New Webpage on Vocal Cord Granuloma

Given the sudden interest patients have expressed in vocal cord granulomas ever since singer John Mayer announced a hiatus in concerts due to his voicebox granuloma, a new webpage has been developed to describe this unusual mass as well as treatment options.

Read all about it here!

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Singer John Mayer Diagnosed with Vocal Cord Granuloma

On Sept 19, 2011, media reported that singer John Mayer has been forced to cancel all upcoming concert plans and delay release of a new album due to a voicebox growth.

This growth was described as a "granuloma."

What exactly is a granuloma?

It is a benign mass commonly due to repetitive mild vocal trauma resulting in exuberant growth of a specific region of the voicebox lining.

To be more precise, rather than the vocal cord itself, granulomas are most commonly found on the vocal process which is the "hinge" that allows for vocal cord movement. It is located in the back area of the voicebox.

An imprecise analogy of what a granuloma is would be a keloid of the skin.

Symptoms include mild (if any) hoarseness, mild intermittent pain on the side of the voicebox where the granuloma is located with talking/singing, rarely coughing up blood, and if large, shortness of breath.

Just like keloids of the skin, surgical removal alone is almost certainly going to fail with recurrence of the granuloma within weeks to months. All repetitive trauma to the area must be addressed to minimize risk of recurrence which is why restricted voice use must be pursued for several months (no loud talking/singing, talking ONLY when you must). Voice therapy helps to "teach" a person how to talk when they talk without causing further injury to the area. As such, botox injection to the vocal cord has been found helpful to semi-paralyze the vocal cords from coming together (chemically induced vocal cord paralysis). Reflux medications are necessary even if a patient has no symptoms as ANY acid exposure to the area is just as bad a trauma due to yelling.

Steroid injections are helpful to minimize the underlying exuberant inflammatory reaction that leads to granuloma recurrence and may need to be performed several times for effect.

To summarize, the steps followed when a granuloma-like mass is discovered on exam is as follows:

1) Trial restricted voice use and reflux medications. Voice therapy also strongly recommended.
2) If no improvement after a period of time, surgical excision to ensure it truly is a granuloma and not cancer or some other pathology
3) Follow-up with steroid injections to the granuloma site. Watch video below.
4) Botox injection can be considered which chemically prevents complete vocal cord adduction preventing the repetitive trauma to the granuloma site.

Read a Rolling Stone report here.

Read more about voicebox granulomas.

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Carbon Dioxide Helps with Nasal Allergies

MSNBC reported recently that a shot of carbon dioxide gas into the nose can help with allergies based on preliminary findings funded by Capnia, a company that makes the product.

Upside:
Symptoms of nasal allergies improved within 30 minutes.
No liquid is involved... just carbon dioxide gas.

Downside:
Lasts only 4 hours
80% has nasal discomfort after use
25% became teary eyed
14-20% developed headaches

My take?
I'll pass on this drug... There are already good drugs with minimal side effects that lasts up to 24 hours already on the market .

Read the story here.

Of note, some readers may point out that there is an older study that had better results. With two one-minute carbon dioxide treatments into the nose resulted in symptom relief within 10 minutes and lasted for 24 hours. Even with these results, I'll still pass... not sure how many people will go with 2 one-minute treatments when a 1 second swallow with an allergy pill or nasal spray use works just as good.

Reference:
Nasal carbon dioxide for the symptomatic treatment of perennial allergic rhinitis. Annals of Allergy, Asthma & Immunology - 19 August 2011 (10.1016/j.anai.2011.07.014)

Intranasal noninhaled carbon dioxide for the symptomatic relief treatment of seasonal allergic rhinitis. J Allergy Clin Immunol. Volume 121, Issue 1, Pages 105-109 (January 2008).

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Intranasal Treatment for Clogged Ears

A common cause of clogged ears with inability to pop them easily is due to eustachian tube dysfunction. There are a number of ways to address this annoying problem, but one of the first steps to try is intranasal medications whether in nasal spray form or nasal drop form.

