Celine Dion Cancels Shows Due to Laryngitis

In late Feb 2012, Celine Dion who was to have performed in Las Vegas Feb 22, 2012, cancelled her show at the last minute at the Caesar’s Palace due to laryngitis on the advice of her doctors.

According to media reports, her doctors instructed her to rest for 7 days to ensure full recovery due to vocal cord inflammation caused by a virus.

What does that mean exactly?

When a virus infects the mucosa of the upper airway, it causes inflammation of the mucosa lining including the vocal cords. With inflammation, the vocal cords swell.

That’s why with laryngitis, the pitch of the voice decreases and it becomes more effortful to talk. To use an analogy, think of a violin string where the thicker string has a deeper pitch than a thin string. It also takes more power to play the thicker string. Watch the video below of normal vocal cord functioning:

In order for voice production to occur, the lining of the vocal cords vibrates very quickly when they come together. If the vocal cords are swollen, they don’t vibrate as easily.

Here’s what inflamed vocal cords might have looked like for Celine Dion. Note the slight bend to the vocal cords and overall dull appearance.

Below is what her vocal cords might look like when they are at peak health!

Voice rest is absolutely important for vocal recovery as quickly as possible. With talking/singing during active laryngitis, further trauma may occur to the vocal cord lining promoting even more inflammation and swelling. It may also lead to another vocal disorder known as muscle tension dysphonia.

Source:
Celine Dion cancels act: laryngitis. UPI 2/26/12

Allergy Shots in the Leg? Abdomen?

It is not uncommon that we have patients that ask if allergy shots can be administered in the leg (or other part of the body) rather than the usual behind the upper arm.

Before we answer that question, let’s ask why we given it in the upper arm in the first place!

1) Easy to access
2) Easy to monitor for any adverse reaction
3) All the good studies done are based on injections administered to the upper arm
4) No good studies performed determining whether injections done at other body sites has equal efficacy to the arm.
5) If anaphylaxis occurs, a tourniquet can be easily applied to the arm proximal to the injection site which theoretically would decrease allergen traveling systemically

Given these answers, is it possible to give allergy shots in other body locations other than the arm?

Yes… BUT…

1) No good studies performed determining whether injections done at other body sites has equal efficacy to the arm.

2) If anaphylaxis occurs, may not be possible to apply a tourniquet easily (if given in the abdomen for example)

3) May not be as easy to monitor for a reaction (if given in the buttocks for example)

SO…

It is recommended that allergy shots be given in the upper arm and not other locations.

Reference:

Ask the expert. AAAAI 2/6/12

Skin Patch Immunotherapy for Allergy Cure

Over the years, there have been a variety of systems via which physicians and researchers have attempted to cure patients of their inhalant allergies.

These include (click here for a description of each):

• Allergy shots
• Under the tongue allergy drops (SLIT)
• Intra-Lymphatic Injections (ILIT)
• Allergy Tablets
• Epicutaneous Immunotherapy (EPIT)
• Intra-Nasal Spray
• Bronchial Inhalers

Well… we can now add skin patches to the list.

European researchers conducted a placebo-controlled, double-blinded trial involving 132 patients with grass pollen allergies. The patients were randomly divided into one of four groups: placebo, low-dose, medium-dose or high-dose patches. Patients applied six weekly patches prepared with grass allergens prior to and during the 2008 grass season and ALL reported improvement in their symptoms (30% in 2008) though one year later, there was a dose-dependent improvement with essentially no improvement in low-dose and placebo groups.

Unfortunately, higher-dose patches had higher rates of adverse events including pruritus, erythema, wheal, or eczema leading to an overall drop-out rate of 8.3% from the study.

This all may sound good and promising, but two of the study’s authors hold patents on patch-based immunotherapy which may lead to study bias.

My take? More study is needed…

Reference:
Epicutaneous allergen-specific immunotherapy ameliorates grass pollen–induced rhinoconjunctivitis: A double-blind, placebo-controlled dose escalation study. The Journal of Allergy and Clinical Immunology
Volume 129, Issue 1 , Pages 128-135, January 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.

Bacon Can Stop Nosebleeds! No joke…

When I saw this research, I had to re-read it to believe it… Nasal packing with good-old fashioned bacon stops nosebleeds!!!

Yes… you heard me correctly… and it was actually published in a reputable ENT journal in Nov 2011. AND, it was conducted here in the USA (Detroit, Michigan).

