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November 30, 2016

Facial Fitness Exerciser - Helps with Facial Wrinkles?

Just in time for Christmas... Came across this in a Facebook post by Dr. Ghaheri regarding a "facial exerciser" that can eliminate facial wrinkles. Brought to you by Japan. Does it work? Don't know...

BUT... It sure looks funny!

You can buy similar items on Amazon!

November 18, 2016

Make Your Own Gaviscon Advance for Reflux Control DIY

Image from Amazon
Before getting into how to make Gaviscon Advance yourself from its component ingredients, you first need to understand how each ingredient contributes to reflux control. If you want to skip to the recipe, look below.

Alginate's affects on improving reflux has been known about for decades. Initial scientific studies on how it improves reflux were conducted in the 1980s.

Alginates are natural polysaccharide polymers isolated from brown seaweed (Phacophycae) and is classified as dietary fiber. Their ability to form viscous solutions and gels have led to their extensive use in foods, cosmetics, and pharmaceutical products for over one century.

As it pertains to reflux, perhaps the most interesting study on alginate was published in 1988 whereby alginate was labelled with 111In radioisotope in order to "see" what happens in the stomach.

In this study, they found that alginate forms an effective floating barrier against reflux... but that
"acid concentrations less than 0.05 N diminished raft formation. In vivo, raft formation was significantly better in normal subjects who ingested dilute acid with the labeled alginate/antacid than in subjects who ingested the labeled alginate/antacid with plain water. Gastric emptying of the labeled alginate was also slowed by the presence of acidified gastric contents. These results suggest that the formation of an effective alginic acid antireflux barrier requires acidic gastric contents." [link]
As such, if alginate is used, a patient should probably not ingest any proton pump inhibitors (nexium, prevacid, prilosec, etc) or H2 blockers (zantac, pepcid, axid, etc) for best effect which may seem counterintuitive.

In the presence of gastric acid, alginate has been found to precipitate forming a thick gel. Such alginate formulations usually contain sodium or potassium bicarbonate; in the presence of gastric acid, the bicarbonate is converted to carbon dioxide which becomes entrapped within the gel precipitate converting it into a foam which floats on the surface of the gastric contents, much like a raft on water. Both in vitro and in vivo studies have demonstrated that alginate-based rafts can entrap carbon dioxide, as well as antacid components contained in some formulations, thus providing a relatively pH-neutral barrier.

Another factor that affects the alginate raft is the presence of calcium and aluminum. Calcium increases raft strength (becomes more solid) while aluminum reduces raft strength (becomes more gel-like).

To summarize, for effective alginate treatment of reflux, acid as well as bicarbonate needs to be present. The level of solidity is determined by calcium and aluminum concentrations.

Alginate in ideal concentrations can be found in Gaviscon Advance sold only in Europe. Be aware that plain "Gaviscon" which is sold in the United States is NOT the same as Gaviscon Advance. However, it can be purchased on Amazon with delivery in a few weeks.

How to Make Gaviscon Advance DIY

However, one enterprising Amazon user figured out a way to make their own Gaviscon Advance equivalent using ingredients readily available in the United States. Given supplies are purchased in bulk, it ends up being cheaper as well over the long term.

Gaviscon Advance is composed of 1000 mg sodium alginate, 426 mg sodium bicarbonate, and 650 mg calcium carbonate.

So one can purchase the following "ingredients" that make up Gaviscon Advance:

WillPowder Sodium Alginate 16 ounce Container
Baking Soda (this is the sodium bicarbonate)
TUMS (this is the calcium carbonate)

To make a "single" dose to be taken after a meal, one would mix:

• 1/4 teaspoon of sodium alginate
• 1/8 teaspoon of baking soda (1/8 teaspoon of baking soda is ~500-600 mg)
• Using a mortar and pestle, crush one 750 mg chewable TUMS antacid tablet into a powder

Mix all of this together (you can use a frother) with a few ounces of water to create a slurry which you can than swallow after a meal.

