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January 11, 2018

Smell Lose After Upper Respiratory Infection

Losing the sense of smell is not uncommon with upper respiratory infections (URI), typically with a viral common cold or flu. According to some studies, smell loss or decrease may occur between 18-45% of  patients who suffer from a URI.

It is estimated that about 1/3 of such patients will fully recover their sense of smell with 2-3 years, most within the first year. Unfortunately, that leaves 2/3 of these patients who suffer from some degree of smell dysfunction.

The key determining factor whether full recovery is expected or not is whether there is still some smell sense present (hyposmia). Those with COMPLETE smell loss (anosmia) have a much higher risk of no recovery.

A secondary factor to predicting whether full smell recovery will happen or not is age. The older the patient's age, the worse potential for smell recovery.

In terms of treatment, literature reports that steroids, vitamin B, zinc, theophylline, and α-lipoid acid can be used to treat post-infectious olfactory loss, but thus far there is no definitive effective therapy available to date.

In spite of smell and taste dysfunction being relatively common complaints, there's only a few centers that actively evaluate and treat patients with these complaints.

In our area, there's only two...

Taste and Smell Clinic in Washington DC

Postinfectious olfactory loss: A retrospective study on 791 patients. The Laryngoscope, 128: 10–15. doi:10.1002/lary.26606

Complaints of olfactory disorders: epidemiology, assessment and clinical implications. Curr Opin Allergy Clin Immunol 2008;8:10–15.

Smell and taste disorders, a study of 750 patients from the University of Pennsylvania Smell and Taste Center. Arch Otolaryngol Head Neck Surg 1991;117:519–528.

Olfactory dysfunctions. Epidemiology and therapy in Germany, Austria and Switzerland [in German]. HNO 2004;52:112–120.

Postviral olfactory loss. Otolaryngol Clin North Am 2004;37:1159–1166

Characteristics of olfactory disorders in relation to major causes of olfactory loss. Arch Otolaryngol Head Neck Surg 2002;128:635–641.

Long-term follow-up of olfactory loss secondary to head trauma and upper respiratory tract infection. Arch Otolaryngol Head Neck Surg 1995;121:1183–1187.

Local and systemic administration of corticosteroids in the treatment of olfactory loss. Am J Rhinol 2004;18:29–33.

Topical therapy in anosmia: relevance of steroid-responsiveness. Laryngoscope 2008;118:1681–1686.

Lipoic acid in the treatment of smell dysfunction following viral infection of the upper respiratory tract. Laryngoscope 2002;112:2076–2080.

December 22, 2017

Criteria for INSPIRE Pacemaker to Treat Obstructive Sleep Apnea (OSA)

Due to effective marketing, I have had more and more patients inquire about the INSPIRE sleep therapy to treat and potentially cure obstructive sleep apnea so that CPAP would not be needed.

First off, our office does not perform this procedure which requires implanting a pacemaker in the chest wall (see image). It works by stimulating the tongue muscle in time with inhalation to prevent the tongue from falling back and obstructing the airway leading to sleep apnea.

For those interested, there are specific criteria that must be met in order to be considered a surgical candidate.

1) Must be 22 years or older
2) On the sleep study report, the AHI score must be 15 - 65.
3) On the sleep study report, there must be fewer than 25% central apneas.
4) Patient must report is unable to tolerate CPAP therapy.
5) There must not be any concentric airway collapse at the palate level (determined on sedated endoscopy)
6) BMI must be less than 32.

Patients must also be made aware that even if they meet surgical criterias, some insurance companies will not cover as it may be considered experimental.

Although any ENT doctor can determine whether a patient meets INSPIRE surgical criteria, only a few ENT doctors are trained to perform this procedure.

You can find the closest ENT doctor who can perform this surgery here.

In my neck of the woods, the closest would be Dr. Stanley Chia at Georgetown and Dr. Mark Jameson at UVA.

What is Found in Normal Nasal Fluid in a Healthy Human Being?

Table from this Reference
Contrary to common belief, normal nasal fluid is not water... It is in fact more similar to sweat than water.

Nasal fluid is normally produced by submucosal glands, seromucous glands, goblet cells, transsudation of blood plasma, mucosal tissue fluid, and tear fluid. The table shown is a description of what electrolytes are contained in normal nasal fluid produced by a normal, healthy human being.

Along with these electrolytes, nasal fluid also contains glycoproteins 10% by weight. Up to 50% of the glycoproteins present in nasal fluid is due to IgA. Smaller amounts of IgG and trace amounts of lipids are also present.

What all this means is that if nasal fluid dries out (ie, during very low humidity weather), the nasal fluid will turn yellow-brown just like water containing sugar. Classically, people would experience increased "boogers" and nasal crusting in the morning.

Beyond adding a room humidifier which will help, I also suggest using an oil-based nasal drop (I like ponaris) to help protect the nasal lining (just like using chapstick to help with dry, chapped lips).

