Actor Larry Hagman Treated for Throat Cancer

In June 2011, actor Larry Hagman was diagnosed with stage 2 throat cancer. It is unclear exactly where the throat cancer was localized to (tongue, tonsil, supraglottis, hypopharynx, oropharynx, etc), but it was treated medically with radiation and chemotherapy.

Larry Hagman is a well-known actor playing oil baron J.R. Ewing in the soap opera Dallas (1980s as well as 2012) as well as Major Nelson in  the TV sitcom I Dream of Jeannie. Most impressive was the fact that he continued to act while undergoing cancer treatment for the Dallas remake.

Yesterday, Aug 29, 2012, media reported that the actor is now "cancer free."

Hogwash...

Throat cancer, especially stage 2, has the potential to come back. Though there may be no detectable signs of cancer currently, there is the possibility of cancer coming back in the future.

The risk of cancer recurrence is highest within the first 2-3 years after treatment completion, and markedly decreases after 5 years.

Typically if cancer has not come back after 5 years, the word "cure" may than be used, but even than, such patients are seen yearly for the rest of their life for cancer monitoring.

Given the high risk of cancer recurrence, patients are seen frequently for the first 2-3 years after treatment.

Every 2 months for the first year. Every 3-4 months in the 2nd year. Every 4 months in the 3rd year. Every 6 months in the 4th year. Yearly starting at 5 years after treatment.

This type of follow-up applies to all head and neck cancer.

Source:
Larry Hagman is cancer-free. SFGate 8/29/12

Larry Hagman. Wikipedia

Bi-Lobed Zenker's Diverticulum

In the not so distant past, I saw a patient who suffered from a bi-lobed Zenker's Diverticulum. Zenker's diverticulum for those who don't know is the abnormal development of a pouch in the throat causing symptoms of phlegm in the throat, food regurgitation, swallowing difficulties, and aspiration.

Most Zenker's Diverticulum is composed of a single central pouch. However, there are more rare varieties such as this bi-lobed pouch seen on barium swallow.

However, at time of surgery (endoscopic staple diverticulostomy), the bi-lobed nature of the pouch essentially disappeared.

Video of how the surgery is performed:

Singer Nicki Minaj with Strained Vocal Cords

Media has reported that pop star Nicki Minaj had to cancel upcoming concerts in England due to injured vocal cords.

She apparently saw a doctor who diagnosed "strained vocal cords" after an x-ray and recommended voice rest for a few days.

The singer apparently ignored this advice and sang in New York City on Aug 18 causing her voice to substantially worsen resulting in her decision to cancel her concerts this weekend.

Details of her vocal cord condition are sparse. However, based on the limited information provided, there's a few things I can guess at.

First off, an x-ray can NOT diagnose any type of vocal cord condition. The singer must have undergone a trans-nasal endoscopic procedure which is the ONLY way to visualize the vocal cord and diagnose any vocal problems.

Given the singer was instructed to rest her voice for "a few days," she most likely suffered from a mild acute laryngitis causing inflamed vocal cords. By ignoring advice to rest her voice, she potentially turned a mild laryngitis into a more severe laryngitis. She probably did not suffer from any physical problems on her vocal cords like nodules or polyps which would take weeks if not months to recover (not days) as happened to singers Adele and John Mayer.

Really, at this point, strict voice rest, hydration, acid reflux control, and steroids (ie, prednisone) would enable her to recover her normal voice ASAP.

Here's a picture of a severe laryngitis (left) compared a normal appearing vocal cords (right). Note that the vocal cords are swollen and red compared to normal pearly white and thin appearance.

 

Source:
Nicki Minaj cancels U.K. concerts due to strained vocal cords. NBC News 8/18/12

Financial Issues with Emergency Room Specialist Care

Imagine this scenario... A young child is playing in the yard when her pet dog bites her face. Bleeding, the child is rushed to the emergency room and the emergency room doctor offers to suture up the child's face.

The next question a parent will probably ask (or demand) is the desire for a plastic surgeon to suture the face instead of the emergency room doctor.

As such, the plastic surgeon is called in and sutures up the face beautifully.

The child and family goes home and that's when the financial nightmare begins...

