Otolaryngology-Head & Neck Surgery

Continuous Positive Airway Pressure The - PubMed Mobile

2012-01-27T23:50:00.001+08:00

More encouraging data on the wavefront of studies on the CVS effects of CPAP therapy on OSA.

Demonstrating an increase in nitric oxide and blood flow and a concommitant decrease in inflammatory mediators, the benefits are similar to and complents pharmacotherapy and exercise for the occlusive and thrombotic vascular diseases - ie. IHD, stroke, PVD.

It will be good to see sleep testing and CPAP become mainstay in the management and prevention of these vascular diseases

http://www.ncbi.nlm.nih.gov/m/pubmed/22278815/

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Polysomnographic findings and clinical presentation of adult men with OSA in China - PubMed

2012-01-27T23:42:00.001+08:00

What's useful about this simple descriptive study is that it represents a closer-to-home Asian profile, and a stratification into 3 equal groups of young/middle-aged/elderly men for comparison.

What the demonstrates is that OSA decreases in severity and CSA increases with age!

The questions this raises is:
1- What physiologic mechanisms are at work to reduce upper airway obstruction and inhibit respiratory drive?
2- What does this mean for long-term follow up? Should we retest and how often to see this reduction, potentially reversal of OSA?
3- How does this change management strategies? Is there a role for weaning off CPAP (given the poor compliance rates, long term) and exploring surgical modalities as age advances? (I can see how this is important so that patients, given something to look forward to are not lost on follow up).

http://www.ncbi.nlm.nih.gov/m/pubmed/22276350/

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Children's Asthma Not Eased by Anti-Reflux Drug

2012-01-26T19:12:00.001+08:00

This is one good example of how children aren't just small adults and extrapolating our experience treating 'acid asthma' successfully in adults isn't transferrable.

The findings in this study isn't surprising since we do know that asthma is an atopic disease which peaks in early childhood and abates after puberty, while the adult variety is a residual of that or a different entity altogether.

The premise for the success of PPIs in adults I believe is that reflux is responsible for prolonging asthma beyond childhood and also for new onset bronchospasm mimicking asthma.

http://m.voanews.com/english/Childrens-Asthma-Not-Eased-by-Anti-Reflux-Drug-138085933.html
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High rate of neck cancer

2012-01-26T18:12:00.003+08:00

The Star highlighted the importance of head & neck cancers in Malaysia, though that paragraph about isn't very clear, it is to say that...
1) NPC is the 5th most common cancer in Malaysia
2) NPC is the top head & neck cancer in Malaysia, and
3) As a group, head & neck cancer is the second most common, after female breast cancer, in Malaysia.

http://thestar.com.my/news/story.asp?file=/2012/1/20/nation/10300494&sec=nation

CPAP cures metabolic syndrome in obstructive sleep apnea (RCT, NEJM)

2012-01-26T14:02:00.002+08:00

This is a fascinating study not just because it demonstrates the benefit of CPAP in reducing sugar, blood pressure, cholesterol, and LDL, but more so for its use of a 'sham CPAP' for placebo!

As the commentator notes, it's unclear if the benefits were the direct result of reducing hypoxic events or more indirectly because of increased activity and exercise in the less somnolent. It would be good to control for that.

http://pulmccm.org/main/2012/randomized-controlled-trials/cpap-cures-metabolic-syndrome-in-obstructive-sleep-apnea-rct-nejm/

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Liow: Heavy snorers may have sleep disorder

2012-01-26T12:44:00.002+08:00

Our Minister of Health has taken cognizance of the serious health implications of OSA.

http://thestar.com.my/news/story.asp?file=/2012/1/8/nation/10225247&sec=nation

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Chemoradiotherapy for Early-stage Nasopharyngeal Disease - The ASCO Post

2012-01-26T12:10:00.001+08:00

Given the better outcomes of Stage III and IV NPC on CCRT, one wonders if the same radiosensitising effect would benefit the earlier stages.

Stage I and IIa NPC has up to now never been candidates for concurrent chemotherapy, since outcomes have been good on radiotherapy alone.

This trial addresses that particular gap in our knowledge and the results suggest that the benefit is not only significant, it is a worthwhile endeavor given the minimal and controllable adverse effects.

http://www.ascopost.com/articles/january-15-2012/chemoradiotherapy-for-early-stage-nasopharyngeal-disease/

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OSA in Pediatric CNS tumor survivors

2011-10-24T11:00:00.002+08:00

An interesting study showing a high prevalence of OSA in children CNS tumor survivors. Rather remarkable is that while SDB is highly prevalent, it is the Obstructive apneas that are more prevalent than Central (14 out of 18). Another subgroup of patients to be on the alert for OSA in.

Excessive daytime sleepiness and sleep-... [Pediatr Blood Cancer. 2011] - PubMed - NCBI:

'via Blog this'

Oropharyngeal examination to predict sleep apnea severity

2011-10-20T15:14:00.002+08:00

It's good to see a study that validates what is widely held belief among ENT surgeons. While assessing the oropharyngeal airway ALONE is hardly a holistic approach, a finding of a narrowed passage by Friedman Tongue Position in a patient with excessive daytime sleepiness or other comorbids of OSA (eg. refractory hypertension, ischemic heart disease) has been highly predictive of OSA in my own practice.

Oropharyngeal examination to... [Arch Otolaryngol Head Neck Surg. 2011] - PubMed - NCBI:

'via Blog this'

Coronary CT Angiography Reveals Vessel Involvement in Obstructive Sleep Apnea : Internal Medicine News

2011-01-02T14:57:00.000+08:00

An important step forward in delineating the relationship between OSA and IHD.

Already we know, hypoxia and sympathetic stimulation places the heart in a state of myocardial with reduced oxygenation.

