1)Inhaled Steroids—Advair is the worst……Local irritation, atrophy, and immunocompromise resulting in mucosal thinning and fungal laryngitis.

2)Testosterone—–can cause a permanent virilization of the female voice in 90% of patients….

3)Decongestants—-dessication and laryngitis sicca….

4)Antihistamines—-same

5)Insufficient Thyroid Replacement

6)Anti-Angiogenic Meds

7)ACE Inhibitors

8)Anticoagulants

9)Diuretics

10)Antipsychotics

There are over 200 known serotypes of HPV.  About 79 million Americans are currently infected with HPV.  About 7% of adults have HPV in their oral cavity.  Only about 3,000 to 13,000 patients in the United States have Recurrent Respiratory Papilllomatosis.  Virtually all of them have active HPV in thier oral cavity.  These patients are afflicted with HPV 6 and 11, which affects primarily mucous membranes.  It is looking more and more like oral to oral transmission trumps oral genital transmission.   It seems to be a different animal all together than cervical HPV.  Serotypes 16 and 18 are the types associated with carcinogenesis.  There currently is no evidence that spouses should be vaccinated and it does not really seem to be easily transmitted between adults.

How the heck can a barnacle stay stuck on the hull of a ship through all the tremendous currents and forces to wash it off?  And, how the heck could systemic or even topical antibiotics ever penetrate the “rubber cement” glycocalyx of snot that many of our chronic sinusitis patients have.   These two properties of biofilms (the ability to stick to a surface and the ability to form a protective glue like coating around themselves) make eradication of infection very difficult.

Infection in the upper respiratory tract is probably best described as detrimental colonization.   It seems that the presence of these bacteria stimulate a chronic inflammatory response (probably via a “superantigen” type of mechanism.  Eradication of enough “disease” is typically accomplished by the patients own defense mechanisms (cilia and immune defenses).  If this is not suffiecient then  topical and systemic antibiotics are often utilized.

Unfortunately, these previously mentioned properties of biofilms lead to a triumph of persistence for the bacteria.  We are then left with surgical options to literally “powerwash” the biofilms away and forcefully apply topical antibiotics.  In many cases, however, this is also unsuccessful.

So how do we get barnacles off a boat?  We add in soaps and surfactants and we physically scrub them off.  That has led to the development of instruments, irrigators, and topical drug administration systems.   We are also toying with the idea of using soaps, and surfactants.

Baby shampoo, bactroban, cortisporin otic suspension, surfactant, and Gentamycin irrigations have all been utilized both in the operating room and as an outpatient.

A Laryngocele is an enlargement or dilation of the sacculous or appendix form the vestige of the Ventricle of Morgagne.  It is often in horn players or glass blowers.  It often presents with horseness, dyspnea, or a neck mass.  Some texts site the existence of an internal laryngocele, however, that is probably best termed a Saccular Cyst and is best resected endoscopically.  When the saccule actually herniates through the foramen in the thyrohyoid membrane (where the internal branch of the Superior Laryngeal Nerve enters).  It will dilate out with a Reverse Mueller’s Maneuver (not with a Valsalva—Positive Pulmonary pressure against a closed glottis) as the diverticulum is supraglottic.   This is sometimes termed “Furstenburg’s sign of the neck.

Diagnosis is primarily clinical and is best confirmed with a contrasted CT scan of the neck.  If it unfortunately becomes infected it is then termed a Laryngopyocele.  Treatment is meticulous excision via external approach.  You will have to make an inferiorly based perichondrial flap and resect some of the lateral thyroid cartilage.  The Superior Laryngeal Nerve needs to be identified and protected.

An internal Laryngocele might be better termed a Saccular Cyst and is probably best managed with an endoscopic excision with the Lindholm Laryngoscope, blunt dissection, and cautery.

Rhinoplasty is a facial cosmetic procedure, usually performed to enhance the appearance of the nose. During the surgery, the nasal cartilages and bones are modified, or tissue is added. Rhinoplasty is also frequently performed to repair nasal fractures. The goal is to restore pre-injury appearance of the nose.

