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What do I do with my old hearing aids?

editor — Tue, 14 Aug 2012 16:35:20 +0000

Information for hearing aid users, and my personal experience with Humanitarian Audiology.

The average lifespan of a hearing aid is about 5-7 years, although proper care and maintenance can prolong the life of your instruments. However, with the new age of digital hearing aid technology, your hearing aids are not so different from your laptop computer or cell phone.

There are going to be advances in technology all the time, making the core of the hearing aid faster and “smarter”. Therefore, after a few years, you may be ready to upgrade to new technology. What some people don’t know, is that there are many ways to give back by donating your old hearing aids, so that others may enjoy the world of sounds we live in.

Hearing loss is a global problem, with approximately 250 million people affected worldwide according to the World Health Organization. However, most of those people do not have the means to obtain amplification on their own. Therefore, several hearing aid manufacturers have partnered with sponsors to create programs that allow donated hearing aids to be dispensed to people with hearing impairment both locally and abroad.

Starkey Hearing Foundation:

The Starkey Hearing Foundation has funded many global hearing missions to South America, Africa, Asia, Europe, and the Middle East. They also provide assistance to Americans who do not have the financial means to purchase hearing aids, through the Hear Now program.

Information on how to apply for the Hear Now program and how to donate to the Hear Now program can be found online. Many celebrities and public figures have become involved in the Starkey Hearing Foundation’s global mission trips, including President Bill Clinton, Barbara Bush, Bill Rancic, and Miley Cyrus. These missions allow hundreds of adults and children to be properly fit with donated hearing aids. The Starkey Hearing Foundation accepts all manufacturers and most models of hearing aids for donation.

http://www.starkeyhearingfoundation.org/index.php

Oticon Hearing Foundation:

The Oticon Hearing Foundation works with hearing health care professionals to create humanitarian trips around the world that provide donated hearing aids to people with hearing loss, as well as education to local healthcare professionals at the mission sites. The goal of these missions is to help provide a sustainable hearing healthcare system in the countries visited, with the help of local professionals.

Oticon’s Hearing With our Hearts program accepts gently used Oticon products for donation to its various humanitarian projects.

Information on where to send your donated hearing aids can be found on the website linked below.

http://www.oticonhearingfoundation.org/index.html

My Experience with the Oticon Hearing Foundation: Project Xanthia in South Africa

The summer after my second year of the UT Dallas Au.D. program, I was fortunate enough to participate in a humanitarian Audiology trip to South Africa. We partnered with the Oticon Hearing Foundation, who sponsored two Audiologists to join us and provided donated hearing aids for dispensing. The experience was truly eye-opening and humbling. We were in South Africa for 3 weeks, and traveled throughout the country. Our trip included hearing tests and dispensing donated hearing aids at local retirement homes, hearing screenings at preschools in various townships, and hearing tests and hearing aid dispensing at the Oticon Xanthia clinic.

We were also able to work with students and professors in the Speech Pathology and Audiology department from Wits University in Johannesburg. This was a great learning experience, especially for us as students, because we were able to discuss our different education systems and the needs of our patients in such different countries. One of the best parts of being an Audiologist is to see the joy on your patient’s faces when they listen through their hearing aids for the first time. To be able to do this for so many people, who would have no other way of getting amplification, was definitely the highlight of the trip.

As a side note: This trip was not all work; we were able to squeeze in a few fun activities! We were in South Africa just 3 weeks after the World Cup tournament. Therefore, we were able to get tickets to see South Africa play Ghana in the World Cup Soccer City Stadium in Soweto. Being the noise-exposure conscious Audiologists that we are, we made sure to wear our hearing protection. With a stadium full of vuvuzelas, this was definitely a good call.

The bottom line of this post: If you have an old pair of hearing aids that are still functional, you can donate them! Also, with both the Starkey Hearing Foundation and the Oticon Hearing Foundation, your donations are tax deductible!.

- Elizabeth Parks Au.D.

What do I do with my old hearing aids?

editor — Tue, 14 Aug 2012 16:35:20 +0000

Information for hearing aid users, and my personal experience with Humanitarian Audiology.

Starkey Hearing Foundation:

http://www.starkeyhearingfoundation.org/index.php

Oticon Hearing Foundation:

Oticon’s Hearing With our Hearts program accepts gently used Oticon products for donation to its various humanitarian projects.

Information on where to send your donated hearing aids can be found on the website linked below.

http://www.oticonhearingfoundation.org/index.html

My Experience with the Oticon Hearing Foundation: Project Xanthia in South Africa

- Elizabeth Parks Au.D.

Home Tracheotomy Care Instructions

editor — Tue, 24 Jul 2012 22:15:33 +0000

One procedure that we perform on patients is a tracheotomy. A tracheotomy is where we make a hole in a patients trachea and then the patient breathes through a tube that is placed through this window. A tracheostomy is usually performed for the following reasons:

1. To relieve breathing difficulties by any blockage in the airway passages for example-

· Foreign body Impactation in the airways.
· Acute infection of the airways
· Edema of the airways
· Paralysis of vocal cords following injury
· Tumors of the vocal cords
· Trauma in the head and neck region

2. As a preliminary step in certain surgeries on the upper airway such as surgical treatments for head and neck cancer.
3. To improve respiratory functions by reducing the length of the airway, which may be required in special lung conditions like Pneumonia, Bronchitis, Emphysema and chest injuries

In these conditions the tracheostomy tube also helps in aspiration of excessive secretion that may be caused due to infection or injury

4. Respiratory nerve damage temporary or permanent causing paralysis of chest muscles that assist in breathing. In these situations performing assisted or positive pressure respirations may be required in conditions like-

· Unconsciousness associated with head injuries
· Barbiturate poisoning
· Poliomyelitis
· Tetanus

These patients may also aspirate their gastric content into the lungs and a tracheostomy tube may be helpful for aspiration these secretions.

5. Severe obstructive sleep apnea that is not controlled with more conventional options such as CPAP or sleep apnea surgery

It is not uncommon for patients to keep their tracheostomy in place even after discharge from the hospital. The remainder of this post is to provide patients with instruction on how to care for their tracheostomy while at home. These are generic instructions that may not apply to every patient. Always consult your physician (typically an pulmonologist or otolaryngologist) before changing your routine tracheostomy cares. Also most of the images below are for metal tracheostomy tubes which are called Jackson tracheostomy tubes. These instructions generally apply to both metal and plastic tracheostomy tubes.

