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October 22, 2017

Oral HPV Infection is Prevalent in Adult Men

A population study was published in October 2017 revealing a high prevalence of oral HPV infection in men between ages 18 - 69 years.

This study is important because HPV is known to increase the risk of not only cervical cancer, but also oral and throat cancer. And in young adults under 50 years, it causes more throat cancer than even smoking. [more info]

From a public health policy concern, more importantly, it is also "contagious" in that one partner can transmit their HPV infection to their partner via sexual contact.

Here are some key statistics the study revealed.

• The overall prevalence of oral HPV infection was 11.5% in men and 3.2% in women (equating to 11 million men and 3.2 million women nationwide).
• High-risk oral HPV infection was more prevalent among men (7.3%) than women (1.4%).
• Oral HPV 16 was 6 times more common in men (1.8%) than women (0.3%) (1.7 million men vs. 0.27 million women).
• Among men and women who reported having same-sex partners, the prevalence of high-risk HPV infection was 12.7% and 3.6%, respectively.
• Among men who reported having 2 or more same-sex oral sex partners, the prevalence of high-risk HPV infection was 22.2%.
• Oral HPV prevalence among men with concurrent genital HPV infection was fourfold greater (19.3%) than among those without it (4.4%).
• Men had 5.4% greater predicted probability of high-risk oral HPV infection than women.
• The predicted probability of high-risk oral HPV infection was greatest among black participants, those who smoked more than 20 cigarettes daily, current marijuana users, and those who reported 16 or more lifetime vaginal or oral sex partners.

Beyond the obvious of avoiding high risk sexual behavior, one intervention to minimize risk of HPV infection as well as transmission between individuals is to get the HPV vaccine (i.e., gardasil). Ideally, the vaccine should be given during the tween years (ages 11-12 years) BEFORE sexual activity occurs. [More Info]

Of note there are currently 3 FDA approved HPV vaccines and both boys and girls can benefit:

• The bivalent HPV vaccine (Cervarix) which addresses HPV 16 and 18;
• The quadrivalent HPV vaccine (Gardasil) which prevents four HPV types: HPV 16 and 18, as well as HPV 6 and 11;
• And finally Gardasil 9 which prevents 9 HPV types: 6, 11, 16, 18, 31, 33, 45, 52, and 58.

Oral Human Papillomavirus Infection: Differences in Prevalence Between Sexes and Concordance With Genital Human Papillomavirus Infection, NHANES 2011 to 2014. Ann Intern Med. [Epub ahead of print 17 October 2017] doi: 10.7326/M17-1363

October 21, 2017

Video Showing What Surgery Day is Like from a Child's Perspective (Rated G)

Too often, parents expressed to me that online surgery videos like tonsillectomy and ear tubes were too "violent" for them to watch with their child. What is needed is a video that they can watch safely with their child that shows what will happen from a child's perspective, but rated G. No blood, no cuts, and no grossness included.

Due to such requested demand, I finally created a video that is "kid-safe" showing what surgery day will be like for them thru their eyes. Narration of the video is even made by a 4 and 5 years old children.

I deliberately made the video generic enough such that it could apply to any type of pediatric surgery whether neck mass incision, tonsillectomy, adenoidectomy, ear tubes, or even hernia repair.

Check it out!

This video was made with the generation donation of materials, personnel, and space provided by Blue Ridge Orthopaedic and Spine Center and Fauquier Health System.

Soon to come will be a "cartoon" version of surgery day in case that would be more appealing for the child than this non-cartoon version.

October 15, 2017

Migraines Pretending to be Sinusitis

It is shocking to me just how many people suffer from migraine headaches. Even more surprising is just how many people present to an ENT clinic with complaints of a persistent sinus infection when really the sinus pain is actually due to a migraine.

In fact, there are some estimates that up to 80% of patients who present to an ENT clinic with primary complaint of sinus headaches or chronic sinusitis ultimately are proven to be suffering from migraines instead. See references below. This reported estimate is a bit high in my experience which runs more around 50%.

Indeed, the typical history I get goes something like this or some variation thereof:
I have a severe sinus infection that has been going on for months... in fact it is so bad that even though I have taken 3 different antibiotics, it has made no difference in my severe pain and pressure I have over my sinuses.
According to the International Headache Society, a headache is diagnosed as a migraine (regardless of location in the head including over the sinus areas) if the headache meets the following criteria:

Any TWO of these pain qualities:

  • Unilateral pain
  • throbbing pain
  • pain worsened by movement
  • moderate or severe pain


Any ONE of these associated symptoms:

  • nausea
  • vomiting
  • light and noise sensitivity

It is also not unusual for a patient to also complain of systemic symptoms that sound like the flu (muscle and joint aches, malaise, fatigue, chills, loss of appetite, etc).

Given the prevalence of migraines in an ENT clinic, it is not unusual for me to at least initiate migraine treatment along with a referral to a neurologist who are the migraine experts.

To try and prevent migraines from happening in the first place, I recommend patients to start the following over-the-counter supplements which often help decrease frequency and severity of migraines. Of course, one has to take for a few months before appreciating any potential benefit.

