CNN: Metallica Drummer Suffers From Tinnitus & Wears Earplugs When Performing

CNN on Dec 28, 2009 published a story on tinnitus (ringing of the ears) highlighting Metallica drummer, Lars Ulrich. Mr. Ulrich has suffered from tinnitus due to loud noise exposure and started wearing hearing plugs whenever performing to minimize further damage to his ears.

"Ulrich said he is concerned about young people, the so-called iPod generation, who listen to loud music, and may not be as vigilant about protecting their ears. 'If you get a scratch on your nose, in a week that'll be gone,; Ulrich said. 'When you scratch your hearing or damage your hearing, it doesn't come back. I try to point out to younger kids ... once your hearing is gone, it's gone, and there's no real remedy.'"

Our office sells ear plugs for musicians as well as hearing aids and other assistive listening devices. We also provide hearing tests.

Read the story here.

How To Persuade a Specialist to see a Patient Quickly!

With the advent of SmartPhones like the iPhone, communication between not only physicians but also patient-physician has become much easier.

To illustrate how such technology has eased communication in order for a patient to be seen quickly by a specialist was recently demonstrated when I received a phone call at home around 9:30PM from the Emergency Room regarding a facial fracture.

ER: Dr. Chang, we have a patient here who seems to have a facial fracture on CT. Overall, however, he does not appear to be in extreme discomfort and there does not appear to be any functional deficits.
Dr. Chang: Tell me about the fractures.
ER: It's a left zygomatic fracture. However, he is able to open and close the mouth as well as swallow without difficulty, so it's not emergent, but probably needs followup.
Dr. Chang: OK. What's his name? Tell him to come to my office in the morning at 9AM.
ER: Sounds great. Will let him know. His name is "John Doe" (not the patient's real name).

I than went to my home computer and loaded up his CT images to evaluate the so-called fracture. Often-times, most facial fractures do not require any intervention. However, some facial fractures, if severe enough, do require repair.

I loaded up the CT images and saw this (floating left zygomatic fracture):


Hmmmm. DOES need surgical intervention, but not something I can handle and this patient will need to see a specialist in facial fracture repair down at a tertiary care center like University of Virginia Medical Center. So, I take out my iPhone and take a picture of this relevant key image and email it to the facial plastic surgeon at UVA to arrange for an appointment (of note, no patient identifiers are included with the image to abide by HIPAA regulations).


Within a few hours, I get a reply back from the UVA plastic surgeon that this patient definitely needs surgical repair and that he would be able to see him the next day afternoon with surgery time blocked off for repair 3 days later.

The moral of the story is that technology is now good enough that given all information provided including radiological images (a picture is worth a thousand words), amazing things can happen, like get a patient seen in less than 24 hours by a sub-specialist who normally is unable to see new patients for 6-8 weeks. Without this image, it may have taken more effort and surgery may have been delayed by a week or two.

Patients can also do this if they are able to email their physician. It's not enough to provide only textual information which may not provide a compelling enough story... Include relevant images!!! Of course, you may need the help of a health professional to guide which images are most important.

It's worth repeating again...

Include relevant images!!!

The extreme importance of images is also why I ALWAYS want to see the CT scan images of any patients who comes in for an appointment and why patients should ALWAYS bring a copy of their CT scan burned onto a CD before seeing their ENT. A report is NOT good enough.

HOWEVER, the very importance of an image to a surgeon can be a double-edged sword as the image you send may PROVE that there's nothing significant going on to the point that a specialist may say that scheduling an appointment would not be worthwhile.

Recurrent Chronic Sinusitis Often Due to Allergies

A recent research paper published in the December 2009 edition of Archives of Otolaryngology Head & Neck Surgery lends credence that allergies may be a VERY important player in patients who suffer from recurrent sinus infections. Such patients will improve with antibiotics only to have their sinus infection symptoms recur shortly after completing the antibiotics.

In the research paper titled "Diagnostic Value of Nasal Allergen Challenge Combined With Radiography and Ultrasonogrphy in Chronic Maxillary Disease" (quite the mouthful), allergy exposure to patients resulted in a rapid and radiographically significant response of sinus disease including mucosal thickening and/or opacification. How fast? Within 60 MINUTES!!!

These findings lend support that should patients suffer from recurrent sinus infections that do not clear readily with antibiotics alone should be investigated for allergies. Furthermore, allergy testing and management should be performed in all patients considering sinus surgery. Why? Because if allergies are playing a role, opening up the sinuses via surgery will only exacerbate allergy triggered sinus infections.

