Reflux (Acid, Non-Acid, Mixed Types) in Neonates & How It May Also Apply to Adults

A study was published this month in the journal Pediatric Research which described reflux characteristics in neonates, but the findings can certainly be applied to adults as well.

What I found gratifying about this study was not so much that reflux was evaluated, but what measurements obtained by 24 hour pH-impedance were taken which apply just as much to adults as neonates. Just exactly what was measured and what did the study find (at least in neonates suspected of having reflux)?

• Only 54% of reflux events was associated with symptoms

• Defined by physical characteristics of reflux events:

• 51.3% were liquid
• 29.1% were gas
• 19.6% were mixed

• Defined by chemical characteristics of the reflux events:

• 48.5% were acidic
• 51.5% were non-acidic

• Defined by how high the reflux traveled away from the stomach:

• 79.2% reached the throat/mouth level
• 20.8% stayed in the chest level

Although these findings are specific for neonates, adults experience similar problems, though precise numbers are probably different and need more study.

Laryngopharyngeal reflux is when reflux reaches the throat level. Depending on the chemical characteristics of the reflux (acid vs non-acid as well as how high it goes), the symptoms may be quite variable. NON-acid reflux is considered "silent" and patients may not experience any symptoms of heartburn. Rather, common symptoms include:

• Phlegmy throat
• Chronic cough
• Swollen sensation in the throat (globus)
• Chronic throat-clearing

These results point out another issue... Common medications used to treat reflux (zantac, pepcid, nexium, prilosec, prevacid, etc) only treats ACID reflux. Not NON-acid reflux.

As such, other modalities must be pursued to address symptomatic non-acid reflux beyond medications involving lifestyle changes including diet as well as surgery.

Whether it be babies or adults, characterization of the spatial-temporal-physical-chemical nature of reflux events as defined by pH-impedance methods offers the best chance of evaluating and treating symptoms due to reflux.

Or in more simplistic terms...

NOT ALL REFLUX IS ACID!!!

NOT ALL REFLUX CAUSES HEARTBURN!!!

Reference:
Significance of gastroesophageal refluxate in relation to physical, chemical, and spatiotemporal characteristics in symptomatic intensive care unit neonates. Pediatr Res. 2011 Aug;70(2):192-8.

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Novel Treatment for Glue Ear?

Glue ear is the layman's term for thick mucoid effusion of the middle ear, usually due to chronic ear infections.

The fluid itself is like maple syrup and usually treated with ear tube placement followed by suctioning as much of the fluid out as possible. However, given there is always some residual present, antibiotic ear drops with steroids is often prescribed.

Unfortunately, these patients are at higher risk of requiring repeated sets of tubes after the body spits them out.

Why?

Because of a phenomenon called biofilms... Think of it as teflon armour made of slime for infections. You can put antibiotics and steroids on it, but they kind of just slip off. Such biofilms make infections nearly 1000 times LESS susceptible to medications. In order to truly eradicate the biofilm (and underlying "hidden" infection), you either have to "scrape" it off which is not possible in the middle ear or use very high concentrations of antibiotics... much greater than that obtained using oral or IV antibiotics.

Though ear drops containing high concentrations of antibiotics are possible, the drops tend to come out of the ear just as easily as they go in preventing prolonged and enduring contact.

That's were the recent innovation comes in...

Scientists in England have developed a biodegradable antibiotic "pellet" that can be inserted into the middle ear during surgery where it will slowly release high concentrations of antibiotics to target any infections present (active or inactive) over 3 weeks continuously. Furthermore, the pellet contains N-acetylcysteine which effectively breaks apart the biofilm.

In essence, this pellet is like an armour-piercing bullet.

Of course, it is not available in the US yet... nor is it FDA approved.

Read more about this here.

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Nebulizer Treatment for Chronic Sinusitis

Many people are already aware of nebulizer treatments to help with breathing during asthma attacks and other pulmonary conditions.

What many people may not be aware of is that such nebulizer treatments can also potentially be used for chronic sinus infections. One of the best known company offering such treatment is Sinus Dynamics.

