About Dr. Jason Hamilton

Jason S. Hamilton, M.D. is the Director of Plastic and Reconstructive Surgery for the Osborne Head and Neck Institute based at Cedar-Sinai Medical Towers. Dr. Hamilton has advanced training in plastic and reconstructive surgical techniques involving the face, head, and neck, and limits his practice to the treatment of these areas exclusively.

• Hereditary Hemorrhagic Telangiectasia - May 25, 2016
• Hereditary Hemorrhagic Telangiectasia: Septal Perforation and Nose Bleeds - May 23, 2016
• Hereditary Hemorrhagic Telangiectasia: Epistaxis and Septal Perforation - May 18, 2016
• Wegener’s Granulomatosis: Autoimmune Disease and Multi-Focal Septal Perforation - May 9, 2016
• Kyle Korver: Facial Injury and Nasal Fracture - March 24, 2015
• Russell Westbrook: Facial Injury and Surgery - March 5, 2015
• Mega-perforation: Pushing the Limits of Septal Perforation Repair - November 26, 2014
• Septoplasty Complication and Septal Perforation - November 24, 2014

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What is Scar Revision?

Scar Revision refers to a procedure that reduces the appearance of scars by matching them to the texture and color of the surrounding skin. It also helps improve function by releasing scar tissue, thereby returning movement to an area of the body (fingers, nose, mouth, eyelids) that may have been tethered by scar tissue. 

Why Do People Get Scar Revision?

There are many reasons to consider scar revision. These include:

• Irritation: scars can be itchy, tender, and painful 
• Function: scar tissue is less flexible and can inhibit function or movement 
• Appearance: scars can make people feel self-conscious, anxious or depressed

Surgical Scars:

Surgical scars can be planned to minimize their appearance, size, and risk of resultant tissue dysfunction. However, some patients heal poorly from even a planned surgical incision and desire scar revision. Post-surgical treatments can be used first to reduce scar size and avoid the need for another surgery. Avoiding the sun or using strong sunblock for a year after surgery will limit hyperpigmentation of the scar. Compression over the scar can reduce hypertrophic scarring, which is when excess collagen accumulates and produces a raised scar. This can be done through taping, gently massaging, or using silicone gel and sheets. However wide, thick, or hyperpigmented scars can still form even if proper post-surgical treatments are implemented. In these cases, scar revision can be considered.

Burn Scars:

Burns may be initially treated with skin grafts, which is the use of healthy donor skin from elsewhere on the body to cover the burn site. 

Donor Sight of the Skin Graft The FDA approved clinical trials for “spray-on skin” in September of 2018. Named ReCell (Avita Medical, Valencia, California), this new technology is an example of an early skin cell regenerator. It enables doctors to produce a suspension of cells by culturing a sample of the patient’s own skin. This suspension contains the cells necessary to regenerate the outer layer of natural, healthy skin and is prepared and applied at the point-of-care in as little as 30 minutes. This could prove an exciting new option in the treatment of burns that will spare the patient the pain of healing a donor site wound. 

Keloids: 

What Are Keloids?

Keloids are raised bumpy scars that form from excess collagen production at the site of tissue trauma. This can happen due to surgery, an accident, or something as simple as ear-piercing in the susceptible individual.

Keloids can be itchy and tender for some people when they are forming, but the itch stops once the Keloid stabilizes. If a keloid does form on a joint it can restrict movement.

People of color are more prone to develop keloids. People under 30 are also at a higher risk. They can appear anywhere on the body; however, keloids are more common on the face, neck, ears, chest or shoulders where there is little underlying fatty tissue. 

Keloids can be painful, itchy, uncomfortable, unsightly and bothersome. People can undergo scar revision to help make these less visible or irritating.

Scar Revision for Keloids:

Removal of the keloid is not advised because the trauma from the incision will simply result in another keloid, and often one that is larger. Alternatives include:

• Cryotherapy: freezing the keloid using liquid nitrogen
• Steroid injections: might decrease itchiness, burning, and redness. It might also help to flatten the keloid and, in some cases, make them smaller. 
• Laser surgery done in conjunction with other treatments can smooth the keloid, reduce discoloration, or flatten the keloid.  
• Topical silicone treatment
• External beam radiotherapy: typically performed in conjunction with a surgical excision for refractory keloids

The post Scar Revision for Surgical, Traumatic, and Keloids Scars appeared first on Los Angeles ENT Doctors ENT Specialists Top Surgeons.

About Dr. Hootan Zandifar

Dr. Hootan Zandifar is board-certified in Otolaryngology and fellowship-trained in Facial Plastics and Reconstructive Surgery. Dr. Zandifar is the director of the Skin Center at the Osborne Head and Neck Institute based at Cedars-Sinai Medical Towers.