The whole idea behind intranasal treatment is the fact that the ears are connected to the back of the nose via a tunnel called the eustachian tube. Watch video explanation.

Normally, when the ears are popped (also known as valsalva), the individual is opening up the eustachian tube to allow pressure and/or fluid in the ears to drain/escape out into the back of the nose. That's why when you blow your nose, you often hear a popping noise in the ears. Read more about how/why this happens here.

Patients suffering from eustachian tube dysfunction are unable to get the tunnel to open up. In this scenario, the pressure or fluid remains trapped in the ear. It's a plumbing problem in its essence.

Given the problem is the eustachian tube, intranasal medications are used to try and open up the tunnel and make it easier for the individual to pop the ears open.

Trick is... how to get the intranasal medications to where the eustachian tube is located in the very back of the nose.

There are a few ways to accomplish this... some which work better than others.

Method 1:
Use a nasal spray medication and aim the bottle to the back of the neck while keeping the head down (looking at the floor). The spray bottle MUST be perpendicular to the face. Why? Take a look at the diagram below:

If you aim the bottle towards the eye or top of the head, the medication is hitting areas of the nose where the sinus cavities are... not where the eustachian tube is located.

You have to look down and point the nasal spray bottle up towards the ceiling because all nasal spray medications use a straw that requires vertical orientation (same reason why when you drink Pepsi from a cup, the cup is upright).

Anatomically, the nasal spray "shoots" the medication straight up to where the eustachian tube is located.

Method 2:
Use an eye dropper and place a drop of the medication into the nose and have it "drain" to where the eustachian tube is located. Practically, this means filling a prescription of the nasal spray medication, opening up the bottle, and pouring the contents into an eye dropper.

This method requires positioning the head such that gravity will ensure proper movement of the medication to where the eustachian tube is located.

There are two ways to achieve this. This first way is the "Head-Tipped-Back Position".

In this position, the nasal drop will "fall" down to where the eustachian tube is located:

Mygind's Position is the alternative position which accomplishes the same thing, but the person is laying down looking up. For some people, this position is more comfortable than bending the head back.

Studies have shown that Method 2 (nasal drops) works better than Method 1 (nasal spray). However based on my personal experience in my patient population, Method 2 is not as well tolerated as Method 1. People often feel like drowning or suffocating when performing this maneuver (mini water-boarding so to speak). Also, it seems to be more irritating to the mucosal lining of the nose and throat.

And as we all know, if it is not comfortable or user-friendly, patients will not do it.

As such, I usually recommend Method 1 (nasal spray) which works "good enough". For patients who are ambitious and are willing, go with Method 2 (nasal drop).

Reference:
Techniques of Intranasal Steroid Use. Otolaryngol Head Neck Surg 130(1):5-24.
Intranasal delivery of drugs to eustachian tube orifice. The Journal of Laryngology & Otology (2011), 125: 934-939

Images taken from Techniques of Intranasal Steroid Use and Wikipedia.

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Best Medication for Dizziness

So how would one go about figuring out the best medication for dizziness due to motion-sickness leading to nausea and even vomiting?

Well, step 1... Put a bunch of people in a machine and figure out the necessary motions that will cause dizziness.

Step 2... Do the same thing, but this time, put people on different medications and figure out what works the best.

Sound crazy?

Well it has been done by the friendly folks at NASA. Why would they perform such unpleasant experiments? It's for the fighter pilots and astronauts who may encounter motion sickness where dizziness may mean the difference between life and death and have no alternative other than medications.

So what medication did they find works the best?

Through trial and error, they have found that a combination of oral scopolamine (not the patch), to suppress vomiting, and dextroamphetamine, to counteract scopolamine's potential to induce drowsiness, reduced the incidence of motion sickness from 70 percent to about 12 percent among passengers in the "Vomit Comet"—a DC-9 aircraft used to achieve brief periods of zero gravity as part of NASA's Reduced Gravity Program.

