Oral Exam Using a Finger

For a good physical exam, physicians use their senses (eyes, ears, nose) to detect disease processes that may not necessarily be obvious to a lay person. Beyond these obvious senses, fingers and hands are also utilized to feel for unusual bumps or masses that may not be obvious to the naked eye.

Take a neck mass for example. Neck masses may not be necessarily visible, but by feeling the neck, may become obvious. To use an analogy, a bowling ball under a mattress may not necessarily be obvious, but if you lay on the bed, would become painfully obvious.

Physicians also use the hands/fingers to examine areas that may not be visible... such as the unpleasant digital rectal exam (inserting a finger up a bung-hole) which is done to detect blood in the stool, rectal/anal cancers, anal muscular incompetence, etc.

However, I find it odd that the mouth is a body area that is not often "felt" around... physicians included.

A finger can appreciate unusual mouth pathology that may not necessarily be appreciated by looking alone. Furthermore, just like the rectal exam, a finger can appreciate base of tongue pathology that cannot be visualized by having a patient go "ah".

I truly feel that actor Michael Douglas would have been diagnosed with his base of tongue cancer much earlier if only a doctor stuck a finger and swept that back area of the tongue. One can "feel" cancer as it is rock hard and very tender. True... it may cause a person to gag, but for a cancer test, it's dirt cheap, fast, and reliable.

However, it does not just have to be areas of the mouth that can not be seen. Even for those ulcerations and bumps of the mouth that one can clearly visualize (or not), it does help to touch it. Is it hard? Soft? Ulcerated? Tender? Grooved? Papillated? Fungating? Rubber-like? Blottable?

Each characteristic provides information to achieve a more accurate diagnosis.

To an ENT way of thinking, if a doctor regularly performs a digital rectal exam, than one can certainly do the same thing at the other end. It's less invasive and provides just as much information.

Say "ah"!!!

Read More

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.

Read More

Novel Treatment for Non-Allergic Rhinits

Non-allergic rhinitis is an extremely frustrating sino-nasal disorder that is characterized by all the same symptoms of sinusitis and allergies, but NOT due to sinusitis or allergies. Rather, I consider non-allergic rhinitis to be the over-sensitive nose syndrome whereby breathing in air containing particulates (whether smoke, perfume, dust, pollen, etc) PHYSICALLY irritates the nose causing symptoms.

This is in contrast to allergies where the pollen causes an immunologic reaction causing symptoms or sinusitis which is due to an infection.

Non-allergic rhinitis is diagnosed by a negative allergy test (meaning symptoms are not due to allergies) and normal CT sinus scan (meaning symptoms are not due to a sinus infection).

Usually, treatment encompasses avoiding triggers (ie, perfume, smoke, dust, etc), applying a barrier nasal emollient (ie, ponaris), anti-histamine nasal spray (ie, astelin, astepro, patanase), and nasal hygiene using saline flushes which washes away the irritants causing symptoms.

Well, a new study published this month have shown another mode of treatment is quite helpful... ICX72, a proprietary homeopathic preparation of Capsicum annum and Eucalyptol, otherwise known as Sinus Buster!

When used twice daily over two weeks, symptoms were found to be significantly improved when compared to placebo. Furthermore, sinus buster alleviates symptoms attributable to non-allergic rhinitis within 52.6 seconds on average.

Past studies have shown improvement using Sinus Buster, but this is the first controlled study demonstrating efficacy.

Of note, unlike nasal decongestant sprays like Afrin which can result in addiction over time (rhinitis medicamentosa), there does not appear to be any addictive component with this nasal spray.

Read the study abstract here.

Read more about this condition here.



Reference:
A randomized, double-blind, parallel trial comparing capsaicin nasal spray with placebo in subjects with a significant component of nonallergic rhinitis. Annals of Allergy, Asthma & Immunology. Volume 107, Issue 2, Pages 171-178 (August 2011)

Intranasal Capsicum spray in idiopathic rhinitis: a randomized prospective application regimen trial. Acta Otolaryngol. 2009 Apr;129(4):367-71.

