Read all about it here!
Showing posts with label procedure. Show all posts
Showing posts with label procedure. Show all posts
Thursday, 22 September 2011
Monday, 5 September 2011
I also stated that "Some surgeons would argue a strong, stiff ball-point pen could have been used to perform the cricothyroidotomy, but as someone who has performed a dozen emergency cricothyroidotomies and tracheotomies in the past, even under the best of circumstances with a knife and being on a hospital floor with help around, it is hard. Furthermore, skin and the windpipe is made of tough 'fabric' and trying to punch a ball-point pen through is laughable. Try doing it yourself on a chicken with the skin on."
Well... it got me thinking... Let's assume for argument's sake that it IS possible to perform a cricothyroidotomy by literally punching through with a stiff ball-point pen into the airway. Would it actually work???
Believe it or not, there are two studies (listed below) I was able to find that tried to answer that very question. Contrary to popular belief... even IF a ball-point pen is able to secure an airway, the majority were found to be unsuitable due to inadequate internal diameter with too high an airway resistance for breathing.
In fact, the only TWO pens that might work (from a breathing standpoint) are the:
Baron retractable ballpoint
BIC soft feel Jumbo
I can't even find these items on Amazon.com.
A sports bottle straw apparently works better than a pen.
Reference:
Bystander cricothyroidotomy performed with an improvised airway. Mil Med. 2002 Jan;167(1):76-8.
Airflow efficacy of ballpoint pen tubes: a consideration for use in bystander cricothyrotomy. Emerg Med J. 2010 Apr;27(4):317-20.
Sunday, 29 May 2011
does work after observing its use and its effects over a 6 month period of time. And before anybody asks... no... I was not paid to write this nor did I get a free one to try. Rather, someone I am close to bought it off Amazon.com and I was a skeptic on-looker.In any case, the caveat being that I know it works (admittedly anecdotal) as long as the hair is dark (ideally black or brown) on very light colored skin (ideally white).
In any case... back to the TRIA. This laser system ideally works best on dark colored hair on light colored skin. The greater the difference, the better it works; the best being black hair on white skin. In fact, the TRIA can't be used at all if you don't have the right hair/skin color combination (TRIA requires a skin check every time before use... unless you "pass," the device will not work).
. This laser system ideally works best on dark colored hair on light colored skin. The greater the difference, the better it works; the best being black hair on white skin. In fact, the TRIA can't be used at all if you don't have the right hair/skin color combination (TRIA requires a skin check every time before use... unless you "pass," the device will not work).There are only a few real differences between this laser system and that used in medical offices.
The TRIA's head is about 1/4 inch in size. The medical-grade laser head can be one inch or larger in size. What that means practically is that if you are using the TRIA for your leg, it'll take a long time and a lot of zaps due to the large surface area.
Also, the TRIA can only be used for about 15 minutes on the highest power before it shuts off for 2 reasons: It "overheats" and needs to cool down or runs out of battery and needs to be recharged. On that last point, you can only use it on battery power (which I suspect is due to safety reasons). After letting it cool/recharge overnight, it is ready to use again by the next day.
Medical-grade lasers do not have these limitations.
Finally, for those technically inclined, the TRIA uses a pulsed diode laser (same as a medical grade laser) with five intensity settings. The highest fluence available is 22 with a wavelength of 810nm, which is lower than what is available from a laser used in the clinic.
Medical-grade lasers do not have these limitations.
Finally, for those technically inclined, the TRIA uses a pulsed diode laser (same as a medical grade laser) with five intensity settings. The highest fluence available is 22 with a wavelength of 810nm, which is lower than what is available from a laser used in the clinic.
Regardless of medical-grade laser hair removal or TRIA, it does require repetitive sessions as the laser only kills follicles that are in the growth phase. Unfortunately, hair are in different phases at any given moment (there are 3 phases) and as such, it may take numerous sessions spaced 1-2 weeks apart over a few months before all hair follicles have entered into the growth phase and thus be able to be amenable to death by laser.
