Fauquier ENT has produced a new video on coblation tonsillectomy for patient educational purposes. It has been added to our YouTube page as well as below. The video shows 3 different views of the procedure, each view being more magnified. It's a little over 4 minutes long in its entirety. Check it out!
Tuesday, 18 December 2007
Wednesday, 5 December 2007
Given the dearth of video on the internet showing exactly how to perform a saline sinus flush using the NeilMed Sinus Rinse bottle, our practice has gone ahead and made one for educational purposes. It has been posted on our YouTube channel, but can be viewed below as well. Click here to go directly to the YouTube video. This link can also be found on our website here.
Instructions on making your own saltwater using home kitchen supplies can be found here.
Saline sinus flushes are generally recommended to patients who have chronic sinusitis or allergy problems which can help alleviate and/or even eliminate symptoms. Children from the age of 5 years and older are able to perform this procedure as well without any difficulty.
There are also devices that perform the same thing:
Instructions on making your own saltwater using home kitchen supplies can be found here.
Saline sinus flushes are generally recommended to patients who have chronic sinusitis or allergy problems which can help alleviate and/or even eliminate symptoms. Children from the age of 5 years and older are able to perform this procedure as well without any difficulty.
There are also devices that perform the same thing:
Tuesday, 4 December 2007
There has been a recent study published in the Archives of Pediatrics and Adolescent Medicine by Hershey Penn State Medical Center revealing the benefit of buckwheat honey
to help with pediatric cough. In fact, it was found to work even BETTER than over-the-counter cough suppressants. This study has been picked up by the general news media as well.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.
Any further questions or concerns should be directed to your pediatrician. Be aware that honey should not be given to infants less than 1 year old due to risk of botulism.
You can purchase buckwheat honey
on Amazon.com.Monday, 3 December 2007
A new video and audio example of a patient with noisy breathing due to a large ball-valving polyp has been posted. This particular polyp is a variation of Smoker's Polyp and is treated with excision and voice therapy. Quitting smoking is also an important component to help prevent this from recurring.
Sunday, 18 November 2007
We have a new webpage on TMJ disorders uploaded. As most people know, TMJ is a joint found immediately in front of the ear where the jaw joins with the skull. What many people may not recognize is that TMJ disorders have numerous symptoms which is often confused as coming from the ear when in actuality, there is nothing wrong with the ear. Such symptoms include ear pain, crackling/popping in the ear, tinnitus (ringing in the ears), pulsating sounds in the ear, etc. Strategies to treat TMJ is also discussed on the webpage.
Friday, 16 November 2007
Fauquier ENT has offered hearing tests, hearing aids (dispensing and repairs), custom ear molds, and assistive listening devices for over a decade. In order to better promote and make our community aware of what we offer, a new web address has been created called:
This web address will take a person directly to our audiology section of our main website (www.FauquierENT.net).
Thursday, 15 November 2007
What to Expect With Hearing Aids
There are three important rules to remember. First: the most important thing to remember is that “We hear with our brain, not with our ears”. Second: hearing aids will not restore normal hearing. Hearing aids help your damaged auditory system work as well as it can. Third: hearing aids are only half of the process towards better hearing. You will be learning to listen and process sound again. Everything will sound different. Voices will be louder and clearer. Your own voice may sound strange. There will be different sounds in your environment that were not there before. Expect a period of adjustment.
History of Hearing Aid Technology and Circuitry
1950 – Analog
1990 – Analog Programmable
1996 – Digital
2004 – Open Fit and Receiver-In-The-Canal
2007 – Wireless Bluetooth
What Hearing Aids are Best
There are several different hearing aid manufacturers on the market. The manufacturers that our office works with primarily are WIDEX, OTICON, and PHONAK. Hearing aids are manufactured with different sizes of shell styles and internal circuitry. Styles are either in-the-ear or behind-the-ear. Hearing aid internal circuitry ranges from entry level to advanced. All of the aids dispensed at our office have the most technologically advanced circuitry, ensuring the best sound quality available. The four factors to consider when choosing an aid are (1) type and degree of hearing loss (2) lifestyle and listening environments (3) dexterity and vision (4) budget. The most appropriate level of circuitry for each individual will depend on these four factors.
The Bottom Line
The cost for one hearing aid ranges from $800 to over $3000 depending on the style and type of circuit selected. In our office, the cost of a hearing aid is determined by the level of internal circuitry and not the shell style.
A complete hearing evaluation takes only minutes and you could be on the road to better hearing.
Our office also provides custom ear plugs for musicians and swimming as well as assistive listening devices & technology such as infrared loop systems for TV and radio, amplified phones, personal body-worn amplifiers, and FM systems.
A full list of our audiological services can be found here.
--Catie Chalmers, MS, CCC/A
There are three important rules to remember. First: the most important thing to remember is that “We hear with our brain, not with our ears”. Second: hearing aids will not restore normal hearing. Hearing aids help your damaged auditory system work as well as it can. Third: hearing aids are only half of the process towards better hearing. You will be learning to listen and process sound again. Everything will sound different. Voices will be louder and clearer. Your own voice may sound strange. There will be different sounds in your environment that were not there before. Expect a period of adjustment.
History of Hearing Aid Technology and Circuitry
1950 – Analog
1990 – Analog Programmable
1996 – Digital
2004 – Open Fit and Receiver-In-The-Canal
2007 – Wireless Bluetooth
What Hearing Aids are Best
There are several different hearing aid manufacturers on the market. The manufacturers that our office works with primarily are WIDEX, OTICON, and PHONAK. Hearing aids are manufactured with different sizes of shell styles and internal circuitry. Styles are either in-the-ear or behind-the-ear. Hearing aid internal circuitry ranges from entry level to advanced. All of the aids dispensed at our office have the most technologically advanced circuitry, ensuring the best sound quality available. The four factors to consider when choosing an aid are (1) type and degree of hearing loss (2) lifestyle and listening environments (3) dexterity and vision (4) budget. The most appropriate level of circuitry for each individual will depend on these four factors.