INTRODUCTION

Your doctor has decided that you will be sent home with your tracheostomy tube in place (Figure 1). You will be instructed and shown how to do your cares. You will also practice these cares. A family member or friend should also learn your cares and practice helping you so that, if needed, someone can assist you at home. This post should help you adequately care for your tracheostomy.

Figure 1

THE TRACHEOSTOMY TUBE

Most tracheostomy tubes have 3 parts (Figure 2). The parts may not be used with another tube. The obturator is used to insert the outer cannula into the trachea. The obturator is removed after inserting the tube and should be kept handy for use should the tube come out. The outer cannula maintains the neck opening. The inner cannula is inserted into the outer cannula and locked into place and should only be removed for cleaning.

Figure 2 - Parts of the Tracheostomy Tube: A. Outer Cannula. B. Inner Cannula. C. Obturator

HAND WASHING/CLEANING SUPPLIES
Because your hands may spread germs, you must wash your hands before and after all cares. Clean supplies must be used.

HUMIDITY
Extra humidity is required because the nose and mouth, which filter, warm, and moisten the air you breathe, are bypassed. The amount of moisture needed will vary. Use an ultrasonic nebulizer, a room-size or cool-mist humidifier in your home. Drinking plenty of fluids also helps to keep your airway moist. Increased humidity will be needed during the winter months when your home becomes dry. More moisture is needed whenever secretions become thick, dry, or form plugs. Pink or blood-tinged secretions may also indicate a lack of moisture. Putting (instilling) saline solution (a salt solution) into the trachea adds moisture and causes a cough to clear secretions from your airway.

MAKING SALINE SOLUTION
Saline solution is a salt solution that can be made by boiling water for 5 minutes, then adding 1 1/2 level teaspoons of noniodized salt per quart of water. Cool to room temperature prior to use. Because germs may grow in the solution, discard unused saline solution after 24 hours.

INSTILLING SALINE SOLUTION
The purpose of instilling saline solution into your airway is to stimulate a cough and clear secretions.
1. Pour a small amount of saline solution into a clean cup.
2. Draw up 2 to 3 cc into the syringe.
3. While taking a deep breath, instill saline solution through the tracheostomy tube.
4. Cough while covering your tube with a gauze sponge or soft paper towel.
5. Repeat until your airway is clear. If unable to clear your airway with saline solution, use suction.
6. When secretions become thick and dry, saline solution may need to be instilled as often as every hour.

CLEANING THE HUMIDIFIER
Germs will grow in a humidifier. Clean the unit to decrease the chance of respiratory infections. Refer to humidifier package insert for cleaning guidelines. Options for daily and weekly cleaning are listed below:
Daily
1. Empty and clean tub with hot, soapy water. Rinse well.
2. Fill with fresh tap water.
3. Never add water to the humidifier without emptying and rinsing the tub.

Weekly
1. Empty and rinse.
2. Fill the humidifier tub with equal parts of vinegar and water and turn the humidifier on for 1 hour. Due to the strong smell of the vinegar, place the humidifier in a room where no one is present.
3. Empty the humidifier and wash all parts with hot, soapy water. Rinse well.
4. Fill the tub with clean water and turn on the humidifier for another hour.
5. Empty and air dry. Unit is ready for use.

SUCTION
The purpose of suction is to remove secretions that you cannot cough out. Suction will clear your airway and help you breathe better. The correct size suction catheter should be used. The catheter should be half the size of the tracheostomy tube.
1. Connect suction catheter to tubing from suction machine.
2. Moisten the catheter tip with saline solution.
3. Take 4 to 5 deep breaths.
4. Gently insert the suction catheter through the tracheostomy tube. Do not cover the suction control vent while you insert the catheter. Pass the catheter as far as you can without force, then withdraw slightly before starting suction (Figure 3).
5. To apply suction, cover the vent with your thumb. Do not apply suction for more than 10 seconds. Release thumb from vent if you feel the catheter grab during suction. Gently rotate the catheter as it is withdrawn

Figure 3 - Thumb Off the Suction Control Vent

6. Suction saline solution to clean the catheter.
7. Do not insert the catheter more than 3 times during a suction period. If more suction is needed, allow yourself a 5- or 10-minute rest.
8. Breathe deeply after the catheter is removed.
In most cases, the use of saline solution and a humidifier keeps your secretions thin enough to cough or suction out. If you have thick secretions, mucous plugs, or a feeling that your airway is not clear, the following may help:
9. Fill the bathtub with hot water and sit in the steam-filled bathroom for 20 minutes.
10. Place a moist all-gauze square over your tracheostomy tube. Keep gauze damp. The gauze may be held in place by folding it over twill tape or bias tape tied around your neck.
11. Stand in the shower with water directed away from your tracheostomy tube.
12. Fill a spray bottle with saline solution and spray into your tracheostomy tube several times a day.

CLEANING THE INNER CANNULA
To ensure that the inner cannula does not become plugged, it must be cleaned.
1. To unlock and remove the inner cannula, turn it until the notch area is reached and slide it out.
2. Use a small brush or pipe cleaners to clean the inner cannula under cool running water.
3. Look through the inner cannula to make sure it is clean. Shake the inner cannula to remove excess moisture.
4. Reinsert the inner cannula and lock in place.

USE OF A TRACHEOSTOMY CORK
If your doctor allows you to cork your tube, do so as directed (Figure 4).
1. Secure the cork string to the tube tie.
2. The cork should be removed for shortness of breath or to cough out secretions that you cannot handle through the nose or mouth.
3. Continue to clean your inner cannula. Remove cork when cleaning and replace.

Figure 4 - Tracheostomy Cork

SKIN CARE
Skin around the tube should be kept clean and dry.
1. Q-tips or a damp washcloth may be used to gently clean around the neck opening.
2. Gauze may be placed under the ties next to the skin. Hold the tube while changing the gauze.
3. Change the gauze if it becomes wet, dirty, or frayed.
4. Look for redness or skin breakdown.

CHANGING THE TRACHEOSTOMY TIE
1. Different ties can be used, such as twill tape, bias tape, or Velcro tube holders.
2. Change the tie when wet, dirty, or frayed. Plan to do this when you have someone to help you.
3. The clean tie should be in place before soiled tie is removed.
4. If using twill tape (sometimes referred to as umbilical tape) or bias tape, cut a piece of tape approximately 30 inches long (Figure 5).

