Laryngospasm in a Child

Washington Post published a story July 23, 2012 regarding a child who suffered from laryngospasm attack that was erroneously diagnosed as asthma.

Laryngospasm is when the true vocal cords (TVC) come together rather than apart when breathing. Normally, only when talking do the vocal cords come together (or adduct) and vibrate to create a voice. When breathing, the vocal cords separate (or abduct) to allow air to pass between the vocal cords and into the lungs. Watch video.

What the story portrayed is not uncommon and patients who suffer from laryngospasm may go for years without the correct diagnosis.

The voice therapy that was recommended is also appropriate to help him cope when an attack occurs.

However, that's also the point where I start to disagree with the article.

It is all fine and dandy to learn breathing coping strategies, but that only deals with WHEN an attack occurs. What about what causes an attack to happen in the first place? Would it not be better to prevent an attack from happening at all and thereby coping strategies don't even need to be initiated?

As such, I do feel it important to start an aggressive workup to evaluate all the known triggers that may initiate a laryngospasm attack. Such triggers include allergy, post-nasal drainage, and reflux.

As long as the trigger is not addressed, a patient can continue to suffer recurrent attacks.

Once the triggers are found and fixed... the laryngospasm attacks can be "cured."

Watch the video below depicting larygnospasm as well as less severe forms of the same (vocal cord dysfunction or paradoxical vocal cords).

Source:
Long-ago asthma diagnosis didn’t explain boy’s difficulty breathing. Washington Post 7/23/12

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.

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.