TV Show HOUSE Exploring ENT Problems

I must clarify that I never really like TV show House for reasons explained here... but patients who love watching House have alerted me to some episodes this season that touched on ENT problems.

So... here goes...

Episode 21 (Season 8): Holding On
Diagnosis: Persistent Stapedial Artery

19 years old cheerleader was admitted after suffering from dizziness, massive nosebleed, and auditory hallucinations. It was ultimately determined that he was suffering from a persistent stapedial artery.

This artery is a congenital defect of the inner ear that should have obliterated during fetal development. However, if persistent, is typically found going through the stapes bone of the middle ear.

It CAN cause symptoms of dizziness as the pulsations of the artery can transmit through the stapes footplate and into the vestibule via the oval window. It can also cause auditory hallucinations by pressing against the nearby temporal lobe as well as a nosebleed. If the artery ruptures, it can only drain through the eustachian tube and out the nose.

However, if the patient presented to the ER with nosebleed and dizziness, a complete physical exam would have been performed and a clearly seen blood-filled middle ear cavity (hemotympanum) would have been seen that even a medical student would have found. That would have indicated an ear issue causing both the dizziness and nosebleed. Also, the patient would have complained of hearing loss with blood in the ear.

From that point, the differential diagnosis is actually quite small and would have been obtained relatively easily.

Episode 17 (Season 8): We Need The Eggs

Diagnosis: Amoebic Meningitis

35 years old man admitted to House’s service after he is discovered crying blood. He later develops light sensitivity, vomiting, and a stiff neck.

After suspecting meningitis, it was discovered that he was using a Neti Pot and was using tap water rather than distilled or sterilized water in order to perform saline flushes. The water happened to contain an amoeba (likely Naegleria fowleri) which caused an amoebic infection of the brain.  The culprit organism Naegleria fowleri causes a life-threatening encephalitis after passing thru the nose and up into the brain where the organism eats neurons for food.

Such brain infections have been recently reported in the news and can be prevented by using water that is boiled, distilled, or filtered.

Fortunately, it is rare.

TV Show SMASH Portrays Ivy With Vocal Issues

In last night's episode (Episode 106: Chemistry) of the new hit TV drama SMASH, the main character Ivy who plays Marilyn Monroe in the show developed laryngitis that affected her ability to sing clearly, especially in the high registers. However, her speaking voice did sound normal.

To treat this condition, she was given prednisone which did help her voice, but suffered unfortunate side effects of mood lability, hallucinations, insomnia, etc.

Did the show accurately portray what actually happens in real life?

Yes...

Laryngitis

Ivy probably did suffer laryngitis, but more in the sense of pre-nodule formation (otherwise known as vocal cord swelling) from vocal overuse given how much singing she has been doing. With such "pre-nodule" formation, the singer is able to sound perfectly normal when talking, but suffers from pitch breaks and onset delays in the high range, especially when singing quietly. Watch a video and audio demonstrating this phenomenon.

I should also point out that this problem is also under-recognized by medical professionals including ENTs... When such singer/patients with vocal cord swelling present complaining of hoarseness, they sound normal... talk normal... and for all intensive purposes seem to be making up their perceived raspy voice.

A simple test to demonstrate vocal cord swelling is to have the singer sing a song at a high pitch (octave above middle C), but to sing the song very quietly. I typically have patients sing Happy Birthday. Listen for any vocal quality problems.

Even though the vocal issue is only in the high range, for professional (and amateur) singers, such "minor" vocal raspiness is a HUGE problem. Consider this... if this patient is singing a solo for a performance where there's several hundred people in the audience... it's hard enough to sing a solo just from nervousness. Now add the concern that you have no idea what your voice is going to do in that one part of the song where it goes high. Confidence is key to a good performance and with an undependable voice, confidence is lost and the performance overall suffers.

Prednisone

Is prednisone really as good as the show suggests? Yes... including the side effects, though they did stretch the side effects some.

Typically steroids provide almost immediate (within 4-12 hours) resolution of vocal cord swelling and inflammation. Problem is, it only works for a short period of time.

I typically prescribe decadron rather than prednisone as I feel it works faster, better, and more reliably than prednisone. I also prescribe it judiciously.

Judiciously means I prescribe it if there's a single major concert or single audition that is very important to the singer. I typically prescribe a single large dose to be taken the night before.