And unlike brain cells... hair follicles CAN come back from the dead and start producing hair again. Hard to say when or why this happens, but is likely due to hormonal factors.
Overall, however, the TRIA can save you a lot of money (compared to getting it done by a physician) if you have the following characteristics:
1) Dark hair
2) Light skin
3) Patience (small laser head on large surface area takes a long time as well as the fact that a single session may need to be broken up over a few days due to device needing to recharge or cool overnight after about 15 minutes of use)
4) High pain threshold (even with a small head... it does hurt. And because it is a small head, there's a lot more zaps to cover the same surface area)
You can buy it on Amazon.com here.
.Friday, 15 April 2011
This procedure is performed on patients with obstructive sleep apnea (OSA) or severe snoring in order to determine where the source of their problem is anatomically located.
This special exam is needed in patients where such anatomic determination is not able to be made in the clinic while they are awake. As such, an anesthesiologist would put the patient to sleep using IV medications and when snoring or obstructive events happen, endoscopy is performed.
Areas that will be specifically examined during sleep endoscopy include:
- Behind the palate
- Uvula
- Back of Tongue
- Walls of the Throat
- Epiglottis
- Voicebox
Why is this information helpful? Well... once it is apparent where and what is the culprit causing a given patient's problems, surgical treatment can be geared more specifically and directly to the area of concern seen during sedated endoscopy.
Read more here!
Thursday, 14 April 2011
Check out the video here!
Sunday, 10 April 2011
The Doctors TV show actually produced a great (and accurate) segment on a relatively new procedure called sialendoscopy. This procedure allows a surgeon to remove a stone that may be blocking your spit gland from draining saliva into the mouth. This is analogous to a kidney stone which blocks urine from draining from the kidney into the bladder resulting in painful swelling of the kidney (causing flank pain).
How does a person know if they have a salivary gland blockage due to a stone? There is a painful swelling located right in front and/or below the ear if the parotid gland is affected, or under the jawbone if the submandibular gland is blocked.
If the blockage persists long enough, it may lead to an infection of the gland itself (sialadenitis).
Traditionally, if the stone doesn't pass on its own with conservative measures, stone removal required surgical removal of the entire gland or making an incision and removing the stone like it's a tumor mass.
Watch the video of this procedure being performed as shown on The Doctors here.
At this time, the only local surgeon I am aware of who offers this unique procedure in the mid-Atlantic region is Dr. Arjun Joshi.
Dr. Arjun Joshi (George Washington University Hospital in Washington DC)
2021 K St NW, Ste 206
Washington, DC 20006
Office Number: 202-741-3250
www.dcheadandneck.com
How does a person know if they have a salivary gland blockage due to a stone? There is a painful swelling located right in front and/or below the ear if the parotid gland is affected, or under the jawbone if the submandibular gland is blocked.
If the blockage persists long enough, it may lead to an infection of the gland itself (sialadenitis).
Traditionally, if the stone doesn't pass on its own with conservative measures, stone removal required surgical removal of the entire gland or making an incision and removing the stone like it's a tumor mass.
Watch the video of this procedure being performed as shown on The Doctors here.
At this time, the only local surgeon I am aware of who offers this unique procedure in the mid-Atlantic region is Dr. Arjun Joshi.
Dr. Arjun Joshi (George Washington University Hospital in Washington DC)
2021 K St NW, Ste 206
Washington, DC 20006
Office Number: 202-741-3250
www.dcheadandneck.com
Monday, 21 March 2011
and it can be mounted on the snowboard helmet and set to record by the press of a button.It was at some point boarding down a black diamond trail that I had an epiphany... Why not use this helmet mountable camcorder in order to record surgical procedures in the operating room?
And... So I did with a few modifications to allow magnified narrow-angle shots... And I wrote a paper on it which was recently published in ENT Journal in March 1, 2011.
In any case, below is a picture of my creation mounted on a surgical headlight.