Using one of several different nebulizers, compounded liquid medications (antibiotics and/or steroids) selected by the physician are nebulized/atomized which the patient than breathes into the nasal passages. The small size of the particles allow medication to theoretically move through the tiniest of sinus openings directly onto the infected tissue. Treatments are quick generally lasting 3 – 5 minutes (depending on medication and device). Here's a video demonstrating how it is used.



Sinus Dynamics™ specifically is contracted by over 14,000 insurance companies across the nation, which means that most patients are able to receive their treatment for little to no cost out of pocket.

Most ENT doctors are already familiar with this product.

Personally, I prescribe this mode of treatment for the particularly difficult sinus infection that has not responded to oral antibiotics and sinus surgery. The major advantage of such a device is not only the fact that it is topical, but much stronger antibiotics can be prescribed that otherwise would be toxic if given orally. Furthermore, more than one medication can be administered simultaneously (for example, a steroid, tetracycline antibiotic, and ceftazidime antibiotic).

Typically, I require a culture with sensitivities to determine what medication would be optimal for this mode of treatment. Another requirement is prior sinus surgery given studies showing greater effectiveness of the delivery system.

Once cultures are obtained and a determination of the optimal medication to treat, a prescription is faxed to the company who will than take care of the insurance coverage and than ship the device and medication(s) to you. The normal turn-around time is less than 1 week depending on the prescription.

An instructional video is included with the prescription as well as customer service representatives via phone to walk through the first treatment if needed.

Of course, sinus nebulizer treatment is not the only topical treatment than can be provided.

Other topical sinus treatments which may be just as effective if not more include saline flushes containing medications (which can be compounded by any willing pharmacy) as well as application of antibiotic ointments directly into the sinus cavity (which is performed by the ENT under endoscopic guidance).

It is up to your ENT physician to determine what is the best course of treatment based on your history, endoscopic sinus evaluation, culture results, CT scans, and response to prior medical regimens.

It should also be noted that there have been several studies performed suggesting such nebulizer treatment for sinus infections to be ineffective. However, it certainly is worth trying when all else has failed (or insurance has denied other treatment protocols).

References:
Nebulized antibiotics for the treatment of refractory bacterial chronic rhinosinusitis. Ann Pharmacother. 2011 Jun;45(6):798-802. Epub 2011 Jun 7.

Current concepts in topical therapy for chronic sinonasal disease. J Otolaryngol Head Neck Surg. 2010 Jun;39(3):217-31.

A prospective controlled trial of pulsed nasal nebulizer in maximally dissected cadavers. Am J Rhinol. 2008 Jul-Aug;22(4):390-4.

Nebulized bacitracin/colimycin: a treatment option in recalcitrant chronic rhinosinusitis with Staphylococcus aureus? A double-blind, randomized, placebo-controlled, cross-over pilot study. Rhinology. 2008 Jun;46(2):92-8.

Deposition of aerosolized particles in the maxillary sinuses before and after endoscopic sinus surgery. Am J Rhinol. 2007 Mar-Apr;21(2):196-7.

Comparison of topical medication delivery systems after sinus surgery. Laryngoscope. 2004 Feb;114(2):201-4.

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New Video on Esophageal Manometry and 24 Hour Multi-Channel pH and Impedance Testing

Our office has created a new video describing what a patient goes through when they undergo esophageal manometry as well as 24 hour multi-channel pH and impedance testing.

This test is often ordered when a patient is suspected to be suffering from reflux, whether acid or non-acid, or is possibly suffering from abnormal muscle activity of the esophagus.

Symptoms that a patient may experience that may lead to such testing include:

- phlegmy throat
- lump sensation in the throat
- chronic throat clearing
- chronic cough
- difficulty swallowing

Watch the video here!

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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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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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Whooping Cough Video by Mayo Clinic

Chronic cough that lasts for months?

Coughing that occurs in groupings to point where vomiting occurs? Loses breath?

You may have whooping cough... Check out this video from the Mayo Clinic.

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Baby Shampoo Used to Treat Chronic Sinusitis

Yes... It's absolutely true! There's even research on this (limited).

The mixture ratio is 1/2 teaspoon of Johnsons No-Tears Baby Shampoo in 8 ounces of saltwater rinsed into the nose using a sinus rinse bottle can help with chronic sinusitis, especially when there's a lot of crusting present and to which all other therapies have failed to resolve.

