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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).

May 26, 2017

Why Do Allergy Skin Prick and Blood Testing Results Sometimes Differ?

Image by Wolfgang Ihloff in Wikipedia
For inhalant allergies, there is a high agreement (~80-90%) in results found between skin prick and blood testing. However, occasionally the results may differ quite significantly... usually in these situations, the skin prick test comes back positive for something whereas the blood test comes back negative or normal. It's also possible that both skin prick and blood testing may come back normal even if a patient is truly allergic.


Before going into an explanation, you must first understand how these tests are performed. Don't worry, this will be a simplified explanation.

To begin, for any substance, there are protein markers called epitopes to which an allergic response can be mounted.

For example, let's take a "cat."

Cat is composed of many different epitopes, both major and minor, to which a human can mount a potential allergic response. For the vast majority of people, only a few of these epitopes can trigger an allergic reaction. Let's call this Epitope A. However, for a minority of patients, a reaction can also occur to Epitopes b and F.

Based on this knowledge, a variety of companies have created a purified "essence of cat" containing Epitopes A, b, and F that can be utilized to test patients for cat allergy rather taking an actual live cat and having it scratch a patient with its claws.

SO... when a skin prick test is performed, a doctor takes a needle and dips the tip of it into this "essence of cat" and pricks the skin of a patient depositing a small amount under the skin.

If a skin reaction occurs (redness and swelling), than the allergy test for cat would be considered positive. The bigger the reaction, the more severely the patient is considered allergic to cat.

With allergy blood testing, however, a computer analyzes the blood taken from a patient to see if it contains a large number of antibodies called IgE that is specific for cat Epitope A.

Assuming a patient is ONLY allergic to cat Epitope A (which the vast majority of patients are), both the skin prick and blood testing will give the same exact positive result.

HOWEVER, if a patient is ONLY allergic to Epitopes b and F but not A, than the skin prick test will still come back positive, BUT the blood test will come back normal! Remember, the blood test can only detect Epitope A, but not b and F.

So that's why a skin prick and blood test may disagree on whether a patient may be allergic to something or not.

And before you ask... skin prick testing typically checks more epitopes for a given substance like cat than blood testing.

Given your newfound knowledge now, can you figure out why BOTH skin prick AND blood testing may come back normal even if a patient may truly be allergic?

It rare situations, a patient may theoretically be allergic to other epitopes not present in the test. For example, what if a patient is allergic to cat Epitope R, x, and W? If that's the case, a skin prick test for cat Epitopes A, b, and F and blood test for cat Epitope A will both come back normal.

If this last situation applies to you, there may not be any good way to get tested for more unusual epitopes other than to go to a tertiary care allergy center. Hopefully with time, biotech companies will develop even better tests that incorporate even more if not all epitopes that may trigger allergic reactions in humans.

May 24, 2017

When is Sinus Surgery Appropriate for Recurrent or Chronic Sinus Infections?

Normal CT Sinus Scan
When a patient suffers from chronic or recurrent sinus infections, sinus surgery is an option to consider especially when medical management has failed. There are the obvious candidates where any reasonable ENT would agree sinus surgery is required, but as with much of medicine, there are times when a patient may get several diametrically opposite opinions whether sinus surgery is recommended or not.

Such opposing recommendations at its core occur due to what a CT scan of the sinuses show.

To begin, let's start with a representative case of a patient who has suffered from chronic recurrent sinus infections. This patient reports 6+ sinus infections per year over the past 5+ years. This patient has been on a number of antibiotics including amoxicillin, augmentin, cefdinir, z-pack, and levaquin along with oral steroids, daily saline flushes, oral allergy medications, and steroid nasal sprays.

First, let's talk about the obvious sinus surgery cases.

On physical exam, large nasal polyps are seen with pus pouring out of the sinuses. A CT Sinus scan obtained shown below reveals sinus cavities that are completely opacified indicating profoundly diseased sinuses. (Black indicates air just like the black around the head. Anything but black indicates something other than air in the sinus cavity, presumably sinus disease.)

Unlike the normal CT Sinus scan at the top, note that the
sinus cavities are completely greyed out.
I would warrant that 100% of ENTs would recommend sinus surgery in this particular situation.