What is our office protocol for evaluating patients with chronic sinus infections?

1) History supportive of recurrent sinus infections in spite of antibiotics as well as trial of allergy medications
2) CT Sinus documenting presence of sinus disease for surgical consideration as well as elucidating whether true sinus problems are causing the symptoms
3) Allergy testing (Our office performs RAST blood testing instead of skin prick testing)

If allergy testing is positive, aggressive allergy control is the first step prior to (or at the very least concurrent with) any other intervention including sinus surgery.

That's it! And research now supports this protocol we follow in our office.

Website That Calculates Your Cancer Risk From Radiological Tests

In the last few weeks, there's been multiple media reports on the increased risk of cancer with common radiological tests due to radiation exposure, however minimal it may be.

Due to this concern, a website called "X-Ray Risk.com" was developed that calculates your increased cancer risk based on type of test, age, and gender.

For example, a CT Neck (a common CT test ordered by ENTs) on a 35 year-old male increases cancer risk by 0.046%. A chest x-ray? Only 0.001%.

Check out the website here.

New Webpage on Submandibular Gland Surgery

A new webpage has been added to our website describing 3 different submandibular gland surgical procedures: sialolithotomy, submandibular gland resection, and sialendoscopy.

This webpage is the third in a series of webpages addressing salivary gland issues including sialadenitis (spit gland infections) and the parotidectomy surgical procedure.

New Treatment Options for Non-Acidic Reflux (LPR)?

It just came to my attention through anecdotal reports that there may be two additional options to treat non-acidic laryngopharyngeal reflux (LPR) causing symptoms of:

• Hoarseness
• Throat clearing
• Phlegmy throat
• Cough
• Globus (sense of swelling in the throat)

Non-acidic reflux is different from the more widely known acid reflux in that traditional medications such as prilosec, zantac, pepcid, etc do not help. Non-acidic reflux basically is when gastric secretions without acid refluxes up into the esophagus to as far as one's voicebox causing symptoms listed above. Heartburn does not occur.

Traditional treatments for non-acidic reflux include the medication reglan (which has gone out of favor) and gaviscon as well as the surgical option Nissen fundoplication. However, there are now anecdotal reports that the medication robinul forte may be helpful by decreasing the overall amount of secretions the stomach produces as well as less invasive procedures called Esophyx performed endoscopically without skin incisions.

Read more about reflux here.

New Webpage on Laser Tonsillectomy

A new webpage has been uploaded describing laser tonsillectomy given how often patients come to our office inquiring about it. We do NOT offer laser tonsillectomy and are not aware of anybody in our region who does offer. However, we are slowly compiling a list on the webpage of surgeons who do offer. If you know of somebody not listed, please let us know.

The closest surgeon to Virginia who offers laser tonsillectomy that we are aware of is Yosef Krespi in New York City.

We offer only coblation tonsillectomy.

Dr. Chang Invited as a Guest for Online Radio Talk Show

Dr. Chris Chang has been invited to participate as a guest in an hour long online radio show hosted by Trish Causey of Musical Theatre Talk. The radio show with Dr. Chang will be aired on January 10, 2010 at 5PM.

Two other members of the voice team that Dr. Chang works with will also be participating including Sarah Maines (singing voice therapist) and Melissa Mainville (functional voice therapist).

More details to come.

Second Stage (of 3) Office Renovations Completed

Over this past weekend, the second stage of 3 office renovations have been completed. One room has been renovated with new flooring, electrical work, paint, and furniture.

Electrical work was done by a friend whereas the other renovations were performed by Cornerstone & Son Construction, LLC. Furniture was purchased at Gerstel Office Furniture which is a fantastic place! They basically purchase furniture from companies that have gone bankrupt or undergoing renovations and sell them to the general public after refurbishing them at huge discounts.

Highly recommend both for pleasant services, being on-time, good price, prompt email correspondence, and excellent job overall.

The final stage will occur once all our paper chart medical records have been cleared out and this space changed to another use. Hopefully this will occur in the next 1-2 years.

New Video on Stopping Nosebleeds by Cautery

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

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

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Oral Appliances to Help Correct Obstructive Sleep Apnea (OSA)

In the November 2009 issue of ENT Today (vol 4; number 11), there was an interesting article titled "Evaluation and Management of Patients After Unsuccessful Sleep Apnea Surgery."

