The Lack of Smell

Many patients present with a loss of smell. The majority present after the loss of existing sense of smell went away. Some of these can be attributed to blockage (polyps, infection, tumors, etc), some to destruction (infection, toxin, etc), some to metabolic disorders (diabetes, thyroid, etc) and there are those that are inherited, life-long disorders. All lead to risk (can not smell spoiled food, can not detect smoke, etc) or decreased quality of life (effect on taste and smell, lack of perception of subtle smells in environment, etc). Many do not find it of importance to be pursued. I would argue that any change of physiology that is noted and persists should be examined. It may not be of life-threatening concern (nasal cancer for example) but it can certainly be examined and considered – we all know the adage, early detection equals early cure. Late stage anything is bad to find.

What about those born without smell. Well a recently published and interesting article discussed this. Those who are born without a sense of smell (called hyposmia) can be divided into two groups. One group, called Type I, have genetic abnormalities that show up in brain, gonadal and other somatic (body) abnormalities. These individuals will typically have a family history of smell disorders. Another group, Type II patients don’t have a family history of smell loss nor any somatic abnormalities and lack the family history. In general, it is reported that 12% of individuals born without a sense of smell are type I and 88% type II. It is interesting that both have a similar degrees of loss of smell.

When examining the patient who presents with a complaint of loss of smell it is important to elicit any history of nasal or systemic disease, head injury or any pathology which contributed to their smell loss. It is also important to learn if the patient was the result of a normal pregnancy and delivery and normal developmental milestones. Learning of a loss of smell function is usually a gradual discovery, with most reporting learning this around age 9–12 years. Generally discovered after noting others are able to notice and respond to odors they could not.

Evaluating patients is critical to learn more. Evaluation should include an extensive history, physical examination of their head and neck, measurements of of smell and taste, laboratory studies of blood, urine, saliva and nasal mucus as well as radiology exams.

If there are not found anatomical, infectious, neoplastic, or other disorders as cause, and it is thought to be possibly inherited, some have tried pharmacological therapies. Response to theophylline has been shown. Theophylline can lead to onset of side effects which vary from mild symptoms of irritability to more severe symptoms of sleep disturbance, tachycardia (fast heart rate) and gastrointestinal discomfort. Use of this agent can be dangerous and must be considered with caution.

Theophylline is a long known drug and belongs to the class of drugs known as methylxanthines. It has been used for over 100 years! Olfactory receptors are interesting. They have neither blood vessels nor lymphatics and do not exhibit mitosis (nuclear division). The olfactory system is dependent on stem cell regeneration to grow receptors. Growth factors are critical to this process. Theophylline may play a role in this.

You can learn more about this topic by looking to this article:

American Journal of Otolaryngology
Vol 37, Issue 3 May-June 2016 pages 175-181
Initiation of Smell Function in Patients with Congenital Hyposmia

If you have any questions regarding disorders of ear, nose, throat, cancer, thyroid / parathyroid, please do not hesitate to call. ENT is trained in 7 core areas during a 5 year residency after medical school inclluding allergy, facial plastic and reconstructive surgery, head and neck, laryngology, otology, pediatric otolaryngology, and rhinology. We are the only surgical specialty dedicated solely to this area above the clavicles.

Philip Harris, M.D. FACS
MidMichigan Physicians Group
Midland / Gladwin / Bay City
Phone (989) 839-6201
www.midmichigan.org/mpg

Are you seeing and treating otitis externa?
Otitis externa (OE), or swimmer’s ear, is very common. In some individuals, the acute form of OE leads to chronic otitis externa (COE). COE is defined as a single episode lasting longer than 4 weeks or more than 4 episodes of OE in 1 year. It is estimated to affect 3%of the population and has a proven negative impact on the quality of life of those inflicted. The end stage of dis-ease, medial fibrosing otitis externa, is very challenging to repair.

