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Even singers may suffer from recurrent tonsillitis and strep that may warrant tonsillectomy with or without adenoidectomy. But unlike non-singers, there is a significant concern that this common operation may adversely affect the singing voice whether in terms of sound, resonance, reliability, and/or stamina.

Over the years, there have been a few studies to investigate what changes to the voice may or may not occur in the singing population, in particular, whether any adverse changes may occur to the singing voice.

In 2001, researchers reported that 4% of singers felt an immediate adverse change in resonance that resolved with time. Additionally, 13% felt an adverse change in voice reliability and 17.4% reported an adverse change in stamina. With respect to reliability, this did resolve with time. However, 4.3% stated continued adverse change in stamina that did not resolve with time.

Beyond that, 25-52% of singers reported no change (whether for better or worse) in any of these criterias.

About 80% reported overall improvement in quality of life (presumably due to less frequent tonsillitis).

One year later in 2002, researchers attempted to more objectively evaluate what vocal changes may occur after tonsillectomy. Before and 1 month after surgery, 10 patients' (not necessarily singers) voice were analyzed using Multi-Dimensional Voice Program with focus specifically on F0, formant freq and bandwidth, jitter, shimmer, and NHR. Overall, they found only minimal changes and therefore, only little effect on the acoustic parameters measured.

In 2008, researchers attempted to evaluate additional objective parameters. Before and 1 month after surgery, 40 male adults' (not necessarily singers) voice were tested using the Multi-Dimensional Voice Program (fundamental frequency, Jitter percent, Shimmer, noise-to-harmonics ratio, voice turbulence index, soft phonation index, degree of voiceless, degree of voice breaks, and peak amplitude variation) as well as nasal resonance, speech articulation, and voice handicap index.

The data showed that 1 month after tonsillectomy, there were improvements in all acoustic parameters:

• subjective decrease of hyper-nasality
• improvement of speech articulation and VHI were achieved
• reduction of the nasal resonance
• Mean F0 decreased from 195 to 168Hz.
• Jitter, Shimmer, NHR, VTI, SPI, DUV, DVB, vAm all significantly decreased 1 month after tonsillectomy (these are all measures of how raspy the voice is)

Why would tonsillectomy (a supralaryngeal structure) influence voice which originates at the laryngeal level? After all, tonsil removal doesn't physically change the voicebox and its contents.

It is speculated that large tonsillar tissue has a damping effect causing a reduction in quality and precision of the vocal sound output. Such damping effects influence the "noise" that the voicebox produces. Also, tonsillar tissue may cause important turbulent air flow through the vocal cords leading to resistance that can interfere with regular voice production. Furthermore, a decrease in airflow resistance after tonsillectomy may also result in less laryngeal adductor force necessary for phonation.

More simplistically stated, consider an organ pipe. The large diameter organ pipes have a different fundamental pitch compared with a small diameter organ pipe. Furthermore, consider the amount of air pressure required when blowing through a small diameter pipe vs a large diameter pipe.

Removing the tonsils essentially changes the diameter of the "pipe" above the vocal cords (from a small diameter to a large diameter) resulting in subtle but measurable changes in acoustic parameters.

Just from my own personal observations having performed tonsillectomy in singers, there is an unfortunately prolonged period of adjustment for singers to "relearn" how to sing with their "new" throat after tonsillectomy that may last months and sometimes even up to one year. Back-to-basics singing lessons and practice may be required before a singer will feel totally comfortable and re-achieve exquisitely precise control over every aspect of their voice.

Keep in mind that this singing adjustment period is totally different and separate from the immediate post-surgical recovery from pain and healing which typically lasts about 3-4 weeks.

References:
Tonsillectomy and Its Effect on the Singing Voice. Arch Otolaryngol. 1942;35(6):915-917. doi:10.1001/archotol.1942.00670010923008

Tonsillectomy and adenoidectomy in singers. J Voice. 2001 Dec;15(4):561-4.

Effects of tonsillectomy on speech spectrum. J Voice. 2002 Dec;16(4):580-6.

Effects of tonsillectomy on speech and voice. J Voice. 2009 Sep;23(5):614-8. doi: 10.1016/j.jvoice.2008.01.008. Epub 2008 May 12.



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Over the years, I have been asked by a number of patients with deviated septums what problems may occur if un-corrected, especially if such patients are also suffering from recurrent nosebleeds. In particular, can a deviated septum be the underlying trigger that causes a septal perforation to occur (purple arrow below)?



