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August 22, 2016

Chronic Cough due to Playing a Wind Instrument

Image courtesy of Iamnee
There have now been a few published case reports where playing a wind instrument caused a persistent cough... one of which ended in death.

Report in 2010 described a trombone player whose chronic cough for over 15 years was ultimately found to be due to a mold called fusarium as well as mycobacterium (cousin to TB) found growing inside his trombone. Each time he inhaled while playing the trombone, these germs inside his trombone was causing an allergic reaction, which led to hypersensitivity pneumonitis, a severe inflammation of the lungs.

The doctor who figured out the problem went on to investigate other wind/brass instruments of other players and found them all contaminated with germs.

Here's another report on a saxophone player who suffered from something similar.

Finally, a report published in 2016 described a musician who developed a severe hypersensitivity pneumonitis from playing his bagpipes which ultimately lead to his death. Cultures obtained of air samples inside the bag were found to contain the fungi Rhodotorula mucilaginosa, Fusarium oxysporum, various species of Penicillium, and Trichosporon mucoides.

In any case, how should wind musicians clean their instruments to minimize risk of developing lung inflammation and chronic cough? Ideally,  clean the entire inside of the instrument with cloth and rubbing alcohol (isopropyl alcohol) after each use.

Of course, chronic cough can occur due to factors that have nothing to do with wind instruments including reflux, allergies, neuropathy, etc.

Trombone Player's Lung: A Probable New Cause of Hypersensitivity Pneumonitis. Chest. 2010 Sep;138(3):754-6.

Hypersensitivity Pneumonitis Due to Molds in a Saxophone Player. Chest. September 2010 vol. 138 no. 3 724-726.

Bagpipe lung; a new type of interstitial lung disease? Thorax doi:10.1136/thoraxjnl-2016-208751. Aug 22, 2016.

A microbiological survey into the presence of clnically significant bacteria in the mouthpieces and internal surfaces of woodwind and brass musical instruments.
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August 21, 2016

Pet Dog May Cause Recurrent Strep Throat

Image courtesy of alex_ugalek
In rare situations, strep throat infection bounces repeatedly among all family members. In such situations, the family's pet dog may be the carrier for strep that may cause such recurrent strep infections among the children and parents. See references below.

Fortunately, in the vast majority of situations, the pet dog has no role in recurrent strep throat infections. Indeed, many healthcare professionals are in fact skeptical that the dog has any role.

Personally, I'm a semi-skeptic, but open-minded to the possibility.

In any case, should the dog become a suspect, the vet should obtain cultures from not only the tonsils, but also the eyes and anus. Should cultures come back positive to human strep, the dog should be given antibiotics.

Otherwise, interventions that may help when a family suffers from recurrent strep throat include antibiotics given to all family members simultaneously as well as performing tonsillectomy in the family member who seems to get strep throat the most which often breaks this distressing intra-familial cycle.

Personal Health. NYT 3/20/1996

Recurrent pharyngitis in family of four. Household pet as reservoir of group A streptococci. Postgrad Med. 1983 Jul;74(1):277-9.

Group A streptococci in household pets' eyes--a source of infection in humans? Scand J Infect Dis. 1997;29(5):469-71.

The family pet as an unlikely source of group A beta-hemolytic streptococcal infection in humans. Pediatr Infect Dis J. 1995 May;14(5):372-5.

August 19, 2016

Family Guy Nasal Spray Addiction

Peter Griffin on Family Guy
A patient came to my office one day with a chief complaint of being addicted to an over-the-counter nasal spray called Afrin. When asked why he started using it in the first place, he mentioned about that "one episode on Family Guy when Peter uses a nasal spray and feels invincible because he can breath so great through the nose and smell everything." Watch video below.

The implication being that he bought and used the nasal spray so he can breath amazingly well though the nose. Too bad it is only temporary.

Problem is, it should only be used sparingly for no more than a few days, otherwise one can eventually become addicted to the nasal spray. Over time, the patient will require using the nasal spray more and more frequently in order to achieve the same effect. Should the patient try to quit, extra-severe nasal congestion will occur which compels the patient to go back and start using the nasal spray again.