What I found particulary informative was the picture that came with the article which I have reproduced below. It is basically a list of all the companies who make oral appliances specifically for patients with obstructive sleep apnea. How nice!

Regardless of the company, they all have the same basic feature of having both an upper and lower occlusal guard which can be adjusted in order to bring the lower jaw forward to prevent obstruction due to tongue collapse. Though our office does not offer any of these devices, some dentists and oral surgeons do. There are also OTC oral appliances one can obtain (which of course do not work as well).

Website Updated Utilizing ReCAPTCHA To Avoid Spam Email

Our website over the past few months has been visited over 4000 times a day. Though such high numbers are great, the downside is that we have started seeing an increasing amount of spam email such that more spam is received than legitimate email.

In order to combat such spam, we have had no choice but to institute a system whereby our email address is hidden until 2 word images are correctly typed in. We have selected ReCAPTCHA to provide this service for two main reasons... it is free and by entering the words in the box, we help to digitize texts that were written before the computer age. Read more about this here.

Of course, we still have a secure email submission form which prevents spam as well as protects confidential private information.

Cheap Quality Prescriptions Thru Costco Pharmacy Mail Order

A patient recently brought this to my attention... but Costco Pharmacy offers very good prices on drugs, especially generics, even if a patient has no health insurance. Furthermore, you do NOT have to be a member to purchase these drugs! Even more importantly, the medications can be considered "good" unlike medications purchased from other online sources from Canada or Mexico.

For example, I searched for these drugs on 11/27/09 and these are the prices that came up:

Allegra 180mg
$79.19 for 30 (Brand Name)
$36.18 for 30 (generic)

Prilosec 20mg
$158.13 for 30 (Brand Name)
$15.18 for 30 (generic)

Flonase
$87.36 for 1 (Brand Name)
$15.28 for 1 (generic)

Of course, with insurance, these prices may be even cheaper!

Check it out here. Click on pharmacy at the top and than look for the "Prescription Price Checker" link.

What Is a Pulmonary Stress Test?

At least in the ENT world, a pulmonary stress test is a very useful test when evaluating a patient with symptoms of shortness of breath, stridor, and/or wheezing that occurs only when exercising. The most common reason for an ENT evaluation in these patients is to determine whether paradoxical vocal cord motion is occurring or some other pathology such as tracheomalacia or laryngomalacia. Usually, the patient has already undergone extensive pulmonary testing for asthma and allergies with everything being normal. Even use of inhalers has not been found to be helpful.

The most difficult part of the evaluation in these patients is to perform the exam WHEN the patient is actually having symptoms (ie, during exercise). Doing an evaluation when without symptoms usually results in a normal exam (not surprisingly).

That's where the pulmonary stress test comes in. The philosophy behind this test is to allow for an evaluation when the patient is actually having symptoms.

Under a controlled situation, the patient is asked to start exercising on a treadmill or bicycle. Heart rate, EKG, respiratory rate, etc are all monitored during exercise. When symptoms of stridor or shortness of breath occur, the ENT performs a fiberoptic laryngoscopy exam on the spot to evaluate vocal cord motion and laryngeal structure. In some cases, even awake bronchoscopy may be performed to look for tracheomalacia.

Our office in cooperation with Fauquier Hospital offers this service.

Image taken from wikipedia.

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.

Taking Tylenol and Ibuprofen Also Has A Potential Risk of DEATH!

The New York Times in July 6, 2009 published an interesting article regarding the potentially fatal risk of taking tylenol and ibuprofen. The story titled "Reasons Not to Panic Over a Painkiller" states that tylenol (due to liver damage) kills about 400 people and hospitalizes about 42,000 every year in the United States. Ibuprofen is even worse. More than 100,000 Americans are hospitalized each year with complications associated with ibuprofen and an additional 15,000 to 20,000 die from ulcers and internal bleeding linked to their use.

The reason I am mentioning these facts with such a ubiquitous medication like tylenol and ibuprofen is because many patients have a distorted sense of what is risky and what is not. I had one parent who refused to give her child zyrtec or benadryl for severe allergies as she did not want to "add poison to her child's body." Though such sentiment is usually laudable (and in some cases, even encouraged by me), in these particular cases, it's odd to say the least, mainly because she was giving her child repeated doses of motrin and tylenol for symptom relief. As far as I know, zyrtec and benadryl has not killed anyone. Tylenol and motrin have... many times.