Well, this blog article is to answer that very question. But first off, a little anatomy...

A nasal septum is a wall that separates the right nasal cavity from the left side. Normally, this septum should be perfectly straight.


However, in some people, the septum may be deviated causing not only nasal obstruction, but increases the risk of nosebleeds.



When the septum is straight, nasal breathing proceeds such that the air smoothly enters the nose without creation of any turbulence.



However, if the septum is deviated, turbulence is created when the air hits the "curve" of the septum. When this happens, the lining of the septum becomes dried out resulting in cracking and increased vascularity which increases the risk of a nosebleed.



The lining of the nose in this situation is much like when a person's lips become so dried out to the point that it cracks and bleeds. Over the years, the septal mucosa in this region may become so damaged that if not fixed, it may ultimately lead to a septal perforation right where the bend of the deviated septum is present.

What makes this situation worse is that such patients will often use nasal sprays to help alleviate symptoms, but nasal sprays like afrin on their own can also cause septal perforations if over-used. Nose-picking also is not unusual in these patients as boogers can get trapped where the septal deviation is located. Nose-picking also is a risk factor for septal perforation due to repetitive fingernail trauma against the septum.

Finally, nasal cauterization which is often employed to stop nosebleeds can cause septal perforations as it works by cauterizing the offending blood vessel. Although this would help stop a nosebleed, it would also risk devascularizing the septal mucosa... resulting in a septal perforation.

That said, deviated septums as a whole RARELY leads to septal perforations and patients as a general rule should not be overly concerned that this WILL happen if they have a deviated septum. Nose-picking, afrin over-use, and nasal cauterization also RARELY cause septal perforations as well.

But, it does happen.



Nosebleed Control by Cauterization (Silver Nitrate and Electrical) - YouTube
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Pretty exciting, but Dr. Chang has co-authored a peer-reviewed journal article on the topic of velopharyngeal dysfunction that was published in the June 2019 journal of Neurographics. Most of his other co-authors all belong to the Department of Radiology at the University of Virginia.

Velopharyngeal dysfunction or insufficiency (VPI) is a condition when the soft palate does not close properly separating the oral cavity from the nasal cavity during speech and swallow. Watch the video below to learn more about this condition.

The journal article is mainly geared towards radiologists and how imaging can be used to evaluate this unusual condition. Although ENTs can diagnose this condition with a nasal endoscope, some VPI conditions can only be truly evaluated using some type of radiological imaging, the current state of the art being real-time MRI.

VPI can be surgically corrected if more conservative management (ie speech/swallow therapy) fails to adequately correct.

In any case, click here to read the full-article. (To download, you have to click whether you desire HTML or PDF once you go to the journal's website.)

Reference:
Velopharyngeal Dysfunction: What a Radiologist Must Know. Neurographics. 9(3):201-211; 2019.


What is VPI (Velopharyngeal Insufficiency)? - YouTube


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MyoGuide: Ultra-Portable EMG for Otolaryngologists (ENT) - YouTube


A new video has been created describing the use of an ultra-portable EMG device called MyoGuide. I've probably been using this compact unit for almost 10 years and given its usefulness and durability, felt a video on this device warranted, especially for otolaryngologists. Most EMG units are huge and require a small cart to move around, but this unit is the size of a hand.

The compact unit contains a high-fidelity amplifier with built-in audio speaker and EMG signal display. Although not sufficient for diagnostic uses which may limit its appeal to neurologists, it is plenty good enough for procedural directed needle placement. Such procedures include botox injections for spasmodic dysphonia, cervical dystonia, facial spasms, etc. Although most otolaryngologists will use EMG for passive muscle activity detection, active stimulation is also possible.

The device is made by Intronix Technologies, a Canadian company, but distributed in the United States by Allergan.
Check out the video!
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Sense of Balance: Truth AND Consequences | Steven Rauch | TEDxKenmoreSquare - YouTube


TEDx talk on balance and dizziness given in May 2019 by Dr. Steven Rauch, Harvard Professor of Otolaryngology and Vestibular Division Chief at the Massachusetts Eye and Ear.


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It is not uncommon that an adult patient presents with a neck mass to an ENT clinic. Unfortunately, upon workup which typically includes a needle biopsy, the neck mass comes back showing cancer, usually, a type of cancer called squamous cell carcinoma, although lymphoma, mucoepidermoid carcinoma, etc occasionally occurs as well. In this blog article, we will focus specifically on the case of the neck mass being squamous cell carcinoma.

