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

Natural Remedies for a Sore Throat, Cough, and Viral Infections

Homeopathy and alternative medicine often get a bum rap, but they have come up with some treatments for sore throats and upper respiratory viral illnesses that actually have been proven to work.

Here’s a few…

1) Honeyhttp://rcm.amazon.com/e/cm?lt1=_blank&bc1=FFFFFF&IS2=1&bg1=FFFFFF&fc1=000000&lc1=0000FF&t=fauentcon-20&o=1&p=8&l=as4&m=amazon&f=ifr&ref=ss_til&asins=B0037JQPUU

Sore throats (and coughing) can be soothed by swallowing honey straight-up or slightly diluted with warm water with honey to make it easier to swallow. The best time to do this is at bedtime given it will stick around for awhile (eating/drinking will wash away the coating). The purpose of honey is to create a throat barrier to ease the discomfort.

Think of it like chapstick to coat irritated lips, but meant for the throat.

Use of honey is also recommended by the World Health Organization which has also published a monogram on viral colds and the various treatments explained. Pay particular close attention to Annex 3 (Page 11) which gives various recipes to treat pediatric cough including the use of honey.

Reference:
Effect of Honey, Dextromethorphan, and No Treatment on Nocturnal Cough and Sleep Quality for Coughing Children and Their Parents. Arch Pediatr Adolesc Med. 2007;161(12):1140-1146.

2) Humidificationhttp://rcm.amazon.com/e/cm?lt1=_blank&bc1=FFFFFF&IS2=1&bg1=FFFFFF&fc1=000000&lc1=0000FF&t=fauentcon-20&o=1&p=8&l=as4&m=amazon&f=ifr&ref=ss_til&asins=B001FWXKTA

Dry cool air increases risk of viral infections as well as giving it to others. As such, add room humidification to a bedroom and keep the door closed (small room humidifiers can’t humidify an entire house… so keep door closed!).

Why does this help? Increased humidification inactivates viruses!

Humidification also helps minimize a persistent dry cough worse at night often due to reactive airway disease triggered by breathing in dry air.

However, keep in mind that if you actively have a viral illness, it is too late for humidity to help. It is best used as a preventative measure.

Reference:
Dynamics of airborne influenza A viruses indoors and dependence on humidity. PLoS One. 2011;6(6):e21481. Epub 2011 Jun 24.
Influenza virus transmission is dependent on relative humidity and temperature. PLoS Pathog. 2007;3:e151.

Heated, humidified air for the common cold. Cochrane Database Syst Rev. 2011 May 11;(5):CD001728.

3) Gargling and Saline Flushes
http://rcm.amazon.com/e/cm?lt1=_blank&bc1=FFFFFF&IS2=1&bg1=FFFFFF&fc1=000000&lc1=0000FF&t=fauentcon-20&o=1&p=8&l=as4&m=amazon&f=ifr&ref=ss_til&asins=B002UZQT58

Gargle with saline water… or even just tap-water on a daily basis. Why does this help prevent viral infections? It washes away the viral particles before it gets a chance to cause problems.

It’s also probably why drinking lots of fluids also helps since the viruses get deactivated in the stomach from the acidic digestion.

Unfortunately, gargling only helps with the throat… saline flushes are required to help with sino-nasal problems.

Reference:
Can we prevent influenza-like illnesses by gargling? Intern Med. 2007;46(18):1623-4. Epub 2007 Sep 14.

4) Xylitol
http://rcm.amazon.com/e/cm?lt1=_blank&bc1=FFFFFF&IS2=1&bg1=FFFFFF&fc1=000000&lc1=0000FF&t=fauentcon-20&o=1&p=8&l=as4&m=amazon&f=ifr&ref=ss_til&asins=B000M4W2E6

This naturally-occurring sugar substitute apparently has all sorts of anti-bacterial as well as anti-fungal properties and has been known to doctors and scientists but hardly marketed or promoted in any fashion.

However, the importance of this compound is that it DOES appear to significantly decrease the incidence of ear infections and sinus infections when used regularly. It comes in nasal spray form as well as gum.

Reference:

Xylitol as a prophylaxis for acute otitis media: systematic review. Int J Audiol. 2010 Oct;49(10):754-61.

A novel use of xylitol sugar in preventing acute otitis media. Pediatrics. 1998 Oct;102(4 Pt 1):879-84.

Xylitol chewing gum in prevention of acute otitis media: double blind randomised trial. BMJ. 1996 Nov 9;313(7066):1180-4.

Failure of xylitol given three times a day for preventing acute otitis media. Pediatr Infect Dis J. 2007 May;26(5):423-7.

Xylitol administered only during respiratory infections failed to prevent acute otitis media. Pediatrics. 2002 Feb;109(2):E19.

Conclusion

Sometimes the BEST medicine are things you can do at home without need for a physician visit… and is based on fact rather than anecdotal evidence.

The Doctors TV Does Chronic Throat Clearing

The Doctors TV show recently did a segment on chronic throat clearing. The ENT expert who explained this very annoying condition was Dr. Reena Gupta, a well-respected laryngologist with the Osborne Head and Neck Institute.

During this TV show, Dr. Gupta provided the two most common reasons for chronic throat clearing which were post-nasal drainage and reflux.

At its most basic explanation, mucus can come from the nose down into the throat (post-nasal drainage) OR mucus can come up from the stomach into the throat (reflux). The end-result is a person desiring to throat clear the mucus up and out.

However, there are other causes which were not addressed by Dr. Gupta during the show.