Or get this... the average woman puts on herself 515 chemicals on her body everyday through self-inflicted use of body and facial moisturizers, perfumes, deodorants and various other make-up products. Click here to read more on this.

There are many other such examples, but it is always nice to have in perspective that even supposedly "safe" medications really aren't safe if taken improperly.

Read the NYT story here to read more about the risks of tylenol and ibuprofen.

Machine Gun Sneezing

ABC News on November 11, 2009 aired a story about a 12 year old girl with an unfortunate condition called "machine gun sneezing". Apparently, she sneezes up to 16 times a minute all day except while sleeping and started after recovering from a mild cold.

To be frank, it's a condition I've never seen before.

Per an allergist interviewed for this story, the condition is extremely rare and "can be triggered by hundreds of causes, including allergies, sinus problems, or growths in the nasal passage."

Read more here. A video of the report can also be found at the link.

This girl was eventually found to have a diagnosis called PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus)! Read more here.

NYT: Single Gene Mutation Allows Humans to Talk and Not Animals

In the Nov 11, 2009 New York Times Science section, a story has been published titled "Speech Gene Shows Its Bossy Nature" where a single gene known as FOXP2 has been found to be responsible for speech (or lack thereof). All animals have an FOXP2 gene, but the human version’s product differs at just 2 of its 740 units from that of chimpanzees, suggesting that this tiny evolutionary fix may hold the key to why people can speak and chimps cannot.

Read more of the story here.

Google Flu Shot Finder

The brainy folks at Google has been at it again... Not only did they produce a map showing the flu trends in the US... but now they have produced a Flu Shot finder based on zip code for both seasonal as well as H1N1 vaccines. The locations are displayed on their Google Maps page.

Check it out here!

McGovern Nipple for Infants Born Unable to Nasally Breathe

I recently received a phone call regarding a newborn who the pediatrician suspected had bilateral choanal atresia. This is a situation in which the infant is not able to breath through the nose. This inability to nasally breath is a major problem because newborns are obligate nasal breathers (newborns do not know how to mouth-breath unless they are crying).

As such, there are two options to immediately perform in order to allow a newborn to breath to stay alive. Intubate... or place a McGovern Nipple. A McGovern Nipple is made by (see picture below):

1) Cutting off the tip of the nipple used in a milk-bottle creating a hole about 1cm in size. Try to preserve as much length as possible!
2) Inserting the nipple into the newborn's mouth
3) Placing a surgical mask such that the mask part is behind the baby's head and using the strings to keep the nipple in place inside the infant's mouth.

This forces the newborn to mouth-breath. Without this contraption, the child will literally suffocate.

I have specifically created this blog article because I had a lot of problems trying to find a picture of this contraption to show the pediatrician. Hopefully, this will make it easier for others to figure out what the heck a McGovern Nipple is and how to make and use one.

The only way to definitively correct this problem is by surgically removing the blockage that is blocking the infant's nasal passage.



Source:
Cummings Otolaryngology Head & Neck Surgery 4th Ed. Chapter 178: Congenital Malformation of the Nose. Volume 4, Page 4101.

RANDOM: Washington Post Cartoon Making Fun of ENT

A patient of mine brought the funnies from the Oct 28, 2009 Washington Post of a cartoon by John McPherson poking fun at ENT.

New Voice-Mail Phone # for Patients With Difficulty Hearing

Due to patient demand, we have established a voice-mail phone number that our patients who have difficulty communicating over the phone due to hearing loss can call and leave a precise message on a voice mail. This service is available everyone whether new or established with our office.

This avoids frustration and difficulty communicating when talking to our front desk (because you can't hear what we say over the phone).

We will check this voice mail several times a day.

The Audiology Voice-Mail phone number is: 540-316-0588

Of course, if you want to talk to a staff member, you can still call our regular main office number at 540-347-0505.

Washington Post Medical Mystery: Rare Severe Sore Throat Caused by Lemierre Syndrome

On Nov 3, 2009, the Washington Post Medical Mystery section published a story titled "Annoying bug turned out to be much more" where a 19 year old female presented with a sore throat which rapidly progressed to a blood clot in her jugular vein, pneumonia, and massive swelling in her neck.

What she ended up having was "Lemierre syndrome" suspected by the diagnosing doctor at Georgetown University Medical Center based on the two telltale symtoms of a jugular infection and presence of a blood clot.

