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.

The Healthcare Dilemma Simplified

As an otolaryngologist in private practice, I have observed from the sidelines the healthcare crisis that is brewing in our nation, being debated in Congress, and bemoaned by fellow colleagues.

Being a simple man, I see the essence of the healthcare problem being summarized in one sentence:

"How to deliver low-cost, high-quality healthcare cheaply."

Being a simple man, I also realize that this statement is nearly impossible to accomplish for something as complex as healthcare delivery.

It's also a concept engineers have struggled with for way longer than medicine has. It is summarized by a great graphic known as the "Engineering Project Triangle". What is achievable is only where the colors overlap.

Design something quickly and to a high standard, but then it will not be cheap. 

Design something quickly and cheaply, but it will not be of high quality.

Design something with high quality and cheaply, but it will take a long time.

In other words, you can only pick two.

In terms of healthcare, the triangle could be known as the "Healthcare Project Triangle."

Design healthcare that is able to provide quality care at low-cost, than not everyone can have it. It's also known as "rationed" care which is what Canada and Great Britain have to some degree.

Design healthcare that is able to provide quality care to everybody, it will be expensive. This is where our healthcare model is currently situated.

Design healthcare this is able to provide low-cost care to everybody, it will suffer in terms of quality. Some would argue this is the HMO model. It's also what we could consider the kind of healthcare that is provided in free clinics.

In essence, you can't have healthcare with all three characteristics. You can only pick two.

Engineers know that and are probably wondering why doesn't everybody else.

"You can only pick two" is what the great debate is all about. Nobody can decide on which two and there are FANTASTIC arguments for the given two a Senator or presidential candidate will promote.

However, in the end, either quality, quantity, or low cost will suffer no matter which healthcare policy is chosen.

So the great debate has been identified...

The great question is what will be sacrificed?

Because unfortunately, there is no great answer.

Reference:
When Nurses Wear "Do Not Disturb" Signs. Dr. Wes.

Sleep Apnea Can Turn Your Child Into a School Bully

This statement is supported by a recently published study indicating that poor sleep, whatever the cause, can be a factor leading a child to bully or display other aggressive behaviors. Among 341 kids who were evaluated, 23% had conduct problems. Of these kids with conduct issues compared to those without, a significant number had symptoms suggestive of a sleep disorder indicated by sleepiness scoring as well as snoring.

It is already known that the prefrontal cortex governs social behavior which is also influenced by sleep. As such, poor sleep can deleteriously influence the brain leading to behavior problems.

Of course, there are other factors that can contribute to sleep problems as well as bullying... such as an unstable family as well as too much technological stimulation (cell phone, internet, television, etc).

As such, as with most things, more study is needed.

But here's my two cents... Applying some common sense here, ask anybody who has pulled an all-nighter whether they are grouchy the next day and I bet you most will say "of course, no duh"!

Well, here's a study that supports that! (No duh!)

All kidding aside, if a child is having behavior issues, it may behoove the parents to see if obstructive sleep apnea is present which would lead to poor sleep quality. At least for kids, obstructive sleep apnea can be addressed surgically by removing the tonsils and adenoids leading to markedly improved sleep quality (and hopefully improved behavior as well!).

Reference:
Aggressive behavior, bullying, snoring, and sleepiness in schoolchildren. Sleep Med. 2011 May 25. [Epub ahead of print]