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"!!!

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Tongue Acrobatics

Impressive tongue acrobatics... Not much more to say! Watch the video here.

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World's Longest Human Tongue

The longest human tongue ever recorded is that of Stephen Taylor and measures 9.8 centimetres (3.86 in). Apparently, his tongue has not stopped growing even though he is a grown adult.

The longest tongue for a female is that of Los Angeles resident Chanel Tapper whose tongue measures 3.8 inches! Her tongue is also quite acrobatic as shown in this YouTube video.

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New Webpage on Bumps or Lesions of the Mouth

Our practice has created a new webpage describing the various bumps and lesions commonly seen in the mouth that leads to a doctor's visit.

Such abnormal things seen in the mouth that's discussed include:

• aphthous ulcer
• herpetic ulcers
• pyogenic granuloma
• fibroma
• papilloma
• cancer

Click here to read more!

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Major League Baseball Bans Under the Tongue Deer Antler Spray Use

On Aug 6, 2011, ESPN reported that MLB players have been issued a warning regarding use of Deer Antler spray administered under the tongue.

Deer-Antler spray contains "potentially contaminated nutritional supplements" along with IGF-1 (Insulin Growth Factor) which players have used in the past as an alternative to steroids, especially given it can't be detected in urine samples (only blood testing).

What's with Deer-Antler spray specifically? Scientists discovered IGF-1 in the velvet of immature deer antlers and IGF-1 is considered a performance-enhancer that mediates the level of human growth hormone in the body.

Why under the tongue (sublingual administration)? Because the mucus membrane is quite thin under the tongue richly underlaid with capillary blood vessels allowing for direct diffusion of the substance directly into the body's bloodstream with little or no alteration. This process takes less than a minute to occur. This is in contrast to swallowing a pill which gets digested in the stomach with acid, further digested in the intestines with enzymes, absorbed into the hepatic circulation where further degradation occurs in the liver before getting into general body circulation for effect. A 30-60 minute process.

That's why sublingual nitrogen is such a potent medication to treat chest pain due to an impending heart attack. It works FAST!

It's another reason why sublingual immunotherapy otherwise known as allergy drops is a growing acceptable alternative to allergy shots to try and cure allergies.

Read the ESPN story here.

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Sleep Endoscopy for Obstructive Sleep Apnea and Snoring

A new webpage has been created describing a procedure called "sleep endoscopy" or "sedated endoscopy."

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

Each of these areas may experience collapse during sleep causing obstructive or snoring symptoms.

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!

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New Anti-Snoring Device... aveoTSD

I received in the mail today a new device called aveoTSD anti-snoring aid by Glidewell Laboratories.

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.

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The Doctors TV Show Does Surgery for Obstructive Sleep Apnea

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.

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Link Between Oral Sex and Head & Neck Cancer

USA Today published a pretty accurate article regarding the rise of certain head & neck cancers with the increased popularity of oral sex and number of sexual partners.

The factor that creates this link is the HPV virus which is associated with tonsil and tongue cancer. Alcohol and tobacco use is more highly linked with such oral cancers, but HPV does appear to be an independent risk factor.

A 2007 study in the New England Journal of Medicine found that younger people with head and neck cancers who tested positive for oral HPV infection were more likely to have had multiple vaginal and oral sex partners in their lifetime. Having six or more oral sex partners over a lifetime was associated with a 3.4 times higher risk for oropharyngeal cancer; cancers of the base of the tongue, back of the throat, or tonsils. Having 26 or more vaginal-sex partners tripled the risk. The association continued to increase as the number of partners in either category increased.

Of greater concern is that "French" kissing may also potentially be a mode of transmission.

The good news (if one is a young, non-smoker diagnosed with HPV-positive tumors) is that about 85% of non-smoking people with HPV-positive tumors survive. That number drops to 45 or 50% in people who smoke and are HPV-negative.

