Treatment of Chronic Draining Ear Infections Using Antibiotic Powder

Rarely, some unfortunate souls have chronic draining ear infections that do not respond well to oral antibiotics nor antibiotic ear drops. What many people and even physicians are unaware of is that there are alternative ways of addressing the chronic draining ear including use of antibiotics in powder form.

The method I like best is by using the Sheehy-House Powder Insufflator Bulb.

The pharmacy will make up gelcaps containing antibiotics (anti-bacterial as well as anti-fungal) and even steroids (usually hydrocortisone).

One first removes the tip of the insufflator bulb.



Than open up the gelcap such that the powder is all in one side and insert into the insufflator tip compartment.



Than replace the bulb tip.



During an active infection, the powder is "puffed" into the ear twice a day. Once back to normal, one puff weekly prevents the ear from becoming infected again. This method eliminates adding more "moisture" to the ear (as when happens when using antibiotic ear drops) as the powder not only addresses the infection, but the drainage itself becomes a medium for the antibiotic powder to do its thing.

Keep in mind that this method requires a prescription and the gelcaps must be compounded. As such, not all pharmacies may be able to fill and not all health insurances will cover compounded medications.

Some common recipes are shown below. Each ingredient is pulverized and placed into a Lilly #4 gel capsule. Capsules should be refrigerated, except the one stored in the insufflator. The insufflator with the capsule in it should not be refrigerated. The exact recipe used depends on the ear infection present.

Recipe #1:
Chloramphenicol 50mg
Sulfanilamide 50mg
Amphotericin 5mg

Recipe #2:
Chloramphenicol 50mg
Sulfanilamide 50mg
Amphotericin 5mg
Hydrocortisone 1mg

Recipe #3:
Chloramphenicol 50mg
Amphotericin 5mg

Recipe #4:
Chloramphenicol 50mg
Amphotericin 5mg
Hydrocortisone 1mg

Recipe #5:
Chloromycetin 50mg
Sulfanilimide 50mg
Fungizone 5mg
Hydrocortisone 1mg

Recipe #6:
Chloromycetin 50mg
Sulfanilimide 50mg
Fungizone 5mg

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USC Stafon Johnson Crushes His Voicebox & Undergoes Emergency Surgery

News organizations including ABC News reported on Sept 28, 2009 that USC tailback, Stafon Johnson, was bench-pressing a 275 pound bar when it slipped and landed on his neck crushing his voicebox resulting in emergency surgery at California Hospital Medical Center. Read the story here.

An endoscopic exam of his voicebox at time of injury may have looked something like this picture shown here, but more severe.


Most likely a trach was performed for a secure airway after reconstruction. After recovery, he is at risk for vocal cord paralysis, stenosis, etc.

Click here to read the full story.

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Bifid Uvula

I recently saw a patient with a most impressive bifid uvula. For those who don't know, the uvula is the midline dangling thing in the back of the mouth. Normally, there's only one, but in this patient, there are 2.

If the clefting extended not only through the uvula, but also the palate, than that would be called a cleft palate. In other words, a bifid uvula is a birth defect that almost became a cleft palate.

A bifid uvula has no impact on swallowing or talking and no further intervention is required.

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"Smoking Kills" Doctor Warned in 1606!!!

On Sept 19, 2009, the BBC published a story "Tobacco Warning from 17th Century" in which a physician, Dr. Eleazar Duncan, wrote a letter published in 1606 stating that tobacco "is so hurtful and dangerous to youth that it might have the pernicious nature expressed in the name, and that it were as well known by the name of Youths-bane as by the name of tobacco."

It goes to show you that physicians have been trying and still trying to get people to stop smoking for over 4 centuries given its ill effects.

Read the BBC story here.

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How Does A Deviated Septum Cause A Nosebleed?

Over the years, I have been asked by a number of patients with deviated septums why that would make them more prone to nosebleeds.

Well, this blog article is to answer that very question. First off, a little anatomy...

A nasal septum is a wall that separates the right nasal cavity from the left side. Normally, this septum should be perfectly straight.

However, in some people, the septum may be deviated causing not only nasal obstruction, but increases the risk of nosebleeds.