The plastic surgeon bills the family for $2,000 for services rendered in the emergency room. The plastic surgeon does NOT participate with their health insurance plan and being a non-participating provider, the bill for care provided is directly sent to the child's family.

Outrageous?

Unfortunately, it is not unusual... and there are lawsuits now pending both against specialist physicians as well as against patients regarding who pays the medical bills.

Here is an article portraying a hand surgeon who has sued numerous patients regarding just this scenario. Most specialists will either write-off or accept any amount after being sent to collection.

Background

If a patient has a medical problem, a call to the medical office is made to see the doctor. However, before the appointment is made, both the patient and office checks to ensure the visit will be covered by insurance. If not, a call to a different medical office is made until one that participates with the patient's insurance is found. However, if the patient decides to see a physician who does NOT participate with his health insurance company, he will be responsible for the entire bill (the office visit will not be covered by insurance).

The same is true for outside specialists called into the emergency room. These outside medical specialists participate only with certain insurances. As such, if they perform services on a patient whose health insurance does not cover that particular medical specialist, the patient will get the entire bill.

Emergency room care IS covered by insurance... because it is an "emergency," but services performed ONLY by the emergency room staff applies. NOT services by outside specialists called in.

What to Do?

So what is a patient to do in order to avoid a surprising large bill?

Ideally, have all services performed by emergency room staff and avoid services by outside specialists. If it is not life-threatening (like a facial dog-bite... ugly, but not life-threatening), have the emergency room doctor do all he can. Than follow-up as an outpatient with a specialist who participates with your health insurance plan.

If an outside specialist MUST be called in, ask whether this specialist participates with your health insurance plan. If not, ask how much the specialist will charge for services rendered. Be aware, if the outside specialist actually comes into the hospital, a consultation fee will be charged (typically around $100-$200). If a procedure is performed, a procedure charge will be present (hundreds to thousands of dollars).

A patient can request whether there is a different doctor who can be contacted should the specialist on-call not participate with his/her health insurance plan. However, be aware that typically only ONE doctor per specialty is on-call to the emergency room at any given time and as such, an alternative doctor may not be available.

Once you are aware of the charges, you as the patient needs to decide whether to proceed with specialist care or not.

Be aware that the insurance coverage issues also applies for specialist consultations during a hospitalization and not just in the emergency room.

Bottom Line

Simply going to the emergency room does not mean all medical services will be covered by insurance, especially services provided by a medical specialist.

If specialist care is required in the emergency room, just ask whether the specialist participates with your health insurance plan, because if not, be aware that you directly will get a bill.

That's just how the medical system is set up currently.

Congressman Putney with Vocal Cord Cancer

Media has reported that Congressman Lacey Putney, chairman of the powerful Appropriations Committee in the House of Delegates, has early stage vocal cord cancer.

He is currently undergoing radiation therapy which has a high chance of cure with relatively minimal side effects along with voice preservation.

My suspicion is that he is suffering from squamous cell carcinoma which is the most common type of vocal cord cancer. Though radiation therapy is a common form of treatment for this type of early stage cancer, surgical excision without the need for radiation is also possible. No chemotherapy is necessary for early stage vocal cord cancer.

Below is a picture of an early stage right vocal cord squamous cell carcinoma.

Compare to normal:

Source:
Putney undergoing treatment for throat cancer. WSLS10 8/15/12

Mouth "Oil Pulling"

The other day, I had a patient ask me about "oil pulling." For those who don't know what oil pulling is:

"Oil pulling or oil swishing is a traditional Indian folk remedy that involves swishing oil in the mouth. It is mentioned in the Ayurvedic text Charaka Samhita, where it is called Kavala Gandoosha or Kavala Graha. Ayurvedic literature describes oil pulling as capable of both improving oral health and treating systemic diseases such as diabetes mellitus or asthma. While scientific evidence is lacking to support any systemic benefits of oil pulling, some studies have suggested that it may reduce oral plaque, halitosis, and gingivitis." [Wikipedia]

The oil used to swish the mouth is typically vegetable based like sesame or sunflower and is performed for 15-20 minutes before being spit out (or swallowed depending on what you want to accomplish).