Quite a bit more steps than just purchasing Gaviscon Advance, but one can also request a Compound Pharmacy to do all this for you with each dose contained within a packet. WeCare Pharmacy in Warrenton, VA does this for patients in our area.

Use of 111In-labeled alginate to study the pH dependence of alginic acid anti-esophageal reflux barrier. Int J Rad Appl Instrum B. 1988;15(5):563-71.

Review article: alginate-raft formulations in the treatment of heartburn and acid reflux. Aliment Pharmacol Ther. 2000 Jun;14(6):669-90.

An alginate-antacid formulation (Gaviscon Double Action Liquid) can eliminate or displace the postprandial 'acid pocket' in symptomatic GERD patients. Aliment Pharmacol Ther. 2011 Jul;34(1):59-66. doi: 10.1111/j.1365-2036.2011.04678.x. Epub 2011 May 3.

November 16, 2016

Does Mouth-Breathing Decrease Risk of Viral Infections?

Image by Magnus Mertens in Wikipedia
The New York Times published an article looking into this very question on Nov 11, 2016. However, the provided answer ("possibly") was incomplete.

In essence, the question of whether mouth-breathing decreases risk of viral infections is based on the idea that contagious viruses spread via the nose by inhaling coughed/sneezed out water droplets infected with viral contagions.

Unfortunately, such viruses can also be spread if such droplets contact the eye. You have to imagine yourself moving through a "fog" of water droplets contaminated with viruses. Such movement results  in your whole body, let alone your face, being contaminated with these infected droplets. That's why the constant reminder to cough/sneeze into your elbow to prevent airborne spread.

As such, the answer "possibly" since mouth-breathing only eliminates one possible way of catching a viral URI.

However, this simplistic answer only applies to certain, but not all viruses. The quoted 1981 research article upon which this answer is based on described an experiment in which the RSV virus was deliberately inoculated directly into the eyes, nose, and mouth of 32 adult volunteers.

The mouth inoculation did not cause infection whereas inoculation into the eyes and nose did.

However, keep in mind that different viruses have different ways of being contagious. The HIV virus is spread through sexual activity, hepatitis through blood, and more relevant to this blog, EBV virus (aka, mono) through saliva via mouth which is why this is also called the "kissing disease."

Furthermore, depending on the aerosolized droplet size, even mouth-breathing may potentially cause infection from the RSV virus if you manage to inhale into the lungs. Droplets that are small enough for people to inhale (either mouth/nose) are 0.5 to 5 µm in diameter and inhaling just one droplet might be enough to cause an infection. Although a single sneeze releases up to 40,000 droplets, most of these droplets are fortunately quite large and will quickly settle out of the air.

So, getting back to the question of what a person can do to prevent catching a viral URI...

Realistically, the best thing to do is avoid being around a sick individual and especially avoid enclosed, poorly-ventilated room crowded with sick people (i.e., subway car, bus, etc).

Beyond that if you don't mind looking silly...

• Wear swimwear goggles
• Wear a mask over the nose/face
• Wear gloves
• Thoroughly wash your hands before touching your face/eyes

More info and viral colds and flu here.

Infectivity of respiratory syncytial virus by various routes of inoculation. Infect Immun. 1981 Sep;33(3):779-83.

A Cold and Flu Risk That’s a Real Eye-Opener. NYT 11/14/16

November 04, 2016

Is Tongue Tie Becoming More Common?

In October 2016, I listened to an interesting lecture by Dr. Ghaheri (ENT in Portland, OR) who at one point attempted to explain through genetics why clinically significant tongue tie may be increasing in frequency.

After all, it seems that every year, more and more moms are reporting breastfeeding difficulty/pain as well as more infants are being diagnosed with tongue tie now than in the past.

One explanation may be due to genetics. He specifically mentioned three research papers that suggest tongue tie is inherited in an autosomal dominant fashion.

