Shape of Human Nose Influenced by Climate

The basic function of the human nose is to warm and humidify the air before it reaches the lungs. Because of the wide variation of human habitats from the polar cold and dry air to the equatorial hot and humid weather, one would expect the nose to accommodate to these climate extremes accordingly thru evolutionary pressures.

In essence, logically one would expect the nose to change shape to enhance time that air is in contact with the warm and moist nasal interior in cold and dry climates compared to the opposite environmental extreme.

German scientists evaluated this hypothesis thru 3D modeling of 100 skulls to analyze the shape of the bony nasal cavity of 10 modern human groups living in five different climates and found that the bony nasal cavity appears mostly associated with temperature effects and the nasopharynx with humidity.

Humans living in cold, dry climates tended to have nasal cavities relatively high and long with an abrupt narrowing in the upper nasal cavity than those living in hot, humid climates. Such characteristics enhance contact between the air and the nasal mucosal tissue that helps to warm and humidify that air.

What does such a nose look from the outside? A narrow, longer internal nasal cavity is generally linked to a relatively narrower and more projected nose.

Read a magazine article about this research.

Reference:
Climate-related variation of the human nasal cavity. American Journal of Physical Anthropology. Volume 145, Issue 4, pages 599–614, August 2011

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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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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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Pediatric ENT Care of Warrenton, Virginia (Fauquier County)

Recently, there has been some confusion regarding whether our office deals with adults only or do we see kids as well... Strangely enough, we also get asked by parents whether our office sees adults when seeing a pediatric patient.

To clear up any confusion, our office does see kids AND adults... starting from birth to the elderly.

Dr. Chang who joined the office in October 2005, was named one of America's Top Physicians by the Consumer's Research Council of America in 2008 as well as a Northern Virginia Top Doctor for 2011 (to be published in February 2011).

Some common problems and procedures for which Dr. Chang sees kids specifically include:

- Tongue Tie Release (starting from ONE DAY OLD!)
- Tonsillectomy
- Adenoidectomy
- Sinus Surgery starting with adolescents
- Ear Tube placement
- Hearing Loss
- Nasal Obstruction
- Nasal Congestion
- Snotty Nose
- Speech Delay
AND many other issues...

Our office has even created videos on a few common pediatric procedures including tonsillectomy, adenoidectomy, earwax removal, ear tubes placement. Watch the video below on tonsillectomy.

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Being a Hairdresser Can Destroy Your Nose!

On Oct 14, 2010, there was a story out of England about a hairdresser whose nose slowly collapsed due to damage sustained from breathing in hair clippings for 35 years.

Apparently, over a period of 20 years, the small hair clippings slowly caused damage to her septum to the point it caused a perforation. The perforation than led to infection which further weakened her nose structure to the point it started to collapse... a type of nasal deformity called a saddle nose.

Of course, it just wasn't her septum that was affected, but also her sinuses leading to persistent headaches, nasal congestion/obstruction.

Read the story here.

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The Science of Nose-Picking

Most everybody does it whether they admit it or not, both in kids and adults. In fact, according to one research survey, people do it about 4 times a day. In 7.6%, they do it >20 times a day!

Nose-picking, also known as rhinotillexomania in medical-speak, generally is a benign, sedentary (and private) solo activity, but when excessive, can lead to a number of medical problems including nosebleeds (25% of nose-pickers), septal perforation, staph infections, etc. In one extreme case, it even led to a self-inflicted ethmoidectomy (sinus surgery)!

Though most people pick their nose with their finger and use their fingernail to "dig" the golden nugget out, it is recommended to avoid use of the nail due to the danger of causing mucosal trauma (just like when itching the eye, use of the fingernail is not ideal). Using a saline nasal spray or saline flushes can help soften as well as minimize nasal crusting accumulation and enable one to "blow" the nasal boogers out. Humidification, especially when the air is cool and dry, is important to prevent hard nasal boogers from occurring in the first place.  Nasal emollients like ponaris are also quite helpful as a preventative measure.

Now, it is a well-accepted fact that ENT physicians are the experts in removing unwanted nasal snot. So what's our secret?

Beyond our 5 years of surgical training, we have fancy equipment in order to obtain optimal visualization of nasal cavity. Use of a nasal speculum as shown below provides direct visualization of the entrance of the nose and suffices in most situations.

However, we are also skilled in the use of nasal endoscopic equipment to examine harder to visualize parts of the nasal cavity.

With visualization, we have at our disposal a large array of equipment that can be used for removal/retrieval. Our workhorse tool is the bayonet forcep. This tool is ideal for the hard nasal crusting in the front part of the nasal cavity.

When the booger is farther back, rather than using bayonet forceps, a tool with forceps only at the tip is utilized (ethmoid forceps). The neato thing with this instrument is that the tip comes in all sorts of different sizes and angles in order to reach into any part of a person's nose!

When the snot is more mucoid rather than hard, a suction device (frasier tip) can be used instead.

So, that's probably more information than you ever wanted to know about boogers, but there you have it!

References:
A preliminary survey of rhinotillexomania in an adolescent sample. J Clin Psychiatry. 2001 Jun;62(6):426-31.

Rhinotillexomania: psychiatric disorder or habit? J Clin Psychiatry. 1995 Feb;56(2):56-9.

Self-induced ethmoidectomy from rhinotillexomania. AJNR Am J Neuroradiol. 1997 Nov-Dec;18(10):1949-50.

Nose picking and nasal carriage of Staphylococcus aureus. Infect Control Hosp Epidemiol. 2006 Aug;27(8):863-7. Epub 2006 Jul 20.