Figure 5 - Tracheostomy Tie

a. Insert tie through opening in the neck plate and bring it around to the other side of the neck.
b. Insert this same end through the other side in the neck plate and pull it through. Secure the tie in a triple knot at the side of the neck.
c. Make sure the new tie is not too tight or too loose. You should be able to slip 1 finger under the tie.
d. Remove the old tie.
e. If the tie stretches with wear, retie it.
5. If using a Velcro tube holder (Figure 6).

Figure 6 - Tracheostomy Velcro Tube Holder

a. Thread narrow Velcro tabs through opening in the neck plate.
b. Adhere tabs to soft material on the band.
c. Adjust and secure to fit your neck.
d. Cut off excess band

Regardless of it the tracheostomy is secured with velcro or twill tape, you want to make sure that the tracheostomy tube is secure and tight to the neck. A good guideline is that you should only be able to fit two fingers between the skin and the trach tie. Below is an image of a tracheostomy tube that is too loose (Figure 7). If a trach tie is too loose, it will allow the tracheostomy tube to flop in and out of the tracheotomy site and potentially fall out.

Figure 7 - Trach ties that are too loose

Below is the same patient as above after the trach ties have been tightened (Figure 8 )

Figure 8 - More secure trach after trach ties have been tightened

CHANGING/REPLACING THE TRACHEOSTOMY TUBE

A spare tracheostomy tube should be sent with you when discharged from the hospital. If you have been instructed to change your tube, this is done about once a week. The recommended interval between trach changes can vary and you should check with your physician first. If using metal tracheostomy tubes, the tracheostomy tube that is replaced can be cleaned and used for the next tracheostomy tube change. If using plastic, disposable tracheostomy tubes, the used tracheostomy tube is discarded after it is removed. For safety, you should always have a spare tracheostomy tube that is the same size and type as the one currently in the neck available. This is regardless if it is metal or plastic tracheostomy tube.

1. Prepare the clean tube:
a. Insert the tie into the opening of the neck plate.
b. Place the obturator inside the outer cannula (Figure 9).

Figure 9 - Obturator in the Outer Cannula

c. Moisten the lower portion of the tube with saline solution.
2. Hold the tube that is in place as you cut the tie.
3. Take a deep breath before removing the tube.
4. Remove the soiled tube and insert the clean tube (Figure 10).

Figure 9 - Inserting the Clean Tube

5. Quickly remove the obturator, take a breath, and secure the tie or Velcro tube holder (Figure 11).

Figure 11 - Removing the Obturator

6. Insert the inner cannula.
If the tube comes out and needs to be replaced:
7. Place the obturator inside the outer cannula. (will have to remove inner cannula in order to place obturator)
8. Moisten the lower portion of the tube with saline solution.
9. Insert the tube.
10. Remove the obturator.
11. Insert the inner cannula.

CLEANING THE TRACHEOSTOMY TUBE (only if using metal tracheostomy tubes, plastic tubes are disposable and should be discarded and replaced with a new tracheostomy tube)

After the tube is changed, clean the dirty tube and store until the next tube change.

Clean plastic tubes with mild soap and water or equal parts of hydrogen peroxide and water. Rinse well, air dry, and store in a clean, covered container.
Clean metal tubes with mild soap and water. Rinse well, air dry, and store in a clean, covered container.
Hydrogen peroxide may be used to clean stainless steel tubes if rinsed well. Do not use with sterling silver tubes.

CLEANING THE SUCTION CATHETERS

Place catheters under cool running tap water to rinse secretions.
Wash catheters well in hot soapy water (mild liquid soap) and rinse with tap water. It may be helpful to attach the catheter to suction to remove any remaining soapy water.
Soak catheters in equal parts of white vinegar and tap water (1 cup vinegar to 1 cup water) for 1 hour. Rinse catheters with saline solution. Connect catheter to suction to rinse inside of each catheter.
Air dry catheters on a clean towel.
Store catheters in a clean, covered container.

CARE OF THE SUCTION MACHINE

Empty suction bottle into the toilet.
Wash the suction bottle and tubing daily with hot, soapy water.

PRECAUTIONS

When bathing or taking a shower, keep water out of tube. Do not swim.
Avoid powders, aerosol sprays, dust, smoke, and lint from facial tissues.
Do not use over-the-counter antihistamines (cold medications), which dry secretions and the airway.

EMERGENCY INFORMATION

Talking on the telephone may be difficult. Plan a way to get help in case of an emergency. Place emergency numbers near the phone, such as the fire department, ambulance, visiting nurse, or doctor.
During cardiopulmonary resuscitation (CPR), breathing must be performed mouth to tracheostomy tube not mouth to mouth.
A medical alert bracelet/necklace from a drug store (Figure 12) should be worn. Information can be etched on the back of the bracelet/necklace to inform others that you breathe through a tube in your neck.

Figure 12 - Medical Alert Emblem

DISCHARGE INFORMATION

Before you leave the hospital, a visiting nurse may be contacted to assist you with your home care and help you obtain supplies. Supplies may be obtained from a drugstore or medical supply company. Arrangements for a suction machine, if needed, will be completed before you leave the hospital. Most patients rent the suction machine. The need to suction may decrease over time. Return the suction machine when no longer needed. Arrange to have a humidifier at home.

HOME SUPPLIES

The following supplies should help with your tracheostomy cares:

Sterile saline solution
5 cc syringes for instilling saline solution
Sterile container for saline solution
Gauze squares to use when coughing (soft paper towels can be used)
An extra tracheostomy tube
Tracheostomy dressing
Tracheostomy ties and/or Velcro tube holder
Tracheostomy brushes/pipe cleaners
A plastic basin for cleaning the inner cannula/tracheostomy tube
Suction catheters
Tubing for suction machine (if not supplied by medical equipment company)

WARNING SIGNS

Please notify your doctor or local emergency room if you feel you are having any of these problems:

Tracheostomy tube comes out and you are unable to replace it
Difficulty breathing
Increased tracheal secretions
Thick, foul-smelling secretions
Chest discomfort
Dry, crusted secretions (mucous plugs) or blood-tinged secretions from the tracheostomy tube
Fever
Open skin, sores, or increased redness around the tube

Again, these are general guidelines for tracheostomy care and may differ from what your physician recommends. Should contact your physician before changing your routine tracheostomy cares.