Though there are plenty of testimonials on the internet and explanations for its amazing effects including the oil's alleged ability to suck plaque off teeth, absorb germs into the oil, make teeth whiter, etc I feel the oil's effects are more mundane in nature.

Just as chapstick is an oil-based compound that treats dried and chapped lips by coating the surface allowing the lip mucosa to heal, oil pulling may just provide a protective barrier to provide a similar function. Oils are essential to skin and mucosal health and when such oils are stripped, problems occur (ask anybody who washes their hand with soap multiple times a day).

As such, I personally don't think it can hurt if someone wants to give oil pulling a try to address oral problems. But I would not recommend this type of unproven treatment to address systemic disorders like diabetes or asthma over more established medical management.

Of note, the references listed below are studies published in less-than-authoratative journals.

References:
Tooth brushing, oil pulling and tissue regeneration: A review of holistic approaches to oral health. J Ayurveda Integr Med 2 (2): 64–8. doi:10.4103/0975-9476.82525.

Effect of oil pulling on Streptococcus mutans count in plaque and saliva using Dentocult SM Strip mutans test: a randomized, controlled, triple-blind study. J Indian Soc Pedod Prev Dent 26 (1): 12–7.

Mechanism of oil-pulling therapy - in vitro study. Indian J Dent Res 22 (1): 34–7. doi:10.4103/0970-9290.79971.

Effect of oil pulling on plaque induced gingivitis: a randomized, controlled, triple-blind study. Indian J Dent Res 20 (1): 47–51. PMID 19336860.

Effect of oil pulling on halitosis and microorganisms causing halitosis: a randomized controlled pilot trial. J Indian Soc Pedod Prev Dent 29 (2): 90–4. doi:10.4103/0970-4388.84678.

Intra-Nasal Trigger Point Injections for Facial Headache

Do you suffer from a stabbing headache in the areas denoted in red? Do these headaches seemingly come out of nowhere one day? Perhaps started after a viral upper respiratory infection?

You may be suffering from a condition known as contact point headache or a type of neuralgia involving one of the nerve plexuses found inside the nose:

• Anterior ethmoid neuralgia (Sluder's neuralgia)
• Sphenopalatine ganglion neuralgia (Pterygopalatine ganglion neuralgia)

This type of headache has often been confused with cluster headache, migraine without aura, sinusitis, or other undefinable pathology especially since CT scans and MRI scans that are obtained often do not reveal any tumor or presence of infection.

In the event of a contact point headache, surgical removal of the offending anatomic abnormality is curative.

However, for neuralgia, trigger point injections may be helpful according to a recent study. Using a 1:1 mixture of 0.5% bupivacaine and Kenalog-40, either the sphenopalatine ganglion or the anterior ethmoid neurovascular bundle or even both are injected. For the sphenopalatine ganglion, the injection is where the middle turbinate inserts into the lateral nasal wall. For anterior ethmoid injection, identify the arch where the middle turbinate inserts superiorly to the lateral nasal wall and inject 5mm above this site.

In a total of 882 nerve blocks in 147 patients, 99.3% had no complications. 2 patients reported visual changes that resolved within 2 days. More importantly, 81.3% claimed improvement in their headache, 17.9% reported no change and 0.79% reported worse pain after the injection.

The typical duration of pain relief was 3-4 weeks. As such, for continued pain relief, the injection needs to be repeated monthly on average.

Reference:
Endoscopic neural blockade for rhinogenic headache and facial pain: 2011 update. Int Forum Allergy Rhinol. 2012 Apr 5. doi: 10.1002/alr.21035. [Epub ahead of print]

Nasal Congestion or Obstruction During Pregnancy

When a woman becomes pregnant, it is not unusual for the nose to become quite congested... uncomfortably so, even to the point of being unable to breath through the nose.

This condition known as "rhinitis of pregnancy" affects as many as 30% of pregnant women and can start in the second month of pregnancy; it tends to worsen later in pregnancy. The nasal congestion should ease up soon after giving birth and be gone completely within two weeks after delivery.

The nasal congestion occurs due to elevated amounts of estrogen causing swelling of nasal mucous membranes. Furthermore, there is a marked increased in circulating blood in the body which also leads to swelling of the tiny blood vessels lining the nose. Bloodflow causing nasal obstruction (turbinate hypertrophy) is not unusual and even occurs in men (laying down on one side causes nasal obstruction that than switches when laying down on the other side; improves when sitting/standing).