Read the story here.

USA Today on Hearing Aids

USA Today on November 2, 2009 published a story entitled "Your Health: Hearing aid guide cuts through the noise" in which best practices for buying a hearing aid is discussed. For the story, Dr. Debara Tucci at Duke University Medical Center was interviewed.

The advice is summarized by an FDA online guide (at fda.gov, click on "medical devices," then "hearing aids") that includes suggestions on how to get your hearing evaluated, how to choose a device and how to get it properly adjusted.

Our practice provides the full spectrum of hearing aid evaluation as well as hearing aid dispensing services (selling, repair, accessories, etc).

There's Always Someone With a Bigger Mouth

Continuing the spirit of Halloween with semi-relevant ENT random news...

Someone forwarded me this picture of a TEN foot great white shark which was bitten by an even bigger great white shark. Apparently, the poor shark was still alive when it was captured in Australia.

Click here to read the story and watch a video!

Crazy Pumpkin Carvings Related to ENT

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




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




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

Nasal Endoscopy to Evaluate Hoarseness on Dr. Oz Show!

On Oct 23, 2009, Dr. Oz (his show) with the assistance of Dr. Jonathan Aviv, demonstrated a procedure called Nasal Endoscopy which is the main method of evaluating a patient with hoarseness. A pretty good and accurate demonstration I may add.

Watch the video clip here.

Of course, I have produced a few video clips of the same of which one can be viewed below. Click here to watch one being performed on a child. Read more about this procedure here as well as what happens when the voice doesn't sound normal here.

Why Does Brain Freeze Occur With Eating Ice Cream and Other Cold Treats?

Believe it or not, this has been the topic of research in the past and even has a medical diagnosis called "sphenopalatine ganglioneuralgia". To sum it up, there are two theories behind this phenomenon:

1) Blood vessel phenomenon: Blood vessels constrict when any part of the body is exposed to cold temperature and dilates when it gets hot. This simple fact can be applied to the biological cause of brain freeze as well. Upon contact with ice, the blood vessels in the roof of the mouth begin to constrict, making the vessels in the head to expand, and thus creating a headache.

2) Trigeminal nerve factor: The trigeminal nerve, or cranial nerve 5 (CN5), is responsible for facial sensation. As a result of eating cold foods, this nerve in the palate of the mouth becomes overstimulated. Stimulation of the nerve causes neurons to fire pain signals to the brain, producing a headache.

Is there a cure? Avoid the culprit cold treat that triggers the pain or eat is slowly. Should you suffer from a brain freeze or sphenopalatine ganglioneuralgia, drink warm fluid or just wait!

Read the research behind these theories:
• Ice cream headache--site, duration, and relationship to migraine
• Ice cream evoked headaches (ICE-H) study: randomised trial of accelerated versus cautious ice cream eating regimen

Possible Dystonia (Rare Neurological Condition) After Flu Shot

Desiree Jennings, a former Redskins cheerleader, received a seasonal flu shot on Aug 23, 2009 and has suffered from a possible dystonia reaction from the flu vaccination resulting in difficulties in eating, talking, and walking.

Here is a link to a video where Dr. Stephen Grill (neurologist) is interviewed by Fox News regarding Desiree's condition.

Here is a video/article of the initial story.

This story is a case of a VERY unfortunate EXTREMELY rare side effect (if true) of the flu vaccine. People should still get the flu vaccine, but be aware that it is not 100% benign in all cases.

However, it seems that Desiree's flu shot reaction may have been psychogenic (and not a true side effect of the vaccine at all). Read this blog article which goes into this in more detail.

Regardless, people have developed rare neurological conditions called laryngeal dystonia otherwise known more commonly as spasmodic dysphonia. The way Desiree talks (from what I can hear from the videos) is distinctly different from patients who suffer from classic spasmodic dysphonia. Click here to hear what laryngeal dystonia/spasmodic dysphonia sounds like.

(Of note, I received both the seasonal and the H1N1 vaccine and have encouraged all my friends, family, and patients who inquire to do so as well.)

Our Office Has Been Renovated!

I have been hard at work all weekend with the generosity of friends as well as services of furniture reupholsters and general contractors. The waiting room as well as Exam Room 1 has been renovated for the better!

It has been a sore point for me that the walls of my waiting room have been drawn upon with crayons by errant kids. Once one kid has drawn upon it, the other squiggles soon followed (Same kid or different kids? I have no idea).

