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June 28, 2017

Swab Culture is Inaccurate Test for Determining Tonsillitis

A fascinating study came out in June 2017 that compared the bacteria found on the tonsil surface by swab versus bacteria found within a core needle biopsy versus bacteria found within the dissected tonsil's core. The take home finding is that a swab culture poorly identifies the bacteria causing recurrent tonsillitis.

Based on 54 children who underwent tonsillectomy, researchers performed a swab, needle biopsy, and core dissection of all tonsils removed. Culture results obtained from all three different methods of sampling were than compared.

The infectious agent obtained from the dissected tonsil core is considered the most accurate to which  the other two methods (swab and needle biopsy) are compared.

What they found was that:

• Culture results obtained from the three methods were in agreement only 63% of the time.
• 16.7% of the surface swab cultures grew something different from pathogens obtained via the other two methods.
• In another 5.6%, the surface swab culture came back negative while the two core cultures were positive for the same pathogens.
• The results of needle biopsy culture and dissected core culture were in agreement 85.2% of the time.
• In only 7.4% did the core needle biopsy culture fail to accurately identify the infectious agent.
• Overall, the sensitivity and specificity of core needle biopsy sampling was 100 and 50% respectively, compared with 82.9 and 30.8% for the superficial tonsillar swab.

In conclusion, getting a swab culture of the tonsil provides the wrong answer not uncommonly.

Obtaining a core needle biopsy provides a more accurate answer to the putative infectious agent, but I doubt that this more invasive test is something that can be tolerated in children in the office, especially given kids already HATE getting just a simple swab done.

As such, although the swab culture is unlikely to go away in the near future even though it's accuracy is questionable, one should consider the results only as a guide rather than a statement of fact and greater weight should be given to clinical findings in deciding whether a presumed tonsil infection is present or not.

Interestingly, the most common organism found in this study was staph aureus... not strep. Keep in mind that rapid strep tests can ONLY say whether strep is present or not... it doesn't tell whether any other organisms are present or not. Other organisms found include Klebsiella, Moraxella, Enterococcus, coagulase-negative staph, pseudomonas, and E coli.

While we are on topic, watch this video explaining why it takes several days to get culture results.

A comparison of tonsillar surface swabbing, fine-needle aspiration core sampling, and dissected tonsillar core biopsy culture in children with recurrent tonsillitis. Ear Nose Throat J. 2017 Jun;96(6):E29-E32.

June 24, 2017

Hearing Loss Helped Thru Music Therapy

Image courtesy of surasakiStock
I have observed that musicians tend to cope with hearing loss much better than those without a music background, even if both have the same level of hearing loss on a hearing test. In particular, musicians with hearing loss tend to understand speech much better in noisy environments whereas non-musicians with hearing loss have trouble even with a hearing aid.

I have also noticed that as one ages, understanding speech in noisy environments with multiple speakers becomes more difficult even with a normal hearing test, especially in non-musicians.

Why is that?

When it comes to understanding speech, normal brain processing is required to interpret the sound the ear picks up.

Speech and non-speech sounds are basically noise. What makes speech special is that there is meaning embedded within the sound. The ear's job is to just pick up sound no matter what the sound is. But it is the brain that takes in all the sound picked up by the ear, processes the sound, and than gives meaning by interpreting sound due to speech. Otherwise sound is just sound without any inherent meaning to it.

With age, not only does memory start to diminish, but also the brain's ability to process sounds start to diminish as well leading to not so much "hearing loss" per se, but "understanding loss."

That's why hearing aids can only help so much in this situation... hearing aids amplify ALL sounds as it is not able to distinguish between "speech" sounds vs other types of sounds. The brain STILL has to process all the sounds being picked up and give meaning to any speech sounds that may be present.

So why do musicians with or without hearing loss able to "understand" so much better than non-musicians in noisy environments?

It's because musicians have over years strengthened the auditory pathways and brain circuits to isolate melodies and pitches from one another. A violinist in an orchestra can literally hear individual sounds made from other instruments in the orchestra effortlessly.