On exam, a common finding are large inferior turbinates. Inferior turbinates are soft tissue outpouchings within the nose that warm and humidify the air as nasal breathing occurs. Normally, they are quite small, but with rhinitis of pregnancy, they can become enormous... even quadrupling in size.

Inferior Turbinates Seen on Exam

Generally speaking, my approach to treating this uncomfortable condition is as follows (assuming all other causes are ruled out and no medical contraindications):

1) Regular HYPER-tonic saltwater nasal irrigations to the nose 3-4x per day. I recommend HYPER-tonic saltwater rather than regular strength saltwater. Why? Salt sucks moisture out of the nose. With regular strength saltwater (aka, normal saline), the saltwater concentration is equal to that found within the body and minimal if any moisture displacement (osmosis) occurs. With HYPER-tonic saltwater, given the increased salt concentration compared to that found within the body, moisture leaves the nose allowing for decongestion to occur.

Nasal irrigations can be performed with Neti Potor NeilMed Sinus Rinse Bottle. Hypertonic salt packetscan be purchased and mixed with 8 ounces distilled water. Or, if you want to make it yourself, 1/2 to 3/4 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of distilled water.

2) Rhinocort AQ (prescription) steroid nasal spray 2 sprays on each side daily. Steroids help to decrease swelling, especially the large inferior turbinates. This steroid nasal spray is the ONLY steroid nasal spray that is Class B for pregnancy.

3) Keep the head elevated when you lie down. This reduces the blood flow to the nose which exacerbates the nasal congestion.

Of course, steps 1 and 2 assume that there is SOME room for the treatment to occur. If the nose is 100% blocked up, use over-the-counter Afrinnasal spray a few times to get things to open up. Once opened up some, immediately start #1 and 2. It is not healthy nor wise to use afrin too much. Ideally, it may need to be used for only 1 day and no more thereafter. Even in non-pregnant individuals, afrin should never be used more than a few consecutive days otherwise risk addiction!

Response to treatment typically occurs within 2 weeks.

Noise Hyper-Sensitivity in Kids

Although we mainly see kids for hearing loss due to fluid in the ears, chronic ear infections, or eustachian tube dysfunction, every so often, a child will show up with the exact opposite problem.

The child hears just fine, but suffers from noise hypersensitivity, also known as auditory hypersensitivity. Such children are overwhelmed from everyday noises whether doorbells, sirens, key clanking, etc; typically high-pitched sounds. The hands will go over the ears in an attempt to dampen the sound and may even become tearful.

This phenomenon is not uncommon in kids with developmental delays, autism, central auditory processing disorders (CAPD), Down's syndrome, etc. But "normal" kids may suffer from this condition as well.

Before going into treatment, one first needs to understand how sound is perceived first.

Human hearing is a complex listening device composed of not just the ability to "hear" the sound, but also to "comprehend" the sound. Disorders like CAPD is analogous to dyslexia where the patient can "hear" sounds perfectly normally, but has trouble understanding what they hear.

As a child develops, the auditory neural pathways in the brain that govern the comprehension of sounds are either reinforced or dampened down with time. For example, auditory neural pathways that allow for speech comprehension are reinforced whereas neural pathways perceiving background noises and other random sounds are dampened with time.

In auditory hypersensitivity, for whatever reason, the auditory neural pathways governing the perception of certain miscellaneous noise like sirens or doorbell are reinforced causing the perception of the sound to be more significant and tremendous than it should be. In a normal child without sensitivity, such pathways are suppressed.

To use an analogy, consider the auditory neural pathway like the road system in the United States. Over time, certain roads like the interstate highway is "reinforced" leading to more drivers using such streets to get from point A to point B far more quickly than if they used local roads. Problems occur if for some reason, cars avoid the highways and local roads are taken preferentially leading to traffic jams and irate drivers.

Auditory hypersensitivity is kind of like that... local roads being "reinforced" when it should be suppressed.

So what can be done to treat this frustrating condition?

In essence, therapy is geared towards reinforcing good auditory neural pathways and suppressing the bad ones that lead to noise hypersensitivity.