Acute otitis externa (AOE) is most often infectious in origin, and can be easily treated with a combination of topical antibiotic and steroid preparations. Systemic antibiotics are rarely needed for AOE. Chronic otitis externa (COE) can be more difficult to treat, but if an underlying cause can be identified this condition can often be successfully managed. In both AOE and COE, pre-vention is fundamental.

The shape of the osseous external auditory canal (OEAC) has often been suggested in literature to be an etiologic factor in COE Clinically we observe that certain shapes are likely to be involved in the development of a chronic inflammation because they hamper proper cleaning of the OEAC. Observation is that curvature of the OEAC, both anteriorly and inferiorly, is a possi-ble cause of this inability of (self) cleansing. Another possibiolity could be that both anterior and inferior curvatures lead to intertriginous eczema as sharper angles enable skin-to-skin contact when inflamed, thus perpetuating the inflammation and leading to chronic disease.

The region of the anterior and inferior curvatures of the OEAC is called the pretympanic recess (PTR) and is located just before the tympanic membrane. Other names include pretympanic sulcus, tympanic sulcus, pretympanic sinus, and inferior tympanic recess. The entire shape of the OEAC plays a role within
COE.

Tacrolimus, a nonsteroidal immunosuppressant, and fluocinolone acetonide oil 0.01%, a medi-um-high potency steroid preparation, may offer additional therapeutic options in the struggle against this inflammatory ear canal/skin condition of often unknown cause. No single therapy will be successful for every patient with COE. The search for an underlying cause, the removal of all possible irritants to the ear canal skin (e.g. Q-tips, water), debridement, and both topical and occasionally, systemic therapy will control (not cure . . .) the disease process in the vast majority of patients.

You can learn more about this topic by looking to these resources:

Otology & Neurotology. 35(10):1790-6, 2014 Dec.
Primary Care; Clinics in Office Practice. 41(1):1-9, 2014 Mar
Current Opinion in Otolaryngology & Head & Neck Surgery. 19(5):341-7, 2011 Oct.

If you have any questions regarding hearing loss or other area of ear, nose, throat, head and neck cancer, sleep surgery, thyroid and parathyroid, please do not hesitate to call. ENT is trained in 7 core areas over a 5 year residency after medical school: allergy, facial plastic and reconstructive surgery, head and neck, laryngology, otology, pediatric otolaryngology, and rhinology. We are the only surgical specialty dedicated solely to this area.

Philip Harris, M.D. FACS
MidMichigan Physicians Group
Midland / Gladwin / Bay City
Phone (989) 839-6201
www.midmichigan.org/mpg

What to do with the tongue for sleep apnea?

Obstructive sleep apnea (OSA) is a common disease and a morbid disease. It is characterized by narrowing and collapse of the pharyngeal airway during sleep that leads to reductions (so called hyppnea) and cessation (apnea) of airflow.

The gold standard to treat moderate to severe disease is continuous positive airway pressure. A large portion of patients however are not compliant and do not get the health benefits of CPAP treatment of OSA. For reference, when adherence is defined as > 4 hours of use per night, 50-80% of patients are labeled as non-adherent. In addition, compliance goes does down after one year of therapy. Talk about depressing. All the money and resources going to treat a disease and not good compliance! Crazy right?

Well, what about surgery? Uvulopalatopharyngoplasty (UPPP) was introduced in 1980 and continues as a surgical therapy. The modest results of overall success of 40% in un-selected patients is not inspiring (but it is more effective in selected patients and even in the unselected, shows benefit since it “can not be taken off” like a CPAP device may be). Why does UPPP fail? Obstructions can occur at many areas along the upper airway and more than 50%  of patients with OSA have multiple levels of collapse. In the obese and severe OSA patient (Apnea- Hypopnea Index > 30), the tongue base accounts for a significant portion of residual obstructions. Specific treatments, such as partial glossectomy, hyoid suspension, genioglossus advancement, and radiofrequency are used alone or as part of multilevel procedures to improve surgical success. Partial glossectomy can include midline glossectomy (MLG), submucosal minimally invasive lingual excision (SMILE), and lingualplasty (LP). Transoral robotic surgery (TORS) improves the visualization of the surgical field, maximizes tissue removal while minimizing risk to vital structures when performing glossectomy procedures for sleep apnea and cancer. 

