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September 29, 2016

Laryngomalacia Video in an Infant with Squeaky Breathing

A video has been created showing what laryngomalacia (floppy infant airway) looks like from the inside. Both normal infant airway as well as infant with moderately severe laryngomalacia is shown including audio.

Infants with laryngomalacia have what parents hear as a "squeaky" or "noisy" breathing, especially on inhalation. Although most infants outgrow this condition, some require surgical intervention (supraglottoplasty) due to failure to thrive, inadequate oxygenation, excessive work of breathing, etc.

For more info on laryngomalacia beyond the video as well as how it is treated, click here.

September 25, 2016

Suction Powered Nasal Irrigation

Most sino-nasal irrigation systems currently in use require passive drainage after flushing... typically into a sink. You squirt the saltwater into one nostril and the flush drains out the other side passively. However, there is a new system called "Navage" made by RhinoSystems that adds suction along with the flush.

The upper chamber is where clean water is held. There are two nasal pillows that goes into each nostril. By pushing a button, the water gets mixed with salt and flushes through one nostril pillow into the nose while the other nasal pillow suctions simultaneously to remove the flush out of the nose from the other side. The fluid is suctioned into the bottom chamber resulting in a "mess-free" nasal irrigating experience.

The upper chamber can hold 8 ounces of water and only works with a SaltPod which also needs to be purchased regularly for the device to work (button does not work if the SaltPod is expended). The SaltPods are NOT reusable. It also requires two AA batteries.

Overall, the concept is sound and essentially performs what much cheaper rinse bottles do (i.e., NettiPot, Neilmed, etc) but in an almost mess-free and convenient way though doubtful it works any better. There will be some residual nasal drainage once you remove, so you may still need that sink after use.

If cost is not a consideration to address allergies, chronic sinusitis, and nasal congestion, it may be worth considering this device for these unique advantages. However, compared to other electronic sinus irrigation systems like the SinuPulse Elite, it lacks a way to control the pressure.

Available for purchase on Amazon.

September 23, 2016

Tonsillectomy Alone Can Cure OSA in Select Adult Patients

Among adults who suffer from obstructive sleep apnea (OSA), treatments are relatively small in number and overall relatively unappetizing for many patients to pursue.

Beyond losing weight, noninvasive treatment for OSA includes CPAP which is considered the gold standard treatment for adult OSA and involves placing a mask of sorts over the face which than delivers continuous positive pressure into the lungs preventing airway collapse and obstruction. Nightly use of an oral device (mandibular advancement device) is another non-invasive intervention that may be helpful.

Otherwise, surgical interventions to treat OSA include UPPP, base of tongue reduction, hyoid advancement procedures, tracheostomy, etc. Unfortunately, all surgical interventions are quite painful to recover from and risks could be substantial.

For patients who fail to tolerate noninvasive treatment and surgical options are considered "too" invasive for a patient to consider, tonsillectomy alone may be a viable option to improve and potentially cure OSA.

According to a 2016 meta-analysis, tonsillectomy alone has a good change of improving and potentially curing OSA in adults IF:

• AHI < 30 (mild to moderate OSA)
• Large tonsils
• Not morbidly obese

In this select patient population, tonsillectomy alone cured OSA in 84% of patients. Significant improvement including OSA cures was achieved 100% of the time. Keep in mind, improvement does not mean cure and such patients will still require CPAP management.

In comparison, in patients with severe OSA (AHI > 30), only 72.4% had improvement in OSA with a cure rate of only 34.4%.

So if traditional OSA surgical options frightens a patient, a simple tonsillectomy alone may be a worthwhile surgical option given the above information and caveats.

Tonsillectomy for adult obstructive sleep apnea: A systematic review and meta-analysis. Laryngoscope. 2016 Sep;126(9):2176-86. doi: 10.1002/lary.25931. Epub 2016 Mar 22.

September 21, 2016

Dr. Chang Panel Speaker at Annual AAO-HNS Meeting San Diego

Dr. Chang was a panel speaker for one talk during the international 2016 AAO-HNS Annual meeting in San Diego, CA on September 21, 2016.

Dr. Chang was honored to participate as a panel speaker for the talk entitled Marketing Your Practice in 2016: Internet, Social Media, and PR which was sponsored by the Young Physicians Section and Media and Public Relations Committee. This talk was moderated by Cristina Baldassari, MD who is an Assistant Professor of pediatric otolaryngology at CHKD.  The other panel speakers included:

Spencer C. Payne, MD - Associate Professor of Rhinology at University of Virginia
Angela Strum, MD - Houston area facial plastic surgeon

September 18, 2016

The Recurrent Recurrent Nosebleed Treatment - Sewing the Nostril Shut!

Bad nosebleeds are quite alarming, even when it happens once. But imagine 4+ bad nosebleeds a week for years that refuses to quit no matter what is tried:

Saline nasal sprays
Afrin nasal sprays
Silver nitrate cauterization
Electric cauterization
• Laser cauterization
Nasal packing
• Skin grafts
Estrogen sprays
• Vascular embolization
Sinus surgery
Septal surgery

And nothing still works!

This is often the situation with patients suffering from HHT (Hereditary Hemorrhagic Telengietasia), though can occur in individuals for other medical reasons resulting in very low platelet and coagulation values (liver failure, blood-thinning medications, etc).