The added insult of oxidative injury is the third and lethal blow it seems..

http://www.internalmedicinenews.com/news/cardiovascular-disease/single-article/coronary-ct-angiography-reveals-vessel-involvement-in-obstructive-sleep-apnea/233e32a8fd.html

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Experiments test if implant can block sleep apnea - Leesville, LA - Leesville Daily Leader

2011-01-02T14:35:00.000+08:00

An impanted synchronised nerve stimulator to increase muscle tone of the tongue, hence preventing retroglossal obstruction. How ingenious!

http://www.leesvilledailyleader.com/news/x224240986/Experiments-test-if-implant-can-block-sleep-apnea

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Prince Of Wales Hospital In Hong Kong First In Asia To Offer Cancer Patients Image-Guided RapidArc® Radiotherapy

2010-12-16T11:54:00.000+08:00

Similar to the high-speed 640 slice CTs, using Arc technology is the most logical thing to do. It really is quite amazing to watch these machines at work.

http://www.medicalnewstoday.com/articles/211522.php

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Guangdong Humen People Suspected Cancer Due To Fumes Emitted From Power Plants - Refractory Industry

2010-12-16T11:22:00.001+08:00

The nasopharynx being the airway brusher, fumes and pesticide-bearing wood dusts are always suspect causative agents.

The Humen people are among the most susceptible in the world to NPC and it doesn't help to be fogged in power plant fumes...

http://business.ezinemark.com/guangdong-humen-people-suspected-cancer-due-to-fumes-emitted-from-power-plants-refractory-industry-31c8dac7a09.html

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Antioxidants for deafness

2010-05-04T00:24:00.000+08:00

Oxygen free radicals is now the scapegoat for everything from diabetes to cancer; so why not deafness?

We've always relegated presbycusis to just another one of the many unavoidable stigma of ageing, inexplicable and irreversible. Ageing is the next frontier of medicine and free radicals are the sands of time in the storm of decay.

Sci Am reviews a fascinating recent animal study that demonstrated slowing of age-related deafness in rats by the administration of antioxidants. An elegant way of elucidating the mechanism of disease AND its treatment in a single experiment.

Unfortunately, the pharma industry will only seize this to sell us a plethora of antioxidants rather than have us relook at our toxic modern diets and lifestyles!

www.scientificamerican.com/article.cfm?id=preventing-hearing-loss

Things aren't always what they seem at first

2010-04-17T17:52:00.001+08:00

Now that 4D IMRT is all the buzz, we are seeing more and more studies on the volume changes of tumors througout the course of chemoradiation. This is imaging science at its best, monitoring progress and titrating treatment according to burden of disease. Perhaps we can learn something in managing other pathologies; like infection for example.

Weekly volume and dosimetric changes during chemoradiotherapy with intensity-modulated radiation therapy for head and neck cancer: a prospective observational study. (http://www.ncbi.nlm.nih.gov/pubmed/20338474)
Bhide SA, Davies M, Burke K, McNair HA, Hansen V, Barbachano Y, El-Hariry IA, Newbold K, Harrington KJ, Nutting CM.
Int J Radiat Oncol Biol Phys. 2010 Apr;76(5):1360-8.

The Master speaks

2010-04-11T20:35:00.001+08:00

When it comes to surgical management of NPC, William Wei always has the last word.

So, it's good that he issues refreshers like this one to keep our management strategies abreast with latest developments.

This appears as the article 'Current management strategy of nasopharyngeal carcinoma' in Clin Exp Otorhinolaryngol. 2010 Mar;3(1):1-12
(http://www.ncbi.nlm.nih.gov/pubmed/20379395)

Other review articles of relevance are linked as well.
(http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=link&linkname=pubmed_pubmed&uid=20379395)

New in OSA

2010-04-11T14:54:00.001+08:00

This is music to my ears.

Authors Xu H, Huang W, Yu L, and Chen L. published in Acta Otolaryngolica this week an article entitled 'Sound spectral analysis of snoring sound and site of obstruction in obstructive sleep apnea syndrome.'
(http://www.ncbi.nlm.nih.gov/pubmed/20377505)

They showed objectively what we have known intuitively, that the higher the obstruction the lower the pitch of noise generated. In fact they found that lower obstructions had a greater proportion of >800Hz and >2000Hz first-snore sounds than higher obstructions.

This confirms the way we clinically differentiate stertor and stridor, and might even spawn a new wave of polysomnogram parameters.

I can tell by the way you snore...

2009-11-12T13:53:00.002+08:00

Wouldn't it be great if we didn't have to do expensive polysomnograms, read incomprehensible charts, and (in the public setting) wait for months for a sleep study? All just to diagnose OSA and say to a patient ok, now we are sure you need treatment. Especially when he's been falling asleep in your waiting room or just come in with head bandaged after his lorry overturned. You know he has OSA.

Well, it seems the people in Brisbane have found a way.

I have been thinking along the lines of a biochemical marker or something that might be detected in the breath. Imagine bus drivers having to check in for a urine test or breathalyser test before they board and you get the idea.

The sleep team in University of Queensland have reported they can HEAR that you have OSA.

I guess I have always had this hunch. Haven't you? There's a rhythmic hiss in the meeting room and you thought it was the air-condition vent until the guy next to you starts nodding. You think the ventilator is leaking when you realise your assistant in OR is stertoring. You know. Nothing scientific. No data to base this on. Just that visceral hunch that there's no way you can be breathing right during sleep if you are hissing with every breath through the day.

But these guys down under have made a science of it and claim over 90% sensitivity and specificity by simply analysing the audio recording of your snore!

Read the Article at HealthJockey.com

Review the scientific papers related to snoring by their lead researcher Dr. Udantha Abeyratne.

Post exposure prophylaxis for Varicella?

2009-11-10T20:35:00.004+08:00

The author of this blog is currently in day 7 of illness, suffering from a moderate form of varicella. In spite of starting acyclovir (thanks to vigilant and quick-acting wife) on the day of eruptions, the disease process was not halted and vesicles are florid. While we are taking precautions against pneumonia, encephalitis, and other adult-onset associated complications, it is my 2yr old that I agonise about.