Tracheotomy links

The University of Iowa Otolaryngology Tracheostomy Home Care Booklet

MedicineNet Tracheostomy
Tracheostomy.com - a website created by a patient's parent that has collected a lot of links and information regarding tracheotomies.

http://tracheotomy.info/ - another website generated by a patient with a tracheostomy.

Tracheostomy - Mayo Clinic information on tracheotomy

www.fauquierent.net Another blog post by Dr. Dr. Christopher Chang that has great images and goes into detail about the actual tracheotomy procedure

-- M. Benjamin Brindley, MD

Predatory Physician Practices Part 2

editor — Sat, 07 Jul 2012 03:50:23 +0000

So a while back I published an article about physicians who, for a variety of possible reasons, seem to try to "up-sell" procedures or other increased revenue generating choices to patients rather than what's necessarily the best. I think this happens sometimes in plastic surgery, but an alarming rate of this is starting to be seen in other parts of otolaryngology as well.

As I've seen increasing instances of this in the last year, I have almost felt like I should publish an advertisement with a picture like this:

With the caption: You're not a nail. Why see a hammer for treatment?

It would be a play on the old adage that if you're a hammer, then everything looks like a nail.

I'd like to address this as it relates to sinusitis. I'm sure if you've read this blog, you've heard, read, or seen advertisements for balloon sinuplasty (BSP). It's a wonderful option for the treatment of refractory sinusitis in many cases. In fact, I was the 52nd person trained on the procedure in the country. I've supported it since its inception. I think it is an excellent option for treatment in many cases. I feel like it is the single best first surgical option for the treatment of frontal sinus disease if medical therapy fails.

You can see a great video about how it works on this website.

In the last year, BSP was FDA approved for use in-office. In other words, whereas in years past you'd have to have sinus surgery in the operating room, now you can have it done in the office. There are a number of advantages:

1 - no general anesthesia (decreases risk of procedure)
2 - no cost for an operating room (tremendous cost typically)
3 - no cost for an anesthesiologist (tremendous savings--the procedure can be done under local anesthesia in the office)
4 - often, you only need to pay for your typical co-pay rather than for a deductible for surgery (potentially, thousands in savings)

So with all these advantages, why my concern?

Because the physician who does this in the clinic makes 10x the money they do in the OR. It is not uncommon for a doctor to make $10k doing this in the office, when they might make $1-2K by doing it in the OR. If all of a sudden you could do less work for more money at your job, we'd all take that opportunity. What if you really wanted that new car, or that vacation, or to pay off that terrible debt you have carried for so long? Would you be tempted to potentially look to do jobs where there wasn't really a need, just to get that extra money?

Maybe you wouldn't. I'm not sure that holds true, unfortunately, for all physicians. So I'd like to ask these questions to you if you were approached to have BSP in the office recently:

1 - Did you have a long history of sinus problems before your ENT recommended BSP, or was it recommended only after a single episode or two? In my opinion, sinus surgery is an elective procedure. It is something that is available as a treatment, but because it is by definition invasive (even if minimally) it should not be the first option offered.
2 - Did your ENT try any medical therapy for your sinus problems before suggesting BSP? Did you know that more than 60% of chronic sinusitis can be cleared with medical therapy without the need for surgery? It's true. So if most people can resolve disease without a procedure, it's worth considering starting with conservative options and then proceeding to more aggressive choices.
3 - Did your ENT suggest that BSP was a great first step, but if it didn't work, then you could go to the OR for a more formal procedure? I think that if you feel you're being sold to try BSP first as an intermediate step before you could get a procedure in the OR, you are not getting full disclosure of the risks, benefits, and alternatives of treatment for sinusitis.
4 - Did your ENT advertise their practice on the radio, on billboards, on TV, in magazines, or online as a BSP office? Did they try to explain how they were the best at it, did the most, or knew what you needed? Perhaps it's because they know how much money it can generate and driving patients into the office is the most important way to generate procedures.
5 - Did they have a CT in their office? I purposefully have avoided this in my office. One risk I'm trying to avoid is ordering a CT simply because I have the economic pressure to make sure I have a return on my investment to get one. An in-office CT is incredibly expensive and making sure it is financially viable is stressful. Can you be sure the CT was ordered because it is what's best for you or what's best for the practice's bottom line? Also, it's a pretty well-understood principle that an ENT shouldn't operate on the sinuses without a CT. Well, then, let's get a CT on everyone right?

So how do you know you're getting the right care? As a physician, if I had sinus problems this is what I would be looking for in an algorithm from my ENT:

1 - First visit, a detailed history and physical which may or may not include nasal endoscopy.
a - If I haven't been treated with medication to prevent symptoms before and my symptoms weren't so bad, I'd expect the ENT to give me a nasal spray, nasal saline irrigation, and a discussion as to whether allergy testing was appropriate. I may want to discuss whether getting a CT was a good idea yet or not.
b - If my symptoms were severe or I had tried these medications in the past, I might expect a trial of antibiotics while awaiting a CT scan to determine whether I should get a month-long course of treatment.
2 - If the meds work, no further treatment necessary
a - unless I don't want to take meds, then we can talk about whether surgery is a good option or not
3 - If the meds don't work and the CT is positive for sinus disease I'd expect
a - a trial of maximal medical therapy which, in my book, includes at minimum nasal saline irrigation, 3 weeks of oral antibiotics (preferably Levaquin), and an intranasal steroid. In addition, I would want to know if oral steroids were reasonable. I'd want to know if putting antibiotics and/or steroids in the nasal saline irrigation was a good idea.
b - to know whether allergy treatment might clear my disease without surgery
4 - If the meds don't work, I don't have allergies, and the CT is negative I'd expect
a - a frank discussion about the realistic expectations of BSP or other sinus surgery--there is even controversy among ENT's as to what to do. My doc better well know why there is a controversy and why they'd recommend one way or another for me.
5 - If surgery is the recommendation and/or this is my preference rather than medical treatment, I'd expect:
a - a full discussion of the risks, benefits, and alternatives of sinus surgery in the OR vs BSP in the office
b - to not feel like I was being pressured. Do I feel that the ENT would offer the same option to their spouse or parent?