When the septum is straight, nasal breathing proceeds such that the air smoothly enters the nose without creation of any turbulence.



However, if the septum is deviated, turbulence is created when the air hits the "curve" of the septum. When this happens, the lining of the septum becomes dried out resulting in cracking and increased vascularity which increases the risk of a nosebleed.



The lining of the nose in this situation is much like when a person's lips become so dried out to the point that it cracks and bleeds.

Surgical correction of the deviated septum would result in a more long-lasting "cure" of nosebleeds as it would eliminate this curve decreasing turbulence.

For more conservative management of nosebleeds, click here.

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Webpage on Epistaxis (Nosebleeds) Updated!

Our practice website has updated our nosebleed (otherwise known as epistaxis) webpage to include more information on procedural treatment of nosebleeds including silver nitrate cauterization, electrocautery, nasal packing, and surgery. The webpage still includes information on conservative treatment as well as causes.

Click here to read more!

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Oral Appliance Can Help With Obstructive Sleep Apnea

In the September 2009 edition of Archives of Otolaryngology Head & Neck Surgery, there was a research paper entitled "An Investigation of Upper Airway Changes Associated with Mandibular Advancement Device Using Sleep Video Fluoroscopy in Patients with Obstructive Sleep Apnea" where use of an oral appliance was found to significantly improve obstructive sleep apnea. The oral appliance increased retropalatal and retrolingual spaces as well as decreased the length of the soft palate and the angle of mouth opening.

Increased retropalatal space and decreased length of the soft palate is similar to what is accomplished by the surgical procedure uvulopalatopharyngoplasty (UPPP).

Increased retrolingual space is similar to what is accomplished by the base of tongue reduction surgery.

Click here to read more about this research.

Click here to read more about OSA and its treatment.

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Washington Post Medical Mystery: Kawasaki Disease

The Washington Post on Sept 8, 2009 published a story called "A Frightful Week for a Little Girl" in its Medical Mystery section on Kawasaki Disease. This disease is rare and difficult to diagnose given its multitude of symptoms that can be due to something more benign including:

• red eyes
• fever
• rash
• neck mass
• red lips/mouth

However, it is the constellation of symptoms according to guidelines that Kawasaki in children should be considered when there has been an unexplained fever lasting five days, when accompanied by other symptoms including red eyes without discharge, red lips or mouth, a rash and a swollen lymph node in the neck. The red eyes and lips/mouth is the hallmark symptom of something more sinister.

To miss this diagnosis and be without proper treatment within 10 days of symptom onset may result in heart attack, coronary artery aneurysm, and even death.

Read the article here.

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Most People Prefer Right Ear for Listening

A well-known asymmetry in humans is the right ear dominance for listening to verbal stimuli, which is thought to reflect the brain's left hemisphere superiority for processing verbal information. This preference for hearing with the right ear is also found in rats, Japanese macaques, harpy eagles, sea lions and dogs.

However, the left ear (and right brain) excels at picking up emotional cues. When it comes to music, pitch, timbre and loudness are discriminated better with left ear (right hemisphere), but duration is better discriminated with the right ear (left hemisphere).

These findings may explain why people are not entirely satisfied when using hearing aids for only one ear. Ideally, BOTH ears should be aided. BUT, if one had to choose between two equally deaf ears, the right ear would be the preferred side.

Read the article here.

Read the research article abstract here.

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NYT: Plastic Surgery May Cure Migraine Headaches???

The New York Times on Sept 2, 2009 published a story "Plastic Surgery May Also Ease Migraine Headaches," in which a modification of the facelift may improve and in some patients, even cure migraine headaches. The research abstract describing this surgical treatment for migraine headaches upon which the NYT story is based on can be read here.

So far, the only patients who are candidates for this type of surgery are those who respond positively to Botox injections and where the trigger points are on the face (not the neck or head region... yet).

Though our office does not offer this type of surgery, we have been successfully performing Botox injections since 2005 to those patients who suffer from migraine headaches.

Click here to read the NYT article.

Read here to read more about Botox injections for migraine headaches.

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How to Get Insurance to Pay for Rhinoplasty Nosejob!

Well... at least part of the cost. I learned of this from a patient who came to see me in order to obtain an "independent ENT evaluation" regarding her deviated septum.