Read the article here (free registration required). Pubmed link is here.
See the full list of publications by Dr. Chang here.
Wednesday, 16 February 2011
According to the literature, the way it works is by advancing the tongue forward thereby preventing the tongue from falling backward and vibrating against the throat's back wall causing snoring as well as obstructive sleep apnea.
The way the device moves the tongue forward is by literally suctioning the tongue tip into the device and holding it in place by vacuum seal.
The theory behind how this device works is sound and mimics what an oral appliance does as well as several surgical procedures including base of tongue reduction, hyoid advancement, and Repose procedure.
The one caveat I have with this device is that it only resolves snoring due to the tongue. It would not necessarily address snoring that comes from the nose or palate. There are other devices/surgeries that would address those areas (breath-rite strips, Pillar procedure, UPPP, septoplasty, etc).
I lied... there's another caveat... Will the suction vacuum hold all night for a patient??? It does come in several different sizes... but still...
Read more about the aveoTSD here.
Read more about snoring here.
Saturday, 5 February 2011
Though the procedure can be performed awake without sedation in adult patients without a severe gag reflex, for those with a bad gag reflex, it must be performed under general anesthesia as shown in this video.
For more info on this procedure, click here.
Check it out here!
Tuesday, 1 February 2011
The Doctors TV show at some point in the past (not sure when), did a segment on surgery used to treat obstructive sleep apnea. The surgery portrayed was UPPP (uvulopalatopharyngoplasty). Dr. Brian Weeks, the featured otolaryngologist, removed the tonsils and uvula followed by suturing the cut mucosa to reposition the soft tissues of the patient's throat.
This operation is a basic surgical method addressing obstructive sleep apnea. However, prior to considering surgical treatment, I typically recommend trial of CPAP for 3 months.
Some things to keep in mind is that obstructive sleep apnea is often due to multiple levels of obstruction. UPPP only addresses mouth-level problems. Other sleep apnea surgery options need to be considered when obstruction exists at other levels including the back of tongue (below the mouth level). Base of tongue reduction helps in this situation.
Watch the video of the TV show here. Watch the video our office produced on this surgery here.
Read more about UPPP here. More info about obstructive sleep apnea can be found here.
Another operation used to treat obstructive sleep apnea in adults along with UPPP is base of tongue reduction. Read about this operation here as well as watch the video here.
Watch the video here.
Wednesday, 19 January 2011
Monday, 17 January 2011
Such robotic surgery performed through the mouth is called Trans-Oral Robotic Surgery, or simply TORS. The DaVinci system is the robotics platform that is most commonly used in TORS.
Using TORS and other approaches, head and neck surgeons have been able to remove the thyroid gland through the armpit, perform base of tongue cancer surgical excision (same cancer that Michael Douglas had), voicebox removal (laryngectomy), vocal cord surgery, etc.
In many of these and other surgeries, any procedure performed through the mouth traditionally was limited to two hands. With the DaVinci system, one technically can fit as many as FOUR "hands" inside the mouth enabling greater surgical flexibility and ease in performing fine dissections that otherwise would be impossible.
There are some downsides however... namely, use of robotic surgery is not compensated by insurance and as such, major medical centers are the only locations where such high-tech equipment is available.
At this time, the otolaryngology department at Johns Hopkins University, George Washington University, and University of Virginia are the only locations in the mid-Atlantic region with access to such robotic technology and the otolaryngology-head and neck surgeons who know how to use it that I'm aware of.
In many of these and other surgeries, any procedure performed through the mouth traditionally was limited to two hands. With the DaVinci system, one technically can fit as many as FOUR "hands" inside the mouth enabling greater surgical flexibility and ease in performing fine dissections that otherwise would be impossible.
There are some downsides however... namely, use of robotic surgery is not compensated by insurance and as such, major medical centers are the only locations where such high-tech equipment is available.