He is an 'exposed' individual. Varicella infections in children are mild and rarely complicated. Being an otolaryngologist, however, we know that Ramsay-Hunt (herpes zoster oticus; i.e. reactivation of virus in facial nerve) syndrome causes debilitating facial palsy - sometimes irreversible. Shingles is painful, too. My question is, should I bother vaccinating him now? He was planned for his jab next week, but now that he is exposed, shouldn't I just wait and see if he develops the infection which would obviate vaccination altogether?

Well, this is where the evidence is really useful:

According to the Cochrane review of randomized trials evaluating varicella vaccine in children and adults; from 3 trials with 110 healthy siblings of household contacts where they received post-exposure prophylaxis (PEP) within 3 days of exposure or not at all:
- varicella developed in 18% (PEP) vs. 78% (no PEP) (p < 0.05)
- moderate to severe varicella developed in 2% (PEP) vs. 76% (no PEP) (p < 0.05)
- PEP group who developed varicella had mild disease (< 50 skin lesions)
- no trials reported on adverse events following immunization

Also, for all my healthcare worker friends out there, don't be a hero (or a chicken, depending why you're delaying.) Get yourself jabbed now! Varicella vaccine is recommended for those who have never had chickenpox and are seronegative for varicella antibodies. The caveat (or bonus) is 1-5% adult develop varicella-like rashes that shed the virus and should be removed from patient contact (perfect excuse for holiday, no?) [Am Fam Physician 1997 Dec;56(9):2291]

Unilateral hearing loss: To MR or not to MR?

2009-10-27T11:29:00.004+08:00

The occasional case of unilateral hearing loss sometimes poses a dilemma. Should we order MRIs to rule out acoustic neuroma for every case of unexplained unilateral SNHL when the incidence is only 1 in 100,000?

Perhaps our suspicion index can be guided by the symptom profile of acoustic neuroma where there is:
93.4% hearing impairment
75.5% tinnitus
40.6% vertigo
38.8% unsteadiness

Hearing loss can be sudden (12-47%) or insidious

Ho & Kveton, 2002, recommended a protocol for investigation:
- for patients with limited symptoms (isolated vertigo, historically explained unilateral hearing loss or tinnitus, or symmetrical hearing loss; estimated risk of acoustic neuroma < 5%): ABR as initial test and MRI if abnormal ABR
- for patients with intermediate symptoms (sudden sensorineural hearing loss or unexplained persistent unilateral tinnitus; estimated risk of acoustic neuroma 5-30%): MRI as initial test
- for high-risk patients with combination of unilateral asymmetric sensorineural hearing loss, tinnitus and decreased speech discrimination (estimated risk of acoustic neuroma > 30%): MRI with gadolinium initially and periodic ABR testing if negative MRI

On the other hand, it is worth remembering that tumor growth is on average 1-2.3 mm/year and less than 30% grow > 2 mm/year so that serial MRIs are hardly helpful and may not require any intervention in the elderly.

References
Arch Otolaryngol Head Neck Surg 2004 Feb;130(2):216
Neurosurgery 2006 Jul;59(1):67
J Laryngol Otol 1994 Feb;108(2):116
Am J Otolaryngol 1999 May-Jun;20(3):157
Neurosurgery 1997 Jan;40(1):1
Otolaryngol Clin North Am. 2002 Apr;35(2):393-404, viii

Risk of CA in MNG

2009-01-16T13:54:00.002+08:00

I was asked this by a friend who has a progressively enlarging non-toxic goitre and a CT scan that showed a huge multinodular goitre with tracheal compression: do I need surgery and why? Should the whole thyroid be removed or can some be spared?

My quick answer was YES you need surgery, and a total thyroidectomy, both because of the risk of occult carcinoma. An FNAC can easily miss malignant foci, MNGs have a risk of malignant change, imaging has no reliable sign of malignancy, and compression heralds worse complications (with or without op).

But what's the risk exactly, and what does evidence say about how much of thyroid to remove? This is what the evidence says:

1)In a review of 317 patients operated for multinodular goiter, the incidence of occult micro-carcinoma was 3.3% (Wahl RA, Goretzki P, Meybier H, Nitschke J, Linder M, Roher HD. Coexistence of hyperthyroidism and thyroid cancer. World J Surg 1982; 6: 385-390)
2) Another review of 98 total thyroidectomies done for MNGs revealed an incidence of 10 cases (10.2 percent) occult carcinomas - seven patients were diagnosed with papillary carcinoma, two with the follicular variant of papillary and one with follicular carcinoma.
http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijs/vol17n1/goiter.xml
2) Total thryoidectomy may avoid need for reoperation in case of incidental thyroid
cancer; a study of 218 patients with euthyroid multinodular goiter and no suspicion for malignancy were randomized to total or near-total thyroidectomy (remnant tissue < 1 g) vs. bilateral subtotal thyroidectomy (remnant tissue> 5g); no significant differences in rates of temporary unilateral vocal cord dysfunction (0.9% vs. 0.9%), hypoparathyroidism (1.8% vs.0.9%) or finding of papillary cancer (9.2% vs. 7.3%) (Arch Surg 2004 Feb;139(2):179 in JAMA 2004 May 5;291(17):2058)

So, with a risk of somewhere between 3-10% occult carcinoma (papillary still being the commonest) and near-total also mean could-miss; I think it's still right to say MNGs should be treated with total thyroidectomies unless surgically difficult; upon which post-operative suppressive thyroxine may be an option.

Proud flesh

2008-04-19T00:46:00.000+08:00

One rarely sees proud flesh outside of the diabetic foot these days, what more in the neck. This patient had a badly infected tracheostomy and was taken of it for a couple of weeks for Pseudomonas infestation. This is the result of a wound desperately trying to fill the gaps with granulation tissue while never being able to epithelialise.

What I had to do was to excise the entire granulating mass with a cuff of skin, all the way down to the strap muscles before redoing the tracheostomy. Wound care is going to be very important for this not to happen again.

Microflap excision

2008-04-07T21:15:00.004+08:00

These vocal cords belong to a middle-aged chronic smoker who has suffered from a hoarse voice for close to a year. His wife has been my patient for many years and she decided to bring him to see me. As you can see there is intense leukoplakia on both vocal cords. A CT scan revealed no framework infiltration or extension into the pre-epiglottic space. I had tried several biopsies using a flexible scope but tissue was inadequate.