In essence, in order for insurance to pay part of the cost of one's rhinoplasty, a few things need to happen.

Step 1:
See a plastic surgeon who will perform your nosejob rhinoplasty. If the plastic surgeon notes a deviated septum or if you also have a significant nasal obstruction, see an ENT. If the plastic surgeon is also ENT board-certified, you still need to see a DIFFERENT ENT in order to obtain an "independent evaluation."

Step 2:
See the ENT who will hopefully agree that there is a significant deviated septum contributing to one's nasal obstruction. Septoplasty IS an insurance covered procedure in order to address the medical condition of nasal obstruction. In the medical note, I've typically phrased the report as follows:

"The patient does have a significant deviated septum to the right (or left as the case may be) resulting in nasal obstruction. In order to correct this problem, it is recommended that the patient undergo a septoplasty procedure. However, given that the patient is to undergo a rhinoplasty by a plastic surgeon and instead of putting the patient under anesthesia twice, it is reasonable to have the septoplasty performed at the same time."

Please understand that if you do not have a significant deviated septum, that is exactly what will be reported!

Step 3:
Give the plastic surgeon the ENT report. Here, a little effort will be needed on both the patient and plastic surgeon's part. More than likely, insurance will deny payment for the surgery. As such, the plastic surgeon will need to write a letter of medical necessity including supporting documentation from the independent ENT evaluation. The insurance may still refuse payment and that's when the plastic surgeon may need to perform a peer-to-peer review.

Generally speaking, the insurance in the end may cover some of the anesthesia and rarely the septoplasty component of the rhinoplasty. As such, a few thousand dollars may at least be saved.

Hope this information helps!

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NYT: Tonsil Stones (aka Tonsilloliths)

The NYT published a story on tonsil stones on Aug 31, 2009. Tonsil stones, otherwise known as tonsilloliths, are "stones" that are found and ejected from tonsils that consist of mucus, dead cells and other debris that collect in the deep pockets of the tonsils and gradually condense into small, light-colored globs. Bacteria feed on this accumulated matter, giving rise to the odor.

The only known cure for tonsilloliths is tonsillectomy, though more conservative measures are encouraged first prior to surgery. There is also a minimally invasive procedure our office performs called tonsil cryptolysis which is a procedure to try and eliminate this problem prior to considering tonsillectomy.

A recent research paper does offer tantalizing clues to address tonsilloliths more conservatively as it found that tonsil stones are more like living biofilms rather than an inert stone. Read the abstract here.

Read the story here.

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Nosebleed Due to a Leech (IN the Nose)!

New England Journal of Medicine published a picture AND video on August 27, 2009 showing a leech inside of the nose that caused one man's nosebleed (also known as epistaxis). Apparently, he had washed his face in freshwater stream 7 days prior to presentation.

Yikes! Poor fellow...

Read the NEJM article here. Watch the video of the surgeon removing the little bugger here...

Read about more common causes of nosebleeds and how to control them here.

Watch a video of how nosebleeds can be treated with cauterization.

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Dr. Chang Featured in Local Newspaper

Well, to be more accurate, Fauquier Hospital used Dr. Chang as advertisement for its "Be Yourself" campaign. Other physicians have been portrayed in a similar fashion. This ad appeared in the September 2009 Discover Fauquier's Values publication.

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Chewing Gum Improves Memory?!!

Image by Mayr from Wikipedia

I came across interesting research that hinted at the possibility that chewing gum improves tasks that require memory recall. This was first suggested in a study published in 2002 in the journal Appetite where chewing gum was found to selectively improve aspects of memory in healthy volunteers. The researchers took seventy-five adults and separated them into three groups: those that chewed gum during a twenty-minute test of memory and attention, those that mimicked the chewing movement, and those that did not chew at all.

They found that people who chewed scored better on long- and short-term memory tests (measured by word recall).

The authors speculated on three possible explanations: brain activity in the hippocampus increases while people chew, so this might help with memory; gum chewing promotes the release of insulin, which might indirectly affect memory; and the most straightforward—chewing can increase heart rate slightly, and this increased blood flow could deliver more oxygen to the brain.