So does glossectomy work to treat OSA? There is data to show that including glossectomy as part of a multilevel surgical plan does improve outcomes across 4 independent sleep metrics, including apnea-hypopnea index, Epworth sleepiness scale, lowest oxygen saturation (LSAT), and snoring visual analog scale (VAS).  A recent article by Murphey et al in Otolaryngology-Head and Neck Surgery 153(3) focused on this exact issue.

If you have any questions regarding chronic cough or other area of ear, nose, throat, head and neck cancer, sleep surgery, thyroid and parathyroid, please do not hesitate to call. ENT is trained in 7 core areas over a 5 year residency after medical school: allergy, facial plastic and reconstructive surgery, head and neck, laryngology, otology, pediatric otolaryngology, and rhinology. We are the only surgical specialty dedicated solely to this area.

Philip Harris, M.D. FACS
MidMichigan Physicians Group
Midland / Gladwin / Bay City
Phone (989) 839-6201
www.midmichigan.org/mpg

What to do with the nasal valve for sleep apnea?

Obstructive sleep apnea is the most common type of sleep-disordered breathing. As obesity prevalence increases, so does OSA. A risk factor for OSA is nasal obstruction. Nasal obstruction can result from multiple causes. Mucosal inflammation, structural abnormalities,  and more lead to nasal obstruction. Treating septal deviation, nasal valve compromise, and turbinate hypertrophy help to address structural abnormalities but do they help treat OSA? 

The nose accounts for more than 50% of upper airway resistance, a surprising large amount. Physiological changes in sleep lead to lower upper airway resistance in individuals breathing through the nose. Mouth breathing is associated with 2.5 times higher airway resistance and narrowing of the the pharyngeal lumen. Bypassing the nose leads to decreased nitric oxide distribution to the lower airway, changes of muscle tone, changes in spontaneous breathing and sleep regulation. 

How then to address this important passageway in treating sleep disorder breathing? The first-line treatment is medical. This may include nasal steroid, nasal irrigations, positional changes, and treatment of inflammatory processes (allergic, infectious, etc). Surgical correction may include septoplasty, nasal valve reconstruction, or turbinate reduction. These medical and surgical interventions may improve nasal flow, allow tolerance and better compliance to continuous positive airway pressure (CPAP) masks. It is important to note that septoplasty alone may not address anatomical obstruction and should be done in conjunction with other procedures such as nasal valve correction when goal is to address nasal obstruction. 

Well, does it help to correct nasal obstruction? A recent article did address than and found that isolated nasal surgery for patients with nasal obstruction and OSA led to significant improvements in Epworth Sleepiness Scare and Respiratory Distress Index but no singnificant improvements in Apnea-Hypopnea Index.  See Ishii et al Otolaryngology-Head and Neck surgery 153(3). 

If you have any questions regarding chronic cough or other area of ear, nose, throat, head and neck cancer, sleep surgery, thyroid and parathyroid, please do not hesitate to call. ENT is trained in 7 core areas over a 5 year residency after medical school: allergy, facial plastic and reconstructive surgery, head and neck, laryngology, otology, pediatric otolaryngology, and rhinology. We are the only surgical specialty dedicated solely to this area.

Philip Harris, M.D. FACS
MidMichigan Physicians Group
Midland / Gladwin / Bay City
Phone (989) 839-6201
www.midmichigan.org/mpg

What about otitis externa?

It is not uncommon for a patient to present with a painful ear that spreads to pain of the temple, jaw and neck. How do we identify the cause and treat this accordingly?

