysis (a laser beam is used to obliterate the tonsil surface causing the crypts and holes where tonsils stones are produced to disappear)

However, there are disadvantages to each of these different methods. For tonsillectomy, the pain during recovery is excruciating and can last up to 3+ weeks. Also, the surgery has to be performed under general anesthesia. Laser cryptolysis is rarely performed mainly because of the risks associated with laser use (eye damage, facial and lip burns, bleeding, etc).

As such, Dr. Chang has developed a new technique that minimizes the drawbacks with these methods called coblation cryptolysis. Pain does not typically last more than 1 week and does not have any of the risks associated with laser use. Furthermore, it can be done without any sedation. Only local anesthesia is used. Watch video on how this procedure is performed.

His technique and findings has been accepted for publication in ENT Journal.

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Speech Therapy Found to be of NO Benefit for Spasmodic Dysphonia

A recent study was published that has found that speech therapy had minimal if any significant beneficial effect on spasmodic dysphonia (a spastic vocal disorder) in a study cohort of 31 patients.

The study was divided in 3 patient treatment groups:

- One-third received no further intervention after botox injection which is considered standard of care in the treatment of spasmodic dysphonia
- One-third received a standard 5-week course of voice therapy after botox injection
- One-third received a 5-week course of sham voice therapy after botox injection

All patients regardless of treatment group experienced improved voice quality in response to botox injection.

However, patients who received voice therapy after botox injection did not experience longer injection effect duration or significantly greater improvements in vocal quality than patients in botox only or botox plus sham therapy groups.

Theoretically, it was felt that speech therapy could help reduce any muscle tension dysphonia that is often present in patients suffering from spasmodic dysphonia. However, this study does bring into question whether this actually happens.... or if botox alone eliminates the trigger and therefore the abnormal compensatory behavior making therapy unnecessary.

However, given the small study group size, more research is required to truly determine whether speech therapy has a role or not in the treatment of spasmodic dysphonia.

That said, voice therapy is THE main way to treat muscle tension dysphonia.


Reference:
Combined Modality Treatment of Adductor Spasmodic Dysphonia. J Voice. 2011 Feb 2. [Epub ahead of print]

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Dr. Chang to Give Lecture on Spasmodic Dysphonia in Richmond, VA

Dr. Christopher Chang will be a guest lecturer on the topic of spasmodic dysphonia in Richmond, VA on June 11, 2011. Dr. Chang was invited to give a 3 hour long talk to the Central Virginia SD Group at the CJW Medical Center Johnston-Willis Campus in the Board Room starting at 12PM.

Dr. Chang is a Yale and Duke trained, board-certified otolaryngology-head and neck surgeon with fellowship training in laryngology. He is considered an expert on spasmodic dysphonia and has patients coming from as far as the Philippines (yes... the one on the other side of the world) every 3-6 months to receive treatment for this rare condition.

Read more about this condition here.

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Books on voice therapy that MIGHT be a useful ADJUNCT to botox injections:

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Sleep Apnea Can Turn Your Child Into a School Bully

Image courtesy of Grant Cochrane / FreeDigitalPhotos.net

This statement is supported by a published study indicating that poor sleep, whatever the cause, can be a factor leading a child to bully or display other aggressive behaviors. Among 341 kids who were evaluated, 23% had conduct problems. Of these kids with conduct issues compared to those without, a significant number had symptoms suggestive of a sleep disorder indicated by sleepiness scoring as well as snoring.
It is already known that the prefrontal cortex governs social behavior which is also influenced by sleep. As such, poor sleep can deleteriously influence the brain leading to behavior problems.

Of course, there are other factors that can contribute to sleep problems as well as bullying... such as an unstable family as well as too much technological stimulation (cell phone, internet, television, etc).

As such, as with most things, more study is needed.

But here's my two cents... Applying some common sense here, ask anybody who has pulled an all-nighter whether they are grouchy the next day and I bet you most will say "of course, no duh"!

Well, here's a study that supports that! (No duh!)

All kidding aside, if a child is having behavior issues, it may behoove the parents to see if obstructive sleep apnea is present which would lead to poor sleep quality. At least for kids, obstructive sleep apnea can be addressed surgically by removing the tonsils and adenoids leading to markedly improved sleep quality (and hopefully improved behavior as well!).

Reference:
Aggressive behavior, bullying, snoring, and sleepiness in schoolchildren. Sleep Med. 2011 May 25. [Epub ahead of print]

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What Exactly Does a Generic Drug Mean (Opposed to Brand Name)?

Some patients are very confused by what the difference between a generic drug versus brand name drug is.

From the patient perspective, they are thinking, how in the world can the same drug be called different things?

Doctors answer by talking about active ingredients, patents, and copays which sometimes confuses patients even more. Well, here's to set the record straight using an analogy.

So let's talk about orange juice.

I consider Tropicana Orange Juice a brand name "drug".

The "active ingredient" in Tropicana Orange Juice is the fruit "orange".

A generic drug equivalent to Tropicana Orange Juice is Target (or other supermarket name) Orange Juice.

They both contain the same active ingredient of oranges, but the name is different.