They have also found that conditioning (repeating movements that induce dizziness) over and over again does result in the development of tolerance to a motion environment in 95% of individuals.

Read more about this here.

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Earthquake Helps Man Regain Hearing... Perhaps Not!

Fox News reported on Aug 25, 2011 about Robert Valderzak who suffered conductive hearing loss for a few months... until the earthquake shook him and the rest of the East Coast after which he was able to hear.

Though this may sound miraculous, conductive hearing loss is one of those reversible type of hearing loss. It is not permanent. Example of conductive hearing loss include:

• Earwax
• Fluid in the ears
• Ear infection
• Eustachian tube dysfunction
• Problems with the middle ear bones

All these problems can be "fixed" and the hearing loss reversed. Permanent hearing loss is due to nerve damage and a reversal of a nerve type of hearing loss could be considered "miraculous."

Now how could an earthquake conceivably reverse a conductive hearing loss? Without benefit of having examined Mr. Valderzak, perhaps he had a lot of earwax and the quake "shook" the earwax out or free (kind of like when a person goes swimming and gets some water in the ear that requires head-shaking to get it out).

It could also be coincidence. There are thousands of people who suffer conductive hearing loss every day for one reason or other. Often, this type of conductive hearing loss will spontaneously resolve one day after days or weeks or even months go by even if not aggressively treated medically. That's why in kids who have fluid in the ears (which causes conductive hearing loss), we sometimes wait 3 months before we put ear tubes in. Quite a number resolve on their own spontaneously.

Now if there are thousands of people with conductive hearing loss and we expect a few to spontaneously recover their hearing each day... and the earthquake was felt by millions throughout the East Coast... I'm surprised that this particular patient is the only one who regained his hearing after the earthquake. I suspect there's at least a dozen that probably regained their hearing that day that the media has not heard/reported about... as well as the day before and the day after. I also suspect that there's probably a few hundred that "lost" their hearing during the earthquake due to earwax, fluid buildup in the ears, ear infection, etc.

Read the Fox New article here.

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New Webpage on Facial Paralysis

Our office has produced a new webpage on the evaluation and management of facial paralysis without any other symptoms.

Click here to read more about this condition.

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New Cartilage Can be Grown From Stem Cells Found in Adult Ears

Cartilage is found throughout the body giving shape to noses and ears and cushion for the joints. However when damaged, is not easily replaced which is why synthetic materials is often used to replace damaged cartilage.

However, Japanese scientists have grown new cartilage using stem cells found in the ear of all places. Specifically, the perichondrium which lines the cartilage of the ear. Perichondrium is also the layer under which a hematoma develops after ear trauma (ie wrestling) that can lead to cauliflower ear if left untreated.

The stem cells were isolated from the perichondrium and injected into mice where chunks of cartilage developed and remained still healthy after 10 months.

So rather than using artificial materials to reconstruct knees and noses, theoretically, stem cells can be retrieved from the patient's ear, injected into mice, cartilage grown and retrieved, and used to replace the damaged cartilage in the patient without worry of rejection.

Reference:
Reconstruction of human elastic cartilage by a CD44+ CD90+ stem cell in the ear perichondrium. DOI: 10.1073/pnas.1109767108

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Possible Cure for Common Cold And Other Viral Infections

For real... at least in mice, but has potential for human application if the promise holds out!

MIT researchers have developed a radical new approach to eradicating viral infections no matter what the virus may be... common cold, HIV, Ebola, polio, dengue fever, etc.

The usual anti-viral antibiotics in use today target the viral replication process which unfortunately often fails with time as the virus adapts and develops resistance to the medication.

The new medication dubbed "DRACO" (Double-stranded RNA Activated Caspase Oligomerizers) approaches viral infections using a totally different approach. It is able to IDENTIFY cells infected with the virus and KILLS the cell itself before the virus has a chance to take over the cell and create more virus copies. As such, the virus itself is not targeted, but rather the infected cells themselves instead.