Every year, half a million people who are interested in improving the appearance and/or function of their noses seek consultation with facial plastic surgeons. Some are unhappy with the noses they were born with, and some with the way aging has changed their nose. For others, an injury may have distorted the nose, or the goal may be improved breathing. But one thing is clear: nothing has a greater impact on how a person looks than the size and shape of the nose. Because the nose is the most defining characteristic of the face, a slight alteration can greatly improve one’s appearance. Rhinoplasty may cost considerably less than you would expect.  Photos can be indicative of a surgeons skills and abilities.

Vitamin D3 is a general immuno-suppressant. Macrophages, monocytes, and other effectors cells of immune system have receptors for Vit D. At a recent Allergy meeting there was a poster presentation that showed supplementing Vit D reduced acute asthma exacerabations in the active group vs. placebo. Also, people high risk for developing MS nowadays are prescribed moderately strong doses of Vit D3. (2000 U/day)

The therapeutic-toxic gap of Vit D is much wider (unlike Vit A). Therefore relatively high doses are well tolerated. There is currently a proposal before FDA to raise the daily requirement of Vit D in an adult to 1-2000 units.

More time is spent indoor over the past 50 years, resulting in less sun exposure. And inadequate intake leads to vitamin D deficiency. Increases in TH2 balance leads to more asthma and allergies. I have not checked in my asthmatic patients, but I am thinking about it.

I think that some of the other information coming out about vit D deficiency and risk factors for other medical problems is interesting as well. D deficiency may be associated with increased risk for multiple sclerosis and insulin resistance.

I remember back in med school, learning that MS risk was greater in northern/colder climates, and the going theory was that “some kind of virus” that thrived in cold climates was responsible! Lack of sunlight or D deficiency was never suspected.

Today’s average sun exposure is far less than 20 or 30 years ago. Using a sunscreen of only 15 SPF blocks 95% of our skin’s ability to make vitamin D. Today people in general have far less unprotected sun exposure – between kids staying indoors and watching TV/playing video games/computer games, and more careful use of sunscreen by both kids and adults – people are just not making vitamin D with their skin the way we used to.

People with darker skin do not make as much vitamin D with sun exposure, and there is evidence that older skin does not make vit D as well either. Obese people are also more susceptible to D deficiency.

Vitamin D is not present in very many foods – cheese does not generally contain D, and yogurt rarely has much (unless it is fortified); the D in milk is destroyed when exposed to light.  All this means that the average person today has far lower D levels than people only 20 years ago.

I wonder if D deficiency and its associated insulin resistance is one more contributing factor to the obesity crisis (along with about a zillion other causes.) I have a question for anyone out there with a lot of experience with sarcoidosis. I have read that dark skinned people in Africa have low levels of sarcoidosis, but people of African ancestry who move to more northern climates have higher levels of sarcoidosis than the average population. I also understand that sarcoid nodules can actually PRODUCE vitamin D – and that countries with the highest level of sarcoidosis are Iceland and Sweden.

I’ve only recently started testing and treating, but I did have a new patient last week who was treated by his primary care doc last year, with marked improvement in his chronic tendonitis. The patient is a 35 year dentist, with naturally dark skin, who had been suffering from elbow tendonitis for over a year, despite NSAIDs and PT. After doing some reading about vit D, he asked his doc to check it. Level came back at 6. Post treatment level was 39 (8 weeks of weekly 50,000 IU of ergocalciferol/vit D2). Patient tells me that he was surprised that his symptoms resolved completely after treatment. Single case, but interesting.

How to replace— I like 1000-2000 u otc daily or.. 50000 units ergocalciferol weekly

Chondrodermatitis nodularis chronica helicis (also known as “Chondrodermatitis nodularis helicis”) is a small, nodular, tender, chronic inflammatory lesion occurring on the helix of the ear, occurring most often in men.

