Adele Speaks About her Vocal Cord Surgery on 60 Minutes

When it was first reported that Adele was undergoing vocal cord surgery in October 2011, there was much speculation regarding what exact vocal cord pathology she suffered from (hemorrhage? polyp?) and what type of vocal cord surgery she underwent for correction (laser? cutting?).

During her 60 Minutes interview with Anderson Cooper which aired on February 12, 2012, many details regarding her vocal cord problems have clarified.

She apparently suffered from a vocal cord polyp with hemorrhage.

Typically, this problem is normally treated with strict voice rest followed by extensive voice therapyprior to surgical consideration. However, this (safe) course of action takes time and as such, she pursued a much more aggressive approach in order to recover her voice as quickly as possible.To explain, a lesson in some basic anatomy first…

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

When there is a hemorrhagic polyp with a blood vessel as in Adele’s case, her vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. When a polyp is present, the vocal changes are even more dramatic. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice very unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. There may even be mild pain associated with this occurrence.In Adele’s case, she remembers the very moment this occurred during a radio interview when she “felt a pop” and her vocal pitch suddenly dropped into the bass range.

This makes perfect sense… To use the analogy of a violin string, the thicker the violin string the deeper the pitch. When hemorrhage occurs, the vocal cord becomes thicker due to blood pooling resulting in a deeper voice instantly.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient’s right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially, during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in the development or exacerbation of a vocal cord polyp. With repetitive cycles of healing and trauma, vocal cord scarring may even develop. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel and associated polyp.

For that, surgical intervention is required.

One option is to precisely cut out the polyp and cauterize the feeding blood vessel at the same time. This approach was the course that Adele pursued. Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. This latter approach is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision and vessel obliteration with a laser at the same time (though not zero). Furthermore, a smaller polyp also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Adele, that was strict voice rest for nearly two months (Nov and Dec 2011). Why? Because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won’t heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

The vocal cord surgical wound MUST heal prior to talking let alone singing for normal recovery. That means strict voice rest. Strict voice rest means no talking, no singing, no whispering, no mouthing words, no throat-clearing, no humming, etc.

Read more about vocal cord polyps here.

Read the 60 Minutes interview here.

Woman Coughs Out Her Throat Cancer

It was reported today a woman literally coughed out a previously undiagnosed throat cancer… and cured herself of it.

She apparently felt a tickle in her throat forcing her to cough… and spat out a 2 cm large mass. No kidding…

The mass was sent to pathology and was diagnosed to be malignant and was told she only had a 50% chance of survival.

To ensure no cancer was left behind, she underwent radiological scans as well as additional biopsies in the base of tongue region where the mass probably originated from and no further trace of cancer was found.

She is very lucky as most base of tongue cancers that’s 2 cm large usually requires not only surgery, but also chemotherapy and radiation treatment.

As the report stated, the cancer was probably on a thin stalk (like a lollipop) that allowed her to cough the entire cancer out!

Source:
Woman in clear after coughing up a cancerous throat tumour. Mirror.co.uk 1/11/2012

Argentine President Had Surgery for Wrongly Diagnosed Thyroid Cancer

On Jan 4, 2012, Argentine President Cristina Kirchner underwent a total thyroid gland removal for papillary thyroid cancer.

On Jan 7, 2012, it was announced that she never had thyroid cancer in the first place! See news report.

Why did this happen? And it does happen unfortunately to not only President of a nation, but to ordinary citizens.

Without benefit of having access to her medical records, I suspect her medical course went something like this which is what happens in the vast majority of patients with a thyroid mass…

She probably had a full medical evaluation including an ultrasound of her thyroid gland which revealed a nodule or mass.

She underwent an ultrasound guided needle biopsy in order to obtain some cells for pathology review. I suspect that the pathologist reported suspicion for papillary thyroid carcinoma. She may even have undergone a thyroid scan which revealed a cold nodule (increasing the likelihood but does not confirm cancer).