To use an analogy, let's use an ant colony as the "viral infection". Current antivirals work by trying to pick off the Queen Ant or the ants themselves. DRACO works by destroying the entire colony. It doesn't care about individual ants or where they came from. All it cares about is the colony itself and initiates it's entire destruction.

For those more intellectually curious, DRACO is able to identify "double-stranded RNA" (ds-RNA) which is ONLY found in cells infected with a virus. One part of DRACO is able to identify and bind to this unique viral marker. The other part of DRACO is a protein that signals the cell to undergo suicide (apoptosis) thereby preventing the virus from hijacking the cell to make more virus particles. If a virus can't make copies of itself, no infection can occur.

Given ds-RNA is unique to viral infections, DRACO does not care what kind of virus it is (remember, it is not targeting individual "ants" to use the analogy). As such, whether it be the common cold or the dreaded Ebola virus, DRACO kills virus-infected cells indiscriminately. If no ds-RNA is present, DRACO remains inactive and healthy cells remain unharmed.

The tests reported in this study were primarily accomplished in cultured human and animal cells, but researchers also tested DRACO in mice infected with the H1N1 influenza virus. When mice were treated with DRACO, they were COMPLETELY cured of the infection. The tests also showed that DRACO itself is not toxic to mice.

More animal tests are underway and if all goes well... human trials may hopefully occur in the future!

Very promising!

Read a media report on DRACO here.

Reference:
Broad-Spectrum Antiviral Therapeutics. PLoS ONE 6(7): e22572. doi:10.1371/journal.pone.0022572

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What About a "Voice-Lift" with your Facelift?

I was informed about this interesting concept on ABC news...

With many aging baby boomers tapping into cosmetic surgery in order to look younger, some are taking it a step further to "sound" younger as well with a "voice lift".

For some, it's not right to look 10-20 years younger after a facelift but still sound like 70 years old.

A hoarse voice with aging is not unusual, but a surgical "voice-lift" is not necessarily the first step that should be taken.

First things first...

• Make sure the hoarseness is not due to something bad like vocal cord cancer. As a person ages, risk of cancer does increase especially if tobacco and alcohol use is present.

• Make sure there are no physical problems with the vocal cords like paralysis, polyp, cysts, reflux, etc.

Beyond that, vocal limitations often seen with the aging voice should first be addressed with voice therapy. Bowed vocal cords as well as compensatory muscle tension dysphonia are conditions often seen in this patient population causing a significant raspy voice and often respond quite well to voice therapy. Should voice therapy fail to resolve the vocal disquality, than surgical options can be considered.

What are the surgical options?

Just like a facial wrinkle may require a collagen injection to plump it up or a chin implant to address a receding chin, the vocal cord can also undergo collagen injections or receive an implant to plump it up and give it volume lost to aging which can lead to vocal problems.

Click here to read more about this procedure.

Click here to read the ABC new report.

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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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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.

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Snore Absorption Hotel Rooms

First hypoallergenic hotel rooms and now "snore absorption" hotel rooms. No kidding...

Crowne Plaza hotels have debuted on a trial basis specially designed hotel rooms to absorb the sounds of snoring. These hotel rooms utilize many different methods to accomplish this including:

• Sound proofing on walls to absorb the loud frequencies, deflect the sound waves and minimise the impact of snoring. The walls use egg box style foam which reduces the noise reverberating in the room
• A specially designed sound absorbing head board that will work together with the sound proof walling to muffle the echo within the room
• An anti-snoring bed wedge which acts as a body pillow, encouraging snoring guests to sleep on their sides or upright. Lying flat on your back makes the base of the tongue and soft palate collapse to the back wall of the throat which causes snoring
• An anti-snoring pillow which uses rare neodymium magnets to create a natural magnetic field, opening the airways and stiffening the upper palate which vibrates during snoring
• A white noise machine which is proven to help drown out the droning snoring noise and help sleep and relaxation

These specially designed rooms are being trialled in nine Crowne Plaza hotels across Europe and the Middle East.

Of course, there are a variety of surgical methods that can potentially cure a person's snore to make such rooms unnecessary.

