Patients with Iodine or Seafood Allergy CAN Receive Contrast During CT Scans

It is a prevalent belief out in the medical (and lay public) community that patients with iodine or seafood allergy can not receive contrast when undergoing certain radiological tests like CT or MRI scans. The concern is that contrast contains minute amounts of free iodide and as such, IV administration of this material puts the patient at risk of a life-threatening anaphylactic reaction.

Contrast is often given in these tests as it traces out bloodflow enabling the physician to see organ and mass architecture much more clearly allowing for improved accuracy in seeing anything abnormal.

Well... rest assured that patients with iodine and seafood allergy CAN receive contrast without any significant increased risk of an allergic reaction as compared to other allergies.

In a large study encompassing 112,003 patients, only 5% had a reaction. The relative risk of a reaction in patients with seafood allergy was 3.0 compared with 2.9 for those with allergy to eggs, milk, or chocolate; 2.6 for those with allergy to fruit and strawberries; and 2.2 for those with asthma [7]. In other words, a seafood allergy increases the risk of a contrast reaction by about the same factor as does any other allergy. At least 85% of patients with seafood allergy receiving IV contrast material will not have an adverse reaction.

Reference:
Formation of potential antigens from radiographic contrast media. Acta Radiol 1987; 28:473-77
Immunologic basis for adverse reactions to radiographic contrast media. Acta Radial 1990; 31:605-612
Contrast media reactions: experimental evidence against the allergy theory. Br J Radiol 1984;57: 469-173
Adverse reactions to intravascularly administered contrast media. AJR 1975;24: 145-152

Burning Tongue or Mouth Syndrome Due to Magnesium Deficiency?

Patients with burning mouth syndrome (BMS) have two major findings: one, burning sensations in their mouth and two, no anatomical changes present in their mouth to relate to this burning.

Dr. Henkin and colleagues at the Center for Molecular Nutrition and Sensory Disorders have clinically distinguished two major groups of patients with BMS. One group has burning limited only to their tongue – called GLOSSOPYROSIS. The other group has burning in their entire mouth, including their tongue, lips, palette, gums and pharynx – called OROPYROSIS. They have recently been able to distinguish these two patient groups biochemically.

Patients with GLOSSOPYROSIS have lower levels of magnesium in their red blood cells (erythrocytes) than do patients with OROPYROSIS or normal subjects.

Patients with GLOSSOPYROSIS have lower levels of magnesium in their parotid saliva than do patients with OROPYROSIS or normal subjects.

However, serum levels of magnesium and serum erythrocyte and saliva levels of calcium are similar in patients with GLOSSOPYROSIS, OROPYROSIS or in normal subjects.

These results suggest that patients with GLOSSOPYROSIS are magnesium deficient.

These findings does suggest magnesium supplementation to reverse the magnesium deficiency may be of benefit in patients with GLOSSOPYROSIS.

Courtesy of Dr. Robert Henkin of the Center for Molecular Nutrition and Sensory Disorders.

Reference:
Biochemical differences in parotid saliva distinguish patients with glossopyrosis from those with oropyrosis: Are there also neurochemical differences? The FASEB Journal. 2011;25:857.4

Study Suggests (Incorrectly?) Steroid Nasal Spray Use Does Not Help with Eustachian Tube Dysfunction

In the May 2011 edition of Archives of Otolaryngology-Head & Neck Surgery, a study was published on a randomized, placebo-controlled, double-blind prospective clinical trial (the best kind of research) to determine whether Nasacort AQ steroid nasal spray can resolve eustachian tube dysfunction as well as ear symptoms related to this disorder. Eustachian tube dysfunction at its mildest would cause symptoms of ear clogging much akin to the way the ears fill up when flying or driving up the mountain. At its worst, can lead to fluid buildup in the ear as well as chronic ear infections.

In the study population of 91 patients, they found that use of a steroid nasal spray did NOT help...

HOWEVER, after reading the paper, there is a major flaw to how the study was conducted which would significantly affect study outcomes. Mainly, how the nasal spray is used would strongly affect whether it will help or not.

According to the paper, patients were instructed to simply administer "2 metered sprays in each nostril once daily (55 µg per spray)..."

Nothing else.

Unfortunately, this type of administration is bound to fail, mainly because using a nasal spray in this manner is inadequate when addressing eustachian tube dysfunction.

First of all, the eustachian tube openings are at 90 degrees to the face, so the steroid nasal spray bottle needs to be directed towards the back of the head and not towards the eye. This needs to be specifically mentioned/demonstrated as it is not intuitive for most patients (and even doctors). The first picture is INCORRECT! The second picture is correct use. Read more here why directionality is important.

Second, a valsalva maneuver (blow air out the nose while keeping the nares pinched) must be performed after nasal spray administration in order to force the nasal spray medicine up into the eustachian tubes in order for the medication to affect the region of concern. Without a valsalva, the nasal spray medicine sits in the nasal cavity which would help with sinus problems, but not the ears which is the area of complaint. Valsalva needs to be done regularly throughout the day during treatment.

Why is this maneuver important? It's like pouring draino (steroid nasal spray) into a clogged toilet, but than not using a plunger (valsalva maneuver).