The Bottom Line
The cost for one hearing aid ranges from $800 to over $3000 depending on the style and type of circuit selected. In our office, the cost of a hearing aid is determined by the level of internal circuitry and not the shell style.
A complete hearing evaluation takes only minutes and you could be on the road to better hearing.
Our office also provides custom ear plugs for musicians and swimming as well as assistive listening devices & technology such as infrared loop systems for TV and radio, amplified phones, personal body-worn amplifiers, and FM systems.
A full list of our audiological services can be found here.
--Catie Chalmers, MS, CCC/A
The Washington Post on November 13, 2007 published a story of a gentleman who suffered from a sharp headache due to Sluder's neuralgia centered in the "anterior ethmoid neurovascular complex".
The amazing thing about this story is that the patient himself figured out what was causing his headache by finding a reference on a microfiche he found in a 1963 article in the British Journal of Laryngology & Otology.
Read the story here.
To read the 1963 journal article entitled "The Anterior Ethmoid Nerve Syndrome" describing this patient's condition, click here.
There was a subsequent correspondence to this article (periodic migrainous neuralgia) you can read here.
Read more about this problem here.
Monday, 5 November 2007
A couple videos have been produced by our office showing how a trans-nasal endoscopic exam is performed and what one would see from this type of exam. Instead of publishing these videos on our website, they have been added to our YouTube homepage. The videos can be found here or viewed below in the embedded player.
Saturday, 3 November 2007
OR, stated another way, "How much did our physician website cost?" So, there have been a few requests over the years on how our website was created which prompted me to write this particular blog where I will go into the details and costs.
•• Summary of Costs ••
Before I go into details, it is important to make sure the costs of running a website is reasonable. After all, if the costs do not justify the expense, no point having a website. A recent blog describing the current costs of setting up a website can be found here.
In any case, here is an overall summary of how much it costs me (one of the physicians in the practice) to develop and maintain our practice's website excluding costs related to time spent. It does help that I as a physician know how to make websites that helps keep costs down.
Expenses
Our domain name "www.FauquierENT.net" purchased at GoDaddy.
• $9.99 per year
Hosting on a Godaddy server the website:
• $50.88 per year
A 128-bit secure SSL for online prescription requests, website email form, appointment requests, etc purchased at Wufoo. Obviously, this is an optional expense. One could just as easily create a webpage stating to call our office for prescription refills or make a form that a patient would have to print out and than fax.
• $24 a month ($288 per year)
Profits
Google Adsense from targeted online advertisement
• About $25 a month ($300 per year)
The wufoo account for online prescriptions, website email, appointments, etc is actually kept as an office expense. The profits I keep to help defray the costs of my expenses maintaining the website.
Keep in mind that our website contains >200 webpages since most web development companies charge for each additional webpage created and maintained.
•• Creating the Website ••
To put it bluntly, one must have some knowledge of how to program in HTML if one wants to have a reasonable appearing website. The creation and maintenance of the website is all performed on my Macintosh MacBook Pro laptop where I have the entire website mirrored on my hard drive. Changes are made on this mirrored website on my computer's hard drive, checked for errors, and than uploaded onto the internet. Given this background, I use the following programs:
Adobe Dreamweaver
My true workhorse program for creating all the different content, images, video, audio, links, etc on the website. Think of it as the Microsoft Word for text documents.
Adobe Photoshop
Powerful graphics program I use to optimize images for web production.
iMovie HD
Free program for owners of Mac computers, I use this program to perform all video editing for web production. This program was heavily used for all the audio-visual effects of the hoarse voice section of our website. The videos themselves were produced on a KayPentax digital system using a chip-on-tip flexible scope.
Adobe Flash
Program used to create the interactive elements of the website. It is used in conjunction with Adobe Dreamweaver. This program is what allows for color changes when a cursor passes over a link or simple animation like a photo slideshow.
DreamsTime
Purchase royalty-free clip art to add to your website for a very low price (less than one dollar). Important as you can't just use random artwork in other websites due to copyright infringement concerns.
Microsoft Word and Adobe Acrobat
These two programs were used to create all forms and documents for patients to download and print at home. Adobe acrobat is the program used to create pdf files which can be opened on any computer whether it be a Windows PC, Mac, Linux, etc.
That's pretty much all that is needed to create and maintain a website!
•• Miscellaneous Website Enhancements ••
So there are various features I have added to the website to make it more useful for visitors such as a google search engine, real-time allergy report, interactive map of our office location, etc. The key thing here is that all these various features are FREE as again, my main motivation is to make the website better without adding cost.
Google Account
This is by far the most important free account to have as Google provides so many free services that many other companies would charge for. Through this account, you can:
• Obtain infinite number of free email accounts with your domain name for everybody in your office (ie, userid@FauquierENT.net). Some knowledge of server protocols is needed, but google does provide a step-by-step instruction.
• Create/Edit your listing under Google's yellow pages.
• Create a Blog (this one!).
• YouTube account for videos.
• Webmaster services to optimize the website for being found by google's search engine.
• Adsense account to insert targeted advertisement within the webpages for which you can get paid
• Get a google search engine for your website.
Google Maps
Add a google map to your website for free pinpointing your office's location. Some programming knowledge is needed.
FeedBurner
A google owned website where you can link info within a blog to your website automatically. You can see this in action on our practice's website (the rotating headlines towards the bottom). This services also provides free enhancement utilities to improve your blog.
Statcounter
Free service which will inform you about your website visitors: how many, which webpages, how long were they on each webpage, what webpages a given visitor saw and in what order, at what time, from where in the world, etc. This is EXTREMELY important information that allows you to figure out how to improve your website from a visitor's perspective.
Pollen Report
Free pollen count report can be added to your website for free. Some programming knowledge required.
Free Web-Based Surveys
Surveys are wonderful tools to determine what patients think of your practice. In the case of a website, it allows you to tap into their thoughts should they volunteer to answer questions you pose to them. SurveyMonkey as well as Wufoo both provide free web-based surveys as well as a more sophisticated format that costs money. I think that for most practices, the free version provides everything you would need. The survey we currently have on our website is located here.
www.LinkTiger.com
This free web-service checks your website weekly for any broken links. That way you can immediately make changes to keep all links functioning because nothing is more aggravating to a website visitor than a website full of broken links.