This situation often calls for the "big" guns in treatment, namely the Young's Anterior Nostril Closure. First described in 1961 (see references below), the procedure is to essentially sew the nostril completely shut. By completely obstructing airflow, any drying effects are eliminated and not uncommonly, the nosebleeds are finally "cured." Understandably, very few patients would be able to tolerate this course of action which should be considered "permanent." With re-creating the nostril opening, the nosebleeds may recur again. But for such individuals, the advantages outweigh the disadvantages.

If only one nostril is to be sewn shut, there should be no septal perforation present, otherwise, both sides need to be closed if this intervention is to work.

Nasal packing accomplishes the same thing in that complete nasal obstruction is accomplished, but will create a toxic bacterial infection if left in place for too long, so is considered only a temporary measure in such patients. Furthermore, removal would only exacerbate any nosebleeds in such nosebleed crippled patients.

Some temporary measures better than nasal packing that mimic Young's Anterior Nostril Closure that also avoids further traumatizing the nosebleed-prone nasal mucosa include:

• Stuffing the nostril with cotton balls completely coated with bacitracin ointment
• Stuffing the nostril and nasal cavity with saran wrap completely coated with bacitracin ointment

Of course, with these two alternative methods, the cotton ball or saran wrap needs to be changed out on a regular basis. Indeed, most patients will elect for sewed nostril closure only after finding significant relief with continuous complete nasal obstruction with saran wrap or cotton balls.

Closure of the nasal cavities in the treatment of refractory hereditary hemorrhagic telangiectasia. Journal Laryngol Otol. 1997; 111:30-33.

Histopathological and histochemical studies on atrophic rhinitis. Journal Laryngol Otol. 1961; 75:574-590.

Closure of the nostrils in atrophic rhinitis. Journal Laryngol Otol. 1967; 81:515-524.

Young's procedure in the treatment of epistaxis. Journal of Laryngology and Otology 1991; 105:847-848.

Modified Young's procedure for refractory epistaxis due to hereditary hemorrhagic telangiectasia. Laryngoscope 1994; 104: 1174-1177

Hereditary haemorrhagic telangiectasia: Young's procedure in the management of epistaxis. J Laryngol Otol. 1994 Sep;108(9):754-7.

The Young's procedure for severe epistaxis from hereditary hemorrhagic telangiectasia. Am J Rhinol Allergy. 2012 Sep-Oct;26(5):401-4. doi: 10.2500/ajra.2012.26.3809.

Nasal closure for the treatment of epistaxis secondary to hereditary hemorrhagic telangiectasia. Acta Otorrinolaringol Esp. 2016 Apr 11. pii: S0001-6519(16)00036-4. doi: 10.1016/j.otorri.2015.12.002. [Epub ahead of print]

Hereditary haemorrhagic telangiectasia: Young's procedure in the management of epistaxis. Journal of Laryngology and Otology 1994; 108: 754-757.

September 16, 2016

Treatment for Loss of Smell and Taste

Image courtesy of nenetus at
A not uncommon complaint of patients presenting to an ENT is a decreased or even loss of smell and taste. Most commonly, this occurs after a viral upper respiratory infection and is transient in nature. However, this complaint may often persist leading a patient to seek help.

An ENT will often evaluate for any physical abnormality that may lead to smell/taste loss including presence of an intranasal mass (ie, nasal polyps), facial trauma, sinus infection, vitamin/metal deficiencies, etc.

However, assuming the patient is otherwise a normal, healthy individual, a relatively recent paper suggests such sensory depreciation is directly correlated with decreased secretion of growth factors in the saliva and nasal mucus. These growth factors apparently act on stem cells in taste buds and olfactory cells to generate the appropriate apparatus for a fully functional taste and smell sense.

The key growth factors diminished in patients with smell and taste loss are cAMP (cyclic adenosine monophosphate) and cGMP (cyclic guanosine monophosphate).

As such, a way to restore normal smell and taste would be to increase cAMP and cGMP via a phosphodiesterase inhibitor drug like theophylline. Researchers have determined that oral theophylline was able to help 50% of patients.

Unfortunately, the side effects of the drug proved trying for patients especially given it takes 2-12 months for improvement to occur. Such adverse effects included restlessness, GI discomfort, and cardiac palpitations. Also, oral treatment required regular blood draws to prevent toxic accumulation.

As such, intra-nasal theophylline was tried in order to resolve these issues and found to be of superior efficacy (80% of patients reported improvement) and faster onset of improvement (1-4 weeks). Best of all, side effects were negligible.

However, the intra-nasal study was performed on only 10 patients and as such, was considered only a pilot study, albeit promising.

But something to consider… while larger studies are pursued with control groups to eliminate placebo effect.

But, for those curious, the nasal spray version of theophylline requires daily administration 0.4ml of saline containing 20 ug of theophylline methylpropyl paraben. The spray should be directed superiorly into the nose where the olfactory nerve is located.

A local compounding pharmacy should be able to make it up for patients. However, it can also be ordered from FoundCare.

Intranasal Theophylline Treatmentof Hyposmia and Hypogeusia. Arch Otolaryngol Head Neck Surg. 2012; 138(11):1064-1070.

cAMP and cGMP in nasal mucus related to severity of smell loss in oatients with smell dysfunction. Clin Invest Med. 2008; 31(2):E78-E84.

Etiological relationships of parotid saliva cyclic nucleotides in patients with smell and taste dysfunction. Arch Oral Bio 2012; 57 (6):670-677.

Aetiological relationships of nasal mucus cyclic nucleotides in patients with smell and taste dysfunction. J Clin Path. 2012; 65(5): 447-451.

An open-label controlled trial of theophylline for treatment of patients with hyposmia. Am J Med Sci. 2009; 337(6):396-406.

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