Eosinophilic Esophagitis (EoE) Treatment Options

Until recently, esophageal eosinophilia was primarily attributed to acid reflux esophagitis. Allergic patients who developed swallowing problems and intestinal symptoms underwent endosocopy and white blood cells called eosinophils were found infiltrating the mucosa. Even though we associate eosinophils with allergy, we did not make that clinical connection until recently.

In the last five years, eosinophilic esophagitis—also known as allergic esophagitis, primary eosinophilic esophagitis, and idiopathic eosinophilic esophagitis—has emerged as an important independent allergic condition found to occur in children and in adults.

Comprehensive allergy testing and immunotherapy for inhalant allergies have proven effective. That is, aggressively treating inhalant allergies with immunotherapy (allergy shots or drops) helps in treating eosinophilic esophagitis. Immunotherapy for food allergies is still being studied.

Singulair, carafate, and chromolyn may be helpful. Xolair and IL-5 inhibitor are still experimental. Food allergy testing is always completed and elimination diets are considered. A trial of an elemental amino acid diet may be entertained, but is rarely practical.

Eosinophilic Esophagitis (EoE) Treatment Options:
1) Swallowed Fluticasone.  (Shake the inhaler for 15 seconds immediately before use.  Do not attach a spacer.  Breathe out through your mouth and then close your lips around the mouth piece.  Hold your breath, press down on the top of the metal canister and swallow.  Do not breath in until the medication is swallowed.  After swallowing, breathe normally.  Wait 15 seconds.  If your were instructed to take two puffs, repeat the above steps.  Replace the mouthpiece cap after each use.  Do not rinse your mouth, eat or drink for 30 minutes following each use.  Each inhaler contains about 120 puffs and will last 30 days taking two puffs twice daily.

You can also use Budesonide mixed with Splenda instead of Fluticasone if you like.
 (Open the Budesonide container and transre teh liquid into a cup.  Add three to 10 packets of Splenda artificial sweetner and mix with a spoon.  Swallow.  Do night rinse your mouth, eat of drink for 30 minutes after taking it.)   The sucralose contained in Slenda forms a thick solution that will coat the esophagus.  Other artificial sweeteners do not do this.

2) Targeted dietary avoidance based on results of skin prick and patch testing to foods. If not successful, I then try empiric elimination diet. Rarely have I needed to resort to elemental diet (in a case of a child with severe oral aversion).
3) Aggressive management of aeroallergen hypersensitivity (can also trigger GI eosinophilia), that is Avoidance, Medications, and Allergy Shots. Singulair is helpful in about one half of the patients.
4) Proton Pump inhibitor (often 2 times per day) These patients generally get scoped quite frequently to monitor their progress. Dysphagia must sometimes be treated by esophageal dilatation.

Temporal Arteritis

Temporal Arteritis is also known as Giant Cell, Cranial, or Granulomatous Arteritis.  It is the most common Vasculititis in the head and neck.  In 50% of cases it is comorbid with Polymyalgia Rheumatica (PMR).  It will often present with anemia, depression, morning stiffness and low grade fever for more than a month.  It is more common in Women and more prevalent over 60.  The vasculitis leads to small vessel ischemia and most notably visual loss.  Patients will often have intense pulsatile cephalagia, hyperalgesia or the scalp, jaws and tongue.  Masticatory claudication is very prevalent.   Odynophagia, odynophonia, anorexia, fever, and streaking erythema over the temporal artery are very common.  The ESR is usually over 40, and often over 100.  Patients will often have high immunoglobulin counts and low albumin.  A third of patients will have othamologic involvement.  Early steroids are indicated and a six centimeter segment for biopsy is taken as there are skip lesions in up to 30% of patients.  If the biopsy is negative and your clinical suspicion is high, might perform a biopsy on the contralateral side.  If the diagnosis is made, you may have to treat with steroids up to 2 years.  You never want to misdiagnose as migraines or treat with ergotomines, as the risk of blindness exists.

Endoscopic DCR

Endoscopic DCR is a relatively straightforward procedure that opens the lacrimal sac into the anterior middle meatus. I typically stent it for anywhere from 2-6 months.  Afterwards, I place the patient on tobramycin drops tid for 10 days.  Success should be greater than 90% and the cpt code is 31239.