In any case, there are other studies that have found steroid nasal sprays to be helpful for eustachian tube dysfunction as listed under references.

Read more about eustachian tube dysfunction here.

References:
Management of Eustachian Tube Dysfunction With Nasal Steroid Spray. Arch Otolaryngol Head Neck Surg. 2011;137(5):449-455. doi:10.1001/archoto.2011.56

The role of topical nasal steroids in the treatment of children with otitis media with effusion and/or adenoid hypertrophy. Int J Pediatr Otorhinolaryngol. 2006;70(4):639-645.

Oral or topical nasal steroids for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev. 2006 Jul 19;3:CD001935.

What is Considered a Normal Number of Reflux Episodes?

Depending on whether one is talking about GERD (gastroesophageal reflux disease) or LPR (layrngopharyngeal reflux), I believe the answer is completely different.

As it pertains to GERD and what literature, doctor, or testing equipment is used, 73 plus or minus some change is what is considered a normal number of reflux episodes a typical adult may experience in a 24 hour period of time.

What exactly does this number mean? This number describes how many times stuff in the stomach regurgitates up into the esophagus which is the tube that carries food down to the stomach after food is swallowed.

The reason why heartburn is not initially experienced is because the lining of the esophagus has a protective layer preventing acid damage. However, once the number of reflux episodes goes higher than 80, the protective layer breaks down and acid damage starts to occur leading to typical symptoms of heartburn and/or chest pain.

Now what about laryngopharyngeal reflux (LPR)?

I would argue that even ONE episode is not normal if symptomatic.

LPR is when stomach contents regurgitate up to the level of the voicebox. At its most basic limited definition, LPR is a near-vomit (vomit being stomach contents that reach the mouth level and beyond). The only difference between LPR and vomit is the volume of regurgitation and location it reaches.

When such regurgitation reaches the voicebox level, a number of symptoms occur, even if it happens one single time.

First, when LPR occurs, the throat feels phlegmy leading the patient to throat-clear the mucus up and out or to re-swallow.

Second, when enough LPR episodes occur, the mucosal lining of the voicebox region starts to get irritated that may lead to a chronic cough. At its worst, it may lead to vocal cord dysfunction and even laryngospasm. Some episodes may even be aspirated into the lungs leading to bronchitis and reactive airway disease.

Third, the sphincter (upper esophageal sphincter) that separates the esophagus from the voicebox may start to tighten which is the body's way of attempting to prevent further reflux from reaching the voicebox. Such muscle tightening may lead to symptoms of difficulty swallowing with food getting stuck at the voicebox level as well as lump in throat sensation (globus).

Heartburn is not very common with LPR (though it may occur) as one needs to remember that there is a protective barrier preventing acid damage to the mucosal lining.

Also, non-acid reflux may be present rather than acid reflux. With non-acid reflux, heartburn symptoms are not as common due to lack of acid presence that would lead to damage (though other factors are present including bile, enzymes, etc).

Given even a single episode of LPR can be considered abnormal if symptomatic, many studies will come back NORMAL due to timing. A barium swallow typically does not take more than a few minutes to perform done during business hours. Same goes for upper endoscopy. BUT... what if the few episodes of LPR occur in the evening or early morning NOT when the studies are performed?

As such, what I consider the BEST study to evaluate for LPR is a 24 hour multi-channel pH and impedance testing. This test looks for reflux during a continuous 24 hour period of time. If it sees reflux, it records what time, how long it lasts for, how high does the reflux go up, what the pH level is, etc. BRAVO or single or dual-probe pH studies are inadequate as they measure ONLY whether acid GERD is occurring or not. These alternative tests can not evaluate for LPR or non-acid reflux.

BOTTOM LINE

With GERD, up to around 73 episodes of reflux is considered normal.

With LPR, even a single episode can be considered abnormal if symptommatic.

I can't provide any literature or research to support my statement as it pertains to LPR other than personal experience. Watch a video I made below showing a patient who is experiencing a non-acid LPR episode during an examination. This patient had a normal upper endoscopy, normal pH study, and normal barium swallow. Look at all the frothy mucus that is bubbling up to and around his voicebox leading to his complaint of phelgmy throat and chronic cough/throat-clearing. Treatment was surgery (nissen fundoplication).

New and Only Over-The-Counter Anti-Histamine Nasal Spray

Up until now, there has been three anti-histamine nasal sprays in the United States market available only by prescription... Astelin, Astepro, and Patanase.

However, in May 2011, Meda Pharma announced a new anti-histamine nasal spray Rhinolast Allergy that is available over-the-counter.

The active ingredient is azelastine, the same one as found in the prescription nasal spray Astelin and Astepro.

Azelastine has a triple mode of action: anti-histamine effect, m,ast-cell stabilizing effect, and anti-inflammatory effect. Azelastine has a rapid onset of action of 15 minutes.

It can be used from the age of 5 years.

This nasal spray can be used in combination with other over-the-counter anti-histamines medications taken orally like zyrtec, claritin, allegra, and benadryl.

Read more about this new nasal spray here.

Read more about allergy medications in general here.