Depending on any coexisting medical problems, I may even start a patient on prescription sumatriptan to try and treat any migraines that do occur to see if it helps.

The Sinus, Allergy and Migraine Study (SAMS). Headache 2007 Feb; 47 (2) : 213-24.

Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache. Archives of Internal Medicine 2004 Sep 13; 164 (16) : 1769-72.

Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012 Apr 24;78(17):1337-45. doi: 10.1212/WNL.0b013e3182535d20.

Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012 Apr 24;78(17):1346-53. doi: 10.1212/WNL.0b013e3182535d0c.

October 05, 2017

Balloon Eustachian Tube Dilation to Treat Clogged Ears (VIDEO)

A new video has been uploaded describing how balloon dilation of the eustachian tube is performed for adult patients suffering from persistently clogged ears. Also known as balloon eustachian tuboplasty, this procedure would be considered an alternative treatment to tube placement in the eardrum.

Our office is preparing to offer this innovative treatment sometime in the near future... just not yet currently, so stay tuned. More info here.

September 24, 2017

How Long to Observe After Severe Allergic Reaction (Anaphylaxis)?

A severe allergic reaction affecting multiple different body systems is known as anaphylaxis. Such anaphylactic reactions adversely affect the skin/mucosa, breathing, gastrointestinal, heart rate, and blood pressure. The key thing to remember is that an "ordinary" allergic reaction is localized whereas anaphylaxis is general affecting beyond one body system.

With anaphylaxis, epipen administration is one of the first and BEST intervention. Other complementary medications to treat anaphylaxis include:

• IV fluids
• Steroids - anti-inflammatory
Benadryl - short-acting but potent antihistamine
Zyrtec - long-acting antihistamine
Zantac - yes, the reflux medication, because about 10% of histamine receptors on the skin are H2 (before you ask, yes, the same H2 receptor found in the stomach involved in acid production)
• Inhalers - especially if wheezing or shortness of breath is present

In the vast majority of cases, anaphylactic reactions resolve with these medication interventions.

HOWEVER, the greater fear is whether the reaction will come back.

Known as biphasic anaphylaxis, it is defined as "a potentially life-threatening recurrence of symptoms after initial resolution of anaphylaxis without re-exposure to the trigger".

Biphasic anaphylaxis can typically occur anytime within 4 days, but is reported to occur in only about 10% of patients. However, clinically significant biphasic reaction is felt to occur in around 1% of patients.

SO... the question is how long should a patient be medically observed for biphasic anaphylaxis after successfully treatment of the initial anaphylactic reaction?

There is no consensus on what the ideal duration of observation should be after successful treatment of anaphylaxis, but most treating physicians (emergency room, allergists, and ENTs) would suggest 1-2 hours for mild anaphylactic reactions and up to 4 hours for moderately severe anaphylactic reactions.

Observation in the hospital for 24 hours would be reserved for patients who suffered from severe anaphylaxis with the following history:

• Delayed administration of epipen or required more than 1 dose of epinephrine
• Unknown trigger
• Required multiple IV fluid boluses to treat significant hypotension

With discharge from medical observation, patients are usually instructed to do the following (given the low risk for possible anaphylactic recurrence for up to 4 days):

• Take benadryl every 6 hours and/or zyrtec twice a day for at least 4 days
• Take a course of steroids (I usually prescribe a medrol dose-pack)
• Have an epipen immediately available on hand for at least 4 days
• If symptoms DO recur, administer epipen and go back to the ER

Clinical predictors for biphasic reactions in children presenting with anaphylaxis. Clin Exp Allergy. 2009 Sep;39(9):1390-6. doi: 10.1111/j.1365-2222.2009.03276.x. Epub 2009 May 26.

Biphasic anaphylactic reactions in pediatrics. Pediatrics. 2000 Oct;106(4):762-6.

Time of Onset and Predictors of Biphasic Anaphylactic Reactions: A Systematic Review and Meta-analysis. J Allergy Clin Immunol Pract. 2015 May-Jun;3(3):408-16.e1-2. doi: 10.1016/j.jaip.2014.12.010. Epub 2015 Feb 11.

Update on biphasic anaphylaxis. Curr Opin Allergy Clin Immunol. 2016 Aug;16(4):346-51. doi: 10.1097/ACI.0000000000000279.

Biphasic anaphylaxis: review of incidence, clinical predictors, and observation recommendations. Immunol Allergy Clin North Am. 2007 May;27(2):309-26, viii.

Incidence of clinically important biphasic reactions in emergency department patients with allergic reactions or anaphylaxis. Ann Emerg Med. 2014 Jun;63(6):736-44.e2. doi: 10.1016/j.annemergmed.2013.10.017. Epub 2013 Nov 13.

September 15, 2017

Why do Old Men Have Big Ears?

Or, the better question is how fast does the ear grow as we age. Apparently this research topic was published in 1995 in the British Medical Journal.

The British researcher measured the ear length of 200 patients and discovered that not only do old men really did have big ears but also that ears grow about 2mm per decade after age 30.

This research won the 2017 Ig Prize for Anatomy.

Why do old men have big ears? BMJ. 1995 Dec 23-30;311(7021):1668.

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