At this point, the patient's main concern is what's next? This situation medically is known as cervical metastasis from squamous cell carcinoma of unknown primary (SCCUP) origin. 

The most important part of treatment is finding the primary source of this cancer such that it is no longer an "unknown primary." The neck mass itself is not the "source," rather it is the result of a cancer found somewhere else in the throat region; it metastasized from somewhere else. The most common primary source of head and neck squamous cell carcinoma with an unknown primary is the tonsil and base of tongue although the cancer can literally occur from any part of the lining of the voicebox, mouth, and back of nose.

Why is it important to (try) and find the primary?

It's because subsequent definitive cancer treatment with surgery, radiation, and chemotherapy can be more focussed and therefore less intense with less side effects. If the primary cancer location is not able to be identified, then treatment with radiation and even chemotherapy requires a wide area of treatment extending from the nose and down to the voicebox region with consequent significant side effects affecting this wide region (radiation burn, trouble swallowing, loss of taste/smell, dental damage, etc).

In the effort to find the primary cancer in order to avoid such a wide field of treatment (beyond nasal endoscopy and a careful physical exam), directed biopsies are performed under general anesthesia which more recently would also include bilateral tonsil removal (if tonsils are still present).  

This situation is one of those in which you definitely WANT the biopsy to come back showing cancer as that would mean the primary site has been identified and subsequent treatment can be de-intensified resulting in less side effects.

If the neck mass is only on one side, why are both tonsils removed? It's because studies have shown that the primary cancer site occurs up to 10% of the time from the side opposite the neck mass!

References:
Role of palatine tonsillectomy in the diagnostic workup of head and neck squamous cell carcinoma of unknown primary origin: A systematic review and meta-analysis. Head Neck. 2019 Apr;41(4):1112-1121. doi: 10.1002/hed.25522. Epub 2018 Dec 21.

Prevalence of synchronous bilateral tonsil squamous cell carcinoma: A retrospective study. Clin Otolaryngol. 2018 Feb;43(1):1-6. doi: 10.1111/coa.12981. Epub 2017 Sep 25.

Investigation and management of the unknown primary with metastatic neck disease: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol. 2016 May;130(S2):S170-S175.


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With spring coming, people are sneezing quite a bit more. However, with more sneezing, there's also more people who try to hold their sneeze for social reasons.

Dr. Chang was contacted by Health.com regarding what bad things could happen if you hold in your sneeze. The article was published on April 24, 2019.

Quoted from the article:
"...the list of possible consequences is scarier than the trailer for Us. We’re talking: fractured cartilage around your voice box, neck pain, fractures of bones in your face, rupturing of ear drums, hearing loss, ear infections, vertigo, air trapped under a layer of skin, broken ribs, hernias, vision changes, and ruptured aneurysms, says Christopher Chang, MD, a Warrenton, Virginia-based otolaryngologist-head and neck surgeon with Fauquier ENT Consultants. All from a sneeze, nervous friends. (Just last year, you might remember, the internet lost its mind when a 34-year-old man ruptured his throat from holding in a sneeze.)

Otolaryngologists call a stifled sneeze a “closed-airway sneeze,” Dr. Chang explains. “When a sneeze is initiated, a lot of pressure builds up in your lungs, and the sneeze is let out all at once forcefully,” he says.

He tipped me off to a 2000 report from the journal Clinical Infectious Diseases that found a stifled sneeze can produce up to a whopping 176 millimeters of mercury (mm Hg) of pressure. Don’t ask me to explain why millimeters of mercury is used to measure pressure, but instead compare that to how much pressure is produced when you let a sneeze rip: a measly 4.6 mm Hg. That is a dramatic difference, Dr. Chang confirms, and “when you hold in a sneeze, that pressure has to go somewhere.”

Our bodies are somewhat flexible and stretchy, obvi, so he likens us to soccer balls: “A soccer ball probably won’t pop, but rarely it could, if you exert enough pressure. It can stretch and come back to normal form. Just like a soccer ball, enough pressure could cause damage to the body, but it’s pretty rare.”

Weirder still is that you, the stifler of sneezes, control where that misdirected pressure goes in your body—which could then affect what unsuspecting and undeserving body part ruptures, fractures, or breaks. If you’re a nose pincher, you’re forcing that pressure searching for an “out” hole up into your face, making it more likely to rupture an eardrum or screw with your vision, Dr. Chang says. Someone who closes their throat to trap sneeze pressure in their chest is more likely to deal with a rib fracture or vocal cord damage.
Read the full article here!