“Cured salted pork crafted as a nasal tampon and packed within the nasal vaults successfully stopped nasal hemorrhage promptly, effectively, and without sequelae … To our knowledge, this represents the first description of nasal packing with strips of cured pork for treatment of life-threatening hemorrhage in a patient with Glanzmann thrombasthenia.”

The current standard of care for nasal packing to treat nosebleeds is using synthetic hemostatic products that appear similar to tampons used for menstruation.

However, this publication in 2011 wasn’t the first to document use of bacon for nosebleeds.

There have been reports on use of bacon since 1940 sporadically (see references below).

In this day and age of cost-cutting and finding cheaper alternatives, bacon is pretty much as cheap as one can go to address nosebleeds. Compare this to synthetic nasal packing which costs on upwards of $50 or more.

Read more about nosebleed management.

Another unusual nosebleed management includes the application of female hormone estrogen (vaginal premarin cream) to the nasal mucosa.

Traditional nosebleed treatment includes nasal emollient application, humidification, nasal cauterization, septoplasty, and eventually nasal packing.

References:
Nasal Packing With Strips of Cured Pork as Treatment for Uncontrollable Epistaxis in a Patient With Glanzmann Thrombasthenia. Ann Otol Rhinol Laryngol 2011;120:732-736.

Rendu-Osler-Weber Disease— Is Embolization Beneficial? Arch Otolaryngol. 1976;102(6):385.

GENERAL PRINCIPLES IN TREATMENT OF NASAL HEMORRHAGE. AMA Arch Otolaryngol. 1953;57(1):51-59.

USE OF SALT PORK IN CASES OF HEMORRHAGE. Arch Otolaryngol. 1940;32(5):941-946.

Nasal Hair Removal and Nasal Sores

It is not unusual that I encounter a patient who develops crusting and sores around the entrance to the nose where coincidentally nasal hair is found… in both men and women.

Other complaints/symptoms beyond crusting and sores include:

• Skin Splitting

• Pimple/Acne Formation

• Scabbing

• Ulcers

People often try applying lotion, neosporin, or cortisone cream… which does help, but not completely with recurrent flareups.

The most common triggers I find that lead to such recurrent sores are nose-picking and nasal hair removal.

The best thing is to avoid doing either… but… if one must…

Nose picking is pretty self-explanatory, but nasal hair removal does require some clarification.

People often use tweezers or even their fingers to pull the offending long nasal hair out for either cosmetic or annoyance reasons.

Yanking nasal hair out is not a good idea beyond the watery eyes it may bring. It causes micro-trauma to the surrounding skin and hair follicle that may lead to infection. Furthermore, just like any other place on the body where hair is removed, ingrown hair growth can also occur.

Aha! one might say… Use an electric nasal hair cutter! That’s a good idea, but make sure it does not cut down to the skin for the same reasons as stated above. Also, ensure the blades are kept sharp to prevent hair pulling.

There are good nasal hair cutters and there are bad ones…

From personal testing of a variety of nasal hair cutters, I like the Groom Mate Platinum XL.

I’m sure there are other good ones, but it may also come down to personal preference.

Now, if there’s an active recurrent nasal sore that’s not healing, the best way to treat it is with prescription cortisporin ointment.

However, best to have a doctor to check it out as there are other more malicious reasons for a nasal sore including skin cancer.
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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

Food Allergy Reaction Video

So the other day, I was watching the movie Hitchstarring Will Smith and Eva Mendes during which there is this one scene where Hitch suffers an allergic reaction from a food he ate during a dinner date. Watch video.

It’s actually a pretty good depiction of a reaction due to a food allergy.

However, given the throat-clearing suggesting airway swelling which extends to his face, he really should have called 911 as this not uncommonly leads to death if the airway swelling is severe enough to obstruct his breathing. Along with facial and airway swelling, his blood pressure probably dropped and his heart rate increased to point he could have passed out due to insufficient blood flow to the brain. Of course, it was a movie and none of that happened, but don’t think for a second that benadryl alone is adequate.

It is a little unusual for an adult to have a previously unknown food allergy with this severe a reaction in someone as old as Hitch, but not impossible.

Treatment was appropriately given with benadrylin the movie, but in reality Hitch additionally should have gone to the ER where epinephrine and steroids also would have been administered followed by several hours of observation.

After recovery, he should ALWAYS carry an epipen with him. He should also probably see an allergist to determine what it was he reacted to so that he can avoid it in the future.

On another note, in the movie, Hitch literally chugs down an entire bottle of liquid benadryl and acts drunk from it. That wouldn’t have happened… rather, he would have gotten extremely drowsy and fallen asleep fairly quickly.

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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.