In any case, they are no more. The walls of the waiting room have been repainted in a two-tone color (sandstone/taupe) giving it a much warmer appearance than before. Furthermore, the waiting room chairs have been reupholstered with pleather to make it easier for cleaning.

Exam Room #1 has also been redone by reducing the space required by the built-in desk to half the size allowing for more free space for movement. The broken electrical outlet has also been fixed eliminating the need for an extension cord for the computer (a real eye-sore).

For those curious, the waiting room chair reupholstering was done by Miller Restorations and the exam room renovations by Cornerstone & Son Construction, LLC. Highly recommend both for pleasant services, being on-time, good price, prompt email correspondence, and excellent job.

Hopefully in the next 6-12 months, further office renovations will be pursued to take advantage of additional office space freed up by the disappearance of paper chart racks now that we've been using EMR the past 2 years.

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.

AP: HHS Secretary Had Skin Cancer (BCC) Removed From Forehead

Associated Press reported today (Oct 22, 2009)that Health and Human Services Secretary Kathleen Sebelius had a Basal Cell Carcinoma (BCC) skin cancer removed from her forehead. Read the article here.

BCC is a very common type of skin cancer that is often curable by complete excision. Often, this procedure is done in the office setting.

Of note, our office regularly performs skin cancer excisions of the head and neck regions.

Nasal Irrigation Beneficial for Pregnant Women With Allergies

Italian researchers have reported in the International Archives of Allergy and Immunology in Sept 2009 that saline nasal rinsing is a safe and effective treatment option for nasal problems in pregnant women with seasonal allergic rhinitis. In their paper titled "Nasal Lavage in Pregnant Women with Seasonal Allergic Rhinitis: A Randomized Study," the researchers instructed the study group to perform hypertonic saline lavages to the nose 3X per day. Of note, HYPERTONIC saline solution was used instead of the more usual isotonic saline solution.

A statistically significant improvement in rhinitis symptoms (rhinorrea, obstruction, nasal itching and sneezing) was found during the observed weeks 2-6. Furthermore, the mean number of daily antihistamines use per patient per week was significantly reduced at weeks 2, 3 and 6. No adverse effect was reported in the active group.

Read the abstract here.

In our office, we recommend the Neilmed Sinus Rinse bottle as the cheapest and most effective way to perform nasal irrigations. Of note, the Neilmed sinus rinse bottle also comes with hypertonic saline version (along with the more common isotonic version). For convenience, irrigation devices (shown below) are also sold, but much more expensive.

Click here to watch a video of how to perform nasal rinses.

WSJ: FDA Approves Gardasil for Boys (and Girls)!

This was reported by the Wall Street Journal on Oct 16, 2009. Why is this significant from an ENT perspective?

Well, gardasil is supposed to vaccinate people from getting HPV related diseases like genital warts which would help both genders when individuals become sexually active. Of more note, it has been specifically shown to help prevent cervical cancer in females which is a big killer of women.

However, it may potentially prevent other types of HPV related disorders involving the head & neck in both men and women (which has not been studied, but likely to still help), including:

Respiratory Papillomas (benign)
Throat Cancer
Oral ulcers/lesions/warts (benign)

In order to receive the beneficial effect of the vaccine, the vaccine needs to be given in 3 doses (at $130 per dose) between ages 9-26.

Read the WSJ article here.

Botox Treatment for Vasomotor Rhinitis (Idiopathic or Non-Allergic Rhinitis)

A new research paper has been published Oct 16, 2009 in Head & Face Medicine entitled "Minimally invasive application of botulinum toxin A in patients with idiopathic rhinitis" in which researchers successfully treated patients with a persistent runny nose not due to any known problems like allergy. Such a condition is called vasomotor rhinitis or idiopathic rhinitis or non-allergic rhinitis.

In this new described method of treatment, a sponge soaked with 40 Units of botulinum toxin type A was inserted into a patient's nose and left in place for 30 minutes. Apparently, this did result in a significant reduction in rhinitis (but not congestion) and lasted for as long as 12 weeks.

Read the abstract here.

Of course, this is a non-FDA approved use of Botox.

Historically, this condition is often treated with nasal sprays (ie, astelin) and decongestants with some success in some patients, but not all patients respond.

Surgical treatment include turbinate reduction which reduces (usually about 50%), but does not cure this condition.