Other reasons for chronic throat clearing include:

Medication Side Effect
Food Allergies or Sensitivities
Zenker’s Diverticulum
Laryngeal Sensory Neuropathy
Anatomic Triggers
PANDAS
Non-Organic Tic

Read more about chronic throat-clearing here.

Watch the TV show segment here.

http://www.thedoctorstv.com/UMInterface_Tremor.swf?at=01823b09-1298-4bc6-a9fe-b70810b73213

Working in a Salon Can Be Unhealthy for Your Nose and Throat!

We already know that small hair clippings from cutting hair can cause septal perforation and chronic sinusitis due to long-term inhalation. Worse case scenario, it can even lead to an external nasal deformity! (Read blog about this here.)

However, it seems that it’s not just hair that can damage the nose, but also hair products especially to straighten/smoothen hair popularly known as “Brazilian” treatments.

In a report published by Washington Post on Oct 17, 2011, such Brazilian hair smoothing treatments often contain a known toxic chemical called formaldehyde and methylene glycol. The FDA has pronounced such products to be unsafe. These chemicals are most commonly used as a preservative to prevent dead tissue (ie, corpses) from decay.

And yet… these products are commonly used in hair salons to potentially unsafe levels resulting in health problems to not just workers, but also customers.

Common symptoms that can result from formaldehyde and methylene glycol exposure include:

• nose-running (rhinitis)

• eye tearing

• throat burning

It can also cause symptoms of chronic sinusitis, taste alteration, smell loss, dry nose, scabbing at the nose entrance, etc.

Best to avoid if at all possible!

Read the WP article here.

Fauquier ENT Now Participates with Chase Health Advance Flexible Payment Options

Due to popular demand, our office now participates with Chase Health Advance. This plan is for those patients without insurance coverage or to help pay for uncovered procedures/services. Flexible payment options are offered only if total charges exceed $1000 (cost can be as low as $48 per month over 24 months). Depending on the promotion offered by Chase Health Advance, there may even be no interest charged! Click here to calculate your monthly payments.

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!

Reflux (Acid, Non-Acid, Mixed Types) in Neonates & How It May Also Apply to Adults

A study was published this month in the journal Pediatric Research which described reflux characteristics in neonates, but the findings can certainly be applied to adults as well.

What I found gratifying about this study was not so much that reflux was evaluated, but what measurements obtained by 24 hour pH-impedance were taken which apply just as much to adults as neonates. Just exactly what was measured and what did the study find (at least in neonates suspected of having reflux)?

• Only 54% of reflux events was associated with symptoms

• Defined by physical characteristics of reflux events:

• 51.3% were liquid
• 29.1% were gas
• 19.6% were mixed

• Defined by chemical characteristics of the reflux events:

• 48.5% were acidic
• 51.5% were non-acidic

• Defined by how high the reflux traveled away from the stomach:

• 79.2% reached the throat/mouth level
• 20.8% stayed in the chest level

Although these findings are specific for neonates, adults experience similar problems, though precise numbers are probably different and need more study.

Laryngopharyngeal reflux is when reflux reaches the throat level. Depending on the chemical characteristics of the reflux (acid vs non-acid as well as how high it goes), the symptoms may be quite variable. NON-acid reflux is considered “silent” and patients may not experience any symptoms of heartburn. Rather, common symptoms include:

• Phlegmy throat
• Chronic cough
• Swollen sensation in the throat (globus)
• Chronic throat-clearing

These results point out another issue… Common medications used to treat reflux (zantac, pepcid, nexium, prilosec, prevacid, etc) only treats ACID reflux. Not NON-acid reflux.

As such, other modalities must be pursued to address symptomatic non-acid reflux beyond medications involving lifestyle changes including diet as well as surgery.

Whether it be babies or adults, characterization of the spatial-temporal-physical-chemical nature of reflux events as defined by pH-impedance methods offers the best chance of evaluating and treating symptoms due to reflux.

Or in more simplistic terms…

NOT ALL REFLUX IS ACID!!!

NOT ALL REFLUX CAUSES HEARTBURN!!!

Reference:
Significance of gastroesophageal refluxate in relation to physical, chemical, and spatiotemporal characteristics in symptomatic intensive care unit neonates. Pediatr Res. 2011 Aug;70(2):192-8.

New Webpage on Peritonsillar Abscess Added to Website

Our office has created a new webpage on the evaluation and treatment of peritonsillar abscess.

Peritonsillar abscess is when a pus collection develops behind the tonsil causing a severe sore throat and trouble swallowing.

Read more on how this condition is treated here.

R&B Singer R. Kelly Undergoes Peritonsillar Abscess Drainage

Reuters on July 20, 2011 reported that R&B singer R. Kelly suffered from a peritonsillar abscess that required emergency drainage.

Peritonsillar abscess is when a pus collection develops within the tonsil causing it to swell. This may occur over a period of 24 hours resulting in a severe sore throat and trouble swallowing. This condition is in contrast to tonsillitis which is when the tonsil itself is infected, but no pus collection is present.

On exam, the affected tonsil may be huge crossing the midline (see picture). The uvula often is pushed to the opposite side and the soft palate may be asymmetrically huge as well.

Treatment is immediate incision and drainage. In an adult, this can be easily performed in the clinic after adequate local anesthesia. The pus is allowed to drain out and the patient often feels much improved within 12 hours. Antibiotics and a short burst of steroids is often prescribed afterwards.

Read the story here.

Read more about peritonsillar abscess management here.