• Folded Ear in Newborns: Treatment Options - April 11, 2018
• Newborn Ear Deformity: What Can Be Done? - April 11, 2018
• Ear Molding: An Overview - November 2, 2017
• Otoplasty for Protruding Ears - September 26, 2017
• Basal Cell Carcinoma: Facial Reconstruction Timing - September 26, 2017
• Clinical Considerations of Mohs Reconstruction of Cheek Defect - September 26, 2017
• Basal Cell Carcinoma: Nasal Bridge Reconstruction - September 26, 2017
• Skin Cancers Involving the Eyebrow: Clinical Considerations - October 3, 2016

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The human ear is a vital structure for both hearing and facial symmetry. It is comprised of three regions: the external ear, the middle ear, and the inner ear. The external ear consists of the pinna (externally visible), the external auditory canal (ear canal), and the tympanic membrane (eardrum). The pinna and external auditory canal are responsible for guiding sound waves from the outer world to the tympanic membrane (ear drum). The middle ear starts at the tympanic membrane and houses the three bones that transmit sound vibrations from the external ear to the inner ear as well as the eustachian tube, which extends to the nasopharynx. The inner ear refers to the cochlea, the auditory nerve, and the structures of balance. Structures in the inner ear convert the sound into signals which are sent to the brain’s auditory cortex by way of the auditory nerve and then to the brain. 

The external ear’s reception of sound, the middle ear’s transmission of sound, and the inner ear’s conversion of sound come together to form normal cohesive hearing. Malformation, deformity, or injury of any of the regions results in impaired hearing. 

What is Congenital Anotia?

Congenital anotia is a birth defect that refers to the absence of one (most common, 79-93%) or both pinna(e). This is often accompanied by a more narrow or even nonexistent ear canal. Regardless of the functionality of the middle and inner ears, the patient experiences hearing loss in that region along with a cosmetic deformity. A CT scan can help determine the extent of the deformity. Possible variants include:

• the presence/absence of the external auditory canal
• the presence/absence of the middle ear bones
• the presence/absence of the cochlea. 

Reconstructive surgery to restore hearing and aid transition to school and avoid social stigma would be performed between the ages of 5 and 10 years old. At this juncture, the unaffected ear, if present, will have reached 85-95% of its adult size. The patient will have enough rib cartilage for reconstruction, if this is what is chosen, and the patient will likely possess a sufficient level of emotional maturity.  

What is the method of reconstruction3?

One of the most common and effective procedures for ear reconstruction is the Brent method. It requires four surgeries to construct a functional and aesthetically appealing external ear made entirely from the patient’s own tissue. Each surgery should be performed approximately two to three months apart to ensure proper healing. 

Stages of Brent Method Reconstruction:

1. Rib Cartilage Graft (Harvesting and Placement)

Ear reconstruction begins with the creation of an ear template from the unaffected ear if available. The template is used to approximate the amount of rib cartilage needed for reconstruction. The surgeon then harvests the rib cartilage and molds it into the shape of an ear. The cartilage graft is inserted under the scalp in the ear’s natural position. 

1. Lobule Transposition

Lobule transposition refers to the creation of the ear lobe. 

1. Tragus Construction

The surgeon creates the tragus from a composite graft of the unaffected ear. 

1. Separating the Ear

In the fourth and final surgery, the surgeon elevates the ear structures away from the scalp flap and covers the posterior section with a skin graft. A sulcus (where the ear meets the skull) is now defined and the ear separates from the cranium. 

Can hearing be restored?

Fortunately, the external and middle ear have different embryological origins than the inner ear; therefore, many anotia patients retain the neurological potential to hear despite the deformity. An audiogram, Weber test, and Rinne test must be performed to determine whether the patient suffers from conductive hearing loss or sensorineural hearing loss. A CT scan is also essential in determining the status of the ear canal and middle ear structures. The ear surgeon uses several criteria to determine if the ear canal and middle ear can be reconstructed, or if bone conduction hearing implants should be utilized. The surgery to open the ear canal is called a canalplasty. The surgery to reconstruct the middle ear is called a tympanoplasty. In appropriately selected patients, this surgery can successfully restore the natural hearing mechanism of the ear without the use of a hearing device. 

A Bone Anchored Hearing Aid (BAHA) can be either worn or implanted to restore hearing as long as the patient has a functional cochlea. A BAHA may be worn as a soft headband when the patient is under 5 years old; at the appropriate age, a titanium implant can be coupled to a sound processor to allow even better sound conduction. A BAHA implant does not require any surgery on the ear canal or middle ear, and vital structures such as the facial nerve or inner ear are safe from harm. The implant is placed behind the ear through a small incision on the scalp, and is tightened a few millimeters into the skull. The sound travels through the implant and vibrates the cranial bones to the cochlea instead of through the external and middle ear. 

Key Points:

• Congenital Anotia is the absence of the external ear, often accompanied by a narrow or absent ear canal
• A CT scan is necessary to discover what anatomical elements are absent or malformed along with the best surgical course of action 
• The most beneficial time for ear reconstruction is between the ages of 5 and 10 
• The Brent method is a four surgery process of ear reconstruction that utilizes the patient’s own cartilage and skin 
• An audiogram, Weber test, and Rinne test must be performed to determine the type of hearing loss one suffers from
• BAHA and canalplasty are two ways to restore conductive hearing loss in patients with anotia. 

The post Congenital Anotia and Its Repair appeared first on Los Angeles ENT Doctors ENT Specialists Top Surgeons.

About Dr. Hootan Zandifar

Dr. Hootan Zandifar is board-certified in Otolaryngology and fellowship-trained in Facial Plastics and Reconstructive Surgery. Dr. Zandifar is the director of the Skin Center at the Osborne Head and Neck Institute based at Cedars-Sinai Medical Towers.

