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.

Celine Dion Cancels Shows Due to Laryngitis

In late Feb 2012, Celine Dion who was to have performed in Las Vegas Feb 22, 2012, cancelled her show at the last minute at the Caesar's Palace due to laryngitis on the advice of her doctors. According to media reports, her doctors instructed her to rest for 7 days to ensure full recovery due to vocal cord inflammation caused by a virus.

What does that mean exactly?

When a virus infects the mucosa of the upper airway, it causes inflammation of the mucosa lining including the vocal cords. With inflammation, the vocal cords swell.

That's why with laryngitis, the pitch of the voice decreases and it becomes more effortful to talk. To use an analogy, think of a violin string where the thicker string has a deeper pitch than a thin string. It also takes more power to play the thicker string. Watch the video below of normal vocal cord functioning:



In order for voice production to occur, the lining of the vocal cords vibrates very quickly when they come together. If the vocal cords are swollen, they don't vibrate as easily.

Here's what inflamed vocal cords might have looked like for Celine Dion. Note the slight bend to the vocal cords and overall dull appearance.

Below is what her vocal cords might look like when they are at peak health!

Voice rest is absolutely important for vocal recovery as quickly as possible. With talking/singing during active laryngitis, further trauma may occur to the vocal cord lining promoting even more inflammation and swelling. It may also lead to another vocal disorder known as muscle tension dysphonia.


Source:
Celine Dion cancels act: laryngitis. UPI 2/26/12