  • Acevedo in 2010 identified a Brazilian family that had both ankyloglossia and dental abnormalities. The study demonstrated an autosomal dominant pattern of inheritance.
  • Han in 2012 identified potential X-linked pattern of inheritance.
  • Klockars in 2007 also suggested that tongue tie is passed in an autosomal dominant fashion and that the prevalence of ankyloglossia in the population is approximately 4-5%.

Autosomal dominant means that for a given trait, if this gene is present, it WILL appear in the next generation, even if only one copy is present (whether from mom or dad).

Autosomal dominant trait also means that over time, it will appear in greater frequency in the population over time.

But this is probably only part of the story because...

Why NOW does it seem to be SO much more common than in the past? After all, tongue tie has been recognized since even ancient times. Aristotle (3rd century BC), Paul of Aegina (7th century AD), Celus (1st century AD), and Galen (2nd century AD) have all described tongue tie in their writings.

The other keys to the puzzle beyond genetics (pure speculation) may be the development of the baby bottle and formula.

Hypothetically, these two "inventions" along with the tongue tie release procedure may have allowed infants with significant tongue tie to better survive infancy allowing their autosomal dominant genes to be passed to future progeny with increased frequency.

Check out the graph below showing infant mortality from 1915-1997 published by the CDC [link].

In the 1850s, infant mortality was about 300 per 1000 births.  In the early 20th century, infant mortality improved to around 100 per 1000 live births. Thereafter, there has been a profound decrease in infant mortality to where it is currently holding steady at around 6 per 1000 births.  [link]

The significant decrease in infant mortality is attributed to a variety of reasons including improved medical care, improved nutrition, improved sanitation (environment), etc.

However, hypothetically, it just may be that under the improved nutrition category, tongue tie may have been a contributing factor to infant mortality.

Infants with clinically significant tongue tie may not have survived infancy back in the pre-20th century due to malnutrition from being unable to breastfeed effectively, whether from maternal factors (decreased milk supply due to poor demand of tongue-tied infants) or infant factors of just not being able to feed that well from an oral mechanical perspective. (This is assuming tongue tie was not recognized and corrected... Read more about the historical debate over tongue tie release here.)

As such, only a small fraction of such infants may have survived to adulthood to pass along the tongue tie autosomal dominant gene.

But along with improved medical care and sanitation, a number of inventions allowed for such tongue-tied infants who otherwise may not have survived to obtain nutrition regardless of breastfeeding difficulties... the baby bottle and formula.

For the baby bottle history,

• In 1841, the glass baby bottle was patented.
• In 1845, the rubber nipple was patented.
• In early 1900s, both were able to be mass-produced cheaply.
• By the 1940s, numerous different baby bottle designs were available.

For the baby formula history,

• In 1867, the first cow's milk formula was developed
• In 1890s, many different raw milk formulas were developed and gained widespread use by 1907 as baby bottles become more readily available
• In 1915, powdered milk was developed
• In the 1920s, such evaporated milk became widely commercially available
• In the 1920s, commercial formula was developed to mimic as close as possible human breastmilk

Concurrent with the development and mass production of baby formula and the baby bottle, breastfeeding decreased substantially from the late 1800s to the 1960s. By the late 1960s, it is estimated that over 75% of all babies were fed exclusively on commercially produced baby formula.

As such, large numbers of tongue-tied infants would have been the beneficiary of not only a substantially lower infant mortality rate but also the bottle and formula by the 1960s of moms who may have had trouble breastfeeding (if breastfeeding was even tried). These infants would have gone on to have children of their own passing along their tongue tie genes into the next generation in the late 1990s and early 21st century.

By this point, we have the perfect storm of:

Increasing prevalence of the tongue tie gene in the human population


Resurgence of breastfeeding interest, especially by the 1990s

As such, one would expect there to be a seeming epidemic of moms reporting breastfeeding difficulty due to the steadily increasing numbers of tongue-tied babies being born.

But is this true???

