Unnecessary Sinus Surgery

A well-respected ENT surgeon, Dr. Salah Salman, recently wrote a book, “Scrubbed Out,” critical of the American health system with its links to corporation, powerful lobbies, administrators, and bureaucrats resulting in care driven by money rather than by medical necessity.

In particular, he focuses in one part of his book on endoscopic sinus surgery in the treatment of chronic sinusitis. The excerpt from the book is quite lengthy and I encourage anybody interested to read a lightly edited version here.

In essence, there are a few unscrupulous sinus surgeons who perform sinus surgery for every patient with facial pain and pressure even though there’s no evidence for any chronic sinus infection whether on CT, endoscopic exam, and other objective testing.

Indeed, in my practice, perhaps only 10% (if not less) of patients with chronic “sinus” complaints actually have pathology related directly to the sinuses that merits consideration of sinus surgery. More commonly, symptoms suggestive of a chronic sinus infection are more commonly related to allergies and atypical facial pain syndromes (ie, migraines, sluder’s neuralgia, contact point headaches, etc).

Unfortunately, in many physicians’ minds including patients, if multiple courses of antibiotics do not resolve pan-facial pain/pressure, the sinuses must be horrible and something more aggressive geared towards the sinuses must happen.

And there’s a few ENT surgeons willing to do just that… and mistakenly so.

It’s not just ENTs, but allergists and infectious disease specialists who also may accommodate what the patient wants for treatment, even if it is incorrect.

If such patients see an allergist in the belief that their symptoms are due to allergies, they will get allergy testing and allergy shots.

If they see an infectious disease specialist, they will get antibiotics.

A much neglected specialist for patients with “sinus” problems are the neurologists given so many of these patients are actually suffering from atypical facial pain syndromes… but nobody (physicians, pharmaceutical companies, hospitals, bureaucrats) gets paid much for this particular problem… and so it gets ignored.

Though sinus surgery has been abused in the past into the present, a more recent, highly reimbursed, and “sexy” sinus procedural development is balloon sinuplasty, also ripe for being abused.

Traditional sinus surgery and now balloon sinuplasty certainly have their place in the treatment of true chronic sinus pathology with astounding success, but only in highly selected patients.

As with everything, the right treatment in the right patient is the right way of doing things.

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Source:
Book Excerpt: A Saga Of ‘Fishy’ Surgery For Chronic Sinus Trouble. WBUR.ORG March 2, 2012

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.

Sleep Apnea Surgery Malpractice Lawsuit

In November 2009, a patient underwent multi-level surgery to treat her mild-moderate obstructive sleep apnea by a Houston, TX otolaryngologist.

The surgery included:

• Uvulopalatopharyngoplasty (UPPP)
• Tonsillectomy (typically considered part of UPPP)
• Adenoidectomy
• Hyoid Myotomy
• Genioglossus Advancement

She unfortunately experienced some unspecified complications stemming from this surgery which apparently has not helped with her obstructive sleep apnea either. A malpractice lawsuit commenced and final judgement is still pending.

Let’s take a closer look at the incomplete information provided.

The patient suffered from mild-moderate obstructive sleep apnea which typically means a AHI score of around 15 (< 5 is normal).

For this level of severity, simultaneous multi-level surgery is not typically performed. Rather such extensive surgery is reserved for severe obstructive sleep apnea.

Also unclear is whether any objective studies were performed prior to surgery to try and localize the levels of obstruction that required correction. Such preoperative studies include a sedated endoscopy as well as trial of CPAP usage.

Assuming patient tried and failed to use CPAP and had objective evidence for multi-level obstruction, what did each of the surgical procedures do?

UPPP, tonsillectomy, adenoidectomy address mouth-level obstruction.

Hyoid myotomy and genioglossus advancement address tongue-level obstruction (the tongue can fall backward while sleeping causing obstruction).

Complications can occur for each of these procedures mainly dealing with bleeding, hematoma, infection, or abscess formation. Swallowing problems can also occur with the hyoid myotomy and genioglossus advancement.

Read more information on obstructive sleep apnea.