The shampoo appears to work via several mechanisms theoretically:

1) It is directly toxic to germs
2) The soap action helps break apart crusting (similarly to the way detergent gets rid of mud from a kid's shirt in the washer)
3) The soap also helps break down and remove biofilms in the sinus cavities which tends to resist antibiotics and cause recurrent sinus infections (just like dishwasher fluid gets filmy food residue off plates)

For saline flushes, the NeilMed Sinus Rinse bottle is recommended for two reasons.

The black cap of the bottle is about 1 teaspoon... and the bottle itself is 8 ounces.

So, for the particularly difficult chronic sinusitis infection patient who has tons of crusting for which all other treatments have failed, the saltwater is made up as per routine using the NeilMed Sinus Rinse bottle, but than to also add 1/2 capful of the Johnson's No-Tears Baby Shampoo as well before use.

They are to flush their nose twice a day for a few weeks.

Reference:
Baby shampoo nasal irrigations for the symptomatic post-functional endoscopic sinus surgery patient. Am J Rhinol. 2008 Jan-Feb;22(1):34-7.

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NPR on Endoscopic Sinus Surgery

NPR published a story on Oct 4, 2010 describing endoscopic sinus surgery using image guidance. The NPR story is actually quite balanced with accurate portrayal of what sinus surgery can or can't do.

Just like in the NPR story, our office performs the same high-definition endoscopic sinus surgery using BrainLAB image guidance (which provides the real-time 3-dimenstional guidance).

Prior to sinus surgery, a patient must fail medical management first (unless nasal masses like polyps are found) including allergy control.

Read the NPR story here.

Read more about sinus surgery here.

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Dr. Chang Blog Article Re-Published on KevinMD

One of Dr. Chang's blog article on laryngeal sensory neuropathy as a potential cause of chronic cough 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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New Reason for Chronic Cough... Playing the Trombone!

NPR published a story on Sept 8, 2010 regarding a trombone player whose chronic cough for over 15 years was ultimately found to be due to a mold called fusarium as well as mycobacterium (cousin to TB) found growing inside his trombone. Each time he inhaled while playing the trombone, these germs inside his trombone was causing an allergic reaction, which led to hypersensitivity pneumonitis, a severe inflammation of the lungs.

The doctor who figured out the problem went on to investigate other wind/brass instruments of other players and found them all contaminated with germs. His results have been published in the journal Chest.

Though the NPR story was on this particular trombone player (whose cough improved once he started cleaning his instrument regularly), the problem is NOT new...

Here's a report on a saxophone player.

There is also this one company called MaestroMD that claims to help with musical instrument sterilization.

This issue was so concerning in Massachusetts, that a law is being passed to require sterilization of musical instruments in schools! Read more here.

I even wrote a blog article about this problem back in January 7, 2010.

In any case, how does the trombone player featured in the NPR story now clean his instrument? He uses a rod with a cloth and alcohol — rubbing alcohol or isopropyl alcohol which he pours down into his instrument after playing.

References:
Trombone Player's Lung: A Probable New Cause of Hypersensitivity Pneumonitis. Chest. 2010 Sep;138(3):754-6.

Hypersensitivity Pneumonitis Due to Molds in a Saxophone Player. CHEST September 2010 vol. 138 no. 3 724-726.

A microbiological survey into the presence of clnically significant bacteria in the mouthpieces and internal surfaces of woodwind and brass musical instruments.

Horn with nasty microbes.

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Laryngeal Sensory Neuropathy (LSN) Chronic Cough Treatment Failure

Laryngeal sensory neuropathy (LSN) is a recently described condition felt to cause a chronic cough in patients when treatment for everything else (allergies, asthma, reflux, etc) has been evaluated and managed. Treatment for this condition is with neuropathic medications including neurontin, elavil, lyrica, nortriptyline, etc.

In the past few months, I have seen a few patients referred to me with chronic cough treated with these medications with minimal or no improvement. OR... the cough initially improved with such medications, but than over time, stopped working.

All these patients reportedly had a full workup with everything being normal and as such, was diagnosed with LSN. These patients were being solely treated with neuropathic medications and nothing else.

