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April 20, 2017

Can Ear Drops Increase Risk of Eardrum Perforation?

With ear tube placement, there is a baseline 2-10% risk that a persistent hole in the eardrum will occur after the tubes come out. However, a study came out in April 2017 suggesting that commonly used antibiotic ear drops to treat ear infections when ear tubes are present may increase the risk of such persistent eardrum perforations after the tubes come out (post-TT TMP).

Specifically, antibiotic ear drops belonging to the fluoroquinolone class is associated with an increased risk of persistent eardrum perforation (post-TT TMP) compared to aminoglycoside class of antibiotics. Fluoroquinolone antibiotics include ofloxacin and ciprofloxacin with or without steroids. Aminoglycoside antibiotics typically include cortisporin or neomycin with steroids.

The next big question is how much higher is the risk of post-TT TMP with use of fluoroquinolone ear drops?

Based on this retrospective cohort study, the adjusted hazard risk was 1.61. Broken down, the adjusted hazard risk was 1.49 for ofloxaxin, 1.94 for ciprofloxacin with hydrocortisone, and 2.00 for ciprofloxacin with dexamethasone. (Value of 1.00 means no additional risk.)

These adjusted hazard risks are based on raw data showing 11 post-TT TMP per 10,000 patient years for non-fluoroquinolone exposure versus 17 post-TT TMP per 10,000 patient years in those exposed to fluoroquinolone antibiotic ear drops.

10,000 patient years is the total sum of observed time during which the incidence of post-TT TMP is observed. For example, if 100 patients are followed for 2 years, that would be 200 patient-years of follow-up.

So, if one were to hypothetically smush together all the patients into a single individual who lived for 10,000 years, use of fluoroquinolone ear drops would occur 6 more instances than one who did not use this type of antibiotic ear drops. (17 per 10,000 person years minus 11 per 10,000 person years.)

So although it does appear that the risk of post-TT TMP is present with fluoroquinolone antibiotic ear drop usage, the additional risk is not large by any stretch of the imagination and the impact on its use for a given single patient is really quite small overall and should not dissuade from its use.


References:
Quinolone Ear Drops After Tympanostomy Tubes and the Risk of Eardrum Perforation: A Retrospective Cohort Study. Clin Infect Dis. 2017 Apr 15;64(8):1052-1058. doi: 10.1093/cid/cix032.

Meta-analysis of tympanostomy tube sequelae. Otolaryngol Head Neck Surg. 2001 Apr;124(4):374-80.

Factors related to persisting perforations after ventilation tube insertion. Int J Pediatr Otorhinolaryngol. 2016 Feb;81:29-32. doi: 10.1016/j.ijporl.2015.11.028. Epub 2015 Dec 7.


April 14, 2017

Video of the Human Voicebox in Action!



In honor of World Voice Day on April 16, 2017, I have created a new video showing how the voicebox is examined using a fiberoptic endoscope threaded through the nose. I created the first version of this video back in 2007 and given better and newer technology, I have decided to do a refresh including more info and examples. Of course, the video and audio quality is also way better compared to a decade ago. Check it out!



April 07, 2017

Wax Removal of Nasal Hair

Screenshot of video by Sepi Balini
Makeup artist and vlogger Sepi Balini posted a video on instagram showing her nasal hair being removed by waxing.

OUCH! 

She's made of tough stuff as most individuals would have at least shed a tear given the nose is extremely sensitive, even with pulling just one nostril hair out. Watch the video here.

However, this is NOT a good idea and I certainly hope is not something that picks up in popularity whether male or female.

Although nasal hair does contribute to air filtration by preventing debris from getting into the nose, the greater concern is infection of the hair follicles. Although an infected hair follicle hurts no matter where it occurs, it is particularly painful in the nasal region. Given the nasal location, one can argue that it is more likely here than other locations given how often air passes through this opening along with germs. Other nasal skin conditions that may also result include:

  • nasal crusting
  • ulcers
  • pimples
  • scabbing
  • skin cracking
  • abscess

Staph in particular likes to hang out among the nasal hair. In very rare cases, an infection in this region of the face (called the "Triangle of Death"), can lead to infection of the brain. Click here for more information on how this may happen.

If you want to remove nasal hair, it is best to trim the hair out with nose hair clippers or a scissor.



April 03, 2017

Increased Risk of Thyroid Cancer From Frequent Use of Disinfectants

Yale researchers have reported that regular exposure to biocides including disinfectants (such as doctors, dentists, nurses, etc) doubles the risk of thyroid cancer. This findings was determined through a population-based case-control study involving 462 thyroid cancer cases in Connecticut collected 2010-2011.

Over the past decade, there has been an increased incidence of thyroid cancer every year and this report may explain part of this alarming trend along with possible over-diagnosis as ultrasound technology and pathology technique has improved. At least in the United States, the average annual increase in the incidence of thyroid cancer is 5%.

