Dr. Chang to Give Lecture on Spasmodic Dysphonia in Richmond, VA

Dr. Christopher Chang will be a guest lecturer on the topic of spasmodic dysphonia in Richmond, VA on June 11, 2011. Dr. Chang was invited to give a 3 hour long talk to the Central Virginia SD Group at the CJW Medical Center Johnston-Willis Campus in the Board Room starting at 12PM.

Dr. Chang is a Yale and Duke trained, board-certified otolaryngology-head and neck surgeon with fellowship training in laryngology. He is considered an expert on spasmodic dysphonia and has patients coming from as far as the Philippines (yes... the one on the other side of the world) every 3-6 months to receive treatment for this rare condition.

Read more about this condition here.

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Books on voice therapy that MIGHT be a useful ADJUNCT to botox injections:

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]

What Exactly Does a Generic Drug Mean (Opposed to Brand Name)?

Some patients are very confused by what the difference between a generic drug versus brand name drug is.

From the patient perspective, they are thinking, how in the world can the same drug be called different things?

Doctors answer by talking about active ingredients, patents, and copays which sometimes confuses patients even more. Well, here's to set the record straight using an analogy.

So let's talk about orange juice.

I consider Tropicana Orange Juice a brand name "drug".

The "active ingredient" in Tropicana Orange Juice is the fruit "orange".

A generic drug equivalent to Tropicana Orange Juice is Target (or other supermarket name) Orange Juice.

They both contain the same active ingredient of oranges, but the name is different.

The generic orange juice is also always cheaper.

Now, some people do not feel there is any difference between the brand name Tropicana and the supermarket branded generic orange juice, but some people insist that Tropicana tastes better and is healthier as it is not made from concentrate.

Others say that in the end, it really is the same because the active ingredient of oranges is the same.

Same controversy and arguments for orange juices also apply to drugs.

Hopefully, people understand the difference between brand name and generic equivalent drugs a little better now.

Personally, I feel if generic drugs work for you, save your money and stick with it rather than a brand name drug.

Anti-Histamine Eye Drops

Allergies often cause eye symptoms of itching, swelling, redness, and tearing.

If other allergy symptoms are also present involving the nose and skin, it is best to try an oral anti-histamine as a first step.

This one oral drug may be able to resolve all these symptoms. As I am fond of telling patients, oral medications affect the whole body as the medication goes to the stomach after swallow, gets digested, and spreads to the big toe just as much as the skin, nose, and eyes.

However, if symptoms are limited to just the eye, it is best to use topical medications like eye drops rather than an oral medication which goes everywhere (where it is not needed).

There are in essence two anti-histamine eye drops available over-the-counter.

The first is the combination of naphazoline and pheniramine found in NaphCon-A and Visine-A (formerly called Ocuhist). Naphazoline is a decongestant that helps eliminate the red eyes whereas pheniramine is an anti-histamine to help eliminate itching. It can be used up to 4X per day for relief.

The other contains the active ingredient ketotifen and has 3 modes of action: anti-histamine, mast cell stabilizer, and eosinophil inhibition. All three actions in essence help resolve current as well as future allergy eye symptoms. It's also why it can be used only twice a day opposed to 4X per day required with naphazoline/pheniramine.

There are three main brands of ketotifen that basically are the same thing:

- Zaditor

- Alaway

- Zyrtec Eye Drops

- Claritin Eye Drops

The "zyrtec" and "claritin" eye drops names are quite misleading in that the eye drops do NOT contain the same ingredient as that found in the oral medication by the same name.

Personally, I prefer ketotifen over naphazoline/pheniramine due to longer-lasting relief per use, 2X per day dosing, and less risk (glaucoma and hypertension specifically). Ketotifen can be used from the age of 3 years (age 6 years for the other).

Of course, if these eye drops don't work, there are prescription antihistamine eye drops that work quite well including pataday/patanol (olopatadine), bepreve (bepotastine),  and lastacaft (alcaftadine). Of course, most insurance companies require trial of OTC eye drops first before they will authorize these prescriptions.

On a final note, there is one steroid nasal spray called Veramyst that has an FDA indication for eye allergies though I suspect all steroid nasal sprays can help similarly. As such, if a patient has only ocular and nasal allergy symptoms, it may be worth trying a steroid nasal spray, though I'm not sure how often this is practiced in reality.

Steroid Inhalers for Asthma Can Cause Fungal Laryngitis

It is a big bummer to be an asthmatic. Not only is breathing a problem, but even the treatment for asthma can cause problems.

Take for example steroid inhalers like advair, symbicort, fluticasone, etc.

All asthma patients know to rinse their mouth out after inhaler use due to risk of oral thrush, but what about from the back of the mouth down to the vocal cords??? This nether region can't be gargled very easily. One can swallow water to rinse this area out, but the vocal cord region would still not be addressed (otherwise aspiration would occur).

And that leads to potential vocal problems... like fungal laryngitis (or thrush of the voicebox). Here's a picture of what that looks like. To compare, normal is shown in the smaller picture.

Note the white patches indicative of fungal growth. This fungal infection can lead to symptoms of a mild (if any) sore throat, but most patients complain of hoarseness as their only symptom.

Treatment is ideally to stop the steroid inhaler triggering the infection, but if an asthmatic needs it... than they need it. As I often tell patients, breathing is more important than voice. Often, anti-fungal medications like diflucan and nystatin can eliminate the fungal laryngitis, but problem is, as long as steroid inhalers are used, it comes right back. And repetitive anti-fungal treatment can place the patient at risk for a drug-resistant fungal infection.

So what to do???

There is one type of little-known (unpleasant) treatment an asthmatic patient can perform to minimize risk of fungal laryngitis while still maintaining steroid inhaler use.

It's called laryngeal washes and it takes a lot of time, patience, and period of discomfort. Think of it as gargling of the voicebox.

The patient takes a curved luer-lock cannula (picture shown) attached to a syringe filled with salt-water. While opening the mouth and sticking the tongue out, the curved end of the cannula is directed such that the end is pointed straight down into the throat. After taking a deep breath in, while saying "ah", salt-water is dripped down into the throat thereby "gargling" the voicebox. Coughing may be inevitable after performing.

This needs to be done after every steroid inhaler use. Or during an active fungal infection, at least 4 times per day.

Gagging is the biggest problem preventing correct usage of this technique. Coordinating the injection while saying "ah" is another issue since if it is incorrectly performed, can lead to aspiration and severe coughing. As such, it is not for everyone.

One can purchase such "luer-lock laryngeal cannulas" from any ENT medical supply company.