Spider Found Living in Woman's Ear for 5 Days

Thanks to @beubank for alerting me to this story about a spider who lived in a woman's ear for 5 days before being removed. As an aside, in typical media blunder of factual error, in the Huffington Post, a picture is shown of the spider stating an "x-ray photo"... COME ON!!! The picture is NOT an x-ray in any way shape and form!!! It's just a regular ordinary picture one takes with a camera.

On that note, August 9, 2012 must be the time for all media to report on all sorts of things found in people's ears and noses.

Fox News reported on a story about a lego being stuck inside a kid's nose for 3 years.

In the past year, I must have removed several cockroaches, ticks, rocks, pebbles, play-doe, paper, cotton, and even one moth. Never a spider however.

In perhaps one of the most impressive arrays of foreign objects removed from the ear, nose and throat (I believe in the thousands) is on display at the Mutter Museum in Philadelphia. All objects were removed by a single ENT (Dr. Chevalier Jackson). If you are ever in Philadelphia, this museum is a must see.

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.

Oral Steroids No Help in Sinus Infections?

Media outlets such as Fox News reported yesterday that oral steroids do not help with sinus infections. This claim is based on a small study of 174 patients with clinical symptoms of an acute sinus infection and given either 30 milligrams per day of prednisolone or placebo pills for one week. Of note, antibiotics were not given.

No significant difference in symptom resolution was found.

Now why would one even think to give oral steroids for sinusitis in the first place?

Steroids decrease inflammation and swelling which theoretically would allow for the sinuses to drain more easily and effectively therefore expediting sinusitis resolution.

Also, there have been studies that suggest steroid nasal sprays do help with resolve sinusitis to a certain extent.

Keep in mind that steroids are NOT antibiotics and do not kill the germs that cause an infection. Furthermore, many viral upper respiratory infections are misdiagnosed as sinus infections.

What this study suggests is that at least for acute sinusitis, oral steroids alone do not help resolve an acute sinus infection.

HOWEVER, keep in mind that oral steroids have been shown to help with nasal polyps and chronic sinus infections when given in the setting of antibiotics and sinus surgery.


Source:
Oral steroid doesn't clear up sinus infections. Fox News 8/7/12

References:
Systemic corticosteroid monotherapy for clinically diagnosed acute rhinosinusitis: a randomized controlled trial. CMAJ August 7, 2012 First published August 7, 2012, doi: 10.1503/cmaj.120430

Chronic rhinosinusitis: epidemiology and medical management. J Allergy Clin Immunol. 2011 Oct;128(4):693-707; quiz 708-9. Epub 2011 Sep 3.

Treatment outcomes and predictors for systemic steroids in nasal polyposis. Acta Otolaryngol. 2012 Jun;132 Suppl 1:S82-7.

Intranasal Corticosteroids in Management of Acute Sinusitis: A Systematic Review and Meta-Analysis Ann Fam Med May/June 2012 vol. 10 no. 3 241-249

Singulair May Help Cure Mild Sleep Apnea in Children

Singulair (generic montelukast as of Aug 2012) is a medication often prescribed for asthma as well as allergies and works by blocking the leukotriene receptor. This mechanism is different than that found in common allergy medications like claritin and benadryl which work by blocking the histamine receptor (anti-histamine).

Singulair has also incidentally been found to possibly help reduce the size of tonsils and adenoids. Given this beneficial affect, singulair may be a helpful intervention in those kids with mild obstructive sleep apnea or nasal obstruction due to adenoid hypertrophy avoid surgical intervention (tonsillectomy and adenoidectomy).

The most recent research published in Sept 2012 suggests that singulair may lessen symptoms in children with non-severe apnea and potentially allow them to skip the surgery.

In the study, 46 children with non-severe sleep apnea received singulair or a placebo for 12 weeks. The kids who received the drug showed improvements in their sleep apnea, their sleep-related symptoms, and the size of their adenoids compared to the placebo group. There were no side effects seen among kids who took the study drug.

Beyond singulair, steroid nasal sprays have also been found helpful to reduce adenoid size.

Singulair can be given from the age of 1 year old.

References:
Leukotriene modifier therapy for mild sleep-disordered breathing in children. Am J Respir Crit Care Med. 2005 Aug 1;172(3):364-70. Epub 2005 May 5.

Leukotriene pathways and in vitro adenotonsillar cell proliferation in children with obstructive sleep apnea. Chest. 2009 May;135(5):1142-9. Epub 2008 Dec 31.

The role of mometasone furoate aqueous nasal spray in the treatment of adenoidal hypertrophy in the pediatric age group: preliminary results of a prospective, randomized study. Pediatrics. 2007 Jun;119(6):e1392-7. Epub 2007 May 28.

Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006286.

Benign Stridor Often Mistaken for Laryngospasm

Laryngospasm causes a high-pitched squeak or wheezing sound when a person is trying to breath due to abnormal vocal cord movement. Watch video regarding this condition.

Larygnospasm (the most severe form of vocal cord dysfunction) is commonly misdiagnosed as asthma and patients may go for years labelled as asthmatic even though they may not have it at all.

However, though laryngospasm is often the victim of misdiagnosis, there is a condition known as non-organic stridor which is often misdiagnosed as laryngospasm (culprit as well as victim of misdiagnosis).

Here is a video example (watch the movie clip all the way to the end) of a patient with non-organic stridor who was initially misdiagnosed with asthma, than misdiagnosed as having vocal cord dysfunction/laryngospasm before being finally correctly diagnosed with having non-organic stridor.

As you can see, the vocal cords remain apart which immediately rules out the diagnosis of laryngospasm.

What is also apparent is the wheeze or stridor noise is due to vocal cord vibration while they are apart.

The fast moving inhalation/exhalation literally rattles the vocal cord membranes just like a strong wind flaps around an American flag resulting in "noise". No need for the vocal cords to come together to create the noise. The fast moving air does it all by itself.

The existence of non-organic stridor is one of the main reasons why laryngoscopy during a "breathing attack" suspected to be due laryngospasm is so important.

It's also why I have my patients run around my office until they become symptomatic before I perform this exam. Why do an exam when breathing is completely normal???

What is the treatment? Just reassurance... Given it is the fast-moving air that is causing the noise, one simply has to slow the breathing down. No inhalers, no epinephrine, no medications are needed.

For whatever reason, by far the most common patient who suffers from non-organic stridor is a female high school athlete.