• Folded Ear in Newborns: Treatment Options - April 11, 2018
• Newborn Ear Deformity: What Can Be Done? - April 11, 2018
• Ear Molding: An Overview - November 2, 2017
• Otoplasty for Protruding Ears - September 26, 2017
• Basal Cell Carcinoma: Facial Reconstruction Timing - September 26, 2017
• Clinical Considerations of Mohs Reconstruction of Cheek Defect - September 26, 2017
• Basal Cell Carcinoma: Nasal Bridge Reconstruction - September 26, 2017
• Skin Cancers Involving the Eyebrow: Clinical Considerations - October 3, 2016

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Allergies occur when the body mistakenly identifies a harmless substance– such as dust mites or pollen– as a threat and reacts to it with an immune response. Individuals with allergies suffer from symptoms that can interfere with their quality of life. There are many treatments for allergies including avoidance, medication, and immunotherapy, which is a form of desensitization.  Immunotherapy can be administered via sublingual immunotherapy (SLIT – also known as allergy drops) or subcutaneous immunotherapy (SCIT – also known as allergy shots). 

SLIT has been shown to be equally effective to allergy shots as a means to treat allergies while avoiding injections. A patient must first have an allergy test to determine what substances trigger an allergic reaction. If positive, the patient will begin a customized treatment program that will desensitize them to the specific allergens they react to. In the case of SLIT, this will be in the form of a tablet or drops. Allergy shots (SCIT) is also customized but is an injection into the deltoid/arm. 

The SLIT treatment is placed in a dropper and the patient will dispense 1-3 drops under their tongue to absorb. This is done daily, thus exposing the body to a small dose of allergen. This daily exposure provokes an immune response in the patient. SLIT works by exposing patients to a small dose of an allergen repeatedly over an extended period of time which builds resistance to it. 

Sublingual Immunotherapy has proven to be an effective treatment for individuals with rhinitis– irritated and or inflamed nasal membranes– caused by sensitivity to dust mites, ragweed, cat dander, grass, and tree pollen. The treatment is currently being tested for its efficacy in controlling food allergies and eczema. Additionally, people with asthma may benefit from SLIT if their allergies trigger asthmatic symptoms or attacks. SLIT is contraindicated in patients who are allergic to any ingredient in the serum besides the targeted allergen, have previously had a bad reaction to sublingual immunotherapy, have severe asthma, a history of severe allergic reactions, or eosinophilic esophagitis (esophageal inflammatory disease).  

This treatment does not provide immediate symptom relief. It builds the body’s immunity over time, sometimes years. Sublingual immunotherapy is yet to be approved by the FDA but has been proven effective in studies and is used as off-label treatment. 

During the course of Sublingual Immunotherapy therapy, patients will have several follow up evaluations. These visits will allow assessment symptom scoring, an evaluation of the patient’s treatment usage, and may also include lung evaluation in the asthmatic patient. Because SLIT is administered by the patient, risks include deviating from the prescribed treatment schedule which would prolong the treatment and make it less effective. To prevent this, the patient should adhere strictly to their treatment schedule.

The post What is Sublingual Immunotherapy appeared first on Los Angeles ENT Doctors ENT Specialists Top Surgeons.

About Dr. Reena Gupta

Dr. Reena Gupta is the Director of the Division of Voice and Laryngology at OHNI. Dr. Gupta has devoted her practice to the care of patients with voice problems. She is board certified in otolaryngology and laryngology and fellowship trained in laryngology, specializing in the care of the professional voice.

• Question: How do the ingredients in e-cigarettes and vaporizers affect respiratory health? - August 16, 2019
• Bad Technique and Vocal Injury - January 9, 2019
• Is Edible Marijuana Dangerous for the Voice? Myths Dispelled - December 18, 2018
• Surprise! You have a hemorrhage - January 31, 2018
• Graves’ Disease: Treatment Overview - September 25, 2017
• Adele and the Stigma of Vocal Injury - July 11, 2017
• Vocal Curbside Consult: How does the thyroid affect the voice? - May 16, 2017
• Vocal Curbside Consult: How do hormones affect the voice? - May 3, 2017

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Although there is not yet significant or conclusive research on vaping and its effect on the larynx and voice, there is proof about the effect of cigarette smoking on the voice. Although some believe vaping is safer than smoking, this too has not been proven. Additionally, smoking and vaping have several characteristics in common that might suggest that vaping is injurious to the larynx and vocal cords.

What is vaping?

Vaping involves using an inhaler cartridge with vegetable glycerin and/or polyethylene glycol, flavoring, nicotine, and/or other substances. The cartridge is put inside an e-cigarette and a sensor in the e-cigarette is triggered to heat this liquid quickly, generating a vapor that is inhaled.  Instead of burning tobacco, as in cigarettes, vaping creates a vapor that the user inhales.

What is in e-juice?

The most common chemicals that are found in a typical vape juice are nicotine, vegetable glycerin, and propylene glycol. Additional chemical substances can also be found in the juice depending on the flavoring; however, the e-juice also most commonly contains pyrazine additives, aldehydes (formaldehyde and acetaldehyde), and trace metals (nickel, chromium, cadmium, and tin). Many of these substances, especially nicotine and chemicals in the flavourings can be toxic and carcinogenic. Also, these substances may behave differently as a vapor than a liquid form; the vapor may potentially be more harmful.