The generic orange juice is also always cheaper.

Now, some people do not feel there is any difference between the brand name Tropicana and the supermarket branded generic orange juice, but some people insist that Tropicana tastes better and is healthier as it is not made from concentrate.

Others say that in the end, it really is the same because the active ingredient of oranges is the same.

Same controversy and arguments for orange juices also apply to drugs.

Hopefully, people understand the difference between brand name and generic equivalent drugs a little better now.

Personally, I feel if generic drugs work for you, save your money and stick with it rather than a brand name drug.

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Anti-Histamine Eye Drops

Allergies often cause eye symptoms of itching, swelling, redness, and tearing.

If other allergy symptoms are also present involving the nose and skin, it is best to try an oral anti-histamine as a first step.

This one oral drug may be able to resolve all these symptoms. As I am fond of telling patients, oral medications affect the whole body as the medication goes to the stomach after swallow, gets digested, and spreads to the big toe just as much as the skin, nose, and eyes.

However, if symptoms are limited to just the eye, it is best to use topical medications like eye drops rather than an oral medication which goes everywhere (where it is not needed).

There are in essence two anti-histamine eye drops available over-the-counter.

The first is the combination of naphazoline and pheniramine found in NaphCon-A and Visine-A (formerly called Ocuhist). Naphazoline is a decongestant that helps eliminate the red eyes whereas pheniramine is an anti-histamine to help eliminate itching. It can be used up to 4X per day for relief.

The other contains the active ingredient ketotifen and has 3 modes of action: anti-histamine, mast cell stabilizer, and eosinophil inhibition. All three actions in essence help resolve current as well as future allergy eye symptoms. It's also why it can be used only twice a day opposed to 4X per day required with naphazoline/pheniramine.

There are three main brands of ketotifen that basically are the same thing:

- Zaditor

- Alaway

- Zyrtec Eye Drops

- Claritin Eye Drops

The "zyrtec" and "claritin" eye drops names are quite misleading in that the eye drops do NOT contain the same ingredient as that found in the oral medication by the same name.

Personally, I prefer ketotifen over naphazoline/pheniramine due to longer-lasting relief per use, 2X per day dosing, and less risk (glaucoma and hypertension specifically). Ketotifen can be used from the age of 3 years (age 6 years for the other).

Of course, if these eye drops don't work, there are prescription antihistamine eye drops that work quite well including pataday/patanol (olopatadine), bepreve (bepotastine),  and lastacaft (alcaftadine). Of course, most insurance companies require trial of OTC eye drops first before they will authorize these prescriptions.

On a final note, there is one steroid nasal spray called Veramyst that has an FDA indication for eye allergies though I suspect all steroid nasal sprays can help similarly. As such, if a patient has only ocular and nasal allergy symptoms, it may be worth trying a steroid nasal spray, though I'm not sure how often this is practiced in reality.

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Steroid Inhalers for Asthma Can Cause Fungal Laryngitis

It is a big bummer to be an asthmatic. Not only is breathing a problem, but even the treatment for asthma can cause problems.

Take for example steroid inhalers like advair, symbicort, fluticasone, etc.

All asthma patients know to rinse their mouth out after inhaler use due to risk of oral thrush, but what about from the back of the mouth down to the vocal cords??? This nether region can't be gargled very easily. One can swallow water to rinse this area out, but the vocal cord region would still not be addressed (otherwise aspiration would occur).

And that leads to potential vocal problems... like fungal laryngitis (or thrush of the voicebox). Here's a picture of what that looks like. To compare, normal is shown in the smaller picture.

Note the white patches indicative of fungal growth. This fungal infection can lead to symptoms of a mild (if any) sore throat, but most patients complain of hoarseness as their only symptom.

Treatment is ideally to stop the steroid inhaler triggering the infection, but if an asthmatic needs it... than they need it. As I often tell patients, breathing is more important than voice. Often, anti-fungal medications like diflucan and nystatin can eliminate the fungal laryngitis, but problem is, as long as steroid inhalers are used, it comes right back. And repetitive anti-fungal treatment can place the patient at risk for a drug-resistant fungal infection.

So what to do???

There is one type of little-known (unpleasant) treatment an asthmatic patient can perform to minimize risk of fungal laryngitis while still maintaining steroid inhaler use.

It's called laryngeal washes and it takes a lot of time, patience, and period of discomfort. Think of it as gargling of the voicebox.

The patient takes a curved luer-lock cannula (picture shown) attached to a syringe filled with salt-water. While opening the mouth and sticking the tongue out, the curved end of the cannula is directed such that the end is pointed straight down into the throat. After taking a deep breath in, while saying "ah", salt-water is dripped down into the throat thereby "gargling" the voicebox. Coughing may be inevitable after performing.

This needs to be done after every steroid inhaler use. Or during an active fungal infection, at least 4 times per day.

Gagging is the biggest problem preventing correct usage of this technique. Coordinating the injection while saying "ah" is another issue since if it is incorrectly performed, can lead to aspiration and severe coughing. As such, it is not for everyone.

One can purchase such "luer-lock laryngeal cannulas" from any ENT medical supply company.

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