I put him under for a proper microflap excision today. Seen here is the epithelium and subepithelial layers raised, revealing the vocal ligament and gelatinous lamina propria covering it. One advantage of doing this is that I can directly inspect for deep infiltration and also examine the ventricle and subglottic space (which were free growth).

As the free edge of the vocal cord was not spared by this exophytic lesion, it didn't seem logical to confine my excision to the dorsal surface only. After all, voice-sparing was no longer my concern. More important was to get a good representative specimen. The dilemma/temptation was to get some tissue from the opposite vocal cord but thankfully caution prevailed. Last thing I need is an adhesion anteriorly and ruin his voice forever.

Should the lesion be non-invasive, I can still go in again to do the other side. If it's malignant then some radical modality will be offered. That's the plan.

GERD in the News

2007-04-25T12:32:00.001+08:00

A new study, published in the journal "Digestion", determined the diagnostic and therapeutic response of the Reflux Disease Questionnaire (RDQ) using the symptom association probability as reference. The symptom association probability objectively determines with a Fisher exact test whether symptoms are due to reflux events taking all symptom episodes and reflux events into account. In addition, the RDQ's construct validity and its relationship to quality of life were ascertained.

The study shows the RDQ to be a valid and reliable questionnaire with excellent construct validity and a good relationship to quality of life. The diagnostic value of the RDQ in primary care is limited, but combination with an additional proton pump inhibitor treatment course might improve the RDQ's ability to discriminate GORD patients according to their symptom association probability outcome.

Medical News Today

Heartburn could be a precursor to gastro-oesophageal reflux disease, British doctors warn and note that the diagnosis of the disease is a relatively new phenomenon.  Statistics show that over a quarter of Britons have gastro-oesophageal reflux disease, also known as the GORD, and thousands of these are not getting the treatment they need. A noted general practitioner, Dr Rob Hicks, said that the GORD as a diagnosis was a relatively new phenomenon and that although most medical practitioners were aware of it, many patients could still be suffering in ignorance. "What we are trying to do is to raise awareness, because there are many people still suffering from heartburn two or three times a week. I would advise them to see their doctor," Hicks said.

MedIndia.com

Combined Approach to Paranasal Sinuses

2006-04-17T15:41:00.000+08:00

Summary of article: Combined anterior-to-posterior and posterior-to-anterior approach to paranasal sinus surgery: an update. Schaefer SD, Li JC, Chan EK, Wu ZB, Branovan DI.Laryngoscope. 2006 Apr;116(4):509-13

This article first reviews the historical development of FESS, from Wigand's postero-anterior approach (expose posterior ethmoids, open face of spehnoid, and retrograde ethmoidectomy) to the antero-posterior approach of Messerklinger & Stammberger (anterior ethmoidectomy followed by antegrade dissection posteriorly, extent determined by disease.) Kennedy's FESS is built on these antecedent techniques with the aim of 'reestablishing sinus drainage & mucosal recovery through restoration of obstructing sinus ostium and removal of devitalised mucous membrane or bone.'

The obvious advantage and disadvantage of the P-A approach is that
1. it avoids the skull base
2. surgery is excessive in cases of limited disease

As for the A-P approach:
1. surgery is selective and limited to pathologic sinus
2. there is potential for penetrating the posterio-inferiorly sloping skull base

The author's (Schaeffer) CAPS (combined approach to paranasal sinuses) is introduced and discussed. It is claimed that CAPS aims to 'bring together the salient features of the AP and PA approaches while observing the concept of functional endoscopic sinus surgery' and is therefore a 'minimally invasive surgery.. seeking the least disruption of form and function of the paranasal sinuses'

Key tenets of the combined approach are :
1. It is a 'disease-and-anatomy-oriented surgical approach'
2. It's goal is to 'conserve sinus anatomy'
3. Surgical principles utilizes 'anatomic relationships'

(It is disease-oriented in that surgery is targeted to 'relieve medically irreversibly obstruction of sinus outflow tracts' and it is anatomy-oriented in that anterior and posterior ethmoid sinuses are approached separately, in view that they are 'embryologically distinct structures... separated by the basal lamella of the middle turbinate.')

The key surgical principles include:
1. Complete uncinectomy necessary for anterior ethmoidectomy and prevent recurrence
2. Identification of MSO necessary to find plane of lamina papyracea
3. Anterograde (AP) dissection of anterior ethmoid cells up to basal lamella, retrograde (PA) dissection of posterior ethmoid cells

The authors' experience indicates that CAPS can be performed under local or general anesthesia, as permitted or tolerated. In this review of 2,344 patients, 'the overall complication rate was 3.4%. The minor complication rate was 2.6% (6 of 2,344 patients), and the major complication rate was 0.8% (2 of 2,344 patients).' Evidence that underscores how this 'hybrid technique' succesfully combines 'the conservation goals of the AP approach and anatomic virtues of the PA approach to ethmoidectomy.'

PubMed link

Blame it all on GERD!

2006-04-05T14:28:00.000+08:00

'Heavner et al., in two animal studies, have demonstrated that exposure of the eustachean tube to simulated gastric content in rodents creates eustachean tube dysfunction. Velepic et al., in two separate studies, have demonstrated a strong correlation of otitis media and GERD. Using a 24-h double pH probe, they found that approximately 60% of the patients had pathologic GERD. In a 2002 study, Tasker et al. demonstrated that middle-ear effusions taken from 54 children contained pepsin/pepsinogen at concentrations up to 1000-fold greater than those in serum 83% of the time. These data suggest that the reflux of gastric juices could be a major cause for otitis media with effusion in children. The link between otitis media with effusion and pharyngeal reflux was further strengthened in a 2004 study by Keles et al. This dual-probe pH study demonstrated that 48% of the children with chronic otitis media effusion had GERD and 64% of the children had pharyngeal reflux. This study suggests that pharyngeal reflux may play an important role in the causes of chronic otitis media with effusion and also that standard single-channel pH probes evaluating for gastroesphageal reflux frequently will miss pharyngeal reflux.'