So to be sure, I think BSP is a great tool. It's also a great alternative to surgery in the OR for many patients. However, when I've seen patients who complain of only having post nasal drainage, have a normal CT, a normal nasal endoscopy, positive allergies, but they've had BSP because it's what the ENT recommended, I become worried that patients are being sold on a procedure for the benefit of the ENT, not for their own health benefit.

As changes in health care reimbursement continue to hurt physicians, the pressure to find great options to make a good living may influence some to err on the side of finance rather than health care.

An informed patient is the best way to make sure you are getting the right options presented. Your sinusitis may feel like there's a nail in your face, but you are not a nail, if your ENT is a hammer, you may only get offered BSP.

--Richard D. Thrasher III, MD

Why postnasal drip is not always caused by postnasal drip

editor — Tue, 03 Jul 2012 10:10:55 +0000

One of the more frequent complaints that bring patients to the ENT’s office is postnasal drip. Often patients will complain of constant postnasal drip, frequent throat clearing, and phlegm that is stuck in their throat. In addition to these symptoms, patients often complain of a constant cough or need to clear their throat. Often they have hoarseness, which they attribute to the frequent coughing.

In some extreme cases, they will complain of feeling like the mucous is blocking their airway and forcing them to choke or gag.

Often by the time these patients show up they have tried a variety of nasal sprays, decongestants, allergy medications, antibiotics, oral steroids and are often frustrated because nothing has helped. They want to know “Why nothing seems to work?”

While the answer seems simple, it is often missed. If your treating the nose and nothing seems to work, maybe it isn’t a nose problem at all. Or to rephrase, maybe the postnasal drip is not actually the problem.

What these patients are probably suffering from is not related to the nose at all, but is actually related to their stomach. They most likely have Laryngopharyngeal Reflux.

The term LARYNGOPHARYNGEAL REFLUX (LPR) refers to the backflow of stomach contents into the larynx and pharynx (the voice box and throat). LPR can occur during the day or night, and many people who have LPR will not have heartburn; so LPR is sometimes called silent reflux. It is also sometimes called extraesophageal reflux disease (EERD)

These patients are often doubtful of this diagnosis. It is common to hear questions like these:

“It can’t be reflux, I don’t have heartburn”.
“How can reflux affect my nose?”
“How can reflux cause increased drainage?”

I have seen patients that have come to me for second or third opinions because the first ENT told them it was reflux and they didn’t believe it.

So to answer their first question, LPR is different from traditional gastroesophageal reflux (GERD) or heartburn. Typically patients who have LPR do not have traditional heartburn symptoms. That is why some refer to it as silent reflux.

The answers to the second and third questions are a little bit lengthier. The reflux doesn’t affect the nose (at least not usually). What is actually happening is that the acid sits on the voice box and throat and burns/irritates these structures.

The average person produces 1.5 liters of mucous a day from their sinuses and 1-2 liters of saliva from their oral cavity. This totals up to 2.5-3.5 liters of fluid a day. The majority of this fluid is supposed to simply trickle down the back of the throat into the esophagus without the patient even being aware of it. In LPR, the irritated laryngeal mucosa and tissues are overly sensitive and then the patient feels every last drop of mucous. So the answer to the third question is that there is not excessive drainage, but increased sensitivity to normal amounts of drainage.

It is kind of like a guy at work who keeps getting hounded by his boss and then explodes on a coworker when asked a benign, innocent question that normally wouldn’t bother him at all.

What are the Signs of LPR?

• Voice changes or hoarseness
• Difficulty swallowing
• Frequent coughing or choking
• A feeling of “something in my throat” (the medical term for is globus sensation)
• Excessive mucus
• Postnasal drip
• Bad / bitter taste in the mouth
• Heartburn

Patients do not typically have all of the above symptoms

What are some of the risk factors for developing LPR?

• Tobacco use
• Alcohol use
• Being overweight
• Stress
• Eating at bedtime
• Eating large meals
• Lying down or exercising after eating
• Drinking carbonated, caffeinated and/or citrus based beverages
• Eating foods high in fat/grease or spice
• certain foods such tomato based products, citrus fruit, chocolate, licorice and mint

Caffeine, Chocolate, licorice, and mints have all been shown to increase the stomachs acid production.

Carbonated beverages, even if caffeine free can cause LPR because the carbonation can cause acid to rise up the esophagus into the throat.

Alcohol doesn’t actually increase the production of acid, but it relaxes the smooth muscles in the esophagus that usually help keep the acid from rising all the way into the stomach.

How is LPR diagnosed?

Usually the doctor can diagnose LPR by examining your throat and voice box in the office. No special preparation is needed for this examination.?The doctor will use a mirror and light, or a special flexible camera (flexible laryngoscope). The tissue in your throat and voice box may look red, irritated and swollen from the acid reflux (backflow) damage. This will eventually go away with lifestyle changes and medication, however, the healing may take a while.

Below is the video from a flexible laryngoscopy that demonstrates some of the findings seen in patients with LPR.

Below is a very well done video that was produced by the Georgia Health Sciences University that discusses how reflux can affect the voice box.

Treatment:
Traditional heartburn can be treated with several medications such as traditional antacids, H2 Blockers (Pepcid, Zantac), or Proton pump inhibitors (PPIs). ?LPR symptoms typically do not respond to antacids or H2 Blockers and require treatment with PPI’s.

Proton pump inhibitors stop stomach acid from forming. The ones currently available are:

• Aciphex (rabeprazole)
• Nexium (esomeprazole)
• Prevacid (lansoprazole) (over the counter Prevacid is 1/2 the prescription strength)
• Prilosec (omeprazole)? (over the counter Prilosec is 1/2 the prescription strength)
• Protonix (pantatoprazole)
• Dexilant (dexlansoprazole)
• Zegerid (omeprazole/sodium bicarbonate)

While treatment of LPR can be successful with once a day dosing, often patients have to take the medications twice a day to eliminate their symptoms. These medications (with the exception of Dexilant) need to be taken 30-60 minutes prior to eating to be maximally effective.
The purpose of these medications is to decrease acid exposure so that the larynx can heal. It isn’t until the larynx has healed that the patients symptoms improve. It can take several weeks to even months of consistent treatment with PPIs before for symptoms begin to improve. Do not expect an overnight, instantaneous improvement.