•• Time Factor ••
People have asked me how much time have I spent creating and maintaining the website. The answer is continuously. Although there may not be any changes needed, I'm constantly thinking of ways to make it better. Questions I keep asking myself are:
• What can I do to make this webpage look better?
• Can I add a piece of relevant artwork without making the webpage too long?
• Why do visitors spend only 5 seconds on this webpage, but 10 minutes on another?
• Are there any new webpages I can add to increase visits to the website?
• Etc
I honestly can't say that our practice's website will ever be completed. Though I don't spend hours and hours every week on it, I do spend a few minutes making minor changes several times a week. Making minor changes on a website takes no longer than making minor changes in a MS Word document, but instead of "saving" the changes, one "uploads" onto the internet any changes.
•• Summary ••
I hope this info is helpful for other medical practices thinking of adding a practice website without the costs from hiring a Web Development Company. I do feel that having a website is imperative in this day and age and I absolutely believe that it has enhanced our practice both in attracting new patients who may have gone elsewhere as well as retaining current ones.
•• Summary of Costs ••
Before I go into details, it is important to make sure the costs of running a website is reasonable. After all, if the costs do not justify the expense, no point having a website. A recent blog describing the current costs of setting up a website can be found here.
In any case, here is an overall summary of how much it costs me (one of the physicians in the practice) to develop and maintain our practice's website excluding costs related to time spent. It does help that I as a physician know how to make websites that helps keep costs down.
Expenses
Our domain name "www.FauquierENT.net" purchased at GoDaddy.
• $9.99 per year
Hosting on a Godaddy server the website:
• $50.88 per year
A 128-bit secure SSL for online prescription requests, website email form, appointment requests, etc purchased at Wufoo. Obviously, this is an optional expense. One could just as easily create a webpage stating to call our office for prescription refills or make a form that a patient would have to print out and than fax.
• $24 a month ($288 per year)
Profits
Google Adsense from targeted online advertisement
• About $25 a month ($300 per year)
The wufoo account for online prescriptions, website email, appointments, etc is actually kept as an office expense. The profits I keep to help defray the costs of my expenses maintaining the website.
Keep in mind that our website contains >200 webpages since most web development companies charge for each additional webpage created and maintained.
•• Creating the Website ••
To put it bluntly, one must have some knowledge of how to program in HTML if one wants to have a reasonable appearing website. The creation and maintenance of the website is all performed on my Macintosh MacBook Pro laptop where I have the entire website mirrored on my hard drive. Changes are made on this mirrored website on my computer's hard drive, checked for errors, and than uploaded onto the internet. Given this background, I use the following programs:
Adobe Dreamweaver
My true workhorse program for creating all the different content, images, video, audio, links, etc on the website. Think of it as the Microsoft Word for text documents.
Adobe Photoshop
Powerful graphics program I use to optimize images for web production.
iMovie HD
Free program for owners of Mac computers, I use this program to perform all video editing for web production. This program was heavily used for all the audio-visual effects of the hoarse voice section of our website. The videos themselves were produced on a KayPentax digital system using a chip-on-tip flexible scope.
Adobe Flash
Program used to create the interactive elements of the website. It is used in conjunction with Adobe Dreamweaver. This program is what allows for color changes when a cursor passes over a link or simple animation like a photo slideshow.
DreamsTime
Purchase royalty-free clip art to add to your website for a very low price (less than one dollar). Important as you can't just use random artwork in other websites due to copyright infringement concerns.
Microsoft Word and Adobe Acrobat
These two programs were used to create all forms and documents for patients to download and print at home. Adobe acrobat is the program used to create pdf files which can be opened on any computer whether it be a Windows PC, Mac, Linux, etc.
That's pretty much all that is needed to create and maintain a website!
•• Miscellaneous Website Enhancements ••
So there are various features I have added to the website to make it more useful for visitors such as a google search engine, real-time allergy report, interactive map of our office location, etc. The key thing here is that all these various features are FREE as again, my main motivation is to make the website better without adding cost.
Google Account
This is by far the most important free account to have as Google provides so many free services that many other companies would charge for. Through this account, you can:
• Obtain infinite number of free email accounts with your domain name for everybody in your office (ie, userid@FauquierENT.net). Some knowledge of server protocols is needed, but google does provide a step-by-step instruction.
• Create/Edit your listing under Google's yellow pages.
• Create a Blog (this one!).
• YouTube account for videos.
• Webmaster services to optimize the website for being found by google's search engine.
• Adsense account to insert targeted advertisement within the webpages for which you can get paid
• Get a google search engine for your website.
Google Maps
Add a google map to your website for free pinpointing your office's location. Some programming knowledge is needed.
FeedBurner
A google owned website where you can link info within a blog to your website automatically. You can see this in action on our practice's website (the rotating headlines towards the bottom). This services also provides free enhancement utilities to improve your blog.
Statcounter
Free service which will inform you about your website visitors: how many, which webpages, how long were they on each webpage, what webpages a given visitor saw and in what order, at what time, from where in the world, etc. This is EXTREMELY important information that allows you to figure out how to improve your website from a visitor's perspective.
Pollen Report
Free pollen count report can be added to your website for free. Some programming knowledge required.
Free Web-Based Surveys
Surveys are wonderful tools to determine what patients think of your practice. In the case of a website, it allows you to tap into their thoughts should they volunteer to answer questions you pose to them. SurveyMonkey as well as Wufoo both provide free web-based surveys as well as a more sophisticated format that costs money. I think that for most practices, the free version provides everything you would need. The survey we currently have on our website is located here.
www.LinkTiger.com
This free web-service checks your website weekly for any broken links. That way you can immediately make changes to keep all links functioning because nothing is more aggravating to a website visitor than a website full of broken links.
