Chronic Cough Due to Statins

Statin drugs (simvastatin for example) are commonly used to treat high cholesterol and have many known side effects... but here's another. Statins are now believed to potentially cause a chronic dry cough according to a recent report!

This chronic cough side effect is common in other types of medications such as ACE-Inhibitors (lisinopril) and angiotensin receptor blockers (losartan) to treat high blood pressure.

Statins were not previously known to cause a chronic dry cough.

Reference:
Chronic cough as a complication of treatment with statins: a case report. Ther Adv Respir Dis. 2012 Jul 3. [Epub ahead of print]

How Can Nasal Obstruction CAUSE Clogged Ears?

It is not uncommon that patients who suffer from a clogged nose also develop clogged ears.

Why??? There are 2 major and 1 minor reasons.

First a little anatomy lesson.

In the back of the nose, there is an opening that leads into a tunnel (eustachian tube) that goes up into the ear. When the ears get clogged, a person can get the pressure out by "popping the ears." This can be accomplished by yawn, swallow, or trying to blow out the nose that is pinched shut. When the ear pops, what happens is that the tunnel opens up allowing pressure to come out the ear. Watch video:



Mucosal Swelling

Now when the patient's nose gets obstructed, it may mean the nasal lining has become swollen making it difficult to breath. It also means the tunnel that goes up into the ear may be swollen shut as well. As such, it may become difficult if not impossible to pop the ears. This is known as eustachian tube dysfunction.

Negative Pressure Inside the Nose

However, there is a more active process that may lead to ear clogging beyond just mucosal swelling of the eustachian tube.

When the nose is obstructed, every time the patient tries to breath in thru the nose, negative pressure is built up in the back of the nose where the eustachian tube opening is located. As such, this negative pressure inside the nose can get transmitted up into the ear resulting in negative pressure to slowly build up in the ear as well which can ultimately cause a clogged ear sensation. This is just like sucking on a straw to draw fluid out of a cup, though in this case, the straw is analogous to the eustachian tube, the fluid is air, cup is the ear, and the mouth is the nose.

Bernoulli's Principle

In fluid dynamics, Bernoulli's principle states that for an inviscid flow, an increase in the speed of the fluid occurs simultaneously with a decrease in pressure.

To use an example, if you are driving a car with the window down, the fast-moving air outside the car creates a negative pressure inside the car causing things to not just blow around, but does cause some suction effect to things within the car (paper inside the car potentially getting "sucked" to the outside).

When the nose becomes clogged, airflow increases in the back of the nose (think garden hose where you have the same amount of water flow, but by changing the nozzle diameter, flow can be increased by making diameter smaller or decreased by making diameter larger). Due to Bernoulli's principle, negative pressure builds up inside the ear due to this increased nasal airflow.

This negative pressure can be transmitted into the ear causing it to become clogged.

So there you have it... 3 reasons why a clogged nose can lead to clogged ears!

That also means that often, if you just treat the clogged nose... the clogged ears will get better as well!

Laryngospasm in a Child

Washington Post published a story July 23, 2012 regarding a child who suffered from laryngospasm attack that was erroneously diagnosed as asthma.

Laryngospasm is when the true vocal cords (TVC) come together rather than apart when breathing. Normally, only when talking do the vocal cords come together (or adduct) and vibrate to create a voice. When breathing, the vocal cords separate (or abduct) to allow air to pass between the vocal cords and into the lungs. Watch video.

What the story portrayed is not uncommon and patients who suffer from laryngospasm may go for years without the correct diagnosis.

The voice therapy that was recommended is also appropriate to help him cope when an attack occurs.

However, that's also the point where I start to disagree with the article.

It is all fine and dandy to learn breathing coping strategies, but that only deals with WHEN an attack occurs. What about what causes an attack to happen in the first place? Would it not be better to prevent an attack from happening at all and thereby coping strategies don't even need to be initiated?

As such, I do feel it important to start an aggressive workup to evaluate all the known triggers that may initiate a laryngospasm attack. Such triggers include allergy, post-nasal drainage, and reflux.

As long as the trigger is not addressed, a patient can continue to suffer recurrent attacks.

Once the triggers are found and fixed... the laryngospasm attacks can be "cured."

Watch the video below depicting larygnospasm as well as less severe forms of the same (vocal cord dysfunction or paradoxical vocal cords).

Source:
Long-ago asthma diagnosis didn’t explain boy’s difficulty breathing. Washington Post 7/23/12

Dirty Air Filters and Allergies - Don't Forget the Car!!!

Most people with bad allergies know to change their home's air filter at least quarterly with at least a 1000 microparticle performance rating (mpr). Such filters will remove pollen, dust, and other airborne particles that may exacerbate allergies as well as keep the vent system within a home clean.

BUT... allergic patients should also not forget to change their car's air filter as well regularly, especially given the car is moving around outside and people often have the air conditioning or heat turned on blowing into the face. And guess what... there are many different quality car air filters.

As such, do recommend that whenever you have your car for maintenance, request the mechanic to show you your car's air filter.

To Ear Plug or Not to Ear Plug

Seems like a fairly simple question... but oh what controversy it stirs up when regarding a patient with ear tubes who wants to go swimming.

There are two schools of thought...

1) Based on evidence and research, no need to wear ear plugs... ever.

The argument... Well, here's the research:

• A meta-analysis of swimming and water precautions.
• Water precautions and tympanostomy tubes: a randomized, controlled trial.
• A meta-analysis of swimming and water precautions.
• The effect of water exposure after tympanostomy tube insertion. 

 2) Based on personal experience, ear plugs should be worn.

The argument:

When there's a tube present through the eardrum, any water that gets into the ear canal can potentially go through the tube and into the middle ear space and cause an infection (otitis media). The middle ear space should remain sterile, but if the water is contaminated with germs, this sterile space becomes violated.

Remember, germs found in swimming pools, lakes, rivers, and oceans can be quite funky to say the least. Think of all the birds and animals that go potty in such bodies of water (let alone humans).

Furthermore, there is a type of ear infection called Swimmer's Ear (otitis externa) which is an infection of the skin lining the ear canal. If swimming can cause Swimmer's Ear, than by golly, it certainly can cause middle ear infections as well.

Also, if swimming can cause life-threatening brain eating amoebic infections (amoeba travels into the nose and up into the brain), than by golly, such water getting into the ear can certainly cause ear infections.

Though research does not necessarily bear this argument out, many ENTs have noted from personal experience that it is not uncommon that a patient with ear tubes presents with a draining ear infection within a few days of swimming.

Given water precautions take minimal effort and costs little ($10 ear plugs or swim cap or ear bands... see below), it seems worth it to play it on safe side.

Conclusion?

What do I typically recommend? Ear plugs when swimming, but not necessary when taking a bath (given tap water is theoretically clean).

Many will disagree depending on who you ask, but that's my personal opinion.