At this time, the otolaryngology department at Johns Hopkins University, George Washington University, and University of Virginia are the only locations in the mid-Atlantic region with access to such robotic technology and the otolaryngology-head and neck surgeons who know how to use it that I'm aware of.
Monday, 3 January 2011
In rank order, the costs of surgery come from (highest to lowest):
• Hospital Charges (MOST expensive charges)
a) Use of OR Room
b) Paying the Circulating Nurse
c) Paying the Scrub Nurse
d) Paying for the medications used during surgery including anesthesia
e) Paying for the OR room cleaning
f) Paying for administrative overhead
g) Use of surgical instruments including cleaning/sterilization after use
h) All disposable used for the surgery (ie, masks, drapes, wires, IV tubing, gauze, etc)
• Anesthesiologist Fees (excluding anesthesia medications)
• Surgeon's Fees (LEAST expensive charges)
The hospital charges run into the many thousands of dollars (typically charges start at around $3000 and goes up from there). The surgeon's fees can be as low as $100 to around $1000 depending on the surgery. The anesthesia's fees are between the hospital charges and the surgeon's fees (yes... anesthesiologists are paid similarly or more than the surgeons per case).
So now that you know where the costs come from, what are some ways to reduce them? Please be aware that the surgeon has no control/authority/influence over the anesthesia and hospital charges which the patient needs to individually deal with each separately.
• Have the surgery done in an Ambulatory Surgery Center if possible. Oftentimes, the costs are almost 50% lower than the same surgery done in a hospital. If possible, the hospital charges can be completely avoided if the surgery is done in the surgeon's office.
• Ask the hospital about self-pay discounts/payment plans.
• Ask the surgeon about self-pay discounts/payment plans.
• Ask about further fee discounts if the total cost is paid all at once up front in cash rather than a payment plan.
• DO get referred by a free clinic if your income level qualifies you. Free clinic referral pretty much means (for most patients), the care including surgery will be provided completely for free. Fauquier County residents have one here.
• If possible, request only local anesthesia which is cheaper than MAC anesthesia (twilight anesthesia) which is cheaper than general anesthesia which is the most expensive.
• Request medication samples (ie, antibiotics for after surgery).
Sunday, 2 January 2011
This actually makes sense to me... When a person sleeps, they can be aroused if noxious stimuli is introduced causing the person to wake up... and most likely yell at the person trying to wake them up. However, in a coma patient, the person does not "wake" up no matter what is being done to them.
During surgery, the last thing you want is for the person to wake up. As such, a coma-state would be preferred rather than a true sleep state.
This finding does have implications for snoring research as there have been several papers (see references below) in the recent past that proposed the use of anesthesia in order to pinpoint where a person's snore is coming from.
Why would this exam be helpful at all? Because one could perform a variety of endoscopic evaluations while a patient is sleeping (or rather coma) to find the culprit tissue vibration causing the snore. Is it the soft palate or nose or tongue or voicebox or a combination of factors? Such an exam is not possible if the person is "sleeping" as they would just wake up.
Without knowing where the snoring is coming from, treatment is at best a good guess.
Though at this time, insurance does not pay for this type of exam... this sleep research does potentially cause one to pause and wonder whether an exam of snoring during anesthesia is an accurate portrayal of snoring during sleep.
After all... a coma is not the same as regular sleep. It does follow that potentially, snoring during a coma is not the same as that found in regular sleep which would invalidate any exam findings regarding snoring localization.
In fact... I wouldn't be surprised if snoring sources found during anesthesia-induced coma is more severe (and potentially different) than that found during regular sleep and may needlessly lead the surgeon to pursue more aggressive snoring surgery than truly required.
Clearly, more research is needed. Indeed, in one paper published back in 1998, snoring was produced during anesthesia in 45.3% of non-snorers and could not even be produced in 18.1% of snorers!!!
References:
General anesthesia, sleep, and coma. N Engl J Med. 2010 Dec 30;363(27):2638-50. Press Release
Validity of sleep nasendoscopy in the investigation of sleep related breathing disorders. Laryngoscope. 2005 Mar;115(3):538-40.