On review of their old records, it became apparent to me that these unfortunate patients actually suffered from MULTIPLE causes of cough that was not being treated. A common condition missed or not treated in these patients was non-acid reflux which can only be diagnosed on 24 hour multichannel impedance testing. Another more common scenario was the presence of mild acid reflux and allergies based on minimal reactivity on allergy testing and reflux that was present, but within normal range on 24 hour testing. Medications for allergies and reflux were tried, but didn't help and so was stopped. (Of note, none of the patients (prior to cough) ever had symptoms of reflux or allergies.)

WRONG!!! Treatment for both should have continued and very aggressively. Why?

Patients need to keep in mind that it is not unusual that a patient may have SEVERAL factors of cough as well, ALL of which need to be treated in order to resolve a persistent cough. Because laryngeal sensory neuropathy results in a hypersensitized larynx, problems with reflux and allergies which ordinarily would not cause a cough (or any other symptoms) in normal patients, will now cause a persistent cough. (This situation is even applicable in patients who have NEVER had any symptoms of allergies and reflux in the past.) In other words, though allergy testing may reveal only mild allergies and 24 hour pH study may show reflux episodes within normal range, these "mild" problems now need to be treated aggressively along with the neuropathy. To reiterate... laryngeal sensory neuropathy is a hypersensitized larynx. In this hypersensitized state, even a little bit of reflux or allergies will trigger a cough which normally would not. Each and every one of these conditions need to be treated aggressively to cure a persistent chronic cough.

The lack of treatment for each and every known cause of cough (even if mild) is the most common reason why treatment of laryngeal sensory neuropathy fails with neuropathic medication.

Case Report:

To illustrate, here is one case I saw a few months back...

Middle-aged patient who has had a chronic cough for about 15 years. Had a full workup done and found to have mild allergies to only alternaria mold (class 1) and dust (class 2). He did not respond to allergy medications and so these meds were stopped. Reflux workup did show significant reflux and so underwent nissen fundoplication which did help the cough by about 30%. His doctor than diagnosed him with LSN and tried him on a variety of neuropathic medication with some, but incomplete improvement. I was than asked to help figure things out.

The first thing I did was to instruct the patient to continue with the neuropathic medication that seemed to work the best for him (elavil 50mg twice a day). I also started the patient on allergy shots as well as an antihistamine and steroid nasal spray. I repeated a 24 hour pH and impedance testing to see if there was STILL reflux going on in spite of the reflux surgery. Lo and behold, there WAS both acid and non-acid reflux occurring, but on the high end of normal (much better than before his surgery). Based on this result, I restarted him on reflux medications daily.

Within 3 months, his cough completely resolved. I slowly tapered the elavil off. Once we both were convinced that his LSN was cured, the daily reflux medication was stopped and used only as needed. Allergy shots could have been stopped as well, but patient elected to continue them, but he no longer needed the daily allergy medications.

SO... what happened?

This patient apparently had allergies, reflux, and laryngeal sensory neuropathy causing his cough. Given he was being treated for only LSN prior to seeing me, that was why he had incomplete improvement of his cough.

I aggressively treated for all 3 factors of his cough. The mild allergies and reflux were brought under tight control preventing them from constantly (even if mildly) irritating his hypersensitized voicebox. Once his voicebox was in an "clean" environment, it was able to heal and desensitize with elavil. Once the voicebox was returned to a normal state, the reflux and allergy was now able to be treated like any other normal person.

The key thing to remember is that patients with LSN belong to a totally different sub-population of patients with a cough. One can NOT treat them as if they are part of the normal population. "Normal ranges" of reflux and allergies do not apply which actually makes sense if one realizes the voicebox in patients with LSN is hypersensitized.

What if EVERYTHING truly did come back normal?

There are 2 things I've done in this situation where there's absolutely no evidence for any abnormalities on any testing, mild or otherwise.

Botox injections to the thyroarytenoid muscle of the voicebox (similarly for spasmodic dysphonia treatment).

OR

Starting combo therapy using two different neuropathic medications, each of which seemed to help singly.


To read more about chronic cough due to LSN, click here.

Of note, SELSAP is a promising test to evaluate for laryngeal sensory neuropathy.