•• Time Factor ••
People have asked me how much time have I spent creating and maintaining the website. The answer is continuously. Although there may not be any changes needed, I'm constantly thinking of ways to make it better. Questions I keep asking myself are:
• What can I do to make this webpage look better?
• Can I add a piece of relevant artwork without making the webpage too long?
• Why do visitors spend only 5 seconds on this webpage, but 10 minutes on another?
• Are there any new webpages I can add to increase visits to the website?
• Etc
I honestly can't say that our practice's website will ever be completed. Though I don't spend hours and hours every week on it, I do spend a few minutes making minor changes several times a week. Making minor changes on a website takes no longer than making minor changes in a MS Word document, but instead of "saving" the changes, one "uploads" onto the internet any changes.
•• Summary ••
I hope this info is helpful for other medical practices thinking of adding a practice website without the costs from hiring a Web Development Company. I do feel that having a website is imperative in this day and age and I absolutely believe that it has enhanced our practice both in attracting new patients who may have gone elsewhere as well as retaining current ones.
Tuesday, 30 October 2007
Audio clips of patients with muscle tension dysphonia before, during, and after speech therapy has been added to our webpage describing this disorder. Note that speech therapy is a dynamic interaction between the therapist and patient in which the patient's responses leads the therapy as opposed to the therapist dictating when and how the therapy proceeds. Click here to listen.
Sunday, 28 October 2007
Starting this week, our office will be initiating automatic appointment phone call reminders. There will be the option to confirm the appointment or have the phone call re-directed to our office to cancel or reschedule an appointment. At this point in time, there will be a strange number (Seattle, WA area code) for those with caller ID. However, in a few weeks, our office number will appear instead.
Friday, 12 October 2007
New video exam of a child with hyper-nasal speech has been posted here. The cause of this child's hyper-nasal speech was due to a right lateral velopharyngeal insufficiency due to a slight right soft palate paresis. In this particular case, the child and parents also noticed that food and liquids kept coming out the nose whenever she swallowed. This deficit spontaneously resolved after about 1 month.
For more examples of causes of nasal speech, click here.
Sunday, 16 September 2007
Dr. Chang now offers botox injections for migraine headaches! Given that most insurance companies do not cover this therapeutic procedure for headaches in spite of its documented effectiveness in the literature, most patients will have to fail or respond poorly to medications before considering this option. Click here for more informtion.
HOWEVER, if neck spasms occur which trigger headaches, botox injection for the neck spasms (and not necessarily for the headaches) may be covered by insurance.
Botox injections are performed every Friday afternoon by Dr. Chang. Other disorders that Dr. Chang treats with botox injections include spasmodic dysphonia, TMJ, cricopharyngeal spasms, vocal cord dysfunction, chronic cough, and head & neck muscle spasms/twitches. We do NOT provide botox injections for cosmetic reasons (ie, wrinkles). For that service, please contact your local plastic surgeon or dermatologist.
HOWEVER, if neck spasms occur which trigger headaches, botox injection for the neck spasms (and not necessarily for the headaches) may be covered by insurance.
Botox injections are performed every Friday afternoon by Dr. Chang. Other disorders that Dr. Chang treats with botox injections include spasmodic dysphonia, TMJ, cricopharyngeal spasms, vocal cord dysfunction, chronic cough, and head & neck muscle spasms/twitches. We do NOT provide botox injections for cosmetic reasons (ie, wrinkles). For that service, please contact your local plastic surgeon or dermatologist.
Wednesday, 12 September 2007
A new webpage describing laryngopharyngeal reflux (LPR) has been uploaded on our website. LPR is different from classic GERD in that although acid reflux from the stomach occurs, typically no heartburn is experienced. Rather, symptoms may include lump sensation in the throat, constant throat-clearing, sore throat, ear pain, cough, etc. Read more about it here.
Some over-the-counter medications used to treat relux are listed below:
Some over-the-counter medications used to treat relux are listed below:
Saturday, 8 September 2007
To What Degree Does Botox Dosage Affect Duration of Side Effects and Duration of Normal Voice After Injection for Adductor Spasmodic Dysphonia?
For many patients who suffer from spasmodic dysphonia, botulinum toxin type A or Botox, injection to the vocal cords is a ritual treatment undergone several times a year to keep the spasms in their voice away. The amount of Botox injected varies from patient to patient. Regardless of the patient and their specific dose, it is intuitive to many patients and healthcare providers that larger doses of Botox injected results in greater side effects (breathy/hoarse voice, dysphagia) and perhaps a longer duration of normal voice. This assumption, logical as it may sound, may not be correct according to a new study published in the June 2007 edition of Otolaryngology-Head & Neck Surgery (Link). According to the study’s author Dr. Christopher Chang (Fauquier ENT Consultants, PLC in Warrenton, Virginia) and coauthors, they actually found that there is a bell curve response of normal voice duration to higher doses of Botox. In other words, at some tipping point, giving higher doses of Botox actually resulted in a decrease in duration of normal voice. The study also reported, not surprisingly, that higher doses of Botox does lead to more severe side effects that lasts longer before normal voice resumes. The impact of this finding is that for some patients, a better and longer response may occur with a LOWER dose of botox.
These results were obtained from 101 patients with adductor spasmodic dysphonia who collectively underwent 876 injections between March 1998 and August 2006. In this study population, the Botox dosage range went from as low as 0.25 Units to as high as 7.5 Units bilaterally. The average dose was 1.62 Units. Based on statistical models, the “ideal” dose was found to be 1.41 Units bilaterally which would give a theoretical zero days of side effects and 87.3 days of normal voice. Based on these same statistical models, giving Botox doses higher than 1.41 units bilaterally theoretically would result in a DECREASE in duration of normal voice while increasing the duration and severity of side effects.
Of course, theory doesn’t always play out in reality as many individuals obtain perfectly good results with Botox dosages much larger than 1.41 Units bilaterally. However, when looking over large numbers of patients with spasmodic dysphonia over many injections over time, the statistical models provided in the study does provide some insights into what may be happening inside the body with each Botox injection.