Acoustic parameters of snoring sound to compare natural snores with snores during 'steady-state' propofol sedation. Clin Otolaryngol. 2006 Aug;31(4):341-2; author reply 342.
Propofol-induced sleep: polysomnographic evaluation of patients with obstructive sleep apnea and controls. Otolaryngol Head Neck Surg. 2010 Feb;142(2):218-24.
The value of sedation nasendoscopy: a comparison between snoring and non-snoring patients. Clin Otolaryngol Allied Sci. 1998 Feb;23(1):74-6.
Saturday, 1 January 2011
When patients travel great distances to see a doctor, this puts the physician in a particularly humbling position. However, it also places additional strain on how care can be provided efficiently and reasonably when geography logistically makes it difficult.
To begin, why would a patient even want to travel great distances to see a doctor? The basic answer is due to the perception that they would receive better care than can be obtained locally. If true, such long distance travel is justified. After all, if you have thyroid cancer and there are no surgeons who can remove this cancer, than by all means, travel is merited.
However, too often, I see patients travel great distances to see a surgeon due to the perception that this one particular doctor is better than the one found locally, EVEN if the local surgeon is quite competent. Here is where the decision to travel becomes... well... less logical, especially if the surgery is for a routine problem.
IF there's a local competent surgeon, I feel it is ALWAYS better to get the surgery done locally. Why? Because if there's any problems after the surgery, it can be easily addressed quickly and with minimal fuss. If the surgery was done hours away, think of the travel, expense, missed time from work, etc NOT just for the surgery, but for any post-operative problems that develop. Oftentimes, the patient concern ends up being unfounded and only reassurance is required, but in order to make that determination, the surgeon needs to do an exam. Imagine the frustration of the patient when a surgeon requests a visit before answering a question about a post-surgical concern... hours of driving to the office, waiting in the exam room, being seen by the surgeon for a few minutes only to hear that everything is fine and normal, and finally driving hours back home.
Even in the hands of the BEST surgeon, problems can arise after surgery. Is the surgical wound becoming infected? Where is that fever coming from? There's a little drainage occurring... is that normal? Why is the skin red? There's a lot of pain and his medications aren't working.
To complicate things further, narcotic pain killers can NOT be called in by federal rules. A hardcopy prescription is required. Now, wouldn't that be mighty inconvenient if a patient (who mind you is in pain), needs to drive hours to the surgeon's office just to pick up a hardcopy narcotic prescription.
The logistical difficulties of dealing with post-operative care after patient discharge is tremendous for both the surgeon as well as the patient if the distance between the two is large.
Now when should a patient travel to have their surgery done?
DO travel to see a surgeon when your local surgeon feels it imperative that you do so either due to the complexity of the problem or inexperience. Especially, if the local surgeon is well-respected and honest. This serves two purposes... you get the surgery done by the best possible... AND, if any problems develop after surgery, your local surgeon is in the loop and can probably handle most routine post-surgical concerns.
I should state that I HAVE performed surgery in patients who live hours away (some even an airflight away) but I ALWAYS encourage patients to try and get the surgery done locally if at all possible due to the reasons stated above. If a competent local surgeon is not available, than that's fine. But if competent local surgeons are present... I do my best to steer patients to get the surgery done locally as it IS for the patient's best interest.
I have also referred patients to other surgeons a long drive away due to one reason or another, even if the patient desperately wants me to do the surgery. I'll be the first to admit if I lack experience to address a given problem. I also follow-up in stating to the patient that if there's any problems that occur after the surgery, to please return to see me rather than making a long-distance trip as there's a good chance I'll be able to address the concern. Everyone wins this way.
Thursday, 30 December 2010
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.
Monday, 13 December 2010
Watch the video below or on our YouTube channel.
Saturday, 4 December 2010
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!
Sunday, 21 November 2010
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.
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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