Oral immunotherapy (OIT) for children’s peanut allergy may be a safe and effective approach, a new study has shown.
Findings from the phase 2 trial, published online January 29 in the Lancet, add to accumulating evidence that children can gradually build tolerance by ingesting increasing amounts of nut protein.
“To our knowledge, our findings provide the first well controlled and accurate estimate of the effect size, benefits, and risks of desensitisation with peanut OIT,” write Katherine Anagnostou, PhD, from the Department of Medicine, Addenbrooke’s Hospital, Cambridge, United Kingdom, and colleagues.
Previous results from small studies have suggested that peanut OIT might be an effective strategy for managing children with peanut allergy. However, until now, the approach had not been thoroughly evaluated in a sizable group of children.
Therefore, the investigators designed a 2-step, randomized controlled crossover trial testing OIT in 99 children aged 7 to 16 years. Children with all levels of peanut sensitivity were included in the trial.
In the first step, children were randomly assigned to 1 of 2 groups. One group received 26 weeks of OIT, which consisted of gradually increasing doses of peanut protein up to 800 mg daily. The other group was advised to avoid peanuts per usual, serving as controls. At the end of the 26 weeks, both groups underwent peanut challenge.
In the second phase, children in the control group were offered the 26-week OIT treatment followed by challenge.
“OIT successfully induced desensitisation in most children within the study population with peanut allergy of any severity, with a clinically meaningful increase in peanut threshold,” the researchers report.
“Peanut OIT raises the reactive threshold at least 25-times so that 84–91% of participants can tolerate daily ingestion of 800 mg protein.”
At the end of the first trial phase, 84% (95% confidence interval [CI], 70% – 93%) of the children in the active intervention group tolerated daily ingestion of 800 mg protein compared with none in the control group. In addition, 62% (95% confidence interval [CI], 45% – 78%) of the active intervention group had become desensitized, which was defined as having no reaction to ingestion of 1400 mg peanut protein (roughly equivalent to 10 peanuts).
After the second trial phase, 91% (95% CI, 79% – 98%) of children who had been assigned initially to the control group were able to tolerate ingestion of 800 mg protein daily, and 54% (95% CI, 35% – 72%) had become desensitized.
The authors point out that it would be unlikely for children to accidentally encounter 1400 mg of peanut protein.
About a fifth of the patients reported adverse reactions to OIT. However most were mild, with oral itching being the most common, occurring after 6.3% of doses (76 children). Gastrointestinal symptoms were also common, with 31 children reporting nausea, 31 reporting vomiting, and 1 reporting diarrhea. In addition, 41 children developed wheeze (0.41% of doses) and 1 child required intramuscular adrenaline.
Treat obstructive apnea events and prevent more serious events before they occur Auto-titrating PAP (APAP) technology from ResMed™ responds to flow limitation, which often precedes snoring and apneas. Review data from a recent studyInformation from Industry
In an accompanying comment, Matthew J. Greenhawt, MD, from the University of Michigan Food Allergy Center, Division of Allergy and Clinical Immunology, Ann Arbor, stressed that although the results of the study are promising, more high-quality data are needed before recommending the therapy to all child and adolescent patients with peanut allergy.
“It is important to understand that OIT research cannot be rushed, and is years away from routine clinical use,” Dr. Greenhawt notes. “Investigative groups need time to refine protocols, revalidate data, understand the mechanisms of OIT, and minimise adverse effects. This must be done without added pressure or heightened expectations to quickly produce a marketable therapy,” he concludes.
Support for this study was received from the Medical Research Council, National Institute for Health Research, United Kingdom. Two coauthors are inventors on a patent application that covers the protocol described in this study. The remaining authors have disclosed no relevant financial relationships. Dr. Greenhawt has reported that he is a member of the Educational Advisory Council for the National Peanut Board and has served as a consultant for Deerfield Industries.
Lancet. Published online January 29, 2014.

In 1979 the Federal Register of the FDA issued a final rule classifying a group of Bacterial Vaccines and Bacterial Antigens with “no U.S. Standard of potency” based on the review of a Panel Recommendations. Because they had insufficient data to support their safety and efficacy. The products never did studies as the manufacturers were not interested in the cost and they were withdrawn. Despite no documented scientific evidence supporting efficacy allergist had given these tablets for over 1/2 century without any adverse effects and many attested to there effectiveness at stopping recurrent upper respiratory infections. We knew most were viral but these bacterial antigens seemed to work.

In 2009 Dr. Bellanti produced a supplement to the Allergy Proceedings on new vaccine of ribosomal nature associated with glycoprotein cell walls from Klebsiella pneumoniae which served as an immunoadjuvant. From the articles it seems the ribosomes stimulate TLR2 and work on the innate immune system and boost the adaptive system.

If you live long enough you see a lot of old ideas recycled. I have some old vaccines from the 50’s and thought the younger allergist would get a kick out of seeing this stuff and a heads up to all of us to watch for a immunomodulator that may be coming soon.