Acute otitis externa (AOE) is defined as generalized inflammation of the external ear canal, with or without involvement of the pinna or tympanic membrane. Clinicians should be aware of modifying factors that can or may alter management (eg, diabetes, immunocompromised state, prior radiotherapy, tympanostomy tube, nonintact tympanic membrane). AOE is uncommon before age 2 years, and very limited evidence exists with respect to treatment or outcomes in this age group. A diagnosis of diffuse AOE requires rapid onset (generally within 48 hours) in the past 3 weeks of symptoms and signs of ear canal inflammation.   In AOE, one commonly finds tenderness of the tragus, pinna, or both, that is often intense and disproportionate to what might be expected based on visual inspection.

Nearly all AOE in North America is bacterial. The most common pathogens are Pseudomonas aeruginosa and Staphylococcus aureus, often occurring as a polymicrobial infection. Other pathogens are principally gram negative organisms (other than P aeruginosa), which cause no more than 2% to 3% of cases in large clinical series. Fungal involvement is distinctly uncommon in primary AOE. Topical antimicrobials are beneficial for AOE, but oral

antibiotics have limited utility. In our office, we will thoroughly clean the ear canal and then place an ear wick to allow 360-degree and full length distribution of aural antibiotic to canal.

Viral infections of the external ear, caused by varicella, measles, or herpesvirus, are rare. Herpes zoster oticus (Ramsay Hunt syndrome) causes vesicles on the external ear canal and posterior surface of the auricle, severe otalgia, facial paralysis or paresis, loss of taste on the anterior two-thirds of the tongue, and decreased lacrimation on the involved side.

Pain relief is a major goal in the management of AOE. Frequent use of analgesics is often necessary to permit patients to achieve comfort, rest, and to resume normal activities. Administering a nonsteroidal anti-inflammatory drug during the acute phase of diffuse AOE significantly reduces pain compared with placebo. Use of appropriate antibiotic in an appropriate manner and with steroid addition leads to more rapid healing. Ototopical drops should be applied with the patient lying down and the affected ear upward. The amount required will vary with the age and size of the patient. Gentle to-and-fro movement of the pinna is often necessary to eliminate trapped air and to assure filling, particularly when a viscous solution is used. The patient should remain in this position for about 3 to 5 minutes.

If you have any questions regarding this or other area of ear, nose, throat, head and neck cancer, sleep surgery, thyroid and parathyroid, please do not hesitate to call. ENT is trained in 7 core areas over a 5 year residency after medical school: allergy, facial plastic and reconstructive surgery, head and neck, laryngology, otology, pediatric otolaryngology, and rhinology. We are the only surgical specialty dedicated solely to this area.

Philip Harris, M.D. FACS
MidMichigan Physicians Group
Midland / Gladwin / Bay City
Phone (989) 839-6201
www.midmichigan.org/mpg

What is venous thromboembolism and why is it important to ENT?

Venous thromboembolism is the process of blood clots forming in the veins of the body and then dislodging .

Venous thromboembolism can be an early sign of cancer. How do we screen for occult cancer in a person who presents with an unprovoked venous thromboembolism? A recent multi-center study in Canada looked at this and was published in the NEJM 373;8 by Carrier et. al. 

The prevalence of occult cancer is low among patients with a first unprovoked venous thromboembolism and cost of screening can be high. Obvious value is gained in identification of occult cancer but costly to find. 

Venous thromboembolism is the third most common cardiovascular disorder. It is considered provoked when associated with a risk factor (trauma ,surgery, prolonged immobility, pregnancy, etc) and not provoked when neither a strong transient risk factor nor overt cancer. 

Up to 10% of patients with unprovoked venous thromboembolism receive a diagnosis of cancer in the year after their diagnosis.  The prevalence of occult cancer was low among patients who were studied and routine screening with CT of the abdomen and pelvis did not provide a clinically significant benefit. It is wise to tell the patients of the 10% number but to not pursue expensive fishing expeditions in every case.  You can learn more by reading NEJM 373;8 by Carrier et. al. 

If you have an unexplained venous thromboembolism, you should consider these causes. Head and neck cancer is commonly associated with this disorder as well.