Before you ask... NO we do not offer this procedure until further research and data becomes available.

MRSA Sinusitis

There seems to be an increasing number of patients I see with MRSA sinusitis. Not many, but definitely not rare. These patients are understandably very concerned with how to treat their MRSA sinusitis.

Beyond the usual protocol that applies to any MRSA infection, if the sinusitis is severe, sinus surgery is recommended for 3 main reasons.

1) Get the infection cleaned out surgically (much like draining an abscess of the skin)
2) Enlarge the openings of the sinus cavity to allow good post-op topical treatment in order to potentially avoid oral and IV antibiotics (though they still may be needed)
3) Sinus infection can be carefully followed endoscopically in the future

By opening up the sinuses, topical treatment can be performed that is sometimes more effective that IV or oral routes as higher concentrations of medication can be delivered right to the area of concern (instead of oral or IV routes which go throughout the entire body causing side effects).

Such topical treatment include:

• Saline flushes (Neilmed Sinus Rinse is our preferred method though irrigation devices shown below are also fine)
• Bactroban Cream or Cortisporin Ointment injection directly into the sinus cavity
• Antibiotic flushes to the sinus cavity
• Chemical saline flushes to the sinus cavity (my favorite being No-Tears Johnson's Baby Shampoo - 1 tsp in 250 cc of saline)

Debridement of the sinus cavity can also be easily performed after sinus surgery in the office.

Once the active MRSA sinusitis infection has cleared, continued topical treatment with daily saline nasal flushes help prevent future sinus infections.

Tionne "T-Boz" Watkins Suffered from Acoustic Neuroma (Brain Tumor)

It was revealed in Oct 2009 that celebrity Tionne "T-Boz" Watkins of TLC fame (Celebrity Apprentice), that she was diagnosed with a type of benign brain tumor called acoustic neuroma. She underwent surgery in 2006 to have it removed and experienced a difficult recovery especially with balance.

One of the earliest symptom of this type of brain tumor is an asymmetric sensorineural hearing loss (ASNHL) or a sudden hearing loss only in one ear (SSNHL). This type of unusual hearing loss is when one ear hears much worse than the other and can only be diagnosed on a hearing test audiogram. Should ASNHL be found on audiogram, an MRI scan of the Internal Auditory Canal with gadolinium contrast is often ordered to evaluate further. An ABR (auditory brainstem response) test may also be ordered instead of MRI, but is not considered as good a test.

Should an acoustic neuroma be found, the surgery to remove it is usually performed jointly by a neuro-otologic surgeon as well as neurosurgeon. In our area, there are only a few surgeons able to perform this type of surgery including Drs. Kesser and Hashisaki at University of Virginia as well as Dr. Bryan McKenzie in Fairfax, VA. Our office can evaluate and diagnose, but we are unable to perform this type of surgery.

Read more about Tionne's struggle here.

Saline Nasal Sinus Irrigation Systems

I must admit... our office is a big fan of the Neilmed Sinus Rinse bottle for patients who suffer from chronic sinusitis and severe allergies as it is cheap, easy to clean, and it works. However, many patients who are already fans of flushing the nose with saline water end up purchasing saline irrigation systems. There's a bunch of these devices sold on Amazon.com. Check them out below, but I would suggest that you first become adept and able to tolerate saline flushes using the Neilmed sinus rinse bottle first prior to paying almost $100 for these devices.

Egg Allergy and the Flu Shot

Several patients have called our office asking whether it is safe to receive the flu shot if they are egg allergic. Generally speaking, for most patients, the blunt answer is that it is safe.

The flu shot vaccine (both H1N1 and seasonal) are egg-based from which this concern arises. It also doesn't help that the pre-flu shot questionnaire specifically asks about egg allergy. Though egg-based, most of the egg protein is filtered out such that there are no egg contaminants. However, it is possible that some egg is present in a vaccine.

To play it safe, the absolute safest way for a patient with egg allergy to get the flu shot is via a few steps:

1) Get a test dose of the flu vaccine where a small amount (0.025cc typically) of the flu vaccine is administered sub-dermally.
2) Wait 10-20 minutes.
3) If there's no reaction (redness and swelling of the skin), get the shot properly into the muscle.
4) If there's a large wheal reaction, it's probably best not to get the flu shot or see an allergist to get desensitized prior to receiving the injection.