Biocide products include not only disinfectants, but also any product capable of deodorizing, sterilizing, sanitizing, and / or killing micro-organisms including bactericides, algicides, fungicides, germicides, and preservatives.

For example, the active ingredient in many "anti-bacterial" soap used in households contains triclosan, a suspected biocide. This biocide is also suspected of causing other types of cancers.

Animal studies have suggested that biocides can trigger thyroid cancer by altering thyroid hormone production. For example, triclosan which is widely found in antibacterial soap is known to decrease serum T3 and T4 thyroid hormones. Drinking water disinfectants including chlorine has also been found to reduce T4 thyroid hormones in animals.

Interestingly, pesticide exposure did not show this same increased risk of thyroid cancer. Pesticides are defined as substances capable of killing some form of organism that is deemed undesirable including insecticides, herbicides, rodenticides, fungicides, molluscicides, and nematodicides.

Obviously, further evaluation is mandated to elucidate the relationship between thyroid cancer and biocide usage. In particular, which exact biocide chemical(s) is/are responsible for this increase given biocides encompass a wide range of chemicals.

Also, there is NO evidence to show that anti-bacterial soap is more effective than regular soap in preventing illnesses. As such, at least for the lay-public, it is recommended to avoid anti-bacterial soap containing any type biocide chemicals and stick with regular soap. Of course for healthcare professionals, we may be out of luck because pretty much any product used to disinfect, clean, sterilize, etc contains biocides. What's worse is that healthcare professionals are exposed to biocides multiple times every day.

Hand-sanitizers should also be avoided, especially if it contains biocides. Triclosan (mentioned above) can quickly absorb through the skin and enter the bloodstream exerting its potentially deleterious effects. If hand-sanitizers are used, ethanol should be the only active ingredient and it MUST be present at concentrations above 60%, otherwise it will be ineffective at killing germs.


References:
Occupational exposure to pesticides and other biocides and risk of thyroid cancer. Occup Environ Med 2017; published online 2/15/17.


March 25, 2017

How Loud is it Where You Live?


The U.S. Bureau of Transportation Statistics has created an interactive comprehensive "noise map" showing how "loud" it is to live in different parts of the United States (for the year 2014). The map depicts data on noise produced primarily by airports and interstate highways. Noise pollution is worst where it is red (80 decibels or higher) and best where it is white (less than 40 decibels).

Check out how loud it is where you live here!

Click here to look at some noise charts comparing decibels to common sounds as well as when it may damage hearing. In my neck of the woods, the noise pollution is not that bad (Warrenton, VA):



However, the metro Washington DC region 45 minutes east is quite a bit louder:



That does not compare to how loud it is in New York City however:


March 24, 2017

Narrow Band Imaging Technology for Cancer Detection Now Available at Fauquier ENT!

Fauquier ENT now offers narrow band imaging (NBI) in the office to better detect cancer and other abnormal lesions in the throat. NBI is an endoscopic imaging technique whereby special filters are used to enhance visibility of vessels and other tissues on or near the mucosal surface. Specifically, it can better "see" dysplastic tissue including pre-cancerous lesions, cancer, and other abnormal mucosal lesions compared to normal light.

The way NBI optically enhances light is by utilizing the 440-460nm (blue) and 540-560nm (green) which is better absorbed by hemoglobin causing blood vessels to appear very dark. Typically, capillaries on the mucosal surface are displayed as a brown color whereas veins deeper under the mucosa appear as cyan.

Overall, the sensitivity, specificity, positive predictive values, negative predictive values, and accuracy for detecting cancer under normal white light were 41%, 92%, 87%, 82%, and 67%. However, cancer detection increased markedly using high-definition narrow band imaging with values at 97%, 84%, 88%, 96%, and 92% respectively.

Throat cancer under normal white light and NBI light.
The cancer is in the center of the photo.

Overall, NBI increases the diagnostic accuracy by about 22% compared to normal white light.

Made by Olympus, the way NBI is performed is via trans-nasal endoscopy whereby a thin black noodle is threaded through the nose and into the throat. The NBI light can than be activated allowing visualization for any abnormal mucosal lesions.

Additionally, the system our office has purchased can also perform high-definition stroboscopy in order to detect subtle vocal cord abnormalities that may lead to a hoarse voice.

References:
European Laryngological Society: ELS recommendations for the follow-up of patients treatedfor laryngeal cancer. Eur Arch Otorhinolaryngol. 2014 Sep;271(9):2469-79.

Narrow band imaging and high definition television in the endoscopic evaluation of upperaero-digestive tract cancer. Acta Otorhinolaryngol Ital.2011 Apr;31(2):70-5.

The diagnostic value of narrow-band imaging for the detection of nasopharyngeal carcinoma. ORL J Otorhinolaryngol Relat Spec. 2012;74(5):235-9.


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