The easiest way would be to see how often "breastfeeding pain" is searched for on google via google trends. Here is the graph showing a steady upswing over time:

How about tongue tie? [link]

The delay in upswing for "tongue tie" keyword searches compared to breastfeeding pain is probably due to the fact that one would need to first recognize that tongue tie may be a cause for breastfeeding difficulty before one can know to search for this keyword phrase.

Though skeptics may consider the increase in tongue tie diagnoses to be one of increased awareness or recognition and not necessarily due to an actual increase in population frequency, it is harder to explain away the increase in reported (or rather searched for) symptom of "breastfeeding pain" over time. Indeed, one would expect the graph of "breastfeeding pain" to remain constant over time if tongue tie frequency truly remained constant.

Just for comparison with a more neutral search phrase that one would not expect to change over time, here is a graph comparing a google keyword search frequency for "breastfeeding pain" (blue) and a more neutral related search term "pregnant swollen breasts" (red).

Just for fun, click here to view a graph for search term frequencies for "breastfeeding pain," "tongue tie," and "pregnant swollen breasts" all displayed on one graph.

If the frequency of google keyword searches is any indication for how frequently a problem exists, than these graphs certainly seem to suggest that tongue tie and the pain it causes with breastfeeding is increasing in frequency over time and will continue to increase in frequency into the future.

Is there a tongue-tie epidemic? I would argue yes based on all the above information, albeit circumstantial evidence.

So, THAT's why it seems tongue tie is so common.

Autosomal-dominant ankyloglossia and tooth number anomalies. J Dent Res. 2010 Feb;89(2):128-32. doi: 10.1177/0022034509356401. Epub 2009 Dec 30.

A study on the genetic inheritance of ankyloglossia based on pedigree analysis. Arch Plast Surg. 2012 Jul;39(4):329-32. doi: 10.5999/aps.2012.39.4.329. Epub 2012 Jul 13.

Inheritance of ankyloglossia (tongue-tie). Clin Genet. 2009 Jan;75(1):98-9. doi: 10.1111/j.1399-0004.2008.01096.x. Epub 2008 Oct 24.

Familial ankyloglossia (tongue-tie). Int J Pediatr Otorhinolaryngol. 2007 Aug;71(8):1321-4. Epub 2007 Jun 22.

History and culture of breastfeeding. Wikipedia. Accessed 11/4/16

Baby bottle. Wikipedia. Accessed 11/4/16

Infant formula. Wikipedia. Accessed 11/4/16

Achievements in Public Health, 1900-1999: Healthier Mothers and Babies. CDC. Accessed 11/4/16.

November 03, 2016

Actor Mark Ruffalo Had Surgery to Remove Acoustic Neuroma

Actor Mark Ruffalo suffered from a left acoustic neuroma that required surgical removal in 2001. The surgery left him with a temporary left facial paralysis that took almost one year to resolve causing him to "disappear" from acting for that period of time. Along with his temporary facial paralysis, he also unfortunately permanently lost his left ear hearing.

It was only recently that he came forward to fully explain what happened in 2001 given his sudden disappearance from the acting world. Speculation about his disappearance included drugs, cancer, AIDS, etc. At that time to quell rumors, he ultimately released a statement that a "minor cyst was removed from his inner ear successfully."

An acoustic neuroma is a benign tumor of the hearing nerve. Initial symptoms of such tumors include slowly progressive asymmetric hearing loss in the affected ear's hearing. Asymmetric tinnitus or ringing of the ear may also be present.

Typically, such patients present to an ENT office with these complaints. An examination of the ear is normal. But a hearing test obtained will show an asymmetric sensorineural hearing loss. With such a finding, an MRI scan of the ear region is subsequently obtained which diagnoses this abnormal tumor (see image below; red arrow).

With an acoustic neuroma, patients are typically given 3 options:

1) Surgery - Mark Ruffalo pursued this option
2) Radiation (ie, gamma knife)
3) Monitor

With options #1 or 2, risks include facial paralysis and permanent hearing loss mainly because the tumor involves the very nerve that allows a person to hear. The reason why facial paralysis is also at risk is because the facial nerve is literally next to the hearing nerve as both nerves enter through the skull.