If you have any questions regarding this or other area of ear, nose, throat, head and neck cancer, sleep surgery, thyroid and parathyroid, please do not hesitate to call. ENT is trained in 7 core areas over a 5 year residency after medical school: allergy, facial plastic and reconstructive surgery, head and neck, laryngology, otology, pediatric otolaryngology, and rhinology. We are the only surgical specialty dedicated solely to this area.

Philip Harris, M.D.
MidMichigan Physicians Group
MidMichigan Medical Offices – McCandless 1                     
2520 McCandless Drive         609 Quarter Street                   Euclid Ave.                             
Midland, Michigan 48640      Gladwin, Michigan 48624        Bay City, MI
Phone (989) 839-6201
www.midmichigan.org/mpg

Hoarseness

There are many causes to hoarseness. A particular cause is paralysis of the vocal cord. This may be the left or the right vocal cord.

Hoarseness caused by left vocal fold paralysis can be due to diseases of the heart (cardiomegaly, mitral stenosis with enlarged left atrium), aorta (aortic arch aneurysm), esophagus (carcinoma), thyroid (cardinoma), or mediastinal lymph nodes (bronchial carcinoma, sarcoidosis, TB, lymphoma, silicosis). Any of these pathologies can destroy, compress, or stretch the vagal nerves, the thoracic sympathetic outflow, and the laryngeal recurrent nerves. The left laryngeal recurrent nerve, in particular, is more commonly affected than the right nerve by a pathologic mediastinal process because of it’s longer intrathoracic course around the aortic arch. However, the etiology of vocal cord paralysis is unknown in approximately 15% of cases. If vocal fold paralysis is found on laryngeal endoscopic examination for cough or hoarseness, further work-up should be pursued to explore this wide differential. 

If you have any questions regarding chronic cough or other area of ear, nose, throat, head and neck cancer, sleep surgery, thyroid and parathyroid, please do not hesitate to call. ENT is trained in 7 core areas over a 5 year residency after medical school: allergy, facial plastic and reconstructive surgery, head and neck, laryngology, otology, pediatric otolaryngology, and rhinology. We are the only surgical specialty dedicated solely to this area.

Philip Harris, M.D. FACS
MidMichigan Physicians Group
Midland / Gladwin / Bay City
Phone (989) 839-6201
www.midmichigan.org/mpg

ENT includes the skin of the head and neck. A syndrome that may be noted is Sweet Syndrome.

What is Sweet syndrome and how does it relate to ENT?

Sweet syndrome is acute febrile neutrophilic dermatosis, a disorder of unknown etiology. It has been associated with autoimmune processes, malignancies, infections, drug reactions, and gastrointestinal disorders, such as inflammatory bowel disease. It can present as severe pain in the tongue and throat or referred pain to the ear. Sweet syndrome is a severe dermatologic disease. Affected patients present with an abrupt onset of tender plaque or nodules and accompanying fever, arthralgias, ophthalmologic manifestations, headaches and, in rare cases, oral or genital lesions.

The diagnosis of Sweet syndrome is confirmed by biopsy. The findings are significant for a neutrophilic dermatosis with interface involvement of the epidermal/dermal junction. Once diagnosed, underlying diseases and / or paraneoplastic syndromes should be sought. First-line treatment for Sweet syndrome is prednisone at 0.5 to 1.5mg/kg/day tapered over 2-4 weeks.

If you have any questions regarding chronic cough or other area of ear, nose, throat, head and neck cancer, sleep surgery, thyroid and parathyroid, please do not hesitate to call. ENT is trained in 7 core areas over a 5 year residency after medical school: allergy, facial plastic and reconstructive surgery, head and neck, laryngology, otology, pediatric otolaryngology, and rhinology. We are the only surgical specialty dedicated solely to this area.

Philip Harris, M.D. FACS
MidMichigan Physicians Group
Midland / Gladwin / Bay City
Phone (989) 839-6201
www.midmichigan.org/mpg

Obstructive sleep apnea affects over 15% of the population, presenting a major health burden. Sleep apnea leads to cardiovascular, pulmonary, metabolic and neurocognitive morbidity.