With larger doses of Botox injected, larger volumes are obviously required. With increased volumes injected, however, there is an increased risk of diffusion of the toxin beyond the vocal cord muscle. Such spread of the toxin beyond the vocal cord muscle would result in a decrease in toxin left behind to exert its effect. Another outcome of this diffusion would be increased side effects as other uninvolved muscles become affected by Botox. As an example stated another way, if 4.0 Units were injected into the vocal cord muscle, 1.5 Units may actually diffuse away affecting other muscles in the area causing side effects. This would leave only 2.5 Units (instead of 4.0 Units) behind to actually affect the vocal cord muscle.
What does this information mean? Well, it does suggest strategies to improve clinical efficacy while causing less severe and shorter duration of side effects. How? By using smaller volumes to decrease risk of diffusion. How can one use less volume, but maintain or even increase effective dosage amounts? By distributing a large dose over multiple injections instead of one injection. By using multiple injections, one is effectively using smaller volumes over multiple injection sites, a strategy known as “saturation of injection site”. Such a strategy may result in improved outcomes after Botox injections without resorting to large doses of Botox with its attendant side effects.
Though physicians throughout the world are investigating other experimental treatment options for spasmodic dysphonia such as selective laryngeal nerve denervation reinnervation, thyroarytenoid myectomy, thyroplasty, and carbon dioxide laser ablation, this study does bring to light that the old standard of Botox injection also has much room to become even better. Although the strategies based on this study have yet to be verified in clinical studies, it does bring up the that fact that even something as straightforward and simple as an injection can be further refined and improved upon.
Dr. Chang does provide Botox injections for patients with spasmodic dysphonia every Friday afternoon in Warrenton, Virignia.
Books on voice therapy found to be a useful ADJUNCT to botox injections:
For many patients who suffer from spasmodic dysphonia, botulinum toxin type A or Botox, injection to the vocal cords is a ritual treatment undergone several times a year to keep the spasms in their voice away. The amount of Botox injected varies from patient to patient. Regardless of the patient and their specific dose, it is intuitive to many patients and healthcare providers that larger doses of Botox injected results in greater side effects (breathy/hoarse voice, dysphagia) and perhaps a longer duration of normal voice. This assumption, logical as it may sound, may not be correct according to a new study published in the June 2007 edition of Otolaryngology-Head & Neck Surgery (Link). According to the study’s author Dr. Christopher Chang (Fauquier ENT Consultants, PLC in Warrenton, Virginia) and coauthors, they actually found that there is a bell curve response of normal voice duration to higher doses of Botox. In other words, at some tipping point, giving higher doses of Botox actually resulted in a decrease in duration of normal voice. The study also reported, not surprisingly, that higher doses of Botox does lead to more severe side effects that lasts longer before normal voice resumes. The impact of this finding is that for some patients, a better and longer response may occur with a LOWER dose of botox.
These results were obtained from 101 patients with adductor spasmodic dysphonia who collectively underwent 876 injections between March 1998 and August 2006. In this study population, the Botox dosage range went from as low as 0.25 Units to as high as 7.5 Units bilaterally. The average dose was 1.62 Units. Based on statistical models, the “ideal” dose was found to be 1.41 Units bilaterally which would give a theoretical zero days of side effects and 87.3 days of normal voice. Based on these same statistical models, giving Botox doses higher than 1.41 units bilaterally theoretically would result in a DECREASE in duration of normal voice while increasing the duration and severity of side effects.
Of course, theory doesn’t always play out in reality as many individuals obtain perfectly good results with Botox dosages much larger than 1.41 Units bilaterally. However, when looking over large numbers of patients with spasmodic dysphonia over many injections over time, the statistical models provided in the study does provide some insights into what may be happening inside the body with each Botox injection.
With larger doses of Botox injected, larger volumes are obviously required. With increased volumes injected, however, there is an increased risk of diffusion of the toxin beyond the vocal cord muscle. Such spread of the toxin beyond the vocal cord muscle would result in a decrease in toxin left behind to exert its effect. Another outcome of this diffusion would be increased side effects as other uninvolved muscles become affected by Botox. As an example stated another way, if 4.0 Units were injected into the vocal cord muscle, 1.5 Units may actually diffuse away affecting other muscles in the area causing side effects. This would leave only 2.5 Units (instead of 4.0 Units) behind to actually affect the vocal cord muscle.
What does this information mean? Well, it does suggest strategies to improve clinical efficacy while causing less severe and shorter duration of side effects. How? By using smaller volumes to decrease risk of diffusion. How can one use less volume, but maintain or even increase effective dosage amounts? By distributing a large dose over multiple injections instead of one injection. By using multiple injections, one is effectively using smaller volumes over multiple injection sites, a strategy known as “saturation of injection site”. Such a strategy may result in improved outcomes after Botox injections without resorting to large doses of Botox with its attendant side effects.
Though physicians throughout the world are investigating other experimental treatment options for spasmodic dysphonia such as selective laryngeal nerve denervation reinnervation, thyroarytenoid myectomy, thyroplasty, and carbon dioxide laser ablation, this study does bring to light that the old standard of Botox injection also has much room to become even better. Although the strategies based on this study have yet to be verified in clinical studies, it does bring up the that fact that even something as straightforward and simple as an injection can be further refined and improved upon.
Dr. Chang does provide Botox injections for patients with spasmodic dysphonia every Friday afternoon in Warrenton, Virignia.
Books on voice therapy found to be a useful ADJUNCT to botox injections:
Monday, 27 August 2007
Fauquier ENT will be closed Sept 17-19, 2007. Our physicians will be attending a medical conference during that time period. Although office staff will be available for a limited number of hours to answer phone calls, no office visits will be scheduled during that time period and no allergy shots will be given. Please schedule accordingly.
Saturday, 4 August 2007
Intra-tympanic steroid injections are offered at Fauquier ENT. This treatment modality is used in patients with sudden sensorineural hearing loss that responds minimally or not at all to systemic steroids (ie, prednisone). This treatment may be used without systemic steroids trial if there are contraindications to systemic steroid use such as intestinal ulcers and diabetes. The downside is that this treatment works best only if given within the first 36 days after the hearing loss occurs.