Source:
Sleep apnea surgery leads to malpractice lawsuit. Southeast Texas Record. 1/23/12

Northern Virginia Balloon Sinuplasty for Chronic Sinusitis

In the past month, local residents of Northern Virginia may have received a magazine newsletter from Prince William Hospital (Manassas, Virginia) that contained a feature story about sinus surgery and about balloon sinuplasty specifically.

It was a great story about how far sinus surgery has come compared to even just 5-10 years ago and the great patient experiences under otolaryngologist Dr. Gardner is not uncommon now.

A few key features of sinus surgery of the 21st century:

• Nasal packing rarely occurs

• Most patients are surprised by how little pain there is

• No facial swelling or bruising… your best friend won’t be able to tell you just had sinus surgery

• Fast recovery

• No incisions on the face or in the mouth

• GPS-like image guidance to make sinus surgery even safer is available
• In select patients, can even be performed in the office without sedation using local anesthesia only

Balloon sinuplasty is a relatively new innovation that allows sinus surgery to even be performed even more comfortably in the office without any sedation (not all patients are candidates).

Such advanced sinus surgery techniques have been available at Fauquier ENT since 2005.

Read more about sinus surgery and balloon sinuplasty.

Source:

Balloon Sinuplasty. Perspectives Winter 2011 Pages 2-3.

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

New Webpage Describing Surgery to Treat Reflux

Given how often we see patients for reflux-triggered ENT problems and the questions we often get regarding surgical options, we have created a new webpage to discuss procedures used to try and cure reflux-triggered ENT symptoms.

Such symptoms may include:

• Chronic cough
• Phlegmy throat (lots of throat mucus)
• Chronic throat-clearing
• Burning throat
• Lump in throat sensation

Heartburn or any burning sensation may not be present at all!

Surgical options include not only the standard laparoscopic Nissen Fundoplication which requires multiple small incisions over the belly, but trans-oral incisionless fundoplication whereby the surgery is all accomplished through the mouth.

Click here to read more!

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.

Misleading FoxNews Report: Laryngitis for 30 Years

On Dec 23, 2011, Fox News reported on a woman who supposedly had laryngitis for 30 years.

The story reported that the woman had a viral URI in 1982 which resulted in laryngitis and a paralyzed vocal cord.

What people should be aware of is that a paralyzed vocal cord is NOT laryngitis. Laryngitis is an infection of the larynx or voicebox. Stating that a paralyzed vocal cord is akin to laryngitis is like claiming a person who has a paralyzed arm/leg from a stroke has an arm/leg infection.

Now it is true that a viral laryngitis can cause a paralyzed vocal cord, but they should not be considered synonymous.

Patients with a paralyzed vocal cord have a very breathy sounding weak voice and a weak cough. They may also suffer from aspiration where liquids/foods go down the wrong way more easily than normal.

Typically, the first way to treat a paralyzed vocal cord is voice therapy. If voice therapy does not make much improvement, surgical intervention can be considered.

Typically, a vocal cord injection is performed if the paralysis onset was within one year. After one year, an implant can be placed as the Fox News report mentioned.

Read more about paralyzed vocal cords as well as watch a video here.

Source:
Woman Gets Voice Back After Suffering From Laryngitis for 30 Years. FoxNews 12/23/11

Robotic Surgery for Obstructive Sleep Apnea

I came across this article the other day regarding use of the daVinci robot to perform base of tongue surgery for obstructive sleep apnea.

For those who don’t know, the daVinci robot system made by Intuitive Surgical is a robotic system whereby the surgeon directs the arms of the robot to perform surgery in difficult-to-access areas of the body.

My feeling is that using a robot to perform sleep apnea surgery is way overkill akin to using a $50,000 sniper rifle to kill an ant on the wall.

Everything the daVinci robot can do can also be done without the robot with equivalent patient outcomes. In fact, without the robot, the surgery can be performed more quickly, efficiently, and with less anesthesia than with the robot.

The article also describes sedated (sleep) endoscopy to determine WHERE the obstruction occurs during sleep. The areas of obstruction can than be precisely addressed surgically. Again, this does not require a robot. In fact, I would hazard to say that even the surgeons quoted in the article does not use the robot to perform this procedure.

There are occasions where the robot may be helpful with ENT surgical procedures, but this is not one of them.

Reference:
N.J. surgeons on the cutting edge in fight against sleep apnea.