Even though vaping does not burn tobacco, both cigarettes and e-liquids typically contain nicotine which is known to be addictive. In fact, e-juice generally contains higher amounts of nicotine than cigarettes; vape users can buy extra-strength cartridges with higher concentrations of nicotine. A single vape cartridge may contain the amount of nicotine found in almost 20 cigarettes. 

How can smoking and vaping affect the larynx and vocal cords? 

The vocal folds are located in the larynx and are involved in breathing and voice production. The smoke or vapor that is inhaled from cigarettes or vaping passes the delicate lining of the vocal cords.

Significant research has been conducted about the effect of cigarette smoking on the larynx and vocal cords. Several studies also suggest that exposure to electronic nicotine delivery systems can cause cellular hyperplasia (growth of cells) and metaplasia (change in cells) in mucosal lining in rats.¹ It is theorized and likely that the same would occur in human tissue. Another experiment assessed the toxicity of vegetable glycerin, which is known to be harmless in liquid form. Its effects change in aerosol form. The experiment concluded that the substance led to squamous metaplasia of the epiglottis epithelium.² Other research shows that nicotine in cigarettes is likely to lead to cancer, including in the mouth and larynx.³

If the delicate lining of the vocal cords are exposed to hot, vaporized chemicals, the tissues are likely to undergo change and lose their ability to behave normally.⁴ This may produce hoarseness, loss of vocal range, voice fatigue, or vocal injury.

How can these disorders affect one’s voice?

Vocal folds produce sound when they make a coordinated, symmetric and smooth vibration. This can be affected by irritants in the air that you breathe. Vaping produces a highly-irritating vapor that is inhaled past the vocal cords, causing inflammation of the lining of the vocal cords. When the lining is irritated, it is more fragile and easy to bruise. Also, it becomes more difficult to work with, making the singer or voice use need to push harder for sound production. Both of these phenomena make injury far more likely. Injury can include vocal fold nodules, polyps, cysts, or other injuries related to vocal trauma. Chronic vaping can also likely cause Reinke’s edema, a condition of chronic inflammation seen in smokers. Edema of the vocal folds leads to the reduction of the frequency range of the singer’s voice.⁵ Finally, it has been proven that vaping results in significant complications in the lungs, which are the power source for the voice⁶. Poor ventilation and inability to generate a strong breath results in a more pushed sound, with throat muscle use rather than breath support. This also increase the risk for injury. 

These diseases and their effects on the voice can deeply affect singers and other people who use their voice for  a living. The only option to avoid these is to abstain from vaping completely.

References:

1. ^{Salturk, Ziya. “Effects of Electronic Nicotine Delivery System on Larynx: Experimental Study.” Journal of Voice, 2015, www.jvoice.org/article/S0892-1997(14)00243-4/fulltext.}
2. ^{Renne, R A. “2-Week and 13-Week Inhalation Studies of Aerosolized Glycerol in Rats.” Taylor & Francis, 2008, www.tandfonline.com/doi/abs/10.3109/08958379209145307?journalCode=iiht20.}
3. ^{Joshua E. Muscat, Hsiao-Pin Liu, et al. “The Nicotine Dependence Phenotype, Time to First Cigarette, and Larynx Cancer Risk.” SpringerLink, Springer Netherlands, 25 Feb. 2012, link.springer.com/article/10.1007/s10552-012-9909-x.}
4. ^{Renne, Roger A., and Katherine M. Gideon. “Types and Patterns of Response in the Larynx Following Inhalation – Roger A. Renne, Katherine M. Gideon, 2006.” SAGE Journals, 2006, journals.sagepub.com/doi/full/10.1080/01926230600695631.}
5. ^{Gonzalez, Julio. “Early Effects of Smoking on the Voice: A Multidimensional Study.” Medical Science Monitor, 2004, www.medscimonit.com/download/index/idArt/13230.}
6. ^{Christiani, D.C., et al. “Imaging of Vaping-Associated Lung Disease: NEJM.” The New England Journal of Medicine, 6 Sept. 2019,     www.nejm.org/doi/full/10.1056/NEJMc1911995.}

The post The Effects of Vaping on the Voice appeared first on Los Angeles ENT Doctors ENT Specialists Top Surgeons.

About Dr. Reena Gupta

Dr. Reena Gupta is the Director of the Division of Voice and Laryngology at OHNI. Dr. Gupta has devoted her practice to the care of patients with voice problems. She is board certified in otolaryngology and laryngology and fellowship trained in laryngology, specializing in the care of the professional voice.