Should we blame everything on GERD? The above discussion, excerpted from 'SPECIAL COMMENTARY: Should otolaryngologists perform pH probe studies?' by Craig W. Senders in Current Opinion in Otolaryngology & Head and Neck Surgery 2006, 14:38–40 seems to say so.

In the past decade or so, more and more 'mysterious' diseases of ENT are finding its origin in acid. From globus pharyngicus, recurrent tonsillitis, chronic pharyngitis to sinusitis. Now, good old 'glue ear' has a new culprit to blame. And which otolaryngologist hasn't been wondering along those lines? It seems in the fragmented world of subspecialised medicine, diseases are pulling us back together!

Heavner SB, Hardy SM, White DR, et al. Function of the eustachian tube
after weekly exposure to pepsin/hydrochloric acid. Otolaryngol Head Neck
Surg 2001; 125:123–129.
Velepic M, Rozmanic V, Velepic M, Bonifacic M. Gastroesophageal reflux, allergy
and chronic tubotympanal disorders in children. Int J Pediatr Otorhinolaryngol
2000 Oct 16; 55 (3):187–190
Velepic MM, Velepic MS, Starcevic R, et al. Gastroesophageal reflux and sequelae
of chronic tubotympanal disorders in children. Acta Otolaryngol 2004
Oct; 124 (8):914–917
Tasker A, Dettmar PW, Panetti M, et al. Is gastric reflux a cause of otitis
media with effusion in children? Laryngoscope 2002 Nov; 112 (11):1930–
1934
Keles B, Ozturk K, Gunel E, et al. Pharyngeal reflux in children with chronic
otitis media with effusion. Acta Otolaryngol 2004 Dec; 124 (10):1178–
1181

HIgh frequency hearing loss from low frequency noise

2005-10-18T14:43:00.000+08:00

It has long been believed that the spectrum of hearing loss closely matches that of the presenting noise. An antiquated study by Mill et al showed that this is not always true.

Human subjects were exposed to an octave-band noise for 24 hours. Temporary threshold shifts increased for the first eight hours of exposure and then were asymptotic. While threshold shifts were largest at about one-half octave above the center frequency of the noise, a second maximum was observed at higher test frequencies. The exact frequency of this second maximum decreased from 7.0 kHz, for a noise centered at 2.0 kHz, to 5.5 kHz for a noise centered at 0.5 kHz. This result could be caused by the travelling wave pattern along the cochlear partition or to the production of distortion products.

PubMed

Effects of gastroesophageal reflux disease in laryngeal carcinoma

2005-10-18T14:35:00.000+08:00

GERD as a contributory factor to laryngeal carcinoma is much appreciated in the ORL community, but just how strong is it as a risk? Should it be aggresively investigated and treated if the risk is high?

An Italian retrospective investigates the association with 36 consecutive non-smoking and non-drinking patients with histologically confirmed SCC of the larynx vs a control, a group of 125 lifetime non-smoking and non-drinking cancer-free subjects. Patients with laryngeal cancer had a higher prevalence of gastroesophageal reflux disease than the control subjects (P < 0.0001).

PubMed

New centre for deafness research

2005-10-13T21:51:00.000+08:00

'A new centre is to open in London in the new year, bringing together the previously disparate fields of research into deafness and communication.

The Deafness, Cognition and Language Research Centre (DCAL) will be based at University College London and will be funded by a 4.5m grant from the Economic and Social Research Council (ESRC), it was announced yesterday.

The aim of the centre is to create "a world-class hub of excellence" that will connect research into neuroscience and linguistics to issues affecting deaf individuals in their communities. It will also seek to challenge the perceptions of deafness and study sign language and communication techniques. All the centre's researchers will be expected to become fluent in British Sign Language.'

EducationGuardian.co.uk

Medical management of middle ear disease in children less than 2 years of age with sensorineural hearing loss

2005-08-07T01:27:00.000+08:00

'Pneumatic otoscopy should be used to diagnose middle ear effusion. Clearance of OME may be prolonged in children with craniofacial abnormalities. Antibiotics provide a small short-term increase in the resolution of OME and may be warranted in children with coexisting SNHL and OME for 4 to 6 weeks. If OME persists for 8 to 12 weeks, bilateral myringotomy and tube placement (BM&T) with short-term tubes will improve hearing and help resolve OME. AOM in children less than 2 years of age should be treated with a 10-day course of antibiotics. Prophylactic antibiotics may be useful in avoiding tube placement in children less than 2 years of age with recurrent AOM. BM&T with short-term tubes are recommended if recurrent AOM persists. Pneumococcal vaccination can decrease episodes of AOM by 6 to 7%.'

Above are the recommendations based on a meta-analytic study by Westerberg BD, et al. in J Otolaryngol. 2005 Aug;34 Suppl 2:S64-9.

Wherefrom the infection?

2005-08-03T18:24:00.000+08:00

A 55yr-old man had craniectomy and drainage for a huge intracranial temporal lobe abscess and an ipsilateral extracranial temporal abscess as seen in this CT scan. He was referred to ENT for clearance of a possible foci of infection from the mastoid or middle ear which would seem to be the case from the 2nd image presented here. A large area of erosion is seen in the mastoid, communicating with the middle fossa as well as the temporal space.

The history, however, was not quite so convincing. He had no history of chronic ear discharge, and was not diabetic. The only lead was one experience of external ear infection 3 months ago after he traumatised his ear canal by overenthusiastic cleaning. Examination would show an external canal filled with pus, a sagging posterosuperior meatal wall, a soft and fluctuant postauricular region and a discharging sinus.

I proceeded to perform a mastoid exploration/cortical mastoidectomy but to my surprise found only a sclerotic mastoid and no foci of disease at all. Drilling was carried all the way down to the bony defect where dura is clearly seen. No pus, granulation, or cholesteatomas found.

So where was the foci of infection? How did an abscess of such magnitude, with such extensive destruction of bone come about? We are hoping a HRCT will give us more clues. Could this be a skull base osteomyelitis secondary to otitis externa?