If it is a singer who is undergoing a series of auditions over a short period of time, I may prescribe a week long course of steroids to maintain its good effects.

The USUAL common side effects are reflux, insomnia, mood lability, and jitteriness. However, for those who are sensitive to medications can suffer many of the side effects experienced by Ivy.

NOW... for the problem with steroids beyond the side effects... Its effects are temporary and the better way of treating vocal cord swelling is behavioral changes as one can't just keep prescribing steroids indefinitely. It is much like giving morphine to a football player to mask the pain of a sprained ankle so he can still keep playing football. MORE vocal injury can occur while taking the steroids!

With steroids, I usually also recommend restricted voice use (strict voice use is even better). What this means is talk ONLY when you MUST talk and with low energy if you do. NO social talking, no whispering, no yelling, no raising voice, etc. Strict voice rest is when you are not even talking at all.

Also, work with a singing voice therapist.

The Doctors TV Show Does Adenoidectomy

Dr. Nina Shapiro was the featured otolaryngologist when The Doctors television show discussed nasal congestion as well as large adenoids. A sanitized view of adenoid removal surgery was also shown.

For a more detailed view of the surgery, click here.

For more info on adenoids and its surgical removal, click here.

Dr. House of TV Fame Would Never Survive in Real World

Would YOU as the patient see a doctor who is a well-known jerk, abuses drugs, gives the wrong diagnosis more often than not, and is known to like ordering very invasive tests??? Be honest...

The other week, a patient with a chronic cough exclaimed to me that she wished the fictional character Dr. House of TV fame actually existed in real life, because he was somebody who can diagnose anything.

I looked her straight in the eye and told her that somebody like Dr. House in the real world would be a physician nobody would want to see for many reasons:

1. In the real world, patients expect doctors to have the correct diagnosis from the beginning (might forgive one wrong diagnosis). Dr. House seems to always get things wrong multiple times before he gets it right. I seriously doubt most patients would have stuck around as long as they do on the TV shows before going elsewhere.
2. In order to achieve that correct diagnosis, Dr. House seems to pursue invasive tests which in reality is something patients rarely like to pursue... and often get second opinions to determine if really needed.
3. Dr. House is fairly abrasive with his colleagues and even with his own patients which pretty much guarantees one star ratings on physician rating websites like HealthGrades.com and Vitals.com.
4. Dr. House is addicted to vicodin, morphine, and cocaine... That pretty much guarantees loss of hospital privileges and perhaps even his medical license to practice in the real world. Furthermore, what would you do as a patient if you found out that your doctor abuses drugs??? Most will go elsewhere.

So given what I know patients want in reality, it boggles my mind why patients in the real world think Dr. House is so great and wish a fictional character like him truly existed.

To flip things around... the real question is why aren't real world patients more forgiving of physician fallibility like those on TV? I'm the first to admit that physicians (in the real world) are not perfect though the expectation is that we are.

The Doctors TV Show Does Chronic Throat Clearing

The Doctors TV show recently did a segment on chronic throat clearing. The ENT expert who explained this very annoying condition was Dr. Reena Gupta, a well-respected laryngologist with the Osborne Head and Neck Institute.

During this TV show, Dr. Gupta provided the two most common reasons for chronic throat clearing which were post-nasal drainage and reflux.

At its most basic explanation, mucus can come from the nose down into the throat (post-nasal drainage) OR mucus can come up from the stomach into the throat (reflux). The end-result is a person desiring to throat clear the mucus up and out.

However, there are other causes which were not addressed by Dr. Gupta during the show.

Other reasons for chronic throat clearing include:

Medication Side Effect
Food Allergies or Sensitivities
Zenker's Diverticulum
Laryngeal Sensory Neuropathy
Anatomic Triggers
PANDAS
Non-Organic Tic

Read more about chronic throat-clearing here.

Watch the TV show segment here.

The Doctors TV Show Does the Mouth

The Doctors TV actually got something totally right!

Actually there are two segments here... One on the mouth followed by another on what happens when food/liquids go down the wrong way causing a reflexive cough.

Enjoy!

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.

NCIS Character Tony DiNozzo Gets Acute Laryngitis

On October 19, 2010, there was a CBS episode of NCIS (Naval Criminal Investigative Service) called "Cracked" in which Special Agent Tony DiNozzo developed acute laryngitis.