I tell patients that the irritation caused by the reflux is kind of like a callus that a carpenter gets on his hands from chronic use. Even when the carpenter retires, it takes time for the callus to soften and resolve. Even after starting on a reflux medication, it takes a while for the larynx to heal, which is why it can take weeks to even months before the symptoms resolve.

What else can be done to control LPR?

Some medicines increase the acid levels in your stomach and cause more symptoms of your LPR. Review all of your medicines including over-thecounter and dietary supplements with your doctor. Do not stop any medicines without speaking to the doctor that prescribed them. These medicines include (but are not limited to):

• Non steroidal anti-inflammatory drugs such as aspirin, ibuprofen
• (Advil) and naproxen (Aleve)
• Vitamin C
• Alpha Blockers: Dibenzyline
• Theophylline: Theodur
• Anticholinergics: Scopolamine
• Beta Blockers: Inderal, Metoprolol
• Calcium Channel Blockers: Calan, Cardizam, Procardia
• Progesterone: Provera, oral birth control pills

Lifestyle Modifications:

• Eat small more frequent meals.
• Drink eight, 8-ounce glasses of water.
• Elevate the head of bed 4 to 6 inches.
• Quit smoking.
• Maintain a normal body weight.
• Elevating the head of the bed

This last item can be achieved by sleeping on extra pillows or placing bricks or risers under the feet of the head of the bed. Alternatively several wedge pillows are available that achieve similar results. Several are available on amazon.com, here is a link to one of them. I am not sure which of these pillows are considered the "best".

Limit these foods and drinks:

• Alcohol including wine
• Caffeinated beverages
• Carbonated beverages
• Citrus based beverages
• Citrus fruits
• Fatty foods Spicy foods
• Tomato-based foods Chocolate, licorice and mint

Do not:

• Wear tight clothing.
• Exercise or sing after a meal.
• Lie down after eating.
• Eat for 3 hours before going to bed.

While LPR is responsible for many complaints of postnasal drainage, cough, throat clearing, globus sensation and hoarseness, many other causes exist. If you have any of these symptoms for a prolonged period of time, you should be evaluated to rule out more serious causes.

-- M. Benjamin Brindley, MD

Tonsil Stones and a New Way to Get Rid of Them

editor — Sat, 16 Jun 2012 15:20:04 +0000

Tonsil stones, called tonsiliths or tonsiloliths, are concretions that form in the pockets of your tonsils. They are extremely common. While not dangerous or an health risk in and of themselves, they can cause irritation at the back of the throat (like the sensation of a popcorn kernal stuck back there), and bad breath (known as halitosis).

Dr. Christopher Chang, an otolaryngologist in Virginia, and I have completed a small study evaluating the efficacy of a new conservative treatment option for tonsil stones. It was the lead article in the ENT Journal for June 2012. Here is a picture and link to the abstract of that paper.

Dr. Chang also has a short video showing the technique on a patient who is under general anesthesia.

If you suffer from tonsil stones that are difficult to control with conservative treatment options, come see us for a visit.

--Richard D. Thrasher III, MD

Hearing Aid Pearls Pt 2

editor — Tue, 12 Jun 2012 14:05:30 +0000

In an previous post we discussed 10 hearing aid pearls to help guide patients through the hearing aid experience. Here are 11 more tips.

11. If you are a Military Veteran, see if you can get it through the VA system. They have good brands and service, but it depends on if you qualify for aids through the VA. Below is a link to an article on getting hearing aids through the VA system that may help
How to Apply for Hearing Aids through the Veterans Administration

12. Don’t expect hearing aids to work like glasses. Patients frequently make this comparison and are disappointed. People imagine that they will “Put on a hearing aid and presto I can hear.” Unfortunately this is not often the case. Frequently if the audiologist programs the aid based on what the audiogram suggests the patient needs, the patient actually won't like it. Often this will be because the sound will seem like too much. Some find these settings painful. It is not uncommon that an audiologist has to start the aid out at lower settings than the patient needs and then dial it up after a few weeks.

- While this is a drawback at first, it is a benefit later on if your hearing changes. When your vision changes, well, its time for new glasses. Rather than having to buy new hearing aids, often the settings can be adjusted to accommodate further hearing loss.

13. Studies show that incorporating hearing aids into your life is a process, NOT an instant fix. It takes 2-3 months to realize the full benefits of their use. Hearing involves the brain as well as the ears. People lose hearing gradually, and they adjust to it. Many are comfortable with what they are used to, namely NOT HEARING. Hearing is a change that for some may be uncomfortable. The sounds they enjoyed not hearing--squeaky doors, crying babies, motorcycles, sirens, sometimes their spouse or other relatives, are now heard and are bothersome. The more gregarious a person is, the more motivated they will be to use hearing aids.

14. Patient acceptance of hearing aids is as variable as patient acceptance of any other elective procedure. Some take to them like a duck to water. Others will never accomplish it, even with maximum patience and persistence by the both the patient and hearing aid dispenser. Most are somewhere between the extremes. Success is highly variable and not totally predictable. It does take a motivated patient who wants to hear. People will not wear hearing aids for any length of time purely for the benefits to their friends and family.

15. The more you can tell your audiologist about your needs (where you have the most trouble, what your work environment is like, etc) when deciding on a hearing aid helps them pick the best product for you. And if it doesn't work well for you, or if it works well in some places but not in others, let them know and this may be able to be fixed. If not, possibly a different aid might be better (which is why the return policy is important).

16. The smaller the hearing aid

a. The less electronics that can be put into it
b. The more maintenance it will require
c. The more likely it is to be lost
d. The faster it will use its necessarily smaller batteries
e. The smallest aids do not have room for directional microphones or volume control knobs.

17. Hearing aid can come in a variety of sizes. Each size/style comes with its own benefits and drawbacks. Some are more appropriate for certain types of hearing loss and your audiologist can make recommendations based on your hearing test. Here is general description of the various styles from smallest to largest:

a. Completely-in-the-canal hearing aids
b. In-the-canal hearing aid
c. In the ear
d. Behind the ear

The image below from Oticon breaks the sizes down even further and discusses the various benefits and drawbacks of each. Click on the photo to enlarge.

