Wrong Site Surgery Performed by ENT

In 2010, an ENT performed a tongue tie release on a 5 years old child who was supposed to undergo a tongue lesion biopsy (apparently 1cm in size over the central dorsal tongue). Tongue tie release was NOT consented for nor discussed with the parents who expected a tongue biopsy to be performed instead. In the investigative report performed by the Department of Public Health:

"When the surgeon was asked whether he examined the patient in the preop area prior to the surgery, he stated, "Usually, I don't examine anybody. I sometimes visit... In this case, there was no time to do a pre-operative visit. From now on, I need to see the patient prior to the surgery." [link]

According to the record, time-out WAS performed. Consent WAS in the chart for a tongue lesion biopsy. Records indicated that all mandated check-lists and time-outs were performed.

So what happened?

1) Surgeon Error: Let's face it... the surgeon made a mistake. Ultimately, it is his responsibility to ensure that the procedure goes smoothly which by definition means doing the correct procedure.

Seeing patients before surgery probably would have prevented this error. Not seeing the patient prior to surgery is not good practice.

Even if a surgeon employs a nurse practitioner or a physician assistant to see patients for him in the office or in the hospital, before any surgery, he personally should examine and discuss the upcoming surgery with all patients.

As an aside, at least once per week, I have patients calling who desire to schedule surgery without wanting to see me first for a consultation appointment. There are many reasons why I mandate that a patient MUST first be personally seen by me in the office PRIOR to any surgery scheduling. Preventing this scenario is one good reason why.

2) Nursing Error??? If the nurses knew what procedure was supposed to be done (according to the report, they did)... they should have spoken up! If they were too afraid to speak up, they should have contacted management to speak up for them... or ask the anesthesiologist to say something.

After all, patient welfare supersedes all else. Having wrong site surgery is the exact opposite.

However, to be fair in this particular situation, I do not believe the nurses knew what the surgeon was doing. Why???

The procedure was being done inside the mouth and a small child's mouth at that... honestly, nobody except the surgeon and possibly the anesthesiologist can really see what the surgeon is doing. The instruments used for tongue tie release is very similar to what would be used for tongue lesion biopsy.

3) Time-Out and Check-List Error: In a typical day, there are so many time-outs and check-lists being performed that it starts to get muted into background noise. It's just like the alarms and blinking lights that I imagine an instrument panel of a sophisticated machine would be for somebody who stares at it all day, everyday. You hear/see it... but than you don't hear/see it.

What people notice are sounds that are unusual for a given situation.

For example, cars make all sorts of noises when being turned on and moving somewhere. However, most people don't actually "hear" the sounds being produced by the car because of our lack of attention to it, because it is repetitive and continuous.

However, if one day, the engine starts knocking, that certainly gets a driver's attention and remembered.

Time-outs and check-lists suffer from inattention... even if performed.

They are a wonderful tool, but utterly undependable for long-term use.

So what would work given it must be done per regulations??? My suggestion would be to mix it up to prevent it from becoming "background" noise.

Have the time-out performed by different members of the surgical staff on every case rather than the same person. Ring a bell before doing time-out one time. On another time, have everyone dance a short jig before doing it. Whatever is done, do NOT make it repetitive which otherwise risks being inadvertently ignored.

The key is to make it different and notable each and every time in order to focus attention and prevent the task from becoming muted into the background.

Source:
CA Fines 14 Hospitals for Medical Errors. Health Leaders Media 8/31/12

Reference:
California Human and Health Resources Department of Public Health Report. 5/18/11

CPAP + Oral Appliance (All-In-One) Device for OSA

A dentist colleague of mine informed me of a new device that combines CPAP mask with an oral appliance for patients with obstructive sleep apnea (CPAP Pro + Mandibular Advancement).

The unique benefits of this combo device are several-fold:

• No straps
• Keeps mouth closed
• Addresses tongue collapse that obstruct the airway by bringing jaw forward
• Can sleep in any position

This device does need to be fitted by a dentist. (For Virginia residents, Dr. Jason Woodside is familiar with this product.)

Of course, it is relatively new and we'll see if patients love this combo CPAP mask more than the traditional masks that have been on the market.

For those patients who do NOT have a problem with tongue collapse, but prefer the no-straps solution of the oral appliance, the company does make a mouthguard that fits only the upper teeth.

Squid Ejaculates Into Woman's Mouth

It happened in June 2012...

A South Korean woman was eating a half-cooked squid when the squid apparently ejected its sperm bag into her tongue causing...

"pricking and foreign-body sensation in the oral cavity. Twelve small, white spindle-shaped, bug-like organisms stuck in the mucous membrane of the tongue, cheek, and gingiva..." [link]

Of course, she immediately spat the squid portion out, but required surgical excision of affected mucosa.