Th take-home message here is that even if you are a non-smoker and non-drinker, you can STILL develop head and neck cancer. Oral HPV infection is strongly associated with oropharyngeal cancer among subjects with or without the established risk factors of tobacco and alcohol use and that oral HPV infection can occur through sexual activity.

Furthermore, it is possible that the HPV vaccine (ie, gardasil) may also be protective (studies pending) for both women AND men.

Read the USA Today article here.

References:
Human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007 Sep 13;357(11):1157; author reply 1157-8

Human papillomaviruses in head and neck carcinomas. N Engl J Med. 2007 May 10;356(19):1993-5.

Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007 May 10;356(19):1944-56.

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Bottles / Vials for Allergy Drops (Under Tongue) Immunotherapy

We have received a number of requests of where one can obtain allergy vials for use in SLIT (sub-lingual immunotherapy) whereby a drop is placed under the tongue to try and achieve allergy cure. This mode of treatment is an alternative to the more traditional allergy shots.

Our office provides both modes of immunotherapy.

Regarding the allergy vials themselves, you can obtain them from Edge Pharmaceuticals. They offer a number of different vial types as shown in the picture. They range in sizes from 15cc to 20cc and provide 40ul to 200ul drops with each dispensation.

Contact Info:

7264 NW 63rd Terrace

Parkland, FL 33067

Phone: 877-580-3343

Fax: 877-581-3343

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Migraine Headaches Associated with Allergies & Response to Allergy Shots

A recent study published this month in the journal Headache reported an association of migraine headaches with allergy severity and response to allergy shots... but only in those less than 45 years of age.

The study suggested that lower "degrees of atopy" (or allergy) were associated with less frequent and disabling migraine headaches in younger subjects while higher degrees were associated with more frequent migraines. The administration of allergy shots was associated with a decreased prevalence, frequency, and disability of migraine headache in younger subjects.

The age cut-off used to described "younger" subjects depending on the measure described was either 40 years or 45 years.

Read the abstract here.

Of course, one must consider the possibility that perhaps what these patients are suffering from is not migraine headaches, but allergy triggered sinus headaches.

Our office provides allergy testing, allergy shots, and allergy drops. We also offer botox injections in the treatment of migraine headaches.

Reference:
Allergy and immunotherapy: are they related to migraine headache? Headache. 2011 Jan;51(1):8-20. doi: 10.1111/j.1526-4610.2010.01792.x. Epub 2010 Nov 4.

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Tongue Piercing Infections

It seems that tongue piercing is slowly becoming more popular than ever... and correspondingly, there seems to be even more tongue infections than ever before due to the piercing.

If tongue piercing MUST happen, it is recommended that you avoid studs made of metal which increases the risk of infection, at least according to a recent study in the Journal of Adolescent Health.

The study demonstrated that studs made of steel might promote the development of a bacterial biofilm leading to increased risk of infection whereas those made of polytetrafluoroethylene or polypropylene are inert to such bacterial colonization.

I should also add that metal studs may cause an allergic reaction leading to painful tongue swelling/itching, especially in those with metal allergies. This is similar to the skin reactions that some people experience with cheap metal jewelry.


Reference:
Tongue piercing: the impact of material on microbiological findings. J Adol Health online, 2011

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Pacemaker To Cure Obstructive Sleep Apnea (OSA)?

The Huffington Post on Dec 27, 2010 published a story about a potential new treatment whose goal is  obstructive sleep apnea cure (OSA) cure using a pacemaker made by Inspire Medical... for the tongue. The New York Times also published a similar story more recently about the same device on 1/8/2014.

The device works by stimulating the nerve going to the tongue (hypoglossal nerve) to contract with every breath a person takes while sleeping.

Why would this help? In some patients with severe obstructive sleep apnea, the tongue falls backward against the throat's back wall (tongue prolapse) causing airway obstruction. By stimulating the tongue's nerve, the tongue is stimulated to move forward when a patient takes a breath preventing obstruction.