• Question: How do the ingredients in e-cigarettes and vaporizers affect respiratory health? - August 16, 2019
• Bad Technique and Vocal Injury - January 9, 2019
• Is Edible Marijuana Dangerous for the Voice? Myths Dispelled - December 18, 2018
• Surprise! You have a hemorrhage - January 31, 2018
• Graves’ Disease: Treatment Overview - September 25, 2017
• Adele and the Stigma of Vocal Injury - July 11, 2017
• Vocal Curbside Consult: How does the thyroid affect the voice? - May 16, 2017
• Vocal Curbside Consult: How do hormones affect the voice? - May 3, 2017

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While surgery of the head and neck is becoming safer as medical technology and surgeons advance, there are always risks associated with surgery. One of the main concerns of patients who are undergoing surgery are those associated with intubation and general anesthesia. Intubation is a delicate procedure and, while there usually are not complications when inserting and removing the soft, plastic tube known as an endotracheal tube (ET), it is not without risk. One of the most common complications of intubation is injury to the larynx (voice box).

What is intubation and why is it necessary?

Intubation is the process of inserting a soft, flexible tube, called an endotracheal tube, into the trachea during surgery. This is required for ventilation, which allows the patient to continue to receive oxygen during surgery. Ventilation is a positive pressure system that mimics the action of breathing while the patient is under anesthesia. The anesthetist uses a device known as a laryngoscope to pull back the tongue and epiglottis and illuminate the larynx, allowing for visualization for effective intubation. Once inserted successfully bewteen the vocal cords into the trachea, a small cuff at the end of the tube is inflated to create a seal in the patient’s trachea, which is necessary for safe air exchnage. Intubation is necessary during procedures that require general anesthesia because the paralyzing and sedative agents that are necessary to complete the surgery also render the patient unable to breathe on their own. 

What are the risks of intubation and how can it affect the voice?

The process of intubation involves placing a flexible tube between the delicate vocal cords and inherently, comes with risks to the trachea, larynx, and vocal cords. If special care is not taken when inserting the endotracheal tube, the vocal cords can be bruised, scratched or otherwise injured in the process of intubation. 

Intubation nearly always results in swelling of the larynx, causing hoarseness or sore throat in the patient post opeartively, especially after longer procedures. However, in rare cases, longer lasting vocal damage can occur. The majority of vocal injuries due to the blunt force of the endoctracheal tube coming in contact with the vocal cords. This is far less common in planned surgery; however, in emergency situations when the patient is suddenly unable to breathe on their own and the careful precautions of a surgical setting cannot be taken, laryngeal injury is more common. These conditions are best managed by a laryngologist, an ENT with specialized training in the larynx and voice. 

While vocal injury from intubation is possible, is is unlikely, especially in a surgical setting with experienced anesthetists. A successful, trouble-free intubation is essential to a successful surgery and allows for the patient to undergo general anesthesia, reducing pain for the patient and making the procedure easier to execute for the surgeons. Intubation is a relatively safe, necessary process that keeps the patient stable during surgery. If a patient is experiencing vocal pain or discomfort after any procedure, an appointment with a laryngologist or vocal specialist should be made to address and treat the issue. 

The post Vocal Injury from Intubation appeared first on Los Angeles ENT Doctors ENT Specialists Top Surgeons.

About Dr. Ronen Nazarian

Dr. Ronen Nazarian is the Director of Otology and Hearing Disorders at Osborne Head and Neck Institute in Los Angeles, CA. Dr. Nazarian specializes in treating hearing and balance disorders. He is board-certified in Otolaryngology-Head and Neck Surgery and has completed fellowship training in Otology and Skull Base Surgery.

• Risks of Surgery for Surfer’s Ear - October 26, 2017
• The Dangers of Untreated Exostosis / Surfer’s Ear - October 26, 2017
• Surfer’s Ear Treatment: Chisel vs Drill - October 26, 2017

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Overview

Congenital microtia is a deformity of the outer ear, but it can also impact structures inside the ear. Patients with congenital microtia may present with canal stenosis (narrowing of the ear canal) or aural atresia (absence of the ear canal). In these cases, a canalplasty may be performed to widen or create an ear canal. In addition, patients can lack a tympanic membrane (eardrum), or only have a partial one, which can be treated with a surgical procedure called a tympanoplasty. Microtia patients can also have problems with their ossicles (malleus, incus, and stapes) which may be too small, deformed, or absent. In these cases, an ossicular chain reconstruction would be recommended. These problems can occur independently of another, but it is common for patients to have more than one issue. Whether patients present with only one issue or all three, they will have hearing loss because the ear canal, tympanic membrane, and ossicles each play a role in hearing; surgical treatment would help restore hearing.

Canalplasty  

Canalplasty is a surgical procedure to treat partial or complete obstruction of the external auditory canal (ear canal) from bone or skin. In patients with canal stenosis (narrowed canal), the procedure widens the ear canal, which allows more sound to reach the tympanic membrane (eardrum). In patients with aural atresia (complete canal closure), canalplasty creates an ear canal. The surgery involves drilling or chiseling through the bone that is obstructing the canal until the tympanic membrane is reached. Canalplasty is a highly effective procedure, but it does carry significant risks. In rare cases, complete hearing loss, infection, and harm to other ear structures may occur. One of the most significant concerns when performing a canalplasty is the integrity of the facial nerve. The facial nerve runs through the external auditory canal and is resposible for motion of the face. This nerve is at risk for damage in canalplasty, resulting in facial nerve paralysis. The surgeon must carefully and often use nerve identification techniquest to protect the nerve. However, because the patient has abnormal anatomy, the facial nerve is often in an atypical location and may be therefore injured. A CT scan prior to surgery can help with surgical planning so that the location of the nerve, as well as the anatomy of the canal and other ear structures, can be assessed. In cases where facial nerve anatomy is not favorable, canalplasty not be recommended; a bone-anchored hearing aid (BAHA) may be recommended for the patient.