Sleep-related breathing disorders are a common problem in children and involve a spectrum of abnormalities ranging from habitual snoring to obstructive sleep apnea (OSA). Habitual snoring is defined as occurring at least 3 nights per week and not associated with obstructive apneas, sleep fragmentation, or gas exchange abnormalities. OSA, the most severe entity in the spectrum of sleep-related breathing disorders, is defined by recurring partial or complete obstruction of the upper airway during sleep accompanied by snoring, repeated arousals, oxygen desaturations, and hypercapnia. OSA can lead to a variety of undesirable sequelae, which range from the physiologically severe, such as cardiovascular complications and failure to thrive, to the less severe but more psychologically important symptoms, such as excessive daytime sleepiness, behavioral disturbances, hyperactivity, attention problems, and poor school performance.

Methods to identify imaging modalities that supplement polysomnography eliciting potential sites of airway obstruction are important. The posterior airway space and tongue base are primary areas of airway obstruction in OSAS and sleep disordered breathing.
CT imaging and sleep endoscopy have been used to accurately assess the posterior airway space (PAS), sedated endoscopy is invasive, and repeated CT imaging risks higher radiation exposure and does not assess the dynamics of the tongue base and PAS. The use of a modified barium swallow study (MBS) as a simple modality to measure PAS is another option. It is simple, has lower radiation, and gives a dynamic tongue base visualization, which may help predict surgical outcomes.

Cephalometric measurements of the PAS can be obtained by using PACS imaging measurement instrumentation, measuring millimetric distance from the posterior pharyngeal wall to the tongue base, at the level of a line drawn from the gonion to the supramentale. MBS may provide less radiation exposure (1-1.5 mSv) than CT of the Head & Neck (3-10 mSv), in a non-invasive modality, and does not require sedation. MBS allows for cephalometric measurement while assessing tongue base movement and changes in the PAS in real time.

If you have questions regarding sleep apnea, airway obstruction, or other ENT areas, please do give us a call at MidMichigan Health.

What came first, my sinus problem or my reflux problem?
Chronic rhinosinusitis (CRS) and gastroesophageal reflux disease (GERD) are common entities that overlap in patient demographics. The pathophysiologic role of GERD has yet to be elucidated, but it is postulated that extraesophageal reflux may contribute to worsening symptoms of CRS.

What do you tell your patient?

GERD occurs when retrograde flow of gastric contents outside of the stomach causes either symptoms or mucosal abnormalities. Symptoms of GERD can be divided into esophageal symptoms (eg, pyrosis and regurgitation) and extraesophageal symptoms (eg, asthma, laryngitis, otits media), with one-third of GERD patients suffering from extraesophageal symptoms. Retrospective analysis of patients undergoing endoscopic sinus surgery (ESS) have found GERD as the only pre-operative characteristic predicting ESS failure. Patients with GERD and CRS still experience similar quality-of-life and endoscopic gains after ESS as patients without GERD. Patients with endoscopically diagnosed GERD and no evidence of sinonasal inflammation (ie, patients with CRS were excluded) on endoscopy have slowed saccharin transport times.

There is emerging evidence that GERD may play a role in instigating and propagating symptoms of CRS. However, patients who report a history of GERD have a comparable treatment outcome after ESS as those without. Similarly, patients undergoing active medical therapy for GERD have no difference in outcomes after ESS compared to patients with GERD without medical therapy.

More studies are needed to help elucidate the role and clinical significance of GERD in treatment outcomes for CRS.

If you have any questions regarding GERD or other area of ear, nose, throat, head and neck cancer, sleep surgery, thyroid and parathyroid, please do not hesitate to call. ENT is trained in 7 core areas over a 5 year residency after medical school: allergy, facial plastic and reconstructive surgery, head and neck, laryngology, otology, pediatric otolaryngology, and rhinology. We are the only surgical specialty dedicated solely to this area.

Philip Harris, M.D. FACS
MidMichigan Physicians Group
Midland / Gladwin / Bay City
Phone (989) 839-6201
www.midmichigan.org/mpg