Genetic Differences Determine Taste Perception

2005-03-17T21:37:00.000+08:00

By Daniel DeNoon
WebMD Medical News
Scientists looked at a specific taste receptor for a bitter substance known as PTC. Small changes in the genes made big differences in the receptor's ability to recognize the bitter chemical. This helps explain why some people can't taste PTC at all while others find it terribly bitter - and still others find it bitter in varying degrees.
Read the full article

Interview: Genes and Deafness

2005-02-25T23:39:00.000+08:00

Host Jennifer Ludden discusses the new research breakthrough on hearing loss with Dr. James Battey, who directs the National Institute on Deafness and Other Communication Disorders at the National Institutes of Health. Dr. Battey explains what research remains to be done, before gene therapy can be tested on humans.

Listen to the interview by Jennifer Ludden

Gene Therapy for Deafness

2005-02-25T23:34:00.000+08:00

By Roger Highfield
American scientists have found that the transplant of a specific gene permits the growth of new hair cells in the inner ear.. The technique, which one day could help millions of people worldwide, was described yesterday by Dr Yehoash Raphael of the Kresge Hearing Research Institute, University of Michigan, in the journal Nature Medicine.
Read the FULL ARTICLE

Cure for sensorineural deafness?

2005-02-25T23:30:00.000+08:00

Researchers in the US have for the first time restored hearing in deaf mammals - a feat that represents a major step toward treating people with acquired hearing loss.

By inserting a corrective gene with a virus, the team at the University of Michigan Medical School induced the formation of cochlear hair cells - the key intermediaries in converting sound waves into electrical impulses - in the ears of artificially deafened adult guinea pigs, according to the Los Angeles Times.

Read the FULL ARTICLE

Just when you taught it was safe!

2005-02-25T13:04:00.000+08:00

from REDNOVA
'The prevalence of asthma has increased worldwide. The reasons for this rise remain unclear. Various studies have reported an association between acetaminophen, a widely used analgesic, and diagnosed asthma. In a prospective cohort study, the rate of newly diagnosed asthma was 63% higher among frequent acetaminophen users than nonusers in multivariate analyses. Studies of patients with asthma suggest that acetaminophen challenge can precipitate a decline in FEV^sub 1^ > 15% among sensitive individuals. Plausible mechanisms to explain this association include depletion of pulmonary glutathione and oxidative stress. This article reviews the existing literature and evaluates the epidemiologic and pathophysiologic evidence underlying a possible link between acetaminophen and asthma. (CHEST 2005; 127:604-612)'

-- An excellent article reviewing the association between acetaminophen and atopic diseases. Could it also be related to allergic rhinitis? Just when you taught some drugs were safe... Ed.

read the FULL ARTICLE

Men 20-29 most at risk for sleep apnea

2005-02-25T13:00:00.000+08:00

by GLOBES Correspondent
'According to a new study, men in their 20s are most at risk for sleep apnea, and need to be screened the most. The study, carried out by the Technion-Israel Institute of Technology, showed that men aged 20 to 29 with severe sleep apnea have 10 times the risk of dying from heart related ailments than their non-sleep apnea peers in the general population, and a much higher risk than older men with sleep apnea.

The Technion study, which appears in the March 2005 European Respiratory Journal, was based on the largest population of sleep apnea patients (nearly 15,000 men) ever to be studied. All were recorded in the Technion sleep clinics in Israel from 1991 through 2000. The researchers compared the risk of dying for men with severe sleep apnea -- having at least 50 breathing stops per hour -- with the general population.'
read the FULL ARTICLE

An aberration in a natural pattern

2005-02-25T10:20:00.000+08:00

by Joan Skelton
'With so many other grieving parents, I weep at this variance. I am 25 years older than he is. I should be dying, not him.

He had actively been in the medical system for three months with golf-ball size lymph nodes, head, face and neck pain, blocked ears, difficulty swallowing, weight loss and fatigue. His treatment was a stent in his ear, then the recommendation of two weeks of bed rest because of "exhaustion" and "viruses," finally antibiotics for "sinusitis" and Percocet. Percocet! Then, a CT scan showed the possibility of a tumour.

At least four health professionals made grievous mistakes in the care of my son. Were they irresponsible? Negligent? Incompetent? Unlikely. Undoubtedly, they are over-worked, tired, stressed out, scratching to maintain a semblance of sanity in a system that would suck out their soul, if they let it. Such is our Canadian health-care system.'

- A grim but not uncommon story to remind us of the 'failures' of the health care system. If only to keep us alert. YY

read the FULL ARTICLE

Brain gene for Presbycusis

2005-02-25T00:17:00.000+08:00

from Health India
A new study conducted by researchers at University of Rochester Medical Center suggests that a "feedback" problem in the brain diminishes our ability to hear.
"Traditionally, scientists studying hearing problems started looking at the ear. But we are finding patients with normal ears who still have trouble understanding a conversation. There are many people who have good inner ears who just don't hear well. That's because their brains are aging." lead researcher, Robert D. Frisina was quoted as saying.
Read the FULL ARTICLE

Saliva Testing for Head and Neck Cancer?

2005-02-25T00:13:00.000+08:00

by Robert Preidt
'New discoveries in proteomics -- the study of proteins found in saliva and elsewhere throughout the body -- is bringing saliva testing within spitting distance of other much-used screens, such as blood or urine testing, the experts said.
Saliva and other oral fluids contain many of the same proteins and other molecules found in blood and urine that can reveal the presence of diseases, including head and neck cancers, the researchers noted.'
Read the FULL ARICLE at Forbes Health

Lives together, beds apart

2005-02-12T15:43:00.000+08:00

by PAULA GANZI LICATA, Newsday.com
'While many older couples remain young valentines at heart, experts say, the increase of snoring, sleep disorders and stirring in bed often spurs partners to consider separate bedrooms. Hertz recommends separate beds or bedrooms for some patients, but stresses taking gradual steps to determine a solution. If the sleep disorder is just movement, as in restless leg syndrome, separate beds in the same room will work, she said. But if the disorder is a noise issue such as snoring, separate rooms may be needed.'
read FULL ARTICLE

Gene Profiling May Improve Treatment of Head and Neck Cancer

2005-02-12T05:55:00.000+08:00

NEW YORK JAN 10, 2005 (Reuters Health)
'The gene expression profile of metastatic head and neck cancer is distinct from that seen with forms that have not spread, a finding that could improve the treatment of this malignancy, Dutch researchers report.

