GABHS has a number of known problematic sequelae that are the primary reason we look for it.  Although rare, ARF (Acute Rhematic Fever) or Rheumatic Heart Disease is our primary concern.  It is a sterile Type II autoimmune attack on the heart valves, myocardium, and joints resulting from the protracted high anti strep circulating antibodies.  It is my understanding that if you treat Strep within 9 days you avoid this possibility.  Apparently you need to treat about 40,000 cases of strep throat to avoid one such case.  With the incidence of a severe allergic reaction to PCN being 1/12,000 so clinical judgement is paramount.  The most winning strategy is to just use the “rapid test” as the decision maker.  Using this strategy, in the US, we could prevent 85 cases of rheumatic heart disease annually at the cost of $727,000 per case prevented.  You are actually more likely to contract Lemeirre’s Syndrome from Fusobacterium with a GABHS infection than Rheumatic Heart Disease.

The changes in voice after rhinoplasty are more personal perception than reality

Patients who have undergone plastic surgery to change the appearance of their nose may also notice changes in the sound of their voice, reports a study in the February issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Changes in voice after rhinoplasty are perceptible to patients as well as to experts, but generally don’t cause problems with speech function, according to the new research by Dr. Kamran Khazaeni and colleagues of Mashhad University of Medical Sciences, Iran. However, they believe that patients considering rhinoplasty – especially those who use their voice professionally – should be aware of “potential voice alterations.”

Shots and Vaccines

Getting an annual flu shot and getting the pneumococcal vaccine are always a good idea. Prevnar is a 7-valent vaccine, whereas Pneumovax is better with 23 stimulating antigens. The pneumococcal vaccine is slightly effective at lessening the incidence of otitis media and probably rhinosinusitis. It changes the infectious agent to non-typable hemophilis, which lessens the efficacy of the aminopenicillins.

Intradermal zovirax and flu vaccine

Vitamins and Supplements

Vitamin D

Zinc (zicam), vitamin C (up to 2,500 mg or 25,000 units per day), echinacea and other supplements remain unproven but certainly have no ill side effects. These can be administered either topically or systemically.

Papaya enzymes in a product called Clearease has been advocated by Dr. Grossan to be used in his Water Pik. Evidence is lacking and benefits seem subjective. A variety of herbal remedies have received attention. Echinacea is well known by many to help with URI’s. Some have advocated horseradish, bromelain, goldenseal, stinging nettle, ephedra and others. They seem harmless.

Adjunctive Thyroid Medicine

Bactroban Ointment

Yeast Reduction Protocol (Antifungals)Adjuntive

Probiotics

Gluten Free Diet

ASA Desensitization

SCIT or SLIT

Long Term Antibiotics (Derm Style)

Macorlides

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.