Not all practices may be familiar with these particular steps. If that's the case, request to take the flu vaccine to an allergy office (including ours), and have us administer it. (Please note that we do not provide egg desensitization.)

If you are only IgG allergic and not IgE allergic to egg, no need to worry. Get the flu shot.

For a more in depth discussion, click here to read a document prepared by the American Academy of Allergy Asthma & Immunology.

New Video Produced on Proper Ear Drop Administration

We have recently produced and uploaded on to our YouTube channel a new video describing how to properly administer ear drops. This video is especially pertinent in patients who have ear tubes.

Watch the video below:

TWO Ear Canals in the Same Ear!

I recently saw a patient who had a complaint of having two ear canals in each of the ears. To my surprise, the patient had exactly that! You can see the second ear canal in the picture below... it is above the normal one and is about 25% the size.

To those in the know, this is due to a congenital birth defect related to the first branchial cleft.

Read more about this birth defect here. Clearly, the way to correct this is surgical.

LA Times: Driving a Convertible May Cause Permanent Hearing Loss!

The LA Times published a story on Oct 6, 2009 entitled "Cruising with the top down? Cover your ears" describing research that assessed noise levels in seven different scenarios where the convertible was traveling at speeds of 50, 60 and 70 miles per hour. Researchers found that drivers were consistently exposed to noise levels between 88 and 90 decibels. Even with the windows up, the noise levels were found to be at 82 decibels.

To keep these findings in perspective, repeated exposure to noise over 85 decibels can result in permanent hearing loss.

To make things even worse, because there is surrounding noise from other vehicles especially in traffic, driving more slowly may end up being just as loud as when driving more quickly.

These findings may be a big bummer for those who love to drive convertibles, but driver beware!!! Perhaps these drivers need to wear ear plugs whenever the top is down.

Read the story here.

NYT: Does Snotty Colored Discharge Require Antibiotics? No!!!

The New York Times published a story on Oct 6, 2009 entitled "The Claim: With a Runny Nose, Green Calls for an Antibiotic." It actually is a pretty good article though I'm not sure how much impact this will have in clinical practice.

The story reports that green discharge from the nose is NOT indicative of a bacterial sinus infection and as such, this symptom should not be the sole reason why antibiotics should be prescribed.

It does reference a research paper that backs this claim up. There are others.

In any case, the last sentence of the story is worth reiterating: "THE BOTTOM LINE: The color of nasal discharge should not dictate the medicine."

Not sure how accepting patients will be of this factoid given how ingrained colored discharge has been equated with sinus infection.

I personally have encouraged saline nasal flushes starting from as early as 5 years old as the main treatment for this issue which some patients have been more accepting than others.

Treatment of Chronic Draining Ear Infections Using Antibiotic Powder

Rarely, some unfortunate souls have chronic draining ear infections that do not respond well to oral antibiotics nor antibiotic ear drops. What many people and even physicians are unaware of is that there are alternative ways of addressing the chronic draining ear including use of antibiotics in powder form.

The method I like best is by using the Sheehy-House Powder Insufflator Bulb.

The pharmacy will make up gelcaps containing antibiotics (anti-bacterial as well as anti-fungal) and even steroids (usually hydrocortisone).

One first removes the tip of the insufflator bulb.



Than open up the gelcap such that the powder is all in one side and insert into the insufflator tip compartment.



Than replace the bulb tip.



During an active infection, the powder is "puffed" into the ear twice a day. Once back to normal, one puff weekly prevents the ear from becoming infected again. This method eliminates adding more "moisture" to the ear (as when happens when using antibiotic ear drops) as the powder not only addresses the infection, but the drainage itself becomes a medium for the antibiotic powder to do its thing.

Keep in mind that this method requires a prescription and the gelcaps must be compounded. As such, not all pharmacies may be able to fill and not all health insurances will cover compounded medications.

USC Stafon Johnson Crushes His Voicebox & Undergoes Emergency Surgery

News organizations including ABC News reported on Sept 28, 2009 that USC tailback, Stafon Johnson, was bench-pressing a 275 pound bar when it slipped and landed on his neck crushing his voicebox resulting in emergency surgery at California Hospital Medical Center. Read the story here.

An endoscopic exam of his voicebox at time of injury may have looked something like this picture shown here, but more severe.


Most likely a trach was performed for a secure airway after reconstruction. After recovery, he is at risk for vocal cord paralysis, stenosis, etc.

Click here to read the full story.