Such therapy programs include listening to special music and ear training exercises. One such program is "The Listening Program".

But one thing is clear... keeping someone with noise sensitivity in silence is the worst thing that can be done. It just reinforces the bad pathways!

Of course, there are other causes of noise sensitivity:

1) Migraines (children may not exhibit the class head pain, but they still can suffer from noise sensitivity)
2) Cochlear hydrops (if associated with hearing loss, tinnitus, sound distortion)

Actress Kristin Chenoweth Suffers from Meniere's Disease

Kristin Chenoweth is an accomplished actress both on TV and live on Broadway having performed in Wicked as Glinda as well as appearances in TV shows Glee and Pushing Daisies.

She also suffers from Meniere's Disease which was diagnosed in 2007.

As such, she is prone to dizzy attacks which may have contributed to well-known falls during performances over the years.

• 2003: Fell off the stage during rehearsals for Wicked
• 2006: Fell off the stage during Broadway revival of The Apple Tree
• 2011: Fell down the stairs during injuring her back on the set of Glee.

And those are just the falls we know about.

Meniere's disease is a disorder of the inner ear which leads to spinning dizzy attacks without any specific trigger. The dizzy spinning typically lasts several hours and is often preceded by tinnitus, aural pressure, and a hearing decrease on just the affected ear.

Fluctuating hearing loss is not uncommon as well.

Diagnosis is not straightforward and is usually obtained by history alone, but supporting tests include ENG (electronystagmography), VEMP (vestibular evoked myogenic potentials), ECoG (electrocochleography), ABR (auditory brainstem response), MRI scan, etc.

Once diagnosis of Meniere's disease is made, treatment occurs in stages:

Stage 1: Eliminate all salt (less than 1000mg of sodium per day), caffeine (no coffee, tea, decaffeinated, sodas, chocolate, etc), and alcohol from the diet.

Stage 2: If stage 1 does not help, addition of a diuretic pill like maxzide.

Stage 3: Invasive procedures which include endolymphatic shunt operation or vestibulectomy using intratympanic gentamyin injection into the ear or surgical lysis.

Flare-ups are treated symptomatically with phenergan and if needed, steroids whether oral or injection into the ear.

Singer Florence Welch Cancels Concerts Due to Vocal Injury

CBS news reported that Florence Welch, the lead singer for British band Florence + The Time Machine, had to cancel two upcoming concerts due to a vocal injury.

Florence Welch (@flo_tweet) herself provided most of the details in a series of tweets today:

July 11, 2012 @ 11:15AM : hello everyone, thankyou so much for all your messages of support, yes its true..it finally happened, I've lost my voice..:(

July 11, 2012 @ 11:18AM : I've sustained a vocal injury and been told i cannot sing for a week.., seriously i felt something snap, it was very frightening.

July 11, 2012 @ 11:20AM : unfortunately this means i will not be able to perform at Benicassim and Optimus alive festival this weekend..i am so so sorry..

Florence used the words "felt something snap" which is pretty classic for a vocal hemorrhage. For those who are Adele fans, something similar happened to her as well in November which mandated a prolonged period of voice rest (months) and even resulted in vocal cord surgery. (read more)

I am guessing that Florence had a blood vessel on her vocal cords that was causing minimal vocal impact. But with the "snap," the blood vessel likely ruptured causing instant vocal decompensation whereby the vocal pitch suddenly becomes much deeper and if bad enough, even complete voice loss as it appears to have happened to Florence.

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this which is what Florence's vocal cords prior to the "snap" might have looked like:

When there is a hemorrhagic polyp with a blood vessel as in Adele's case, her vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. If it is small, the changes may be non-existent. If it is more pronounced, the vocal instability may be noticeable and for a singer, it may make the voice very unpredictable.

When the blood vessel becomes engorged and traumatized (singing forcefully, screaming, coughing), it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle (typically right before period).

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully which increases chance of vocal cord hemorrhage. Rupture (even in the middle of a performance) results in hemorrhage into the vocal lining itself causing a sudden and complete loss of voice (see picture to right). There may even be mild pain associated with this occurrence. This is the "snap" sensation Florence felt.