Intranasal capsaicin reduces nasal hyperreactivity in idiopathic rhinitis: a double-blind randomized application regimen study. Allergy. 2003 Aug;58(8):754-61.

The long-term effects of capsaicin aqueous spray on the nasal mucosa. Clin Exp Allergy. 1998 Nov;28(11):1351-8.

Beneficial effects of intranasal applications of capsaicin in patients with vasomotor rhinitis. Eur Arch Otorhinolaryngol. 1991;248(4):191-4.

Read More

Test That Distinguishes Between Bacterial or Viral Infections

From the pages of CSI: Miami... a commonly used forensic chemical called luminol to identify traces of blood at crime scenes has been modified to be used in a novel medical test that can help differentiate a viral infection from a bacterial infection.

Why is this important?

Not uncommonly, it is sometimes hard to differentiate between a bacterial infection which is treated with antibiotics from a viral infection which is NOT treated with antibiotics. Unfortunately, in the healthcare system, too often, antibiotics are given if an infection is present whether viral or bacterial which is leading to multi-drug resistant infections like MRSA.

Well with this test, physicians can potentially use it to determine whether antibiotics should be provided or not. Such a test may also be reassuring to patients who desire antibiotics, but can be told with confidence that it is not necessary and at worst, dangerous.

The way this test works is by identifying the characteristic glow "signature" after luminol is applied to a suspect infection. If it glows a certain way... it's a viral infection. If it glows in a different way... it's a bacterial infection.

For those scientifically inclined and curious, the glow is due to a byproduct of the body's defenses fighting off infection called "Reactive Oxygen Species". The luminol reacts with this byproduct creating a glow.

Of note, the test is not yet available, but perhaps soon???

Reference:
Differentiation between Viral and Bacterial Acute Infections Using Chemiluminescent Signatures of Circulating Phagocytes. Anal. Chem., 2011, 83 (11), pp 4258–4265
DOI: 10.1021/ac200596f Publication Date (Web): April 26, 2011

Read More

Rapid Strep Test Positive But No Sore Throat

Occasionally, I see patients who have received throat swabs for strep that have come back positive... even if they have no signs or symptoms of pharyngitis.

In this situation, there are 2 main actions a physician may take (I am biased towards one):

1) Prescribe antibiotics until throat cultures are normal
2) Do nothing

Personally, if a patient is without throat symptoms and has no history of rheumatic fever or kidney damage, I would not have even bothered obtaining a strep test. What for???

Also, a person can be a carrier for strep without suffering any health problems. As such, even if the strep test is positive, but if the patient has no symptoms, I do not recommend treatment. (Which again begs the question of why bother getting a strep test if no treatment will be recommended regardless of the test result.)

I would go so far even to say follow-up cultures are NOT necessary after antibiotic treatment for strep throat if a patient does not have any more symptoms and exam is normal.

Which is why I find it surprising when children and adolescent patients receive multiple courses of antibiotics when they feel perfectly fine, but have received treatment just because a strep test came back positive.

Of course... that's just my opinion as I do acknowledge that there's another school of thought which supports antibiotic treatment of all strep positive cultures with follow-up cultures to ensure eradication.

However, according to the 2012 clinical practice guidelines published by the Infectious Diseases Society of America (statement 12),

"We recommend that GAS carriers do not ordinarily justify efforts to identify them nor do they generally require antimicrobial therapy because GAS carriers are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for developing suppurative or nonsuppurative complications (eg, acute rheumatic fever; strong, moderate)."

Depending on the doctor you see, you will get different opinions. But it is good for patients to be aware of the varying views on this topic given how common sore throats are.

Reference:
Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis. (2012) 55 (10): e86-e102. doi: 10.1093/cid/cis629

Read More

Non-Sedated ABR & OAE Now Offered at Fauquier ENT

What is ABR/OAE? ABR (Auditory Brainstem Response) as well as OAE (Oto-Acoustic Emission) are specialized hearing tests that can evaluate whether a child/infant/newborn can hear without requiring them to respond.