Based on a diagnosis obtained on a needle biopsy, standard of care treatment is complete thyroid removal followed by radioactive iodine treatment.

I suspect the surgeon who did the surgery did discuss with the patient the option of removing only half the thyroid gland (side with the mass) and waiting on final pathology to confirm presence of cancer before removing the rest of the thyroid gland. However, this would mean TWO separate operations on different days as it does require time for final pathology results to become available.

Given I’m sure President Kirchner is a VERY busy person, she probably elected to have the whole thyroid gland removed rather than undergoing the possibility of two operations. The risk being she may ultimately have a total thyroidectomy done when no cancer was actually present at all!

SO… was there a mistake made (if any)?

Was it the pathologist who reported cancer in the needle biopsy?

Was it the surgeon who did not confirm cancer by removing only half the thyroid first?

Let’s look into the mind of the pathologist…

From the pathologist perspective, it is better to be safe and over-call things… because it is FAR worse to miss a cancer diagnosis. Imagine if the pathologist stated NO thyroid cancer was seen on the needle biopsy… only to be wrong and the Argentine president dying of thyroid cancer at some point in the future due to this misdiagnosis. The medical-legal liability and fear of being sued forces not only pathologists but also radiologists to report slight abnormal findings just to be on the safe side. Such reports will often state:

 ”Cells [or CT scan] have some features suggestive of cancer. Clinical correlation recommended.”

This vague statement can be interpreted in two ways… The pathologist is NOT saying there is cancer present. He is stating it might be present, but he’s not sure. Which means the burden of liability now passes to the surgeon…

From the surgeon’s perspective, he now has to deal with whether to operate or not based on an equivocal diagnosis on needle biopsy. What if he does NOT operate and cancer WAS present? There was than a delay in cancer treatment and theoretical decrease in survival.

OR… take the safe route and operate, but acknowledge that there is the possibility that no cancer was present and that surgery was actually not truly needed in the end. Complicating this course of action is that surgery has risks (and what a bummer if “unnecessary” surgery was performed and complications happened).

The compromise solution would have been to remove just the side where the thyroid nodule was present, but than a 2nd operation would have been needed if cancer WAS found.

So, was there “malpractice” committed by any physician in the care of President Kirchner?

Probably not because the decision making by various physicians in her care probably tended towards being safe rather than sorry (for not only the patient, but also the physicians).

There are many variations on this theme… Other courses of action that could have occurred or been taken include:

1) Monitoring with repeat ultrasounds and needle biopsies
2) Getting multiple 2nd opinions
3) Repeating radiological scans
etc
etc

Danger is what if some say do it and some say don’t do it. Some scans or needle biopsies suggestive for cancer and others that aren’t?

As the old saying goes, too many cooks ruin the soup. OR, you see five doctors, you may get 5 different opinions.

At some point, YOU as the patient needs to decide what to do and live with the consequences of your decision.

Why does this even occur???

Because NO test is 100% accurate.

Source:
Argentine President Cristina Kirchner wrongly diagnosed with cancer. The Telegraph Jan 7, 2012.

Argentine President Undergoes Thyroid Surgery

BBC News reported today that popular Argentine President Cristina Fernandez de Kirchner underwent total thyroidectomy for papillary thyroid carcinoma, a highly curable form of thyroid cancer.

Thankfully, there were no complications and she is expected to be discharged from the hospital in the next 2 days.

Thyroidectomy is when the entire thyroid gland is removed which is necessary whenever thyroid cancer is present.

What are some of the complications that could have occurred?

• Vocal cord paralysis, either one or both vocal cords
• Hoarseness
• Calcium level problems which can lead to heart arrhythmias
• Bleeding which can compress the airway necessitating a tracheostomy

Read more about thyroid surgery here.

Source:
Argentine President Fernandez undergoes cancer surgery. BBC News Jan 4, 2012.