18. Bells and Whistles. Hearing aids are coming out with all sorts of bells and whistles to encourage the consumer to buy a specific hearing aid. Whether or not they are worth the extra money depends on several factors including the patient’s type of hearing loss, work environment, cell phone use, etc. It is really up to the patient (and sometimes the audiologist) to determine which bells and whistles they want. Here are just a few of the options:

a. Directional versus omnidirectional microphones. Traditional hearing aids amplified all of the sounds around you. This could be fine, or if you are in a noisy environment may actually make things worse. Some hearing aids now have a directional microphone that when in a noisy environment will only amplify the sounds in front of you instead of every sound. Do you really need to hear the bus boy cleaning up the table behind you or the baby crying two booths over?
b. Bluetooth. Can really help if you have to use the phone often. Can also be used to connect to musical sources such as MP3 players, televisions, etc.
c. Multiple program settings. Hearing aids can now have multiple settings based on the patient’s preference and environment. They can have a setting for noisy environments, music, quiet environments, outdoors, etc. Each of these programs can be individually adjusted or modified based on the persons needs. Some of these hearing aids require the patient to press a button to toggle between the settings. Some hearing aids are getting so advanced that the hearing aid itself can judge what type of environment it is in and automatically adjust to the appropriate setting with out the wearer having to do anything.
d. Integration with other technology. Some hearing aids allow the user to change the volume or programs using PDA’s or smart phone apps.

19. Watch out for dogs (and other pets). Not sure why, but dogs seem to love hearing aids. If your not careful, your slippers may not be the only thing Fido chews up. Unlike the slippers though, the dog can actually swallow the hearing aids. I am sure that other pets have done the same and I don’t want to single out dogs, but just haven’t personally heard of a cat or rabbit doing the same thing.

20. With the small hearing aids, KEEP THEM AWAY FROM YOUR PILLS. I had a patient call me once after he couldn’t find his hearing aid one morning. He takes several pills and swore he took all of them. Could not find one of his hearing aids but did find one of his blood pressure medications he thought he had taken. In his rush that morning, he treated his high blood pressure with a hearing aid. Unfortunately it did not lower his blood pressure, and once he realized his error, probably actually raised it some.

21. Kidding aside, if you have small children, you need to make sure to keep the hearing aid batteries out of reach. Ingestion of hearing aid batteries, watch batteries, etc can result in significant damage if swallowed due to the corrosive acids that can leak out. Can also cause problems if stuck in a child’s nose or even ear. Click here for an article on the dangers of button batteries and children.

-- M. Benjamin Brindley, MD

TransOral Robotic Surgery (TORS)

editor — Wed, 06 Jun 2012 21:53:12 +0000

The Ear Nose & Throat Centers of Texas is proud to introduce TORS for obstructive sleep apnea to Collin County utilizing the DaVinci robot

Dr. Thrasher has completed extensive training travelling to the University of Pennsylvania as well as Baylor Medical Center in Houston to become certified on the robot. This is the first of several posts designed to introduce the robot and its uses for improving the care of patients in North Texas. We welcome you to ask questions and come in for a visit if this is a medical condition.

The first video is of Shaq describing his experience being diagnosed with sleep apnea.

While CPAP is the best option for the treatment of OSA, for those who cannot or will not use it, surgery, particularly utilizing the DaVinci robot, can be quite successful compared to surgical techniques that were available just 5 years ago.

Scent and Sensibility

editor — Tue, 05 Jun 2012 08:30:24 +0000

"I get no respect, I tell ya"

As far as the 5 senses go, smell doesn’t get any respect.

Often when we are kids we argue about which would we rather be, blind or deaf. You never hear anyone debating on whether they would rather be blind, deaf, or lose their sense of smell. In fact, most people don’t even know that the medical term for loss of smell is Anosmia.

Anosmia (pronounced /æ n ??z m i ?/) is a lack of functioning olfaction, or in other words, an inability to perceive odors.

Olfactory bulb – sends nerve fibers across the skull base to smell receptors that line the roof of the nasal cavity

Just like there are degrees of hearing loss and degrees of visual loss, there are also some patients who have decreased sense of smell. This is referred to as hyposmia.

Anosmia can be caused by a variety of problems such as

Often multiple items on this list cause the anosmia. For instance often we see patients with a deviated septum that prevents airflow to the smell receptors, but also has nasal allergies or smokes which further inflames the nasal mucosa and narrows the nasal passages further.

These causes can be categorized into three different types.

Problems with the conduction of the actual odors to the receptors in the nose

Sinus infections
Nasal Polyps
Nasal masses
Deviated nasal septum
Upper respiratory infections
Cigarette Smoke

Problems with the nerve receptors themselves

Head Trauma
Cigarette Smoke
Intranasal drug use
Post Laryngectomy patients

Problems with the brain that interfere with the brain registering the smells.

Head Trauma
Parkinson’s Disease
Alzheimer’s Disease
Brain tumors

Head trauma patients who sustain head trauma, especially from high-speed car crashes, can suffer from anosmia.

The brain sloshes back and forth from the sudden stop and shears the nerves (that are fixed to the bone in the skull base) that go to the smell receptors.

Often this type of anosmia can be permanent

This one case demonstrates how nasal masses or lesions can cause decreased sense of smell.

70 y.o. female who presents with 10 year history of decreased sense of smell and decreased taste. Symptoms began gradually many years ago has not changed in years. Did not have any workup for this until she came in with a different complaint. Had some mild nasal congestion. She uses nasal steroids, which helps her congestion some but has no impact on her sense of smell.

Flexible nasal endoscopy was performed that demonstrated bilateral masses that blocked air from getting to the smell receptors.

CT scan was performed to better visualize the nasal masses. In these series of scans, the first scan is the actual CT scan, and the second is the same CT scan but the nasal mass has been highlighted in red.

The patient recently underwent surgery and the pathology demonstrated a rare but benign nasal lesion called Respiratory epithelial adenomatoid hamartomas. Hopefully removing these will help her anosmia.

Anosmia can cause health concerns that many people are not aware of. Natural gas is actually odorless, but the smell that we associate with natural gas is actually added so that we can smell gas leaks. Without a sense of smell, you would not be able to detect gas leaks or fires as quickly. It also protects us from eating or drinking spoiled food. It is not uncommon for patients with anosmia to get food poisoning from drinking expired milk or other foods. Also, smell plays an important role in taste and people with anosmia frequently notice that their food doesn’t taste as good.

If anosmia is caused by the odors not getting to the smell receptors, often it can be reversed. If the problem is due to a deviated nasal septum, enlarged nasal turbinates, nasal masses, nasal polyps or chronic sinusitis, surgical intervention often can correct the problem.