These tests are completely non-invasive. Just like an EKG measures a heart's electrical activity using little stickers, ABR/OAE testing checks out the electrical activity from the ear to the brain. Special stickers on the head enable us to "see" whether the brain "hears" any sounds introduced into the ear.

If the ABR/OAE testing comes back normal, rest assured your child's hearing in both ears is normal.

Specifically, OAE is performed by placing an earpiece and playing clicks into the ear. The machine than listens for an echo which indicates that the ear "heard" the clicks.

ABR is performed just like an OAE, but special leads are placed behind the ear and forehead which measures brainwaves (just like an EEG or an EKG) to see if the brain "hear" the clicks produced by the testing machine. There are several different types of ABR (regular, tone burst, bone conduction, ASSR) depending on the age of testing and reason for the testing.

Traditionally, ABR/OAE testing required sedation in order to obtain accurate and reliable results as any muscle activity can lead to false reports. Furthermore, there are a lot of wires going from the patient to the equipment and as such required the patient to stay still. In the case of infants/children, this mandated general anesthesia in a hospital operating room.

Fortunately, new technology that our office possesses eliminates the need for such sedation and still obtain accurate ABR/OAE test results. Our office uses Vivosonic Integrity which incorporates wireless technology and the use of an in-situ bio-amplifier which amplifies biologic electrical activity at the ear source thereby reducing interference from environmental electric, magnetic, and RF field-induced noises. This also dramatically reduces artifacts which result from other muscular and ocular electrical activity.

What does this all mean for a patient?

It means that an ABR/OAE can be obtained in our office on a child/infant who is actively moving and playing around, eating food, chewing gum... all without being attached to wires. No sedation. No medications. No needles. No pain.

Click here for more info.

Read More

Extremely Discounted Blood Tests for Cash-Paying or Uninsured Patients

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

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

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

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

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

Read More

Tilt-Table Test: An Under-Utilized Study To Evaluate Light-Headed Dizziness

We often see patients for dizziness. Many of these patients do not have an ear etiology for their dizziness given principal complaint of light-headedness, especially with standing/sitting up from a laying down position. In this scenario, a blood pressure issue is the more likely cause. Why? Because when you get up from a laying down position, gravity pulls the blood down and away from your head resulting in a transient lack of adequate blood-flow to the brain resulting in light-headedness... and even a fainting spell if severe enough.

Normally, the body is able to compensate for such position changes quickly, but when it doesn't, watch out... Light-headed dizziness or fainting/blacking out will occur.

The best test to evaluate this problem is a tilt-table test. Check out the video to see how this test is performed. Be aware that not all hospitals offer this type of test.

Read More

A New Method of Allergy Testing (Multi-Array Chip Technology)

A MIT researcher has developed a new and possibly more accurate blood test for allergies using multi-array chip technology. The paper is titled "Multidimensional analysis of the frequencies and rates of cytokine secretion from single cells by quantitative microengraving" and is published in the journal Lab on a Chip.

This chip technology uses a microscopic engraving process to create thousands to millions of tiny wells (or multi-array) on a chip where a different "blood test" can occur in each well. An overly simplified explanation of how testing occurs is as follows:

Inside each well, the chip manufacturer can place a different type of food or pollen protein such as milk or cat dander. A blood sample placed into the well will than allow allergic cells to "react" with the protein. If the cell (and therefore the person) is sensitized to the protein, the cell will release chemicals called cytokines that can be measured.

Given there are thousands to millions of wells, all of them microscopic in size, only a small amount of blood can be used to test for a whole array of food and pollen allergies.

Read the actual research here.

Unfortunately, our office does not utilize this innovative technology... yet... to test people for allergies. We use RAST. Using the results obtained, we are able to provide allergy shots or allergy drops.

Read More