Read more about these rooms here.

Read more about snoring treatments here.

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New Webpage on Peritonsillar Abscess Added to Website

Our office has created a new webpage on the evaluation and treatment of peritonsillar abscess.

Peritonsillar abscess is when a pus collection develops behind the tonsil causing a severe sore throat and trouble swallowing.

Read more on how this condition is treated 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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Speech Therapy Found to be of NO Benefit for Spasmodic Dysphonia

A recent study was published that has found that speech therapy had minimal if any significant beneficial effect on spasmodic dysphonia (a spastic vocal disorder) in a study cohort of 31 patients.

The study was divided in 3 patient treatment groups:

- One-third received no further intervention after botox injection which is considered standard of care in the treatment of spasmodic dysphonia
- One-third received a standard 5-week course of voice therapy after botox injection
- One-third received a 5-week course of sham voice therapy after botox injection

All patients regardless of treatment group experienced improved voice quality in response to botox injection.

However, patients who received voice therapy after botox injection did not experience longer injection effect duration or significantly greater improvements in vocal quality than patients in botox only or botox plus sham therapy groups.

Theoretically, it was felt that speech therapy could help reduce any muscle tension dysphonia that is often present in patients suffering from spasmodic dysphonia. However, this study does bring into question whether this actually happens.... or if botox alone eliminates the trigger and therefore the abnormal compensatory behavior making therapy unnecessary.

However, given the small study group size, more research is required to truly determine whether speech therapy has a role or not in the treatment of spasmodic dysphonia.

That said, voice therapy is THE main way to treat muscle tension dysphonia.


Reference:
Combined Modality Treatment of Adductor Spasmodic Dysphonia. J Voice. 2011 Feb 2. [Epub ahead of print]

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At Home Laser Hair Removal That Works

Without going into TOO much detail of how I know this... I have personally observed that the TRIA Laser Home Removal System 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).

The way laser hair removal works is that the laser beam is selectively absorbed by the hair follicle causing its death and destruction while preserving other skin structures. As such, the hair follicle needs to be as "different" a color to the skin around it in order for the laser to work. Otherwise, you end up burning the skin as well as the follicle. Depending on the laser used, different colored hair can be targeted on different colored skin. Because of this, the same laser can NOT be used for everybody.

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).

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.

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.

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Burning Tongue or Mouth Syndrome Due to Magnesium Deficiency?

Patients with burning mouth syndrome (BMS) have two major findings: one, burning sensations in their mouth and two, no anatomical changes present in their mouth to relate to this burning.

Dr. Henkin and colleagues at the Center for Molecular Nutrition and Sensory Disorders have clinically distinguished two major groups of patients with BMS. One group has burning limited only to their tongue – called GLOSSOPYROSIS. The other group has burning in their entire mouth, including their tongue, lips, palette, gums and pharynx – called OROPYROSIS. They have recently been able to distinguish these two patient groups biochemically.

Patients with GLOSSOPYROSIS have lower levels of magnesium in their red blood cells (erythrocytes) than do patients with OROPYROSIS or normal subjects.

Patients with GLOSSOPYROSIS have lower levels of magnesium in their parotid saliva than do patients with OROPYROSIS or normal subjects.

However, serum levels of magnesium and serum erythrocyte and saliva levels of calcium are similar in patients with GLOSSOPYROSIS, OROPYROSIS or in normal subjects.

These results suggest that patients with GLOSSOPYROSIS are magnesium deficient.

These findings does suggest magnesium supplementation to reverse the magnesium deficiency may be of benefit in patients with GLOSSOPYROSIS.

Courtesy of Dr. Robert Henkin of the Center for Molecular Nutrition and Sensory Disorders.

Reference:
Biochemical differences in parotid saliva distinguish patients with glossopyrosis from those with oropyrosis: Are there also neurochemical differences? The FASEB Journal. 2011;25:857.4

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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.

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Video of Endoscopic Salivary Stone Removal (Sialendoscopy)

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

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