Intra-tympanic steroid injections have also been found to potentially help certain patients with tinnitus.
Watch video of this being performed here or watch below.
References
• Intratympanic corticosteroids for Meniere's disease and vertigo. Otolarngol Clin N Am. 37:955-972. 2004 Link
• Intratympanic perfusion for the treatment of tinnitus. Otolaryngol Clin N Am. 37:991-1000. 2004 Link
• Intratympanic steroids for sensorineural hearing loss. Otolaryngol Clin N Am. 1061-1074. 2004 Link
• Intratympanic Dexamethasone for sudden sensorineural hearing loss after failure of systemic therapy. Laryngoscope. 117:3-15. 2007. Link
• Intratympanic steroid injection for treatment of idiopathic sudden hearing loss. Otolaryngol Head Neck Surg. 133:251-59. Link
• Clinical efficacy of initial intratympanic steroid treatment on sudden sensorineural hearing loss with diabetes. Otolaryngol Head Neck Surg. 141:572-578. Link
• Hearing outcomes of daily intratympanic dexamethasone alone as a primary treatment modality for ISSHL. Otolaryngol Head Neck Surg. 141:579-583. Link
Intra-tympanic steroid injections have also been found to potentially help certain patients with tinnitus.
Watch video of this being performed here or watch below.
References
• Intratympanic corticosteroids for Meniere's disease and vertigo. Otolarngol Clin N Am. 37:955-972. 2004 Link
• Intratympanic perfusion for the treatment of tinnitus. Otolaryngol Clin N Am. 37:991-1000. 2004 Link
• Intratympanic steroids for sensorineural hearing loss. Otolaryngol Clin N Am. 1061-1074. 2004 Link
• Intratympanic Dexamethasone for sudden sensorineural hearing loss after failure of systemic therapy. Laryngoscope. 117:3-15. 2007. Link
• Intratympanic steroid injection for treatment of idiopathic sudden hearing loss. Otolaryngol Head Neck Surg. 133:251-59. Link
• Clinical efficacy of initial intratympanic steroid treatment on sudden sensorineural hearing loss with diabetes. Otolaryngol Head Neck Surg. 141:572-578. Link
• Hearing outcomes of daily intratympanic dexamethasone alone as a primary treatment modality for ISSHL. Otolaryngol Head Neck Surg. 141:579-583. Link
Thursday, 2 August 2007
Fauquier ENT has been offering allergy treatment with shots or drops for patients with allergies for quite some time. Our office also offers a type of allergy treatment known as pre-seasonal rush therapy which is geared towards patients with severe allergy symptoms to only ONE specific seasonal pollen (ie, grass, tree, or weed). Benefits include allergy immunotherapy ONLY once per year for a few months each year instead of allergy injections or allergy drops all year round for many years. And of course, there is the benefit of decreased allergy symptoms as well. This treatment can also be used in conjunction with a patient's regular allergy shot or drop treatment if multiple mild allergies are present, with only one highly allergic seasonal pollen. Click here for more information.
Saturday, 21 July 2007
Recently, it was brought to my attention that websites by other entities have linked to webpages contained within our website. Here is a list of those websites (excluding search engines, directories, wikis, etc):
Allergy Blog
MenieresInfo.com
New York Voice Center
VoiceDoctor.net
MonkeyFilter | Not Speechless Blog
EconoCulture Blog
Blog Fauquier
National Voice Center Referral Database
Allergy Blog
MenieresInfo.com
New York Voice Center
VoiceDoctor.net
MonkeyFilter | Not Speechless Blog
EconoCulture Blog
Blog Fauquier
National Voice Center Referral Database
Monday, 16 July 2007
Wednesday, 11 July 2007
Her name is Dr. Carmen Ana Ramos Pizarro and she has a PhD in speech-language pathology with an emphasis in voice science. She will be at Fauquier Hospital every Monday afternoon to lend her considerable expertise and experience to assist in caring for patients with vocal problems.
She obtained her speech pathology PhD at University of Wisconsin-Madison majoring in the voice sciences. She went on to be the director of the Voice Clinic at the Grabschied Voice Center in New York City as well as Puerto Rico Medical Center before coming to Northern Virginia.
Addendum 1/3/08:
Her status is pending Virginia Licensure.
She obtained her speech pathology PhD at University of Wisconsin-Madison majoring in the voice sciences. She went on to be the director of the Voice Clinic at the Grabschied Voice Center in New York City as well as Puerto Rico Medical Center before coming to Northern Virginia.
Addendum 1/3/08:
Her status is pending Virginia Licensure.
Monday, 9 July 2007
Pictures of a Zenker's Diverticulum after barium swallow has been posted here. Zenker's Diverticulum is an abnormal pouch (or diverticulum) that forms in the throat that leads to swallowing problems. It is treated endoscopically via a procedure known as endoscopic staple diverticulostomy (ESD).
Dr. Chang has published extensively on the use of ESD to treat Zenker's Diverticulum and is able to provide this service in Northern Virginia.
Friday, 6 July 2007
Dr. Christopher Chang recently published an article in ENT Journal on ways to make an office run more efficiently and cheaply using strategies developed by Toyota Motor Company. To read all about it, click here.
Sunday, 24 June 2007
On June 22, 2007, Dr. Chang was elected to become the Treasurer of the Duke Otolaryngology Alumni Society for a 2 year term. The Society is a 501(c)(3) organization. The organization's website is:
http://www.DukeOHNS.com
http://www.DukeOHNS.com
Thursday, 14 June 2007
I recently saw a female patient complaining of a deep voice... and it's been getting deeper over the years. She also is a big-time smoker and talker. Fiberoptic laryngoscopy revealed early stage Smoker's Polyps. An example of Smoker's Polyps with video and audio feed is shown here on our website.
This condition almost always is due to the combination of smoking (a lot) and talking (a lot). Though it is not cancer, it is yet another reason to stop smoking!