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NPR: Injuries To Kids From Swallowed Disc Batteries Are No Joke... It Is An EMERGENCY!!!

In fact it is a STAT emergency... NPR published a story on Sept 20, 2010 regarding Chuck E. Cheese's recall of two toys (a light-up ring and glasses) due to a disc battery used to power them.

These disc batteries can be access by small children if they smash apart the toy. The Consumer Products Safety Commission says two kids have had problems with batteries; one swallowed it and the other stuck it up his nose.

The danger is that when a disc battery is inserted into a nose (for example), a localized electric current is created between the positive and negative poles of the battery within the nose. This electric current basically "electrocutes" the lining inside the nose leading to tissue damage and ultimately necrosis (tissue death) within an hour. The same applies even if the battery is swallowed or put into the ear canal.

Treatment is IMMEDIATE removal... as soon as possible. Regardless of the day or time. STAT...

In the last 10 years, 13 deaths related to swallowed batteries have been reported, 12 of which are due to disc batteries (20 millimeter lithium cells).

Small children should NEVER be able to access disc batteries.

Read the NPR story here.

Read about the recall itself here (also from NPR).

Reference:
Preventing Battery Ingestions: An Analysis of 8648 Cases Published online May 24, 2010
PEDIATRICS (doi:10.1542/peds.2009-3038)

A Review of Esophageal Disc Battery Ingestions and a Protocol for Management Arch Otolaryngol Head Neck Surg. 2010;136(9):866-871. doi:10.1001/archoto.2010.146

Images of the toys that have been recalled...

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Nasal Surgery Helps With Snoring

Researchers have found that surgery to improve nasal breathing in setting of nasal obstruction, congestion, and/or resistance can also help with snoring.

Depending on the study, surgical relief of nasal obstruction improves snoring in a range from 35% to as high as 86%. Unfortunately, complete CURE (ie, no snoring whatsoever) is less likely occurring in <15% of patients. What are the possible nasal surgeries one can undergo to relieve nasal obstruction and potentially achieve snoring improvement? They include:

• Septoplasty
• Adenoidectomy
• Turbinate Reduction
• Sinus Surgery

Reference:
Nasal Surgery for Snoring in Patients With Obstructive Sleep Apnea Laryngoscope. 118:354-359, 2008.

Can Snoring Relief After Nasal Surgery be Predicted. Clin Otolaryngol 19:41-44, 1994

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Intra-Nasal Cooling System Effectively Chills Brain After Cardiac Arrest

In a study in this month's Circulation, a new nasopharyngeal device was used to initiate cerebral cooling during cardiac arrest. This device, called RhinoChill made by BeneChill cools the major vascular structures of the brain thereby improving neurological outcome.

Use of this device was found to increase survival over CPR alone by 27% and a 26% increase in neurologically intact survival.

Reference:
Intra-Arrest Transnasal Evaporative Cooling. A Randomized, Prehospital, Multicenter Study (PRINCE: Pre-ROSC IntraNasal Cooling Effectiveness). Published Online on August 2, 2010.

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Video: Chopstick Enters Nose and Pierces Brain in Child

A reader recently emailed me this amazing AP video of a 14-month-old toddler who was playing in the kitchen when he fell, sending a chopstick up thru his nose and into his brain. Surgeons were able to remove the chopstick and the child did just fine.

However, it is quite likely this child has now permanently lost his sense of smell (anosmia) since the smell nerve is located where the chopstick entered the brain (cribiform plate). There is no way to "fix" nerve damage in this area after it has occurred (at this time).

Such trauma like this is unfortunately not uncommon, though not with such precise nasal entrance into the brain. More commonly, I've seen mouth and oral injury rather than nasal (fork or chopstick in the mouth while a child is playing).

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Vaginal Premarin Cream for Recurrent Nosebleeds?

It is an old trick of the trade where a physician may prescribe vaginal premarin cream to treat recurrent nosebleeds.

The premarin cream (just as it does when placed vaginally) causes the nasal mucosa lining to thicken thereby "burying" the superficial blood vessels that are often the culprits for recurrent nosebleeds. Application is by rubbing the cream 2-3X per day to the anterior wall of the nasal septum (Kiesselbach's plexus) where 90% of nosebleed sources are located.

Understandably, males may be reluctant to be prescribed this medication due to the small (but temporary) risk of breast enlargement given the very small amount that can be systemically absorbed (based on vaginal studies, less than 20 pg/ml).

Furthermore, given there are other good options for treating nosebleeds including nasal emollients, cauterization, and packing, this option is mainly for females who are scared to death of nasal cauterization/packing when other more conservative treatment fails.

Though I wish I can provide a few good references... there aren't any. It is considered general knowledge. The only one I was able to find is:

Mehriz A, Weber DR. Estrogen therapy for recurrent epistaxis: case histories and literature review. Hosp Pharm. 1999;34:1057-1064.

The vast majority of research on use of premarin cream for recurrent nosebleeds is actually for treating individuals suffering from Hereditary Haemorrhagic Telangiectasia (HHT), also known as Osler-Weber-Rendu Syndrome.

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New Video on Stopping Nosebleeds by Cautery

A new YouTube video has been uploaded describing how nosebleeds are stopped using silver nitrate cauterization. The video was produced by our office and just in time for the cold and dry air that winter brings along with numerous nosebleeds.

The video is part of our collection of videos on our YouTube channel.

>

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Crazy Pumpkin Carvings Related to ENT

In celebration for Halloween today, I have found a few crazy pumpkin carvings courtesy of Extreme Pumpkins.




Here is the one that I carved, complete with snotty tissues:




If you have another relevant one, please comment and include a link to a picture. Enjoy!

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