In Adele's case, she remembers the very moment this occurred during a radio interview when she "felt a pop" and her vocal pitch suddenly dropped into the bass range.

This makes perfect sense... To use the analogy of a violin string, the thicker the violin string the deeper the pitch. When hemorrhage occurs, the vocal cord becomes thicker due to blood pooling resulting in a deeper voice instantly. If significant hemorrhage is present, the vocal cord may not even be able to vibrate causing vocal loss.

How is this treated?

Initially, during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in the development or exacerbation of a vocal cord polyp. With repetitive cycles of healing and trauma, vocal cord scarring may even develop. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel and associated polyp if present.

In Florence's case where she was told to be on strict voice rest for only one week, I suspect no polyp is present. Just hemorrhage.

If polyp is present, surgical intervention may be required.

One option is to precisely cut out the polyp and cauterize the feeding blood vessel at the same time. This approach was the course that Adele pursued. Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. This latter approach is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision and vessel obliteration with a laser at the same time (though not zero). Furthermore, a smaller polyp also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Adele, that was strict voice rest for nearly two months (Nov and Dec 2011). Why? Because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won't heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

Source:
Florence Welch told not to perform "to avoid permanent damage" to voice.  CBS News 7/11/12

Hearing Aid Styles and Colors - There Are Many!

It is not uncommon that a patient with hearing loss interested in hearing aids mistakenly believe there's only TWO hearing aid styles.

The kind that goes in the ear and the kind that goes behind the ear.

Although that is true, there are more different variations of both types that catches many people by surprise.

Image taken from NIH

There also seems to be a generational gap in what style is preferred by patients.

"Older" folks in their 60's or older prefer the styles that go in the ear, mostly because of the stigma associated with hearing loss and use of a hearing aid that reinforces and reminds them of their age. Also, because they remember the large skin-toned BTE that used to be the only option.

The "younger" generation typically prefer the min-BTE that go behind the ear. It probably helps that so many people use wireless bluetooth earpieces almost like a status symbol.

Beyond where hearing aids go, they now come in different colors and patterns for further personalization! Skin-tone is no longer the only color option.

New Medical Device to Cure Excessive Sweating

Everybody sweats, but some sweat more than others to the point where even constant anti-perspirant usage is insufficient.

Beyond botox which is painful and lasts only a few months, options have been few until now...

A new medical device called Miradry destroys sweat glands by heating up the junction between the second and third layer of the skin using microwave after sucking up secretions. Before the procedure, numbing injections are required.

A company study shows patients who used Miradry experienced an 82 percent reduction in sweat over 18 months. Patients may require the procedure to be repeated for ultimate sweat control.

So far, it is available ONLY for underarm treatment.

However, for those with excessive facial sweating, botox injections or robinul medication is still the only treatment, but who knows... perhaps Miradry will soon be available for the face/neck area at some point.

References:
Clinical Evaluation of a Microwave Device for Treating Axillary Hyperhidrosis H. Chih-Ho Hong, MD, Mark Lupin, MD et al; Dermatologic Surgery 2012; 38:728-735

A Randomized, Blinded Clinical Evaluation of a Novel Microwave Device for Treating Axillary Hyperhidrosis: The Dermatologic Reduction in Underarm Perspiration Study Dee Anna Glaser, MD et al; Dermatologic Surgery 2012; 38:185-191

Microwave thermolysis of sweat glands Jessi Johnson, PhD et al; Lasers in Surgery and Medicine 2012; 44:20-25

R&B Singer Maxwell with Vocal Cord Hemorrhage

At least that's what the Washington Post reported on June 22, 2012. This has resulted in cancellation of his summer tour.

Per media reports, his vocal cords are swollen with hemorrhage.

Some fans may recall that something similar happened to Adele in winter of 2011 which resulted in her also canceling a number of engagements. She ultimately had surgery to correct her problem.

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. If a voice is present, it is much deeper than normal due to the additional "weight" of blood and edema (just like a violin string where the thicker the string, the deeper the pitch). There may even be mild pain associated with this occurrence.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in a vocal cord polyp or vocal cord scarring. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel.

For that, surgical intervention is required.

Such surgical intervention is much like trying to get rid of varicose veins in the leg.