References

• Management of Recurrent Laryngeal Sensory Neuropathic Symptoms. Norris BK, Schweinfurth JM. Ann Otol Rhinol Laryngol. 2010; 119:188-191. Link
• Chronic cough as a sign of laryngeal sensory neuropathy: diagnosis and treatment. Lee B, Woo P. Ann Otol Rhinol Laryngol. 2005 Apr;114(4):253-7. Link
• Gabapentin in the Treatment of Intractable Idiopathic Chronic Cough. Mintz S, Lee JK. Am J Med. 2006; 119(5):e13-15. Link
• Laryngeal Neuropathy as a Cause of Chronic Intractable Cough. Mishriki YY. Am J Med. 2006; 119(5):e5. Link
• Sensory neuropathic cough: a common and treatable cause of chronic cough. Bastian RW, Vaidya AM, Delsupehe KG. Otolaryngol Head Neck Surg. 2006 Jul;135(1):17-21. Link
• Effectiveness of amitriptyline versus cough suppressants in the treatment of chronic cough resulting from postviral vagal neuropathy. 2006. Jeyakumar A, Brickman TM, Haben M. Laryngoscope 116(12):2108-2112. Link
• The irritable larynx syndrome. Morrison M, Rammage L, Emami AJ. Journal of Voice. 1999;13:447-55. Link
• Vagal neuropathy after upper respiratory infection: a viral etiology? Amin MR, Kaufman JA. American Journal of Otolaryngology, 2001;22(4):251-256. Link
• Cough and paradoxical vocal fold motion. Altman KW, Simpson CB, Amin MR. Otolaryngology-Head & Neck Surgery. 2002;127(6):501-11. Link
• Botulinum Toxin A: A novel adjunct treatment for debilitating habit cough in children. Sipp JA, Haver KE, Masek BJ, Hartnick CJ. ENT Journal 2007;86(9):570-572. Link
• Use of botulinum toxin type A for chronic cough: a neuropathic model. Archives of Otolaryngology-Head & Neck Surgery. 2010;136(5):447-452. Link
• A new treatment option for laryngeal sensory neuropathy. Halum SL, Sycamore DL, McRae BR. Laryngoscope. 2009. Link
• Postviral vagal neuropathy. Rees CJ, Henderson AH, Belafsky PC. Annals Otol Laryngol Rhinol. 118(4):247-52, 2009. Link

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Botox for Chronic Cough

There was a new report in the May 2010 issue of Archives of Otolaryngology-Head & Neck Surgery that discussed the use of botox to achieve significant improvement, if not cure, in adult patients with a chronic cough due to sensory neuropathy. In this report titled "Use of Botulinum Toxin Type A for Chronic Cough: A Neuropathic Model", there are 4 case studies that were presented. The results they reported stated that cough relief occurred after a median of 7 injections with a mean dose of 4.0 Units per treatment session for a mean duration of 25.7 months. To watch a video of how the botox is injected into the voicebox to treat chronic cough, click here or watch below (the procedure is the same as that performed for spasmodic dysphonia).

Of note, this is the 2nd report on use of botox for chronic cough, the first was published in 2007 in ENT Journal and was done on kids. Click here to read that report.

I tend to use botox as a last resort when other medical management strategies have failed. Hidden triggers of cough including reflux, allergies, and asthma need to be addressed prior to consideration of botox. Often, I'll give a trial of neuropathic medications if laryngeal sensory neuropathy is suspected.

To read more about chronic cough, click here.

To read the actual report on use of botox to treat chronic cough, click here.

Botox is performed by Dr. Chang every Friday afternoon for spasmodic dysphonia, laryngospasm, as well as chronic cough! We also use botox for migraines, facial wrinkles, and torticollis.

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Chronic Cough May Be Due to Obstructive Sleep Apnea!

A new study was published in the April 2010 journal Cough entitled "Chronic cough and obstructive sleep apnea in a community-based pulmonary practice."

Apparently 44% of patients with a chronic mysterious cough were found to have obstructive sleep apnea. In these patients, 93% had cough improvement when the obstructive sleep apnea was corrected!

Read the abstract here.

Of course, there are many other causes of chronic cough including reflux, asthma, allergies, etc. In rare cases, when all else comes back normal, the cough may be due to laryngeal sensory neuropathy.

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New Webpage on Balloon Sinuplasty to Treat Chronic Sinusitis

A new webpage has been created describing the balloon sinuplasty technique to address chronic sinus infections.