Bizarre but true...

Source:
Squid Injects Woman's Tongue With Sperm Bag As She Eats In Korea. Huffington Post 6/15/12

Reference:
Penetration of the oral mucosa by parasite-like sperm bags of squid: a case report in a Korean woman. J Parasitol. 2012 Feb;98(1):222-3. Epub 2011 Aug 11.

"Mouthwatering" Foods May Be a Misnomer?

In the spirit of Thanskgiving where thoughts of food predominate, British researchers have determined that humans are NOT able to produce more saliva by merely thinking of foods whether hungry or not.

This includes looking at pictures of sumptuous foods.

What researchers did determine is that SMELLING foods increased salivary production significantly. Tasting and chewing was even more influential in salivary production.

So at least for humans, unless the food is smelled, tasted, or chewed, mouthwatering just does not happen.

Of note, salivary production was determined by placing cotton pledgets inside the cheeks (saliva produced by the parotid glands) and a suction device under the tongue (saliva produced by the submandibular glands) on healthy volunteers.

Read MSNBC report here.

Reference:
IS THE MOUTHWATERING SENSATION A TRUE SALIVARY REFLEX? Journal of Texture Studies Special Issue: Food Oral Processing - Physics, Physiology, and Psychology University of Leeds, U.K. Volume 42, Issue 3, pages 212–216, June 2011

Posterior Tongue Tie

An ordinary garden-variety tongue tie (also known as ankyloglossia) is a rare condition whereby the tongue is anchored to the floor of the mouth preventing the tongue tip from moving freely.

Patients with tongue tie have greater difficulty with:

• feeding if infant
• speech if school-age child
• french kissing if young adult

Treatment is tongue tie release which can be done at any time if difficulties arise. In infants and young adults, this procedure can be done in the office under local anesthesia only. In school age kids, it typically requires sedation given lack of cooperation with keeping the mouth open and tongue still.

Posterior Tongue Tie

Though tongue tie is rare, there is an even more rare subtype called submucus tongue tie or posterior tongue tie.

This condition is when the tongue tie is hidden UNDER the mucus lining of the tongue/mouth. You can't see this type of tongue tie, but you can feel it if you run the finger underneath the tongue from side to side where the tongue tie would be. One would feel a tissue band (speed-bump sensation with finger sweep) where the tongue tie would be.

Treatment is a bit more complicated than a regular tongue tie release in that the mucus lining has to be incised in order to expose the tongue tie prior to release. Once the tongue tie is released, the incision is sutured closed.

Given the more complicated steps to address this rare condition, it does need to be performed under sedation.

Cigarettes Contain Radioactive Polonium

Cigarettes are known to cause cancer...

But we now know there's another reason why... they contain radioactive material, specifically polonium-210!

Tobacco companies also have known about it since 1959. As reported in ABC, historical documents reveal tobacco companies not only knew about the radioactive substance, but studied it, then refused to do anything about it!

They figured out that:

1) It caused "cancerous growths" in the lungs of smokers,
2) Calculated how much radiation a regular smoker would ingest over 20 years

Then they kept the research secret. The level of deception is breath-taking.

The radiation alone from cigarettes can account for up to 138 deaths for every 1,000 smokers over period of 25 years.

Even more disturbing, is that ALL tobacco products on the market today still contain radioactive polonium. This is in spite of washing techniques available since 1980 to remove the radioactivity but refused by tobacco companies to perform whether due to cost or the fact that washing would remove the addictive nicotine component as well.

Take home message?

STOP smoking! It's killing you through not only harmful chemicals, but also radioactivity!

Read the ABC article here.

Reference:
Cigarette Smoke Radioactivity and Lung Cancer Risk. Nicotine Tob Res (2011) doi: 10.1093/ntr/ntr145

Oral Exam Using a Finger

For a good physical exam, physicians use their senses (eyes, ears, nose) to detect disease processes that may not necessarily be obvious to a lay person. Beyond these obvious senses, fingers and hands are also utilized to feel for unusual bumps or masses that may not be obvious to the naked eye.

Take a neck mass for example. Neck masses may not be necessarily visible, but by feeling the neck, may become obvious. To use an analogy, a bowling ball under a mattress may not necessarily be obvious, but if you lay on the bed, would become painfully obvious.

Physicians also use the hands/fingers to examine areas that may not be visible... such as the unpleasant digital rectal exam (inserting a finger up a bung-hole) which is done to detect blood in the stool, rectal/anal cancers, anal muscular incompetence, etc.

However, I find it odd that the mouth is a body area that is not often "felt" around... physicians included.