Intradermal Vaccines

There has been good data on the efficacy of vaccines given intradermally vs subcutaneously or intramuscularly. It actually seems to function superiorly in children and the elderly. I personally take my flu shot this way as I feel it also limits my systemic side effects.   0.1 ml of both the influenza vaccine (Fluogen) and the Herpes Zoster Vaccine (Varivax) in opposite arms seems to lessen the frequency and severity of recurrent upper respiratory tract illnesses.

Scabies

I very experienced allergist and friend surprised me when he treated what I thought was just a heat rash with Permethrin.  Scabies (Sarcoptes scabiei) is an itch mite that is highly contagious.  It can be sexually transmitted for sure, but it is not always so.  It does however require close contact to spread and seems limited to humans (it is not compatible with pets).  Itching is severe and it forms papules that often blister.  Microscopy scrapings can be difficult and there is even a PCR test available.

Middle Ear Treatments

There was an interesting study on the middle ear volume, and it ended up being about 1.4 ml in non diseased individuals.  In reality, you rarely get a full ml of fluid into the middle ear when you inject it.  There is a number of reasons we put medications directly into the middle ear, such as Meneir’s Disease, sudden sensorineural hearing loss, etc…  We are typically using an anti inflammatory such as dexamethasone or an ablative medication such as Gentamycin.  Sometimes we combine the agents.  When I use the Dexamethasone, I do no dilute, and I put in as much as the middle ear will handle.  I typically anesthetize the ear with phenol or EMLA and have patient stay laying in the injection position without swallowing for 20  minutes if possible.

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Challenging scalp lesions

Exposed calvarium represents an interesting challenge in reconstructing scalp defects.  In order to lay on a skin graft, tissue such as a temporalis flap needs to be mobilized to give a base for the graft to survive on.  Otherwise, large “pinwheel” type flaps can be constructed to close this primarily with good success.

This defect was closed with a double layer temporalis muscle flap underlying an occipitally based scalp advancement flap.

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Tongue Tie

I am reposting this because of a social media interest in what is termed “posterior tongue tie”.  It is described as a fibrous banding deep in the floor of mouth that causes feeding difficulties.  It seems to be a problem mostly manufactured by those wanting to exploit others. Most of us think of being tongue-tied as a situation where we find ourselves too excited or nervous to speak. Actually, tongue tie is a term for a relatively common physical condition that limits the use of the tongue, medically called “ankyloglossia”.

tounge_tie_mediumBefore we are born, a strong cord of tissue (the frenulum) that guides development of mouth structures is positioned in the center of the mouth. After birth, the frenulum continues to guide the position of incoming teeth. As we grow, it recedes and thins.

This frenulum is visible and easily felt if you look in the mirror under your tongue. In some children, the frenulum is especially tight or fails to recede and may cause tongue mobility problems.

The tongue is one of the most important muscles for speech and swallowing. For this reason, having tongue tie can lead to eating or speech problems, which may be serious in some individuals.  Posterior tongue tie is a nebulous term that lacks a clear definition or treatment.

Lip “Tie”

Labial Frenulectomy

Frenum_composite 1106CFP_PC_Frenum_AB-1A labial frenectomy is a form of frenectomy performed on the lip.

The labial frenulum often attaches to the center of the upper lip and between the upper two front teeth. This can cause a large gap and gum recession by pulling the gums off the bone. A labial frenectomy removes the labial frenulum. Orthodontic patients often have this procedure done to assist with closing a front tooth gap. When a denture patient’s lips move, the frenulum pulls and loosens the denture which can be uncomfortable. This surgery is often done to help dentures fit better.

The removal of the frenulum does not cause any adverse effects to the lip and mouth.  The real question is if it has any beneficial effects.

“Potential” benefits include better feeding, diminished decay of the front incisors, and avoiding a central diastema (gap in the front teeth).  I remain a bit skeptical that the benefits exist.

Challenging scalp lesions

Exposed calvarium represents an interesting challenge in reconstructing scalp defects.  In order to lay on a skin graft, tissue such as a temporalis flap needs to be mobilized to give a base for the graft to survive on.  Otherwise, large “pinwheel” type flaps can be constructed to close this primarily with good success.IMG_1689IMG_1863