It's not just Afrin. There are other nasal sprays that have the same addictive potential including 4-way and Zicam. All these nasal sprays contain one of the following active ingredients: oxymetazoline, phenylephrine, pseudoephedrine. User beware!

When the patient mentioned Family Guy to me, not sure what I was thinking, but I thought it was a wholesome family friendly sit-com. Clearly, I don't actually watch Family Guy, but it got me curious about how this medical condition got represented in a pop culture cartoon let alone even being mentioned. Thankfully, there's a YouTube that shows this particular clip...

To read more about treatment options to address this condition, click here.

Please note that other classes of nasal sprays are NOT addictive such as steroid nasal sprays (flonase, nasacort, rhinocort, etc) as well as anti-histamine nasal sprays (astelin, astepro, patanase, etc)

The nasal sprays below are NOT addictive:

August 07, 2016

Hillary Clinton's Constant Throat-Clearing

Image by Gage Skidmore in Wikipedia
Many viewers noted that presidential nominee, Hillary Clinton, constantly cleared her throat during her speech at the Democratic National Convention on July 28, 2016 (watch video below). About 22 times in fact. Media have noted that this throat problem has been going on for far longer... since January 2016.

Why is she clearing her throat so often?

Is it manufactured as some have suggested?

Or could there be a medical reason for her throat problem? For what seems to be a relatively minor annoyance can require an unusually long and extensive workup to diagnose, treat, and resolve mainly because so many different conditions can cause this symptom. Indeed, Mrs. Clinton has been throat-clearing for at least the past 6 months if reports are to be believed. This obviates a simple answer or treatment.

Should Mrs. Clinton come to my office wondering what could be done to eliminate her unintentional chronic throat clearing, the following steps would be pursued:

1) Endoscopic laryngoscopy to evaluate for any physical problems in the voicebox region. Specifically, evaluating for any evidence of mucus collection in the hypopharynx which could be due to Zenker's diverticulum, esophageal dysmotility, laryngopharyngeal reflux, etc.
2) Depending on the endoscopic findings, trial of the following interventions may be recommended:
     • A reflux medication like nexium to address any reflux getting up into her throat. Avoiding fatty, fried, spicy, tomato-based foods would also be advisable.
     • Nasal sprays like flonase and astelin to address any post-nasal drainage that may be dripping down into her throat
     • Avoiding egg, wheat, and dairy which seem to increase the amount of throat phlegm in some patients.
3) Ensuring she is not taking any medications known to cause throat-clearing as a side-effect. The top two category of medications are ACE Inhibitors like lisinopril as well as ARB (angiotensin receptor blockers) like losartan, both used to treat hypertension. Less commonly, high cholesterol statin medications like simvastatin may be a factor.
4) Tests would be ordered including:
     • Allergy testing to evaluate for any allergic triggers
     • Barium swallow to evaluate for any esophageal pathology beyond the voicebox
     • Bloodwork to check for any autoimmune disorders like Sjogren's which may cause saliva to thicken and collect in the throat.

Depending on the results of the above initial steps, further testing may eventually be pursued including :

     • Esophagoscopy
     • 24 hour multichannel pH and impedance testing with manometry
     • PepTest
     • SELSAP

Although throat-clearing appears to be Mrs. Clinton's main symptom, other patients may complain of other related throat problems including:

     • Globus
     • Chronic cough
     • Phlegmy throat

Hopefully, Mrs. Clinton gets her throat symptoms resolved as soon as possible as it apparently is happening frequently enough to distract her constituents/audience where focus should instead be placed more on her message.

However, she as well as others who suffer similarly need to be aware that there are MANY different causes for chronic throat clearing and without knowing what is causing it, the treatment will be haphazard and commonly ineffective.

WATCH: Clinton's Constant Throat Clearing. DailyWire 7/29/16.

August 05, 2016

Hearing Amplifiers That Work Almost as Well as More Expensive Hearing Aids

CS50+ High End Hearing Amplifier
In my last blog, I argued that hearing amplifiers are not safe to use in patients with hearing loss. In fact, such hearing amplifiers can potentially cause further hearing loss given indiscriminate amplification of sound frequencies where hearing loss may be minimal/absent.