For certain cancers, such as head and neck squamous carcinomas (HNSCCs), early detection of metastases to nearby lymph nodes is critical for appropriate therapy, senior author Dr. Frank C P. Holstege, from University Medical Center Utrecht, and colleagues note. Unfortunately, these metastases are often difficult to detect, resulting in inappropriate treatment for many individuals.

In the present study, reported in the February issue of Nature Genetics, Dr. Holstege's team describes the identification of gene expression profiles that correlate with HNSCC lymph node metastases.'

AAAAI Urges Seasonal Allergy Sufferers to Consider Immunotherapy

2005-02-12T05:51:00.000+08:00

from An AAAAI News Release
'For seasonal allergy sufferers, the cold winter weather brings much needed relief from watery eyes and runny noses. But with the peak allergy season around the corner, few allergy sufferers find time to relax. Rather than dreading the months ahead, a technique called immunotherapy, or allergy shots, may rid their suffering once and for all.'

Insect Ears?

2005-02-12T05:45:00.000+08:00

Many leave their hearing aids at home, by Mary Duenwald, NEW YORK TIMES

'In the pipeline are hearing aids that mimic the hearing apparatus of a kind of parasitic fly, Ormia ochracea, which has a keen sense of where sounds come from.

This insect's ears are connected by a platelike structure that senses both vibrations and pressure in such a way as to act like a tiny directional microphone, said Lynn Luethke, an audiologist and neurologist at the National Institute on Deafness and Other Communication Disorders in Bethesda, Md.

Hearing aids patterned after the fly's ear are expected to be ready in the next three to six years, Luethke said.'

Through with Chew Week

2005-02-12T05:40:00.000+08:00

Herald-Dispatch.Com
'In an effort to call attention to the dangers of using smokeless tobacco, The Appalachian Family and Children First Council has proclaimed the week of February 13-19 as "Through with Chew Week."

The public awareness campaign is designed to reduce the use of smokeless tobacco, especially among young people, said Maxine Lewis, community tobacco prevention specialist for the Lawrence County, Ohio, Health Department. According to the Centers for Disease Control, 6.6 percent of senior high school students use smokeless tobacco.'

Adverse Effects of Fluoride

2005-02-11T18:17:00.000+08:00

New York (ArriveNet - Feb 10, 2005) “The combination of gastric problems, difficulty in swallowing, leg muscle pain, and pain in the knee and hip joints is a key indicator of fluoride toxicity, and patients using high-concentration home fluoride treatments should be monitored for these symptoms,” is reported in the January 2005 Journal of the American Dental Association.

Laryngopharyngeal reflux reviewed

2005-02-11T10:40:00.000+08:00

'Over the last 3 decades, many reports have implicated refluxed gastric acid as a cause of, or as a contributory factor in, development of chronic laryngeal and pharyngeal disorders. Although this putative cause-effect relationship has been strengthened by more recent evidence, the body of evidence on causation, diagnosis, and treatment of these increasingly diagnosed disorders is still evolving. A variety of symptoms, functional and structural abnormalities involving the larynx, and other contiguous structures positioned proximal to the esophagus constitute the spectrum of these disorders (see the list below). Various terms such as supraesophageal gastroesophageal reflux disease (GERD), atypical GERD, laryngopharyngeal reflux (LPR), and extraesophageal complications of GERD have been used to describe this group of symptoms and signs.'
- Jeegar Jailwala and Reza Shaker reviews the theory and literature regarding laryngopharyngeal reflux at emedicine.com.

Dystonia and Botox injections

2005-02-11T10:39:00.000+08:00

The first thing you notice about "Joey" is that his head is turned and tipped to one side; his left ear rests on his hunched-up left shoulder. He has to turn his whole upper body to look at you. Joey has torticollis, also known as cervical dystonia, meaning that his neck muscles are in an involuntary spasm that forces his head into its painful, abnormal position. - Mary Kugler from About.com writes about the diagnosis and treatment of facial and cervical dystonia.

How I straightened out my dizzy BPPV world

2005-02-10T17:25:00.000+08:00

from The Republican
In writing this column, I run the risk of being charged with practicing medicine without a license. But if what I have to share helps just one person, I'm willing to take the chance. I'm going to write about BPPV, the acronym for benign paroxysmal positional vertigo. It's a dizziness that is caused by infinitesimal granules of debris that have the formal name of "otoconia," and are crystals of calcium carbonate, which come from a spot in one's ear called the utricle.

Top 10 reasons for sore throat

2005-02-10T17:20:00.000+08:00

Throats are Easy Targets for Irritation
There are many causes of irritating, scratchy and painful sore throats, making it difficult at times to swallow, eat and talk. According to Lisa Chavis, R.Ph., pharmacist consultant to Cepacol® sore throat products, "Viruses and bacterial infections are frequently to blame, but are not always the culprit." Here is a breakdown of the top 10 reasons throats get sore:

Rhinitis news

2005-02-10T17:14:00.000+08:00

FDA MedWatch: ZyPREXA (olanzapine) and ZYRTEC (cetirizine HCI)
PharmaLive.com (press release) - Newtown,PA,USA. Eli Lilly and Company has received reports of medication dispensing or prescribing errors between our atypical antipsychotic ZyPREXA (olanzapine) and the antihistamine ZYRTEC (cetirizine HCI) marketed by Pfizer. These reports include instances where Zyprexa was incorrectly dispensed for Zyrtec and vice versa, leading to various adverse events in some instances. These errors could result in unnecessary adverse events or potential relapse in patients suffering from schizophrenia or bipolar disorder.