--Dr. Chang
Wednesday, 13 June 2007
A new video of bilateral thyroarytenoid paralysis (partial vocal cord paralysis) via fiberoptic stroboscopy of the voicebox is shown here. Note the harsh and breathy quality to the patient's voice. It was felt that his condition was brought on by a viral upper respiratory infection. After a prednisone burst and taper along with limited voice use, his voice returned to normal in 2 weeks.
An example of complete unilateral vocal cord paralysis is shown here.
As people may know from reading our article on snoring on our website, there are many different levels in our upper airway anatomy that may contribute to the noise produced. However, most commonly, the culprit sources are the tongue and palate. Procedures such as the "Pillar Procedure" that has recently received media attention as well as UPPP address only the palate. Procedures like base of tongue reduction, hyoid advancement, etc that address the tongue are more difficult and morbid.However, I was recently at a conference where a prominent Australian ENT gave a talk where he mentioned one previously unreported way to treat OSA and snoring due to the tongue...
DISCLAIMER: I am not advocating one way or another this treatment! I am just mentioning as something of interest. As always, see your doctor before proceeding with any type of treatment!
Apparently, there is a community in Australia where citizens put tongue bolts in their tongue, not because it looks cool, but because it really, truly helps with snoring as well as OSA. Apparently, when these citizens go to sleep, they place a rubber band around the tongue bolt and anchor it to their front teeth. This method would prevent the tongue from vibrating as it would stretch and stiffen the tongue AND also prevent the tongue from falling backward.
This simple procedure actually duplicates the surgical procedures performed in the United States including hyoid advancement, genioglossus advancement, Repose tongue advancement, etc. All these surgical procedures for the tongue, in essence, try to anchor the tongue forward, just like the tongue bolt/rubber band technique.
Now that's food for thought!
Tuesday, 12 June 2007
We have suddenly noticed a number of phone calls to our office as well as inquiries from our established patients regarding the Pillar Procedure for snoring and obstructive sleep apnea after a recent television news report.
We used to offer this procedure, but as of Jan 2010, we no longer do.
An article entitled "Neo-Ossification of the Cricothyroid Joint After Elective Cricothyroidotomy: A Case Report and Discussion on the Merits of This Procedure" authored by Dr. Chang has been published in pre-print form online in the Journal of Trauma, a peer-reviewed publication. This article will be published in print in the near future. Click here to view the pubmed stub.
Tuesday, 5 June 2007
In the June 2007 edition of the journal Otolaryngology-Head & Neck Surgery, Dr. Chang's original research has been published. The title of the paper is "Relationship of botulinum dosage to duration of side effects and normal voice in adductor spasmodic dysphonia." Click here to read the abstract.
Dr. Chang treats patients with spasmodic dysphonia using BOTOX every Friday afternoon. To watch a video of how exactly her performs this procedure in a patient, click here.
Books on voice therapy found to be a useful ADJUNCT to botox injections:
Sunday, 3 June 2007
Two new webpages have been added to our website. The first new webpage describes where snoring comes from and how it is treated. Obstrutive sleep apnea as how it relates to snoring is also discussed. Click here to check it out!
The other new webpage added describes sinusitis. CT scan of normal as well as abnormal sinuses are shown. Check it out here!
Our office provides complete management (medical to surgical) of sinusitis whatever its cause.
Wednesday, 16 May 2007
A new webpage regarding the rare and unique situation in which patients with all the symptoms and history consistent with allergies come back negative to all allergy testing. Our office does provide options for treatment including allergy shots or allergy drops. Click here for more info.
Monday, 23 April 2007
Fauquier ENT web domain services used to be with Registerfly.com. However, given recent problems in management, ICANN withdrew accreditation from this company. To ensure smooth internet services, Fauquier ENT initiated the transfer of domain services to Godaddy.com which was successfully completed today. During the transfer which takes 24 hours to complete, occasional glitches in accessing our website may occur.
Monday, 9 April 2007
A new webpage listing all the laryngologists (voice specialist) in the United States and the world has been posted. This list is a compilation based on a list maintained by Dr. Thomas and MJ Dance Jr. Head and Neck Rehabilitation Center.
The list can be found here.
The list can be found here.
Thursday, 5 April 2007
A new website heralding the creation of a new organization dedicated to helping people with poor vocal/speech quality has been created. The new organization, called the Virginia Voice & Speech Center, is a consortium of professionals including ENT physicians, speech pathologists, and singing voice instructors.
http://www.VVSC.org
Friday, 16 March 2007
There is a new study beginning the spring/summer of 2007 in Warrenton, VA to address the excessive dry mouth patients experience after undergoing radiation treatment for head & neck cancer. The primary objective is to assess the impact of the drug Evoxac (cevimeline) on salivary flow at a dose of 30mg three times daily. Of note, this drug and dosage has already been approved by the FDA for treatment of dry mouth in patients with Sjogren's syndrome, an autoimmune disease that causes dry mouth.
Fauquier ENT is one of only 13 sites nationally participating in this study which is coordinated by the Duke Clinical Research Institute and the American Academy of Otolaryngology-Head & Neck Surgery.
Contact our office if you would like to participate in this study. This study is anticipated to be completed end of 2008.
Fauquier ENT is one of only 13 sites nationally participating in this study which is coordinated by the Duke Clinical Research Institute and the American Academy of Otolaryngology-Head & Neck Surgery.
Contact our office if you would like to participate in this study. This study is anticipated to be completed end of 2008.
Sunday, 4 March 2007
A recently published article suggested that tonsillectomy was associated with a decrease in the incidence and frequency and an increase in the time to the next infection in children with recurrent strep throat.
This finding is something many ENTs have suspected, but now there is evidence to support.
Reference: Efficacy of Tonsillectomy in Treatment of Recurrent Group A B-Hemolytic Streptococcal Pharyngitis. Laryngoscope. 116:1946-1950. 2006. Link
This finding is something many ENTs have suspected, but now there is evidence to support.