One option is to precisely cut it out. Watch a video on this approach (video shows a vocal cord mass removal, but just pretend the mass is a blood vessel as the approach is identical).

The other option is use of a laser which is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision (though not zero). Shown below is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser.

Read more about laser treatment of vocal cord pathology here.

Read the Washington Post story here.

Scientists Publish Research on Breakthrough Treatment for Tonsil Stones

Title sounds very exciting... even more so when I realized it was talking about the research paper that I co-authored with fellow ENT colleague Dr. Richard Thrasher on a new way of addressing tonsil stones.

I never really considered myself a "scientist,"but glad to hear that at least somebody considers me one!

This article apparently came out on MedicalXpress, a medical news website. It has also been picked up in a few other channels as listed under sources.

Source:
Scientists Publish Research on Breakthrough Treatment for Tonsil Stones. MedicalXpress 6/20/12

New Minimally Invasive Technique to Treat Tonsil Stones Developed by Dr. Chang. Fauquier ENT Blog. 6/14/20

Ear, Nose & Throat Journal publishes research on breakthrough treatment for tonsil stones. EurekaAlert 6/20/12


Reference:
Coblation cryptolysis to treat tonsil stones: A retrospective case series. Ear Nose Throat J. 2012 Jun;91(6):238-54.

New Minimally Invasive Technique to Treat Tonsil Stones Developed by Dr. Chang

Dr. Chang developed an innovative minimally invasive technique to treat tonsil stones using coblation technology. His findings have been published in this month's ENT Journal. In fact, his research made the front cover of the journal! Dr. Richard Thrasher of ENT Centers of Texas was a co-author in the study.

This technique called coblation tonsil cryptolysis is unique in that it can be performed in adult patients without sedation using only local anesthesia, much like laser tonsil cryptolysis. As with laser cryptolysis, pain is significant for only a few days and most adults can resume normal diet and activity within 1 week. In contrast, tonsillectomy entails significant morbidity for several weeks. However, coblation avoids the significant disadvantages of laser use, including the potential for airway fire, retinal damage from reflected scatter, dealing with plume from vaporized tissues, oral/facial burns, and the high cost of purchasing and maintaining laser equipment. After a single session of coblation tonsil cryptolysis, a significant decrease and even elimination of tonsil stones can potentially be achieved.

Read more about this mode of treatment here.

Read the research article here.

Sheryl Crow With Benign Brain Tumor

It was announced yesterday that Sheryl Crow has a benign brain tumor known as a meningioma.

The Grammy award winning singer did not disclose what her symptoms were that led to the discovery of this tumor which often is made by an MRI scan of the head.

From an ENT perspective, such a tumor can be confused with an acoustic neuroma if found in an area of the brain called the cerebellopontine angle (CPA) and patients will often initially present to an ENT with symptoms of:

• Ringing of the ear on just one side (tinnitus)
• Sense of ear fullness on one side that does not go away
• Hearing loss worse on one side (asymmetric sensorineural hearing loss)
• More rarely, balance problems

After a basic exam of the ear, a hearing test is performed. If the hearing test shows a significant asymmetry in NERVE hearing (as opposed to conductive hearing loss which is hearing loss NOT due to a nerve problem), an MRI scan of the head with gadolinium is often ordered.

The tumor can be seen very easily on this type of scan.

Other testing that might be performed include:

• ABR (Auditory Brainstem Response)
• OAE (Otoacoustic Emission)

Depending on the location of the meningioma, the patient may see either a neurosurgeon or a neuro-otologic surgeon (sub-specialized ENT surgeon). Typical options depending on symptoms, location, and size include:

• Monitor
• Surgical excision
• Radiation ("gamma" or "cyber"-knife)

It is unclear what course of treatment she has elected to pursue.

Source:
Sheryl Crow Assures Fans Her Brain Tumor Is Non-Cancerous. People 6/6/12.

Movie Director John Woo Has Throat Cancer?

Famed movie director John Woo apparently is being treated for throat cancer. The director of such movies including Mission: Impossible II is apparently undergoing treatment in the United States.

Details are sparse.

However, he apparently "has been admitted into a hospital for 4 months" which leads me to think that his throat cancer is late-stage which usually requires both radiation and chemotherapy for definitive treatment. Surgery may or may not be required, though hard to say without more information.