Given that caveat, there are a new breed of high-end amplifiers that approach the quality and safety of hearing aids. Such high-end hearing amplifiers typically run $300+, can be purchased over-the-counter (i.e., Amazon), and distinguish themselves from the low-end amplifiers in several key ways. Unlike low-end amplifiers which simply turn up the volume regardless of what type of hearing loss a person has and regardless of the sound environment (loud restaurant versus library), high-end amplifiers try to:

• Adjust the sound amplification based on what type of hearing loss you have. Typically, a hearing screening is performed through a smartphone. (Essentially, your smartphone is performing a hearing test.)
• The smartphone than adjusts the hearing amplifier sound output based on the results of the hearing screening (thereby minimizing risk of hearing damage to frequencies that hear better/normally).
• Finally, the device allows the user to select the sound environment such that hearing is optimized. For example, through a smartphone app, one can choose a setting for "movie theater" versus "restaurant" versus "library".

If you think about it, these are the exact same elements that make a hearing aid.... well, a hearing aid.

However, all these elements are driven by the user instead of a professional hearing specialist. Furthermore, such hearing amplifiers, even if high-end still fall short of the sound quality provided by a good hearing aid.

In any case, which are some of these high-end hearing amplifiers you can purchase directly? Check these out...

• Soundhawk
• CS50+
• Bean T-Coil


Low-End Hearing Amplifiers (just as an FYI that should be avoided)


July 30, 2016

Hearing Aid versus Hearing Amplifier, What's the Difference?

Can you tell if this is a hearing aid or amplifier?
Hearing aids are expensive costing around $800+. Hearing amplifiers look exactly like hearing aids... except they are often under $50 and you can purchase them in a store like Amazon. So beyond the dramatic difference in price, what exactly is the difference between the two, especially since both do appear to help people with hearing loss, hear better?

After all, both increase the volume of sound transmitted to the ear and they look almost identical.

Per the FDA, hearing amplifiers are categorized as a "personal sound amplifier" and are NOT intended for use by people with hearing loss. 
"[Hearing amplifiers] are not intended to make up for impaired hearing. Instead, they are intended for non-hearing-impaired consumers to amplify sounds in the environment for a number of reasons, such as for recreational activities. [Only] hearing aids... intended to compensate for impaired hearing." [link]
That said, many people with hearing loss find benefit from using a hearing amplifier. So why the fuss and concern?
Graph 1 showing how hearing amplifier use increase
the volume of all frequencies.

It's mainly because such amplification devices may actually cause even more hearing damage to someone who already has hearing loss.


Bluntly, using a hearing amplifier is analogous to the teenager who is playing music too loudly on his headphones leading to hearing loss.

To explain as simply as possible...

Hearing amplifiers are essentially a volume knob on a music player or television. It increases the volume of all frequencies (Graph 1).

Graph 2 showing how a hearing aid amplifies
only the frequencies where hearing loss is present.
Hearing aids selectively amplify ONLY the frequencies where hearing loss is present (Graph 2).

SO... if a person with hearing loss only in the high-frequencies uses a hearing amplifier, the patient may eventually suffer from permanent hearing loss not just in the high-frequencies... but also in the low and mid frequencies from loud-noise trauma caused BY the hearing amplifier (Graph 3).

Use of a hearing aid would have avoided hearing damage in the low and mid frequencies because it would have amplified JUST the high-frequencies thereby preserving overall hearing health.

So what should a person with hearing loss do?
Graph 3 showing noise induced hearing loss
caused by a hearing amplifier.

First, makes sure it is not a reversible type of hearing loss such as that found with eustachian tube dysfunction, earwax, otosclerosis, ear fluid, etc as well as brain tumor.

Once medical causes of hearing loss are ruled-out, than discuss with your ENT or audiologist on the different types of hearing aids available. Read more about hearing aid costs here.

Different types of hearing amplifiers can be found on Amazon as shown below. These are NOT hearing aids!

However, there are high end hearing amplifiers  that approach the quality (and potentially the safety) of hearing aids.  Such high end hearing amplifiers include:

Bean T-Coil

Read more about such high-end amplifiers here.

Low-End Hearing Amplifiers

High-End Hearing Amplifiers

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