Option #3, watchful monitoring via serial MRI scans on a yearly basis is possible because these tumors grow VERY slowly and is NOT cancer. Average growth is about 1mm per year. The only downside with doing nothing is that as the tumor grows, the hearing typically gets worse and eventually, facial paralysis may occur. Pursuing surgery or radiation when the tumor is much larger also increases the risk of hearing loss and facial paralysis after treatment.

In the case of Mark Ruffalo, the acoustic neuroma was the size of a walnut. Surgical removal which took 10 hours caused a facial paralysis that required one year to fully return back to normal. It took about 6 months before some movement returned to his left face. His left ear hearing, as already mentioned, was permanently damaged.

Watch a video with Mark Ruffalo explaining his experiences.

The Kid Stays In The Pictures.

The Hulk: The Last Angry Man. Rolling Stone 5/4/15


November 01, 2016

Chiropractic Nasal Balloon Procedure to Treat Sinuses, TMJ, Concussion, etc

Screen shot from YouTube
A patient recently came to my office complaining of chronic sinusitis that has been treated over the past year unsuccessfully by a chiropractor using a "balloon that is inserted into the nose and inflated several times."

Curious about this interesting technique, I investigated further what and how allegedly this procedure works. It is called "Nasal Release" or "Neuro Cranial Restructuring" or "Endo-Nasal Cranial Facial Release" and is performed by chiropractors or naturopaths to purportedly treat deviated septum, chronic sinusitis, snoring, crooked teeth, crossed eyes, traumatic brain injuries, migraines, low back pain, TMJ, tinnitus, and neck pain.

More fringe practitioners will also claim it can help treat Alzheimer's, anxiety, arthritis, bursitis, rheumatism, attention deficit disorder, dyslexia, hyperactivity, learning disabilities, autism, cerebral palsy, depression, obsessive-compulsive disorder, Down's Syndrome, dystonia, deafness, glaucoma, double vision, insomnia, low energy, fibromyalgia, chronic fatigue, muscle spasms, bruxism, osteoporosis, Parkinson's disease, tremors, phobias, poor concentration, relationship difficulties, sciatica, kyphosis (hunchback), lordosis (swayback), scoliosis (spiral spine), seizures, sleep apnea, strokes, vertigo, whiplash syndrome, and wrinkles (replaces a face lift).

This release begins by inserting a small tampon shaped balloon into the nose and transiently inflating for 1-3 seconds. This is done 3 times on each side. What practitioners claim they are doing is placing the balloon into the concha (or turbinate). Inflating the balloon causes outward pressure within the concha thereby creating a space where the bones are pinched against each other. It also "unlocks" the skull's membranes and suture lines thereby allowing it to become more mobile and flexible as well as improve circulation of blood and brain fluid. Patients often report hearing/feeling a pop when the balloon is inflated.

Watch some YouTube videos below demonstrating how this technique is performed.

From an ENT perspective, there is no scientific evidence that this technique works... other than to perhaps open up the nasal passages to some degree by manually lateralizing the mucosa of the inferior turbinate. It perhaps may manually mimic something a nasal spray like Afrin can do. Of course, any improvement that occurs is temporary and symptoms will typically return within a few days.

The "pop" that patients feels is either when the mucosa separates from each other or when the inferior turbinate bone cracks with forced movement from balloon inflation.

Nasal balloon release is also NOT the same thing as balloon sinuplasty that ENTs perform. Read here for more info about balloon sinuplasty.

Furthermore, there are potential dangers with this technique the way it is performed. A 2003 report described a septal fracture requiring surgical repair after nasal release. Furthermore nosebleeds is not uncommon after this procedure.

A complication from neurocranial restructuring: nasal septum fracture. Arch Otolaryngol Head Neck Surg. 2003 Apr;129(4):472-4.

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