A non-musician may be able to appreciate the orchestral music as a whole, but would have trouble humming/singing back the sound produced ONLY by the viola section, for example.

So how can a non-musician learn to understand better in noisy environments whether hearing loss is present or not? It's what I call hearing music therapy. This type of treatment is being investigated more aggressively now. NPR even did a story on this type of music therapy to help with hearing loss early in 2017.

For those patients who may benefit from this type of hearing therapy, I suggest the following:

1) Join a chorus (typically, a church choir)
2) Listen to classical music and pick one instrument to follow the sound it makes throughout the entire song ignoring all else. Start with trios before moving on to quartets, than string orchestras, than full symphonic orchestras. I usually suggest Mozart, Bernstein, or Copland as starting points.
3) Spend at least 30-60 minutes a day performing this activity (even if it is in a car going to and from work)

When doing such music therapy, it should not be a passive activity. One has to ACTIVELY listen and work at it regularly, otherwise, improvement will not be expected to occur.

More Info:
'Like Brain Boot Camp': Using Music To Ease Hearing Loss. NPR 5/31/17

Hearing and music in dementia. Handb Clin Neurol. 2015; 129: 667–687.

Auditory Reserve and the Legacy of Auditory Experience. Brain Sci. 2014 Dec; 4(4): 575–593.

June 23, 2017

Ear Skin Tags in Babies and Their Removal

Image by Kalus D. Peter in Wikipedia
It is not uncommon that a baby is born with "skin tags" around the front of the ear. They are also NOT the same as the skin tags that develop later in adulthood which are benign and easily removed. Infant skin tags may contain not just skin but also fat and cartilage. Infant ear tags often occur by themselves, but sometimes may occur in association with anomalies of the kidney, inner ear,  craniofacial bones, and potentially other structures.

The pediatrician will often evaluate for any systemic abnormalities that are associated with infant ear tags, but often will refer such patients to an ENT to get hearing testing done to determine whether any hearing loss is present due to abnormal inner ear development.

As long as such ear tags, which are known as accessory tragus or branchial cleft remnant, lack cartilage and have a narrow stalk, they can potentially be tied off and strangulated using a thread. However, if cartilage is present or the base is too wide to tie off, removal would require surgical excision. Ear tags will not go away on their own.

When such ear tags are on the ear around the helix or tragus, there is minimal risk present with excision.

However, if the tag is located further away from the ear and is located more over the cheek region, there is a very real risk of permanent facial paralysis because the facial nerve is located just under the skin. In some cases, the skin incision itself made to remove the skin tag may accidentally cut or injure the facial nerve resulting in paralysis.

Facial Nerve is Colored PURPLE
According to one study in 12 infants (necropsy), the facial nerve can be located just 4mm below the skin. I get paper cuts deeper than that! The facial nerve can also be located only 5mm from the ear canal. For a frame of reference, 4-5mm is basically shorter than the length of this dash:  —

With time (years), the facial nerve gets buried deeper and deeper away from the skin such that by adulthood, the facial nerve is located 2cm or more below the skin around the ear region (closer to the surface towards the midline face and deeper under the skin further away from the midline).

As such, one typically waits until around 4 years old before removing skin tags that are more on the cheek region rather than on the ear in order to minimize risk of facial nerve injury.

Facial Nerve Identification in Children. Otolaryngol Head Neck Surgery 93:173-176; 1985

Anatomy of the facial nerve in fetuses and stillborn infants. Plast Reconstr Surg. 1966 Jun;37(6):566-74.

The early development of the parotid gland around the facial nerve and its branches in man. Anat Rec. 1970 May;167(1):63-77.

June 15, 2017

Vocal Cord Changes Throughout the Menstrual Cycle

It is not unheard of that a fertile female singer experiences slight fluctuations in the quality of the voice throughout the menstrual cycle. In particular, in the immediate premenstrual period, up to 40% of female singers may note a deeper shift in the vocal range, tone inaccuracy, and/or tendency to develop vocal cord hemorrhage.