If nasal allergies are cause, treatment of this often help decrease edema in the nasal cavity and increases nasal airflow to the roof of the nose where the smell receptors are located. These can be controlled with oral antihistamines, nasal steroids, nasal antihistamines, allergy shots, and avoidance of known allergic triggers. Some also advocate nasal saline irrigation to help wash allergens and pollution off of the nasal mucosa as well.

If the patient is a smoker, quitting can help the sense of smell return. The tobacco products can cause nasal congestion, which causes anosmia, but also can be toxic to the smell receptors. These receptors can regenerate but it can take months after a patient quits smoking for this to occur.

Increased attention has been given to anosmia in recent years as it is frequently seen in Alzheimer’s and Parkinson’s disease. Some studies have even suggested that detection of anosmia (not from nasal masses as the patient above), may be a predictor of developing either of these diseases.

If the problem is caused by problems with the smell receptors or the way the brain processes the smell, often nothing can be done.

So what should a person do they think they have anosmia? Evaluation by an otolaryngologist is a first step. The evaluation looks into causes and possible treatments based on the suspected cause. The workup can vary based on the individual patients symptoms and physical findings. In cases where it is permanent, the person should take safety measures to protect themselves. Gas leak detectors are available for these patients that detect natural gas that are similar to carbon monoxide detectors.

References:

Eloy J, Friedel ME, Eloy J, Mirani NM, Liu JK. Bilateral olfactory fossa respiratory epithelial adenomatoid hamartomas. Arch Otolaryngol Head Neck Surg. 2011;137(8):820-822. doi:10.1001/archotol.137.8.820.

-- M. Benjamin Brindley, MD

Hearing Aid Pearls Pt 1

editor — Fri, 01 Jun 2012 10:00:58 +0000

So you have hearing loss, what now?

Hearing loss can result from a variety of causes

While conductive hearing loss can often be restored; sensorineural hearing loss is usually permanent.

If the hearing cannot be restored, then the main option available to a patient is hearing aids (unless hearing loss is bilateral and severe, in which case they may be a candidate for a cochlear implant which is a whole different discussion).

Patients who are considering hearing aids are often overwhelmed when they start researching their options. It is my hope that this post will act as a guide to help simplify and guide people through this decision.

Hearing Aids Pearls

Consumer Reports July 2009 issue had a great review of the process of buying hearing aids, and most of it can be found online without a subscription to Consumer Reports at this link. Their recommendation was to get hearing aids from an office that has both an ENT (otolaryngologist) and an audiologist in the office (I am biased since I work in this kind of an office). This way you get a thorough evaluation. Their research showed that people who purchased their hearing aid from a company staffed by both an otolaryngologist and audiologist were more satisfied with their purchase.
- Why is there a difference? As mentioned above, there are some medical causes of hearing loss that can be reversed. It is not uncommon to see a patient that has gone to a "members only wholesale warehouse club" or some free standing hearing aid center and been sold a hearing aid even though their hearing can be restored with either a surgery or other interventions. The main problem is that these free standing facilities make money of off hearing aid sales and telling a patient they need to see an ENT does not sell hearing aids.
- Realistic expectations. Some patients have profound hearing loss with word recognition scores around 10-15 % (means that even when you correct for the hearing loss with amplification, the patient still only understands about 10-15% of the words they hear). Often patients with this degree of hearing loss have been sold hearing aids and are under the impression that the hearing aid will fix everything. It is not necessarily inappropriate to sell this type of patient hearing aids because they may find it helpful, but often they are not informed about the poor word recognition. This is most likely because the audiology technician/salesman does not want to risk losing a sale.
- This often leads to disgruntled patients and often these are the patients that give hearing aids a bad name. When I see a patient with that severe of hearing loss, I usually let them know that the benefit from an aid may be limited and make sure they have realistic expectations.
- The only way the freestanding audiologist can make money is by selling hearing aids. The physician's office isn’t going to close because you didn't buy aids or the most expensive ones.
If you go to a free standing hearing aid center, make sure it is staffed by an audiologist and that you are seen and evaluated by an actual audiologist and not an audiology tech or hearing aid dispenser. A hearing aid dispenser or technician may not have much more than a high school diploma while an audiologist usually has their masters or doctorate in Audiology.
Pick a location close to home. Hearing aids often need to be adjusted or tweaked and if you have to drive an hour to get it serviced, you are not going to and will just be unhappy with your hearing aid.
Pick a place that has been around for a while. This is again for the same reason as pearl #3. After buying a hearing aid, you would hate to discover that the establishment you obtained your hearing aids from has closed.
Base your purchase on your hearing and not what looks best. Many people want in-the-ear aids. Depending on the pattern of your hearing loss, this may not be the best style of hearing aid for you. Your audiologist will be able to tell you which style of hearing aid will work best for you based on your individual hearing loss.
Be aware that if you don't like the hearing aid(s), you can return in and get most of your money back if returned in 30 days. This is considered standard in most states.
Talk to family and friends and see whom they recommend (and who they don't recommend). Also ask why they feel the way they do.
Some insurance companies are now trying to sell hearing aids to their customers. The patient has his or her hearing checked and then mails in the audiogram. Someone from the insurance company then calls and lets you know which hearing aid you need based on the results. These hearing aids are cheaper than other aids due to bulk purchasing. The main problem with this is that the insurance companies have not established any way for the hearing aid wearer to have the aid adjusted. An audiologist usually can adjust hearing aids with software from the manufacturer. To my knowledge, these insurance companies have not provided the software to audiologists so that these hearing aids can be adjusted. When purchasing a hearing aid, you are buying not only the product, but also the ability to service the product. Currently these programs only provide the hearing aid but none of the service. It is a pretty new program, but I suspect that the patients that go this route may not be as happy with their hearing aids as other consumers.
Don't be pressured into buying an aid. If they seem like a used car salesman, go elsewhere.
I recommend going somewhere that offers more than just one brand of hearing aid. Often there are benefits to each aid and you should have more selection than one brand. Some of the better known brands include (in no particular order): Phonak, Oticon, Unitron, Starkey, ReSound, Siemens, Sonic, Widex

Look for more hearing aid pearls in part two of this blog article. It will discuss such things as hearing aid models/styles, hearing aids through the Veterans Hospital system, and adjusting to life with hearing aids.

- M. Benjamin Brindley, MD