MOLD Allergies
allergies.about.com - USA
Molds may be a major contributor to seasonal and perennial allergic rhinitis, as well as other health problems. Although thousands of molds exist, only a few dozen different types are significant allergens. Mold spores can easily become airborne and can be found almost anywhere. Because they are so small, mold spores may invade the protective mechanisms of the nose and upper respiratory tract.

Antibiotics don't seem to increase bacterial resistance

2005-02-06T02:46:00.000+08:00

from USNews.com
Doctors are often reluctant to prescribe antibiotics for people with chronic sinus infections because bacteria can develop resistance to the antibiotics. Researchers in Boston looked for resistant bacteria in those patients.

What they found: Patients did not tend to have more resistant bacterial populations over time. If anything, their bacteria may have become less resistant to antibiotics.

Chronic Sinusitis Breakthrough

2005-02-06T02:41:00.000+08:00

Two 1999 scientific breakthroughs may lead to long-term relief for allergy and chronic sinusitis sufferers.

The most startling announcement was published in the 1999 Mayo Clinic Proceedings. Researchers found that chronic sinusitis, a condition that affects about 37 million people in the United States, is apparently caused by an immune response to fungus.

Up until then the cause of chronic sinusitis was unknown, but it was suspected to be an allergic response. This research indicates that the condition is not caused by an allergic reaction, but by an immune reaction.

Full article at Allergies.About.Com

Anti-Fungus Drug Useful for Sinus Problem

2005-02-06T02:40:00.000+08:00

NEW YORK (Reuters Health) - Treatment with a nasal spray containing the anti-fungal drug amphotericin B reduces the swelling and inflammation that occurs with chronic rhinosinusitis, a common cause of stuffy nose and facial pain, new research shows.

Amphotericin B is an old drug that can cause serious side effects, particularly to the kidneys. However, when given as a nasal spray, the drug does not get absorbed, effectively avoiding these effects, researchers report in the Journal of Allergy and Clinical Immunology.

Rhinosinusitis - Review of January 2005

2005-02-06T01:16:00.000+08:00

by Y.Y.Yap, MD

Our understanding of rhinosinusitis and how we can best treat this ambiguous condition is in rapid evolution.

Fungal etiology for RSS
First off we have Gosepath J and Mann WJ. take a closer look at the role of fungi role in initiating and maintaining CRSS. While fungi are ubiquitously present in ALL, an immunologic sensitization in RSS patients is evidenced by specific cytokine production in blood-derived lymphocytes not found in controls. Sasama J, et.al also supports this theory showing from literature that eosinophilic inflammation in the nasal mucosa seems to be a specific reaction to certain molds in the nasal and paranasal cavities. Hence the shift from a bacteria-driven etiology to a fungal based one for RSS. It's implications for research and treatment is pressing and is reviewed in these articles. As though to dispel all doubt, Ponikau JU, et.al boldy instituted a clinical trial and showed that intranasal amphotericin B reduces inflammatory mucosal thickening on both CT scan and nasal endoscopy and decreases the levels of intranasal markers for eosinophilic inflammation in patients with CRS.

Recurrent Rhinosinusitis - something different?
Bhattacharyya N, Lee KH. try to distinguish Chronic Recurrent (CRRSS) from Chronic Persistent Rhinosinusitis (CPRSS) by looking at a distinct group of patients who have symptom free periods between at least 4 episodes of RSS symptoms a year. Interestingly the chronic recurrents (CRRSS) seem to suffer more, require more antibiotics and miss work more than the chronic persistents.

FESS for children?
Lieser JD, Derkay CS review the role of FESS in children. Present consensus for FESS in children are 'when maximal medical therapy, adenoidectomy, and culture-directed systemic antibiotics have all failed with persistence of sinonasal disease, when anatomic abnormalities predispose to chronic rhinosinusitis by obstructing normal sinonasal drainage pathways, in sinonasal polyposis to facilitate application of topical steroids', among others. The debate for the best timing for surgery and the fine balance between interfering with facial growth vs. quality of life continues.

No limits!
The greats have spoken! Cohen NA and Kennedy DW. have come forward to defend a larger role for the endoscopic surgeon, stating: 'Endoscopic sinus surgery is no longer exclusively for the management of chronic rhinosinusitis and nasal polyposis. Sinonasal malignancies, as well as anterior skull base lesions have become part of the rhinologist's responsibility. Furthermore, selective lesions managed through traditional craniotomies may now be accessed via trans-sinonasal transcranial endoscopic routes.' They attribute this increased scope, safety and efficacy to advancements in imaging technology including image acquisition, three-dimensional reconstruction, stereotactic navigation, and CT-MRI fusion.

Rapid steps forward are being made on the basic science, pharmacotherapeutics and surgical fronts in rhinology. The future is bright!

Link Between Cancer And Common Asian Nut

2005-02-01T02:07:00.001+08:00

Study Confirms Link Between Cancer And Common Asian Nut - from NewsRx.com

November 4, 2004

Over the past couple of decades, scientists have been perplexed by a substantial rise in the incidence of head and neck cancers among Taiwanese men. According to cancer statistics, the disease increased by 85% among men there from 1981-2000.

A new study, presented at the American Association for Cancer Research Third Annual International Conference on Frontiers in Cancer Prevention Research, now suggests that the increased incidence may be linked to increased domestic production of a popular legal stimulant in Asia called betel quid.

Chewing betel quid, traditionally practiced in many parts of Asia and in Asian immigrants around the world, can be likened to tobacco use in the U.S. It is often rolled like a cigar or intricately folded and generally consists of a betel palm leaf spread with lime paste (calcium hydroxide) wrapped around a slice of areca nut. Betel quid is chewed for many reasons, including for its stimulant effects, to satisfy hunger, to sweeten the breath, and as a social or cultural practice.

However, betel quid also is considered a nuisance in Asia where the reddish juice, generated by the act of chewing betel quid, can be found all over the ground and on public buildings. Also considered a major public health risk, it is believed to be a leading cause of oral cancer in this part of the world.