Tympanoplasty

Tympanoplasty is surgical procedure that is performed when microtia patients have a deficient or absent eardrum. Fascia, a tissue found between skin and muscle, is taken from behind the patient’s ear. It is used as a graft to replace or create the missing portion of the eardrum. If a sufficient ear canal exists and the graft needed is fairly small, the surgeon may choose a transcanal approach, which involves placing the graft through the ear canal, without external incisions. In more complicated cases, the surgeon may make an incision behind the ear, which allows access for more involved surgery. This is called a post-auricular approach. As with canalplasty, there is risk of facial nerve injury in a tympanoplasty, but occurs more infrequently. There are also chances of permanent hearing loss and altered sense of taste, but these are rare.

Ossicular Chain Reconstruction

Ossicular chain reconstruction is a surgical procedure to replace the ossicles with a prosthesis, and is used in patients where ossicles are underdeveloped or absent. The ossicles are normally found in the middle ear, behind the eardrum, so the eardrum must be lifted to access them. Risks of this procedure include facial nerve injury, hearing loss, or a dislodged prosthesis, although these are all uncommon.

The post Hearing Restoration Surgeries for Congenital Microtia appeared first on Los Angeles ENT Doctors ENT Specialists Top Surgeons.

About Dr. Reena Gupta

Dr. Reena Gupta is the Director of the Division of Voice and Laryngology at OHNI. Dr. Gupta has devoted her practice to the care of patients with voice problems. She is board certified in otolaryngology and laryngology and fellowship trained in laryngology, specializing in the care of the professional voice.

• Question: How do the ingredients in e-cigarettes and vaporizers affect respiratory health? - August 16, 2019
• Bad Technique and Vocal Injury - January 9, 2019
• Is Edible Marijuana Dangerous for the Voice? Myths Dispelled - December 18, 2018
• Surprise! You have a hemorrhage - January 31, 2018
• Graves’ Disease: Treatment Overview - September 25, 2017
• Adele and the Stigma of Vocal Injury - July 11, 2017
• Vocal Curbside Consult: How does the thyroid affect the voice? - May 16, 2017
• Vocal Curbside Consult: How do hormones affect the voice? - May 3, 2017

View All Posts

The e-cigarette industry has rapidly grown within the US in the last several years. E-cigarettes were created as an attempt to wean people off of traditional cigarettes while still providing people with nicotine. This concept seems ideal because people believe they can consume nicotine while bypassing the side effects of smoking a cigarette, which includes tooth decay, loss of senses (smell, taste), and various forms of cancer. However, people may not recognize that vaping results in exposure to various chemicals that differ from cigarettes. Because vaping is relatively new, there is limited research on how it affects the human body. To help answer the question about the impact of vaping on respiratory health, we can start by considering the chemicals that are consumed.

What are the most common ingredients?

The basic ingredients in the e-liquid that are inhaled are propylene glycol, vegetable glycerin, and nicotine. Depending on the flavoring, e-liquids contain many other chemicals that are specific to the artificial taste the company is trying to create. An important fact to remember when examining the ingredients is that the chemicals go through pyrolysis and endothermic reactions when turned into vapor because of the heating component. These chemicals in aerosol form will have different effects than in liquid form.

Propylene Glycol:

Propylene glycol is an organic compound that lacks color and smell and is found in some food, skin care, and steam products. It could be assumed that propylene glycol is safe because it is found in so many products, but traditionally it has been used in small doses and is not vaporized for inhalation. Studies have been done that provide insight on the possible effects inhaled propylene glycol could have on humans.

One experiment used rats to test the effects of nasal inhalation of propylene glycol over a 90 day period. The results found that there was an increase in mucin in pre-existing goblet cells or the increase of goblet cells in the nasal cavity. Goblet cells are responsible for mucus secretion, but too much mucus is undesirable. In addition, exposure caused epistaxis (nosebleeds) and discharge from the eye, most likely due to the dehydration of the nostrils and eyes.¹

In another study, people working with theatrical smoke containing propylene glycol were monitored and examined after two years. The results show that the employees that had longer exposures developed chronic wheezing and chest tightness and their overall lung function decreased . For those who were acutely exposed to the fog, they developed temporary cough and dry throat. It is stated that the most efficient way of reducing these symptoms is elimination of exposure when possible.²

Vegetable Glycerin:

Vegetable glycerin, also known as glycerol, is a compound that lacks color and smell, tastes sweet, and is non-toxic. It is commonly used in cosmetics, drugs, and food and is generally a “safe” chemical for human use. Research shows that glycerol can be helpful by moisturizing skin and improving dehydration, but these benefits are derived from glycerol being consumed in a solid or liquid fashion, not an inhaled, vaporized form.