Briefly, a balloon catheter (similar to angioplasty used to treat clogged heart arteries) is used to enlarge the openings into the sinus cavities without the need for any cutting or tissue removal.

Read more here.

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New Video On Balloon Sinuplasty for Chronic Sinusitis Uploaded

A new video describing balloon sinuplasty has been uploaded on our YouTube channel. Balloon sinuplasty is a relatively new minimally invasive sinus surgery technique to open up diseased sinus cavities without removing mucosa or bone.

In essence, the technique involves threading a tiny guidewire to first identify the sinus opening and than acts as a guide for the balloon catheter. Once the balloon is positioned at the opening of the sinus cavity, it is inflated thereby enlarging the sinus cavity opening.

Watch this sinus surgery technique below or on our YouTube channel here.



Here is an animation of what exactly is going on:

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Can Playing a Wind/Brass Instrument Be a Source of Recurrent Infections?

Is playing a wind/brass instrument a significant factor for recurrent strep, URI's, sinus infections, etc in people? Is such use contagious? If so, how does one even go about "sterilizing" the instrument after use by a sick person so that they don't infect themself again as well as players around them when blowing into it?

I got asked these questions by one astute parent of a trumpet player. After some inquiries and research, I actually don't have a good answer to whether they may be contagious and a source of germs, though it would make sense that they would be (well-known medical principle being bacteria grows in dark wet areas).

In any case, there are various techniques as well as common sense to try and semi-sterilize the instrument to prevent potential bacterial growth deep in the pipes of wind/brass instruments:

1) Don't share your instrument! Here's a journal article regarding the hazards of sharing instruments.
2) Thoroughly dry out the instrument after use via air and brush.
3) Never play the instrument while you are sick.
4) Replace the reed if it looks nasty. Clean mouthpiece thoroughly daily.
5) Brass instruments can indeed be washed in the bathtub with warm soapy water (not so for silver!)
6) Many players commonly angle their instruments up in the air when playing allowing some fluid to drain back. This practice can create a path for harmful bacteria to make its way back into the mouth from the body of the instrument. Try and avoid doing this!

There is also this one company that claims to help with musical instrument sterilization.

MaestroMD

This issue was so concerning in Massachusetts, that a law is being passed to require sterilization of musical instruments in schools! Read more here.

Here's a NPR news article on a trombone player whose instrument  caused a chronic cough due to mold contamination.

Do readers have any other suggestions? Please post a comment!

References:
- A microbiological survey into the presence of clnically significant bacteria in the mouthpieces and internal surfaces of woodwind and brass musical instruments. Link

- Horn with nasty microbes. Link

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Recurrent Chronic Sinusitis Often Due to Allergies

A 2009 research paper lends credence that allergies may be a VERY important player in patients who suffer from recurrent sinus infections. Such patients will improve with antibiotics only to have their sinus infection symptoms recur shortly after completing the antibiotics.

The research described how allergy exposure to patients resulted in a rapid and radiographically significant response of sinus disease including mucosal thickening and/or opacification. How fast? Within 60 MINUTES!!!

These findings lend support that should patients suffer from recurrent sinus infections that do not clear readily with antibiotics alone should be investigated for allergies. Furthermore, allergy testing and management should be performed in all patients considering sinus surgery. Why? Because if allergies are playing a role, opening up the sinuses via surgery will only exacerbate allergy triggered sinus infections.

What is our office protocol for evaluating patients with chronic sinus infections?

1) History supportive of recurrent sinus infections in spite of antibiotics as well as trial of allergy medications
2) CT Sinus documenting presence of sinus disease for surgical consideration as well as elucidating whether true sinus problems are causing the symptoms
3) Allergy testing (Our office performs immunoCAP blood testing instead of skin prick testing)

If allergy testing is positive, aggressive allergy control is the first step prior to (or at the very least concurrent with) any other intervention including sinus surgery.


Reference:
Diagnostic Value of Nasal Allergen Challenge Combined With Radiography and Ultrasonogrphy in Chronic Maxillary Disease. Arch Otolaryngol Head Neck Surg. 2009 Dec;135(12):1246-55. doi: 10.1001/archoto.2009.189.

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MRSA Sinusitis

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

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

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

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

Such topical treatment include:

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

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

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

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