Such vocal changes are hypothesized to be secondary to the affect of estrogen and progesterone on the vocal fold tissues, and especially any blood vessels that may be present. Such changes may include vascular dilation, vocal cord edema, and reduced laryngeal muscle tone.

An interesting study came out in 2017 assessing the anatomical and functional features of the vocal cords during different phases of the female menstrual cycle. In particular, the laryngeal vascular changes were described in 17 healthy fertile female volunteers not using hormonal contraception.

Two examination were performed, the first early in menstrual cycle when progesterone levels are lowest and the second during pre-menstruation when progesterone levels are highest.

Not surprisingly, increased laryngeal vascularity was seen when progesterone levels are highest suggesting increased vocal cord congestion during premenstrual days.

These findings may explain any hormone-related alterations which may lead to variable vocal performance in some, but not all women. (Most women do not experience any vocal changes throughout the menstrual cycle.)

In particular, women who experience a larger difference between peak and trough levels of progesterone may experience greater variability in vocal quality due to more dramatic changes in laryngeal vascularity.

In such female singers who suffer from vocal quality variability in relationship to the menstrual cycle, birth control pills have been helpful to minimize this fluctuation both from a hormonal as well as vocal perspective.

Menstrual Cycle, Vocal Performance, and Laryngeal Vascular Appearance: An Observational Study on 17 Subjects. J Voice. 2017 Jun 5. pii: S0892-1997(17)30113-3. doi: 10.1016/j.jvoice.2017.05.001. [Epub ahead of print]

Variations in vocal frequency perturbation across the menstrual cycle. Journal of Voice. September 1989Volume 3, Issue 3, Pages 233–243

Does a hormonal vocal cord cycle exist in women? Study of vocal premenstrual syndrome in voice performers by videostroboscopy-glottography and cytology on 38 women. Journal of Voice. June 1989Volume 3, Issue 2, Pages 157–162

The impact of hormonal fluctuations on female vocal folds. Curr Opin Otolaryngol Head Neck Surg. 2004 Jun;12(3):180-4.

Voice and speech changes in various phases of menstrual cycle. J Voice. 2013 Sep;27(5):622-6. doi: 10.1016/j.jvoice.2013.02.006. Epub 2013 Mar 15.

The Effect of Menstrual Cycle on Singing Voice: A Systematic Review. J Voice. 2017 Mar;31(2):188-194. doi: 10.1016/j.jvoice.2016.04.018. Epub 2016 May 24.

A study of voice changes in various phases of menstrual cycle and in postmenopausal women. J Voice. 2010 May;24(3):363-8. doi: 10.1016/j.jvoice.2008.10.005. Epub 2009 Jan 29.

Association between birth control pills and voice quality. Laryngoscope. 2004 Jun;114(6):1021-6.

Effect of the menstrual cycle on voice quality. Arch Otolaryngol. 1978 Jan;104(1):7-10.

June 12, 2017

Beat Boxer Tom Thum Posts Endoscopic View of His Voicebox

Dr. Matthew Broadhurst and beat-boxer Tom Thum produced a video showing what the voicebox looks like when beat-boxing.

Click this link to see what beat-boxing looks like on an MRI scan.

Video showing general information regarding laryngoscopy:

Ancient Maori Technique of Eardrum Perforation Repairs - Chicken Bone and Cobwebs

New Zealand ENT Dr. David Grayson alerted me via Twitter to the interesting factoid that the Maori (indigenous Polynesians of New Zealand) were performing eardrum perforation repairs using a technique that is startlingly similar to the way eardrum repairs today are performed. Of course, we currently use instruments better than a chicken bone and spider cobwebs.

Read the description!

This description was documented by Sir Patrick Eisdell Moore (1918-2015).

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VIDEO: How Does the Human Voicebox Work?


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