However, WHAT IF the nasal endoscopic exam was essentially unremarkable AND the CT Sinus scan obtained came back completely normal as shown below? Again, the same exact patient history as stated above.

Normal CT Sinus Scan
In this scenario, a patient may get different recommendations if they pursued several different ENT opinions. Some ENTs would recommend sinus surgery based on history in spite of normal exam and CT sinus scan. The argument being that it just happened to be normal on the day of the examinations. The analogy being, if a child has a history of 7+ strep throat infections in the past year, but the exam happened to be normal on the day he sees an ENT, tonsillectomy and adenoidectomy would still be recommended.

However, the majority of ENTs (myself included) would argue against sinus surgery in spite of the history. Why?

The counter-analogy I use in this scenario is an abscess of the skin. A surgeon would cut open the skin ONLY IF an abscess is present in order to "release" the pus (incision & drainage or I&D). Sinus surgery is kind of like that, but it's the sinus rather than the skin... As such, doing sinus surgery with a normal CT Sinus scan is like cutting open the skin when no abscess is present... for example, if only a rash or cellulitis is present, neither of which is a reason to cut open the skin.

Furthermore, based on clinical criteria alone, sinus infections are notoriously difficult to diagnose. Sinus infections can be confused with viral infections, allergies, and even deviated septum with enlarged turbinates.

Typically, an aggressive workup is pursued beyond a CT scan and endoscopic exam to evaluate all other possibilities on the assumption that the patient may have been misdiagnosed with recurrent sinus infections when the symptoms were actually due to something else. My favorite statement being,
"maybe the antibiotics did not work for your sinus infections because you never had a sinus infection in the first place."
What does this workup entail?

Allergy testing and if positive, AGGRESSIVE allergy management including even allergy shots. (Sometimes, if the allergies are bad enough, taking just one allergy medicine is inadequate. One may need to take several allergy medications.)
• Evaluate for large inferior turbinates or deviated septum that may cause persistent symptoms of nasal congestion and feeling stuffy. Treatment would be turbinate reduction and septoplasty... not sinus surgery.
• Evaluate for possible immunodeficiency. It just may be that the patient is getting recurrent infections, but not because of any underlying sinus anatomic issues, but because the immune system is much weaker than normal leading to the inability to fight off infections as easily as someone with a normal immune system.
• Miscellaneous considerations include neurologic (trigeminal migraine, contact point headache, etc) as well as autoimmune abnormalities.

If and only if this workup comes back normal and the patient continues to get bona fide sinus infections that are culture positive, sinus surgery can potentially be considered even if the CT Sinus is normal. However, in just this type of scenario, it may be worthwhile to get a 2nd opinion just to ensure nothing got missed.

May 15, 2017

Why Does Airplane Food Taste So Bad?

Image by Wikipedia
People universally complain about how bad airplane food is... However, the reason may surprise you in that it's not the airline's fault, but your body's.

Based on research performed in 2010 at the Fraunhofer Institute in Germany where they have a replica airplane cabin and can simulate different altitudes, cabin pressure, cabin external wall temperature, relative humidity, noise level, vibration, light, air circulation, etc... food scientists discovered that high altitude (low cabin pressure) and dry air essentially degrades the human sense of smell and taste to a state equivalent to having a bad viral cold.

And everyone knows how food tastes with a bad viral cold.

Researchers found that at about 8,000 feet where air pressure is much lower than at ground level, the detection and recognition thresholds of odorants become much higher confirming that the sense of smell becomes more impaired as the pressure decreases. When it comes to taste, the threshold for detecting salty and sweet was also much higher while bitter was not noticeably affected. The threshold for monosodium glutamate (MSG) and umami (or savoriness), was only slightly impaired at low pressure.

Humidity is also much lower in airplanes hovering around 30% which can dry out the nose and dull the olfactory nerve endings in the nose essential for tasting flavor in a food.

White noise from the drone of the airplane engines can also adversely affect perception of taste and smell independent of air pressure too. [link]

A Feast for Research. Fraunhofer IBP.

Why Airplane Food Is So Bad. The Atlantic 5/19/14

Airplane noise and the taste of umami. Flavour 2014, 3:2

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