New Webpage on Thyroid Mass (Evaluation and Management)

A new webpage has been uploaded to our practice website describing the evaluation and management of a thyroid mass. Surgical removal is discussed along with risks involved.

Click here to read more!

Cigarettes Contain Radioactive Polonium

Cigarettes are known to cause cancer…

But we now know there’s another reason why… they contain radioactive material, specifically polonium-210!

Tobacco companies also have known about it since 1959. As reported in ABC, historical documents reveal tobacco companies not only knew about the radioactive substance, but studied it, then refused to do anything about it!

They figured out that:

1) It caused “cancerous growths” in the lungs of smokers,
2) Calculated how much radiation a regular smoker would ingest over 20 years

Then they kept the research secret. The level of deception is breath-taking.

The radiation alone from cigarettes can account for up to 138 deaths for every 1,000 smokers over period of 25 years.

Even more disturbing, is that ALL tobacco products on the market today still contain radioactive polonium. This is in spite of washing techniques available since 1980 to remove the radioactivity but refused by tobacco companies to perform whether due to cost or the fact that washing would remove the addictive nicotine component as well.

Take home message?

STOP smoking! It’s killing you through not only harmful chemicals, but also radioactivity!

Read the ABC article here.

Reference:
Cigarette Smoke Radioactivity and Lung Cancer Risk. Nicotine Tob Res (2011) doi: 10.1093/ntr/ntr145

Oral Exam Using a Finger

For a good physical exam, physicians use their senses (eyes, ears, nose) to detect disease processes that may not necessarily be obvious to a lay person. Beyond these obvious senses, fingers and hands are also utilized to feel for unusual bumps or masses that may not be obvious to the naked eye.

Take a neck mass for example. Neck masses may not be necessarily visible, but by feeling the neck, may become obvious. To use an analogy, a bowling ball under a mattress may not necessarily be obvious, but if you lay on the bed, would become painfully obvious.

Physicians also use the hands/fingers to examine areas that may not be visible… such as the unpleasant digital rectal exam (inserting a finger up a bung-hole) which is done to detect blood in the stool, rectal/anal cancers, anal muscular incompetence, etc.

However, I find it odd that the mouth is a body area that is not often “felt” around… physicians included.

A finger can appreciate unusual mouth pathology that may not necessarily be appreciated by looking alone. Furthermore, just like the rectal exam, a finger can appreciate base of tongue pathology that cannot be visualized by having a patient go “ah”.

I truly feel that actor Michael Douglas would have been diagnosed with his base of tongue cancer much earlier if only a doctor stuck a finger and swept that back area of the tongue. One can “feel” cancer as it is rock hard and very tender. True… it may cause a person to gag, but for a cancer test, it’s dirt cheap, fast, and reliable.

However, it does not just have to be areas of the mouth that can not be seen. Even for those ulcerations and bumps of the mouth that one can clearly visualize (or not), it does help to touch it. Is it hard? Soft? Ulcerated? Tender? Grooved? Papillated? Fungating? Rubber-like? Blottable?

Each characteristic provides information to achieve a more accurate diagnosis.

To an ENT way of thinking, if a doctor regularly performs a digital rectal exam, than one can certainly do the same thing at the other end. It’s less invasive and provides just as much information.

Say “ah”!!!

New Webpage on Bumps or Lesions of the Mouth

Our practice has created a new webpage describing the various bumps and lesions commonly seen in the mouth that leads to a doctor’s visit.

Such abnormal things seen in the mouth that’s discussed include:

• aphthous ulcer
• herpetic ulcers
• pyogenic granuloma
• fibroma
• papilloma
• cancer

Click here to read more!

Tall Women (Over 5’1″) Have Higher Risk of Cancer!

Female models may be tall and beautiful, but they are also at markedly increased risk of developing cancer. The New York Times reported on a fascinating research article regarding height of a women and risk of cancer.