Reference: Efficacy of Tonsillectomy in Treatment of Recurrent Group A B-Hemolytic Streptococcal Pharyngitis. Laryngoscope. 116:1946-1950. 2006. Link
Wednesday, 21 February 2007
A new video and audio examination of a patient with posterior glottic web after a traumatic and prolonged (2 week) intubation after a motor vehicle accident is posted. A posterior glottic web is a scar band that spans across the back aspect of one to the other vocal cord preventing it from opening fully. Such a restriction would restrict airflow resulting in "noisy" breathing as demonstrated in this sample.
Saturday, 17 February 2007
Dr. Chang was quoted in the Fauquier Times-Democrat Newspaper. The article was about blogging. Read the full article here.
Quoted:
In Warrenton, Fauquier Ear, Nose & Throat Consultants maintain an active blog on office news and medical innovations for readers, not all of whom are local patients.
"People from all over the world are visiting," said Dr. Christopher Y. Chang, who created the blog as "the most convenient way to organize office news items over time in an easily searchable and archived format. Plus it is free."
Wednesday, 14 February 2007
Our office has been closed from 2/13/07 to 2/14/07 due to severe weather conditions. Also, the server handling our email has crashed sometime in 2/13/07. Technicians are working to get this back up so patients can email us. Please call/fax to get in touch with us until repairs have been made (hopefully soon!).
ADDENDUM (2/16/07): Email is working now... Thank you for your patience.
ADDENDUM (2/16/07): Email is working now... Thank you for your patience.
Sunday, 11 February 2007
I read this article in USA Today on vocal cord dysfunction and though this condition does exist, I do believe it is over-diagnosed. Another common cause of stridor with exercise is due to non-organic stridor where the vocal cords are so pliable, they vibrate even when they are widely apart, especially in young female athletes.
The key for diagnosis is to perform a fiberoptic laryngoscopy when symptommatic. Previous patients of mine know that I make them run laps around our office building until they start having symptoms at which time I will perform the exam. Here is more info on this particular topic.
The key for diagnosis is to perform a fiberoptic laryngoscopy when symptommatic. Previous patients of mine know that I make them run laps around our office building until they start having symptoms at which time I will perform the exam. Here is more info on this particular topic.
On January 15, 2007, an article appeared on spasmodic dysphonia in USA Today. Click here to read the article.
Dr. Chang treats patients with spasmodic dysphonia using BOTOX every Friday afternoon. To watch a video of how exactly her performs this procedure in a patient, click here.
Books on voice therapy found to be a useful ADJUNCT to botox injections:
Dr. Chang treats patients with spasmodic dysphonia using BOTOX every Friday afternoon. To watch a video of how exactly her performs this procedure in a patient, click here.
Books on voice therapy found to be a useful ADJUNCT to botox injections:
Monday, 5 February 2007
A new audio and video strobe examination of a singer with true vocal cord swelling has been posted here. This example clearly demonstrates the hourglass gap with vocal cord adduction due to the swelling as well as onset delays and pitch breaks common in this particular disorder.
Vocal cord swelling is a very common and treatable cause of hoarseness in singers and in people who just plain like to talk a lot. It is considered the first stage before formation of nodules/polyps/cysts if not treated.
Wednesday, 31 January 2007
Not sure why more doctors don't prescribe nasal steroids (ie, flonase, nasacort, rhinocort, nasonex, etc) in addition to antibiotics to treat sinusitis, especially those in which it is recurrent or chronic. It's been shown that nasal steroids do help more than antibiotics alone. The study I'm most familiar with is the one published in JAMA in 2001.
Reference: Comparison of cefuroxime with or without intranasal fluticasone for the treatment of rhinosinusitis. The CAFFS Trial: a randomized controlled trial. JAMA. 286(24):3097-105, 2001. Link
Reference: Comparison of cefuroxime with or without intranasal fluticasone for the treatment of rhinosinusitis. The CAFFS Trial: a randomized controlled trial. JAMA. 286(24):3097-105, 2001. Link
Monday, 29 January 2007
Due to complaints that webpages in VoiceInfo.org took forever due to multiple videos incorporated into the webpage itself, changes have been made to allow a user to download only those videos they would like to see by clicking on a link. A still photo of a scene from the video will be displayed to give the user an idea of what the video will contain.
www.VoiceInfo.org
www.VoiceInfo.org
Wednesday, 17 January 2007
There has been a recent Cochrane review regarding whether serous fluid in the middle ear improves with decongestants and/or anti-histamines which are commonly prescribed by both pediatricians and ENTs for this condition. This review which analyzed the results from 7 studies revealed that these medications had NO impact on the resolution of serous otitis media. In fact, there were significant side effects detected in 1 out of every 9 children prescribed these medications without any significant impact on the fluid.
Reference: Extracts from the Cochrane Library: Antihistamines and/or decongestants for otitis media with effusion (OME) in children. Otolaryngol Head Neck Surg 136(1):11-13, 2007. Link.
Reference: Extracts from the Cochrane Library: Antihistamines and/or decongestants for otitis media with effusion (OME) in children. Otolaryngol Head Neck Surg 136(1):11-13, 2007. Link.
Wednesday, 10 January 2007
Allergy drops or sublingual immunotherapy (SLIT) is a viable alternative for patients who do not wish to or are unable to undergo allergy shots. These drops are administered under the tongue daily and can be given at home. Such patients may include those afraid of needles, patients who travel a lot (therefore unable to go to a physician office to get weekly allergy shots), patients on beta blockers (which is a contra-indication to allergy shots), or children. For more information, click here.
The one downside is that allergy drops are NOT covered by health insurance at this time. To see other differences between allergy shots and allergy drops, click here.
Monday, 8 January 2007
The audiology section of the website has been renovated and expanded. Patients will soon be able to download relevant forms and read about the various hearing aids, hearing tests, and other hearing-related services that Fauquier ENT provides.
Friday, 5 January 2007
One of our patients today brought us an article describing a drug, acamprosate (Campral), used to treat alcoholism that was found to also help with tinnitus in 86.9% of patients in a placebo-controlled drug study. Our practice is open to trying this medication for those interested. More info can be found here.
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