A finger can appreciate unusual mouth pathology that may not necessarily be appreciated by looking alone. Furthermore, just like the rectal exam, a finger can appreciate base of tongue pathology that cannot be visualized by having a patient go "ah".

I truly feel that actor Michael Douglas would have been diagnosed with his base of tongue cancer much earlier if only a doctor stuck a finger and swept that back area of the tongue. One can "feel" cancer as it is rock hard and very tender. True... it may cause a person to gag, but for a cancer test, it's dirt cheap, fast, and reliable.

However, it does not just have to be areas of the mouth that can not be seen. Even for those ulcerations and bumps of the mouth that one can clearly visualize (or not), it does help to touch it. Is it hard? Soft? Ulcerated? Tender? Grooved? Papillated? Fungating? Rubber-like? Blottable?

Each characteristic provides information to achieve a more accurate diagnosis.

To an ENT way of thinking, if a doctor regularly performs a digital rectal exam, than one can certainly do the same thing at the other end. It's less invasive and provides just as much information.

Say "ah"!!!

New Webpage on Bumps or Lesions of the Mouth

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

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

• aphthous ulcer


• herpetic ulcers


• pyogenic granuloma


• fibroma


• papilloma


• cancer

Click here to read more!

Robotic Mouth Sings the "Natural" Way

When it comes to robotics, the sounds they make is either due to the machinery that runs them or an electronic recording that comes out of a speaker.

Well, there's a scientist, Hideyuki Sawada, who is working on a robotic "mouth" that produces sound the same way humans do.

- Lungs to power the voice using airflow
- Vocal cords to create the noise to create a voice
- Pharynx (Throat) to create the space and harmonic overtones that affect the "quality" of the voice
- Articulators (lips, teeth, tongue) to produce speech

In this picture of the robot, the lips are pretty obvious (the oval fish-mouth appearing aperture). The lungs are the glass jar on the right. The vocal cords are located where the glass jar connects to the pharynx which is represented by the skin-toned plastic pipe with the pistons attached at the bottom.

Here's a video showing it in action.

Here's another video showing a REAL human voice in action.

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 Man With the World's Largest Mouth!

Francisco Domingo Joaquim's 6.69 inches wide mouth has earned him the dubious title of the 'World's Widest Mouth' by the Guinness Book of World Records.

His main claim to fame is the ability to put a can of Coke into and out of his mouth with ease as well as spin it around inside his mouth with his tongue. Watch a video here.

Read more about him and his amazing mouth here.

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!

Washington Post Medical Mystery: Kawasaki Disease

The Washington Post on Sept 8, 2009 published a story called "A Frightful Week for a Little Girl" in its Medical Mystery section on Kawasaki Disease. This disease is rare and difficult to diagnose given its multitude of symptoms that can be due to something more benign including:

• red eyes
• fever
• rash
• neck mass
• red lips/mouth

However, it is the constellation of symptoms according to guidelines that Kawasaki in children should be considered when there has been an unexplained fever lasting five days, when accompanied by other symptoms including red eyes without discharge, red lips or mouth, a rash and a swollen lymph node in the neck. The red eyes and lips/mouth is the hallmark symptom of something more sinister.

To miss this diagnosis and be without proper treatment within 10 days of symptom onset may result in heart attack, coronary artery aneurysm, and even death.

Read the article here.

Exercises of the Mouth and Throat Improves Sleep Apnea!!!

In the May 2009 edition of the American Journal of Respiratory and Critical Care Medicine, a research article by Dr. Lorenzi-Filho claimed that regular exercises involving the tongue, soft palate, and lateral pharyngeal wall significantly improves obstructive sleep apnea (OSA) both objectively and subjectively. The exercises mainly consisted of playing a wind instrument known as didgeridoo. Patients randomized to these exercises had a significant decrease (P < 0.05) in neck circumference (39.6 +/- 3.6 vs. 38.5 +/- 4.0 cm), snoring frequency (4 [4-4] vs. 3 [1.5-3.5]), snoring intensity (3 [3-4] vs. 1 [1-2]), daytime sleepiness (14 +/- 5 vs. 8 +/- 6), sleep quality score (10.2 +/- 3.7 vs. 6.9 +/- 2.5), and OSAS severity (apnea-hypopnea index, 22.4 +/- 4.8 vs. 13.7 +/- 8.5 events/h). Changes in neck circumference correlated inversely with changes in apnea-hypopnea index (r = 0.59; P < 0.001). This may be a great (and non-invasive) adjunctive treatment for OSA! Click here to read more.

Clinical trial registered with www.clinicaltrials.gov (NCT 00660777).