Of course, this treatment works ONLY if the obstruction is due to tongue prolapse.

There are other treatments that also accomplish the same thing including:

• Base of tongue coblation/reduction
• Geniohyoid advancement
• Repose procedure
• Oral appliance

At least in our office, we only offer the base of tongue reduction to address tongue prolapse that may lead to obstructive sleep apnea.

This pacemaker for the tongue is currently experimental and not available for the general public yet.

Sources:
Sleep Apnea: Experiments Test If Implant Can Block Sleep Problem. Huffington Post 12/27/10

For Sleep Apnea Patients, a Possible Alternative to Masks. NYT 1/8/14

Reference:
Upper-Airway Stimulation for Obstructive Sleep Apnea. New England Journal of Medicine. January 9, 2014DOI: 10.1056/NEJMoa1308659

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Allergy Shots in Britain Require a LONG Waiting Period Afterwards

I recently heard that one reason why allergy shots are rare in England (and why sublingual "under-the-tongue" drops aka SLIT, are so common) is that British patients are required to wait under observation for anaphylaxis as long as ONE HOUR after each and every injection!!!

In fact, initially the waiting period was as long as TWO HOURS when the British Committee for Safety of Medicines became alarmed with some deaths that followed allergy injections in 1986. Subsequently, the safety committee decreed that these injections could only be administered when full equipment to cope with any emergency was at hand and further required that the patient must remain under supervision in the clinic for two hours after the injection. This had the effect of stopping this method of treatment completely, mainly because of the long waiting period.

That's quite a pity especially when considering that allergy shots were first "invented" in 1911 by two British physicians, Drs. Leonard Noon and John Freeman.

Read more about the history of allergy desensitization in England here.

Of note, our clinic provides allergy testing, allergy shots, and under-the-tongue allergy drops. And no... we do not make patients wait 1 hour after an injection.

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Coffee Decreases Risk of Head & Neck Cancer

Researchers at University of Utah found that regular coffee drinkers who drank more than four cups of coffee a day had a 39 percent decreased risk of two types of head and neck cancer: oral cavity and pharynx cancers. In the study published in the journal of Cancer Epidemiology, Biomarkers & Prevention, they found however, that coffee did not decrease the risk of laryngeal cancer. Coffee contains over 1,000 different chemical compounds, including cancer-fighting antioxidants, and it’s those antioxidants that may provide a “plausible explanation” for reducing the cancer risk.

However, patients should not take this study as an excuse to increase their coffee intake specifically to counteract known cancer-causing behaviors including smoking, drinking alcohol, and chewing tobacco.

Read a CNN report on this here.

Reference:
Coffee and Tea Intake and Risk of Head and Neck Cancer: Pooled Analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiol Biomarkers Prev, June 22, 2010; 1055-9965.

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Cool X-Ray Video of What Happens Anatomically During Speech

Voice is sound production. Speech is what ultimately comes out the mouth after the sound is modified by the tight coordination among the throat muscles, palate, tongue, lips, teeth, etc. An example of a voice problem is hoarseness. A speech problem would be stuttering, or nasal-sounding words, or mumbling.

Speech researcher Christine Ericsdotter precisely captured the intricate movements of the tongue, lips, pharynx and jaw during speech using a rapid-fire X-ray.

Check out the video she created here!

This link provides a cartoon animation of how each sound in the English language is produced from an anatomical standpoint.

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NYT: How Tongues Taste Carbonation in Soda

The New York Times published a story on Oct 19, 2009 regarding how tongues taste that "carbonation" we all appreciate when drinking soda pop beverages. The story entitled "How Tongues Taste the Carbonation in a Fizzy Beverage" reveals that the carbonation is NOT due to the bubble popping, but rather a taste receptor.

As we all know, there are receptors for five tastes: sweet, sour, salty, bitter and umami (sometimes termed savory).

It is the receptor for sourness that is responsible for the taste of carbonation.

Read the story here.

Read the research here.

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