In an experiment studying the effects of aerosolized glycerol on rats, they were tested for toxicity from inhalation after 2 week and 13 weeks. The findings showed that the rats formed squamous metaplasia of the epiglottis, which is a change of the epithelium. This information shows that glycerol alters the original cells which may trigger further changes and, one could hypothesize, a starting point for cancerous changes.³

Nicotine:

Nicotine is extracted from tobacco and is highly addictive, contributing to serious physical and mental withdrawal symptoms when trying to taper off or stop use. One might be most familiar with this e-liquid ingredient because it is most well known for being the main component in traditional cigarettes. There is a collection of scientific evidence that proves how harmful smoking is, especially to the respiratory system and emphasizes that abstaining from use is safer for people. The best predictor of how vaping will affect the respiratory health is examining the effects of cigarettes.

Research shows that smoking causes damage to the alveoli (balloon like air sacs in the lungs which allow for the exchange of oxygen and carbon dioxide) making someone more susceptible to a plethora of problems. Chronic Obstructive Pulmonary Disease (COPD), which is a large category describing lung disease, is commonly seen in smoking patients, specifically emphysema and bronchitis.

In addition, smoking is known to cause cancers of the lung, larynx, and mouth, among other sites. There are many other side effects to smoking including laryngitis, hoarseness, loss of taste and smell, and bad breath that all negatively affect one’s life.

Other Known Chemicals:

A chemical found in some e-liquids is diacetyl, which is an organic compound that gives a buttery-like flavor. A study performed on rats shows that diacetyl had a negative effect causing epithelial necrosis (death of epithelial cells) as well as suppurative to fibrinosuppurative inflammation in the nose, larynx, trachea, and bronchi.⁴ In addition, diacetyl is most known for generating bronchiolitis obliterans, familiarly known as popcorn lung. This condition damages the lungs’ smallest airways, leading to breathing problems which eventually could result in death.

Lastly, another hazardous chemical found in some e-liquids is the organic molecule formaldehyde. It is in many wood products and is used to preserve specimens in labs, but it is classified as a “probable human carcinogen.” Repeated inhalation of formaldehyde makes cause susceptibility for spontaneous cell change leading to tumor growth.

What does all this information mean?

Each chemical in e-liquids appears harmful enough in isolation, but the combination and then vaporization makes this even more concerning. From the research, it can be hypothesized that vaping will provoke irritation to the mouth, throat, and airway. This irritation can manifest with coughing, itchiness, sore throat, and dry mouth.

It can also be assumed that repeated vaping has more serious effects and the consequences can be worsened with longer exposure. One main concern is that vaping leads to squamous metaplasia which shows that the aerosol is causing a change in the normal cell structure . Cellular change brings up the possibility of cancer, given that cancer is the change in cells leading to abnormal cell growth and proliferation. It can be hypothesized that people who vape are more susceptible to malignant tumor growth, and the above information certainly suggests the need for more research.

The other main concern is the damage to the lungs and respiratory tract. In theory, vaping will generate similar respiratory problems to smoking such as COPD, bronchitis, and emphysema and some flavorings will cause popcorn lung, both due to the constant intake of vapor damaging the body’s air passages and alveoli. These conditions can be serious leading to chronic, irreversible damage and possibly death.

It is also essential to understand that since the vast majority of e-liquids contain nicotine, vaping is just as addictive as smoking a cigarette

Studies have already shown that vaping is not definitively a “safer and healthier” alternative to smoking and seem to result in health complications that may be equivalent to traditional cigarettes.

References

1. Suber, Robert L., et al. “Subchronic Nose-Only Inhalation Study of Propylene Glycol in Sprague-Dawley Rats.” Food and Chemical Toxicology, doi:10.3897/bdj.4.e7720.figure2f.

2. Varughese, Sunil, et al. “Effects of Theatrical Smokes and Fogs on Respiratory Health in the Entertainment Industry.” American Journal of Industrial Medicine, vol. 47, no. 5, 2005, pp. 411–418., doi:10.1002/ajim.20151.

3. Renne, R. A., et al. “2-Week and 13-Week Inhalation Studies of Aerosolized Glycerol in Rats.” Inhalation Toxicology, vol. 4, no. 2, 1992, pp. 95–111., doi:10.3109/08958379209145307.

4.  Hubbs, Ann F., et al. “Respiratory Toxicologic Pathology of Inhaled Diacetyl in Sprague-Dawley Rats.” Toxicologic Pathology, vol. 36, no. 2, 2008, pp. 330–344., doi:10.1177/0192623307312694.

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• Sadness about the injury
• Stress about meeting obligations (financial, performance, etc)
• Fear that their voice will never be the same again
• Self-doubt that something so fundamental to their identity is ‘damaged’
• Self-recrimination that something they did (or didn’t do) caused this injury

Each emotion requires attention; the healing process is directed as much to the vocal cords as it is to the artist’s mental state. The last point, though, is usually the most destructive.

This emotion surfaces in many ways but usually takes the shape of “Did I do this to myself?” This is expected in an environment where many vocal coaches’ claim to fame is injury prevention. The world piles on singers when they are injured for having “bad technique.” Is this true, though? How do technique and injury actually relate to each other?

I have the privilege of caring for vocalists which means I diagnose injury frequently. This puts me in a unique position to assess the factors leading to injury. I discuss the artist’s history leading up to injury extensively and have accumulated mountains of data about the factors that precipitated their injury.