Source:
Woo reportedly suffers from throat cancer. China.org.cn 5/26/12

How Does Nasal Packing Stop Nosebleeds?

It is not unusual for an ENT or an Emergency Room physician to see a patient with a very bad nosebleed... the kind that can potentially be life-threatening given how much active bleeding is occurring.

In these situations, nasal packing is the fastest and best way of stopping the nosebleed.

For any type of active bleeding, direct pressure tamponades the bleeding thereby stopping it... whether it be a stab wound to the leg or a bad nosebleed. In essence, direct pressure exerts a certain amount of pressure that exceeds the blood pressure preventing blood flow. The corollary being if the amount of direct pressure being exerted is LESS than the blood pressure, bleeding will still occur.

With nasal packing, pressure is exerted by the packing material and pressed against whatever the bleeding source is within the nose.

My personal favorite packing material is called the rapid rhino made by Arthrocare (I have no financial ties to the company). It is in essence a balloon covered by a bio-compatible self-lubricating fabric. This device is inserted into the nose in a deflated state. 

Once fully inserted into the nose, it is than inflated using a standard syringe. Enough air is inflated into the device such that the pressure exerted by the balloon exceeds the blood pressure of the vessels within the nose.

The key point here is that enough pressure must be exerted by the balloon device. If the patient's blood pressure exceeds the balloon pressure, bleeding will still occur and MORE air must be pushed in. As such, in patients with high blood pressure, more air must be inflated into the balloon device to stop a nosebleed compared to a patient with low blood pressure.

So, here is what it looks like to insert a rapid rhino nasal packing.

Step 1: After hydrating the fabric, the nasal packing is placed at entrance of nose.

Step 2: Nasal packing is fully inserted into the nasal cavity.

Step 3: The nasal packing balloon is than inflated with enough air pressure to stop the nosebleed.

Obviously, blood pressure must also be controlled and the nasal packing can be removed in about 3 days for patients not taking any blood thinners or anti-coagulants (coumadin, plavix, ticlid, pradaxa, aspirin, ibuprofen, etc). For those on such medications, packing may need to be kept in place longer.

For more information about nosebleeds.

Beastie Boys Adam Yauch Dies of Parotid Cancer

On May 4, 2012, Adam Yauch, one of the founding members of the Beastie Boys, died of a "rare parotid gland cancer" that he had been battling since its diagnosis in 2009. For those who do not know what a parotid gland is... it is one of the major glands that produce saliva or spit and is located immediately in front of the ear (looks like fish eggs in the picture taken from Wikipedia). It is about the size of the palm of the hand.

It is unclear exactly what type of parotid gland cancer Adam Yauch had, but here's a list of what it could have been:

• Acinic Cell Carcinoma
• Adenocarcinoma
• Squamous Cell Carcinoma
• Mucoepidermoid Carcinoma
• Carcinoma ex-pleomorphic adenoma

Thankfully, the vast majority of parotid tumors are benign growths such a pleomorphic adenoma or Warthin's tumor.

Typically, with any type of parotid mass, the sequence of events to diagnose and treat such masses occur in a standard fashion:

1) Mass appreciated by patient or primary care doctor
2) Patient sees ENT who confirms mass localized to parotid gland
3) CT scan of the neck with contrast ordered to further evaluate the mass
4) Fine needle biopsy obtained of the mass for pathologic diagnosis
5) Surgical excision performed... an operation called "parotidectomy"
6) If needle biopsy indicated cancer, neck dissection is also performed to remove all lymph nodes that may contain cancer followed by radiation therapy to the whole area.

Parotidectomy surgery is a "difficult" surgery mainly in the sense that one of the main risks of surgery is permanent facial paralysis. Why? It is because the nerve that allows facial movement goes right through this gland (in yellow in the picture above).

As such, the vast amount of time dedicated to this surgery which may last anywhere from one to several hours is identifying and isolating all involved branches of the facial nerve. The actual parotid gland mass removal takes less than 15 minutes.

Read more about this surgery here.

Source:
Adam Yauch Dead: Beastie Boys' MCA Dies After Battling Cancer. Huffington Post 5/4/12.