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Image From Butterfly Network
I had the good fortune of being able to test-drive an amazing new product called the Butterfly iQ. It is an ultra-compact, pocket-sized, portable ultrasound device for under $2500 when most ultrasound machines cost tens of thousands of dollars. The entire ultrasound technology is built into the handheld body itself. Real-time images are viewed on a smartphone via a wired connection. This one ultrasound can be used to image the entire body!

The cost of ultrasound devices are set to drop dramatically over next few years heralded by the Butterfly iQ. This is due to new technological developments where the traditional ultrasound transducer with expensive piezo crystals is replaced with a markedly cheaper “ultrasound on a silicon chip.” I would not be surprised if ultrasound devices eventually approach commodity status where even children can buy a "toy" ultrasound for a reasonable price just like they can with microscopes currently.

As of April 2019, the Butterfly iQ device is $1999 with a required 1 year subscription to cloud services for image storage that is $420 (individual cost).

Check out my Butterly iQ video review below.

Butterfly iQ: Pocket-Sized Ultrasound - YouTube



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With spring coming, people are running more outside. However, with the nice weather, allergies are also flaring up. So what should an allergic runner do?

Dr. Chang was contacted by journalist Corey Stieg regarding this very situation, in an article published by Refinery29 on April 8, 2019.

Quoted from article:
If you have trouble breathing because your nose feels stuffy, for example, using a steroidal nasal spray ahead of time, such as Flonase or Nasacort, can be very helpful, explains Christopher Chang, MD, a board-certified otolaryngologist in Warrenton, VA. "Such nasal sprays minimize nasal congestion and blockage," because they're applied directly into the nose to reduce nasal passage swelling, he says. Plus, they tend to have minimal side effects.

To that point, many allergy sufferers might balk at taking an antihistamine medication before a run, such as Zyrtec or Benadryl, because they tend to make you feel very drowsy. But if you're someone whose allergy symptoms extend "beyond the nose," such as a skin rash, then you would benefit from an oral antihistamine, such as Allegra, before your run, Dr. Chang says. If you've never taken allergy medications before, it's a good idea to check with your doctor or healthcare provider first.

From there, your post-run routine is as important as the preparation. "When back home, take a shower immediately for good measure," Dr. Chang says. That'll help get any pollen or debris off of your face, skin, and eyelashes. Using a neti pot with a saline solution can also help flush anything out of your nose that would continue causing problems, he adds. Finally, if you're having trouble falling asleep after an evening run because of allergy symptoms, you may want to take Benadryl, he says.
Read the full article here!

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Normal Septum without Mucosal Swelling
Allergies are very common and is well known to contribute to nasal obstruction. A deviated septum and turbinate hypertrophy are also common anatomic reasons for nasal obstruction as well. As such, it is also not uncommon that patients suffering from bad allergies also have nasal anatomic reasons for nasal obstruction.

The quandary is whether surgical intervention to resolve nasal obstruction will actually work if the same patient also has bad allergies.

The answer is YES... with a big BUT.

• Such patients must understand that surgery will NOT cure allergies and that allergy management will still need to occur even after surgical intervention.

• Nasal obstruction may STILL occur if allergies flare up during a particularly bad pollen season or with extensive animal exposure to pets you are allergic to.

• The perceived benefit after nasal surgery from patients with very bad allergies will not be as significant compared to patients with only mild allergies.

That said, the benefit of having nasal surgery even with bad allergies are that the nasal obstruction and congestion symptoms are not as bad and that allergy attacks have to be more severe in order to cause equivalent significant sino-nasal symptoms.

Why?

Because after nasal surgery, there is more "space" for allergy-triggered swelling to occur before nasal obstruction happens. Take a look at what happens after a septoplasty in the images below. The blue arrow points to a deviated septum in the first image, whereas the septum is straight in the second image.


Compared to the normal septum without mucosal swelling shown at the very top... allergy-triggered mucosal swelling will certainly cause some degree of nasal obstruction and congestion even after surgery as shown in the second image above. However, in the setting of a deviated septum, the nasal obstruction and congestion will be more severe as shown in the first image above.

Same is true after turbinate reduction... Allergies will still cause the turbinate mucosa to swell... but will not occur as severely after surgical reduction.

Reference:
A Prospective Study of Outcomes of Septoplasty with Turbinate Reductions in Patients with Allergic Rhinitis. Otolaryngol Head Neck Surg. 2019 Mar 26:194599819838761. doi: 10.1177/0194599819838761. [Epub ahead of print]


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