Most injury is caused by what I call a “vocal perfect storm.” By this, I mean that there are usually a few things which, in isolation, wouldn’t cause an injury. However, when combined, there are just enough things going on to create an injury.

What are the factors that can make up a vocal perfect storm? The most common element is illness. A basic upper respiratory infection (a cold) affects the upper respiratory tract (this includes the nose, sinuses, pharynx/throat and larynx/vocal cords). The vocal cords become swollen. When performer is singing or speaking on swollen cords, vocal bruising is more likely to occur.

Once bruising has occurred, the foundation for injury has formed. Illness is the most common factor but what other factors can contribute to an increased risk of injury?

• Factors that can play into a vocal perfect storm include:
• Coughing
• Upper respiratory tract infection/having a cold
• Poor monitors – not being able to hear yourself and pushing
• Exposure to smoke (in the venue or out)
• Reflux (diet changes while on tour, eating late, etc)
• Allergies (moldy venues, dusty buses, etc) and postnasal drip
• Lack of sleep
• Inconsistent vocal coaching
• Not warming up
• Smoking (cigarettes, marijuana, vaping, etc)

Two or more of these factors increase the risk of injury during performance.

Note, “bad technique” is not on that list – but inconsistent vocal coaching is. The role for vocal coaching is injury prevention and early detection of injury. Short of truly damaging vocal styles, singers do not tend to utilize techniques that cause injury. An excellent vocal coach takes a singer’s natural approach and optimizes it for best output. Technique adjustments can lead to improved endurance and stamina and the singer can feel dramatically better as those adjustments are made. Small adjustments can result in huge changes for the singer. The coach is also the best set of ears for your voice to detect a problem at the earliest signs. But technique alone will not prevent injury.

The vocal cords are part of the human body and therefore affected by your internal environment. It is fueled by the air you breathe and so the external environment also impacts the voice. There are multiple variables, therefore, that can increase the risk of injury. This knowledge should help the singer to escape the feelings of shame that often accompany a diagnosis of injury. Most importantly, recognizing the risk factors listed can help the singer to control them. Working with your laryngologist can help you identify what is affecting your voice and control it before you find yourself in a vocal perfect storm.

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I’ve written about this previously in an article that focused on smoking marijuana and the associated risks to the voice. Smoking anything is risky to the vocal cords, as it induces laryngitis which increase the risk of vocal bruising and permanent injury. Further, lung irritation and chronic bronchitis are common in those who smoke marijuana. Many singers have worked around this by ingesting (eating or drinking) marijuana instead of smoking it, and this does indeed appear to come with a lower risk to vocal health. Despite this evidence, a theory has been circulated that marijuana use in any form causes dilation of blood vessels and therefore results in the same risk of vocal bruising as smoking. This theory assumes two fundamental points which must be confirmed before we can draw any conclusions:

• Orally ingested marijuana results in dilation of blood vessels
• Dilation of blood vessels increases the risk of vocal bruising

If those points are true, then it would fundamentally change how I counsel my singers and professional voice user patients. I was glad to have an opportunity to query the literature and revisit my conclusion that ingested marijuana was safer. Perhaps this new theory was correct?

I did an extensive literature search and found a recent article which reviewed the existing literature on the subject. Though published in an open source journal, the publications that were referenced were credible. The following information was found:

• There is no clear conclusion about the effects of marijuana/THC on vasculature. This article reviewed 112 articles that had been published in peer- reviewed journals and still said the literature is not definitive.
• However, there is significant “evidence for vasoconstrictive effects of cannabinoid administration.” This means there is evidence that blood vessels constrict (get smaller). This is in direct opposition to the above theory that edibles dilate blood vessels in the vocal cords. One must assume that the above theory was not based upon current research.
• The review article also stated “Early experimental results in the rat have hinted to a vasoconstrictive activity of THC comparable to that of norepinephrine (Adams et al., 1976). The fact that a simple vasodilation does not account for all of the substances’ complex influences on cardiovascular tone was strengthened by the description of the “triphasic” or “triple” effect (Siqueira et al., 1979; Varga et al., 1996; Malinowska et al., 2012).”
  Again, this reinforces that the effects are complex, may be dilation or constriction of blood vessels but that evidence points to constriction.
• There is also no proof that blood vessel dilation increases the risk of hemorrhage. For example, Viagra, a drug that works because it dilates blood vessels, is listed as having no effect on the voice by The National Center for Voice and Speech

Both of the premises were therefore incorrect. There is no evidence that ingestion of marijuana increased the risk of vocal hemorrhage.

Dispelling vocal myths is vitally important to prevent singers from misguided advice. Misinformation often spreads when one person’s opinion is portrayed as fact without substantiating research. Clinician intuition is important but the reader has to be able to differentiate fact versus opinion. Those in the practice of giving advice need to be transparent about whether or not our advice is research and fact-based, we must revisit our opinions, review existing literature, and keep discourse active. Based on this process, the evidence clearly supports that ingested marijuana poses no risk of vocal hemorrhage and is far safer than inhaled.

References
Richter JS, Quenardelle V, Wolff, V et al A Systematic Review of the Complex Effects of Cannabinoids on Cerebral and Peripheral Circulation in Animal Models. Front Physiol. 2018; 9: 622.

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

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