Specifically, for every four-inch increase in height over 5 feet 1 inch, the risk that a woman would develop cancer increased by about 16 percent, especially for:

• Colon Cancer (RR per 10 cm increase in height 1.25, 95% CI 1.19—1.30)
• Rectal Cancer (1.14, 1.07—1.22)
• Malignant Melanoma (1.32, 1.24—1.40)
• Breast Cancer (1.17, 1.15—1.19)
• Endometrial Cancer (1.19, 1.13—1.24)
• Ovarian Cancer (1.17, 1.11—1.23)
• Kidney Cancer (1.29, 1.19—1.41)
• Brain/Spine Cancer (1.20, 1.12—1.29)
• Non-Hodgkin’s Lymphoma (1.21, 1.14—1.29)
• Leukaemia (1.26, 1.15—1.38)

It is hypothesized that the levels of growth hormone responsible for human height might also be involved in cancer development or because taller people are at greater risk for mutations simply because their bodies are comprised of more cells.

The increased cancer risk was found to be also true across Asia, Europe, Australia, and North America populations.

Perhaps now there’s a reason why the average female is 5 feet, 3.8 inches tall! It’s a balance between social preferences for being tall versus negative biological consequences for being tall.

The good news here (if there’s any) is that head and neck cancer does not increase with height.

Read the NYT article here.

Read the research abstract here.

Reference:
Height and cancer incidence in the Million Women Study: prospective cohort, and meta-analysis of prospective studies of height and total cancer risk. The Lancet Oncology, Volume 12, Issue 8, Pages 785 – 794, August 2011 doi:10.1016/S1470-2045(11)70154-1

Why Are You Looking in My Mouth When It’s My Ear Hurting?

One June 20, 2011, NPR aired a great story about how a person may not “see” a person getting beat up on the side of a jogging path when they are focused on a task (pursuing another jogger)… even if they pass RIGHT BY THE FIGHT!!!

In fact, only a third of the subjects reported seeing this mock fight when the experiment was conducted at night. Even more surprisingly, broad daylight didn’t improve the statistics (only 40% noticed the fight).

Though the situation and circumstances do not exactly correspond, there is a lesson to be learned here that applies to a medical visit.

As an ENT, I often see patients for a very specific complaint…

“My right ear hurts.”
“I have a bad cough.”

No matter what the complaint, unless it is for a specific task (there is earwax… can you remove it), I most always still do a complete ear, nose, and throat exam no matter the complaint.

Why???

Because often the symptoms are “the jogger” in the example above which is noticed to all exclusion when “the fight” is the more important event that should have been noticed.

Let’s go to the examples stated above…

“My right ear hurts.”

Though a patient may wonder why the heck I look in the mouth when their ear is the main complaint, it’s mainly because there are other things that can cause ear pain… some of it life-threatening.

Tonsil cancer can cause ear pain (without any other symptoms) as well as a base of tongue abscess. Obviously, giving antibiotics to treat the right ear pain totally misses the fact that there was tonsil cancer that got missed or the tongue abscess which requires an emergency trip to the operating room followed by a few days in the intensive care unit.

“I have a bad cough.”

This statement is pretty self-explanatory. Why bother looking in the ears??? A loose hair in the ear canal can cause a persistent dry cough. Why look in the nose if the cough is coming from the throat? Severe allergies and nasal polyps can lead to post-nasal drainage leading to a chronic cough. Why would an ENT than ask about my blood pressure medications? Because ACE inhibitors like lisinopril cause a chronic dry cough as a side effect.

The point being with these examples is that medical doctors are trained to not just focus in the exact symptom the patient is complaining of, but the entire picture. It doesn’t do the patient any good if a doctor gets tunnel-visioned to the point where they don’t notice what may be a very obvious thyroid mass or the large nasal polyp.

SO… next time you see a doctor for a specific complaint, humor us, and answer fully all questions about your medical history, surgical history, medications you are taking, and the physical exam we will perform on you… even if you are there for just a “simple” earache.

Read the NPR story here and the police beating that triggered this inattention experiment.