Follow-up studies in 2004 supported these initial findings.

A more recent study in 2009 using 101 student volunteers found that it wasn’t the gum per se but any candy (cinnamon candy in the study) or oral stimulus can help a person remember information. Based on this study, it was felt that the oral action as well as the scent of the candy/gum served as a memory cue for information.

Maybe those gum-smacking kids in class did know something the rest of us did not.

Fortunately, fear not teachers... There are other studies that have been done that have not replicated these results at all and even contradicts them.

Chewing gum can also exacerbate/cause TMJ problems.

Image taken from Wikipedia.

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Another Reason to Stop Smoking... Decreased Sense of Taste

Greek researchers published a study in which they described a significant decrease in taste ability in smokers compared to non-smokers. In the study titled "Evaluation of young smokers and non-smokers with electrogustometry and contact endoscopy," 62 male Greek soldiers were evaluated for smoking and taste by using two different instruments called electrogustometry (measures taste thresholds) and contact endoscopy (wich evaluated the morphology and density of papillae on the tongue's tip).

This study could explain why smokers not only complain of decreased sense of taste, but also change in the way things taste (dysgeusia).

Click here to read the study abstract.

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Online Hearing Test (Audio)

Phonak, one of the major manufacturers of high end hearing aids, has developed a screening hearing test you can do online in the comfort of your home.

Take the test here.

If you do poorly on this exam, please see your local ENT in order to get a more reliable hearing test and see what options you have to improve your hearing (or keep what hearing you have left).

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Another Article on Dangers of Hearing Loss from Loud Concerts and iPods

The Daily News on Aug 21, 2009 published yet another article on the dangers of loud concerts and iPods resulting in permanent hearing loss. The article is titled "Beware: Loud concerts and iPods make music dangerous."

In our practice, there have been a few patients every year in their 20s and 30s who have experienced sudden hearing loss as bad as 80 year olds after attending a loud rock concert. The hearing disappears after the concert... and it never comes back. This phenomenon is called Sudden Sensori-Neural Hearing Loss or SSNHL for short.

Please wear ear plugs... and if you experience hearing loss or ringing/tinnitus after being exposed to loud noises that does NOT come back within a few days, see your local ENT as soon as possible. There are only a few medications that can help reverse the hearing loss, but only works if given within the first 2 weeks ideally and not more than 4 weeks.

Read the full article here.

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Music Can Help Understanding Speech in Noisy Environments?

Many older adults will say, 'I can hear what you're saying, but I don't understand you,' especially in a location where there is background noise (such as a restaurant) leading to frustration and social isolation. However, new research is offering tantalizing clues to prevent this from happening through music training.

Musical training makes musicians really good at picking out melodies, such as the treble line or the sound of their own instruments, from surrounding complex sounds. This improved perception in noise in musicians was linked with better working memory and tone discrimination ability. The results imply that musical training enhances the ability to hear speech in challenging listening environments by strengthening auditory memory and the representation of important acoustic features

Thirty-one study participants, with normal hearing and a mean age of 23, were divided into one group with music experience and another without it. They had to listen to sentences presented in increasingly noisy conditions and repeat back what they heard. The music group did significantly better.

The study does suggest that by reinforcing the pervasive effects that musical experience has on sound-processing abilities, better speech understanding can be obtained in noisy environments and underscores the importance of music education being more accessible to the general population

Read the story here.

Reference:
Alexandra Parbery-Clark, Erika Skoe, Carrie Lam and Nina Kraus. Musician Enhancement for Speech-in-Noise. Ear and Hearing, (in press)

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NYT: Wolfgang Amadeus Mozart Death Due to Strep Throat?

Image by Wikipedia

Well according to a NYT article published on Aug 17, 2009, yes he potentially did. In the article titled "What Really Killed Mozart? Maybe Strep," the journalist reports on a paper published in the Aug. 18 issue of The Annals of Internal Medicine where the researchers have done an epidemiological analysis that suggested he was a victim of an epidemic streptococcal infection.

Read the NYT article here. Read the actual paper abstract here.

This story illustrates how far we have come in controlling what is now considered a benign infectious problem which can be easily treated with antibiotics or tonsillectomy.

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