The show's chief medical examiner, Dr. Ducky Mallard, examined Special Agent Tony DiNozzo and instructed him on strict voice rest for 24 hours which Tony ignored.

If I was on the show, I would have performed a much more thorough examination that would include fiberoptic laryngoscopy (and/or stroboscopy) in which the vocal cords could be directly examined as shown in this video:

Based on his hoarseness, lack of productive cough, and acute onset, I suspect Tony developed acute VIRAL laryngitis. Here's an example of what I suspect I would have seen on laryngoscopy if one was done (video is actually stroboscopy, a much more intensive examination than laryngoscopy):

This exam is different than acute BACTERIAL laryngitis in which pus on the voicebox would be seen as shown in this video (also stroboscopy):

Overall, treatment for acute viral laryngitis is strict voice rest as the esteemed Dr. Mallard recommended, though 24 hours is a bit optimistic. I probably would have prescribed a course of steroids to help with the swelling as well as hydration.

Should Tony keep on talking in setting of acute laryngitis, he runs the risk of developing muscle tension dysphonia.

Hollywood! Otolaryngology is Cool, Isn't It?

So there are lots of television shows on ER physicians (ER, Chicago Hope), general surgery (Gray's Anatomy), OB & pediatricians (Private Practice), plastic surgery (Nip/Tuck), ID doctors (House), etc etc.

What about shows/movies where an otolaryngologist is the star? Any thoughts on this lapse by Hollywood?

Of course, there's Dr. McSteamy on Grey's Anatomy who started out as an ENT, but than is mainly portrayed as a plastic surgeon.

What's up with that???

Dr. Chang Featured in TV Medical News Program on CBS 6/5/10

On May 21, 2010, a video crew came to our office to film a segment on Dr. Chang and what he does (or rather a very small part of what he does) as an otolaryngology-head and neck surgeon.

Dr. Chang along with 9 other practices were featured in a medical news television show "American Health Front" that aired on June 5, 2010 at 7PM on Channel 9 (WUSA-TV CBS).

The main focus of what Dr. Chang talked about are the different causes of nasal obstruction and their treatment including:

Allergies
Septal Deviation
Turbinate Hypertrophy
Adenoid Hypertrophy
Nasal Polyps

Dr. Chang to be Featured in TV Medical News Program on CBS

On May 21, 2010, a video crew came to our office to film a segment on Dr. Chang and what he does (or rather a very small part of what he does) as an otolaryngology-head and neck surgeon.

Dr. Chang along with 9 other practices will be featured in a medical news television show "American Health Front" that will air on June 5, 2010 at 7PM on Channel 9 (WUSA-TV CBS).

The main focus of what Dr. Chang talked about are the different causes of nasal obstruction and their treatment including:

Allergies
Septal Deviation
Turbinate Hypertrophy
Adenoid Hypertrophy
Nasal Polyps

TV Show "Glee" Character Rachel Has Laryngitis? Tonsillitis?

On May 11, 2010, Glee aired its eighteenth episode titled "Laryngitis". In this episode, Rachel suffered from a lost voice which was attributed to tonsillitis or is it laryngitis.

It was a bit confusing as it would seem her lost voice was attributable to laryngitis (title of the episode), but than she was diagnosed with tonsillitis by the TV doctor which really has nothing to do with laryngitis. I guess it is possible that she had TWO conditions going on at the same time even though she did not mention a sore throat at any time.

I can say for certain that the TV doctor was not portraying an otolaryngologist mainly because he was wearing a stethescope around his neck (our profession does not carry a stethescope on our person).

In any case, I doubt Rachel had tonsillitis. The main complaint with tonsillitis is a sore throat and not a lost voice. As such, she probably had a mild case of laryngitis which in most cases, only time, voice rest, and hydration should have been adequate. Antibiotics do not play a role in most cases of laryngitis which are virally induced.

Dr. Chang on NBC news!

Well, at least his face from 2 angles. The video appeared on 5/20/08 on the 10PM NBC local evening news in Dallas, TX. Dr. Chang was present in the OR with Dr. Thrasher while the TV crews were filming. Watch the full footage below.

This video was later nationally syndicated and shown throughout the United States including Washington DC a few weeks later.