Physiology and pathophysiology of respiratory mucosa of the nose and the paranasal sinuses. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2010; 9: Doc07.

December 15, 2017

Is 1 Liter of Nasal Fluid Produced a Day Truly Normal?

Ask any ENT how much nasal drainage is normally produced by a healthy human nose every day and you will be told 1 liter. But that's not what this blog article is about. Rather, HOW was this amount determined? What is the research behind this volume? The answer is surprisingly difficult to find and still up in the air... If any readers can do some sleuthing beyond what I report below, I would be much appreciative!

The vast majority of references found on simple google searching are quotes from ENT's interviewed for a magazine or newspaper article.

On deeper searching, 1 liter of normal nasal drainage can be found mentioned in research articles or medical texts, but still no explanation on how this volume was determined.

• "Approximately 1 liter of fluid is produced by nasal epithelium each day." [Medical Textbook, page 120]

• "A rough calculation of the daily volume of secretion and transudate from the nose is 1000 cc." [Research paper, page 126]

• "Mucociliary clearance is defined as cleaning of upper and lower airway by interaction of nasal mucus (about 200 g or 2 litre/day produced by the respiratory mucosa)" [Research paper, reference #36]

• I was able to find actual research describing methods to determine nasal secretion volume in animal studies. Here's one on guinea pigs.

• Using similar methods in animals, here's a research paper that described inserting filter paper into the nasal cavity of people and weighing how much secretions were absorbed after a period of time, but such information may not be entirely accurate due to nasal irritation from the filter paper itself.

• Here's another research paper describing a method of measuring nasal fluid by the urea concentration present.

Why is this Important?

One of the most common complaints people have when seeing a doctor is post-nasal drip or post-nasal drainage.

Typically such an abnormal sensation is NOT attributable to actual increase in nasal fluid volume, but rather changes in consistency and/or protein concentration along with environmental factors related to humidity and temperature.

However, if the underlying facts related to normal nasal fluid volume is incorrect, it does bring into question whether current treatment strategies is not ideal or at worst, frankly inaccurate.


Thus far, I have been stumped regarding where exactly the claim that a normal human nose produces 1 liter of fluid.

If any reader can shed light on this claim, that would be wonderful! Please report your findings below under the comment section.

Ideally, the information I am most interested in is the original source reference as well as the methodology used to determine the nasal fluid volume.

Nasal anatomy, physiology, and function. J ALLERGY CLIN IMMUNOL 72:123-128, 1983

Bacteriology of Humans: An Ecological Perspective. By Michael Wilson. John Wiley & Sons, Jan 26, 2009 - Science - 360 pages

A new method of the measurement of nasal secretion in guinea pigs. Int Arch Allergy Appl Immunol. 1991;95(1):29-34.

The Source of Nasal Secretion in the Normal Condition: Fluorescein Tests. Acta Oto-Larnyngologica. 1949;37:446-50.

Physiology and pathophysiology of respiratory mucosa of the nose and the paranasal sinuses. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2010; 9: Doc07. Published online 2011 Apr 27. doi: 10.3205/cto000071

A standardized filter paper technique for assessing nasal secretory activity. Clinical Allergy, 1981, Volume 11, pages 287-292

Estimation of nasal epithelial lining fluid using urea as a marker. J ALLERGY CLIN IMWJNOL 1993;92:457-65.)

Allergologie-Handbuch: Grundlagen und klinische Praxis. Stuttgart: Schattauer; 2006.

December 08, 2017

Steps a Patient with Chronic Sinusitis Goes Thru

For the vast majority of patients with sinus infections, a trip to the primary care doctor's office and a prescription for antibiotics is all that is required. However, for the unfortunate few, several courses of oral antibiotics do not seem to help as much as it should.

In such cases, these patients eventually end up at an ENT office for further evaluation and management.

ASSUMING the patient has bona fide chronic or recurrent sinus infections and not some other medical problem confused for a sinus infection such as trigeminal migraines, these are the typical steps such patients go through in order to address their sinusitis. Keep in mind that some of these steps may be flipped or merged depending on an individual's unique clinical situation.

Step 1:
Endoscopic evaluation of the nasal cavity and if possible, the sinuses. If purulent drainage seen, culture are obtained in order to identify the organism and determine what antibiotics will work best to kill it (known as C&S). More oral antibiotics along with steroids typically prescribed at this stage. Nasal flushes with xlear or chitorhino can be tried especially if plain saline sinus flushes not helpful.

Step 2:
If not already done, allergy testing to evaluate for any allergic triggers that could be contributing or even driving the sinus infections. If allergies present, aggressive allergy medical management is started including medications and allergy shots.

Immunologic testing is also often performed in order to determine if there is some sort of immunodeficiency resulting in the body being unable to fight off infections as well as it should. Such immunologic testing typically evaluates for immunoglobulin (Ig) levels. More rarely, testing may include cellular immune functionality (lymphocytes, B cell memory, etc). If any immunologic dysfunction present, referral to immunology specialist is made.

Step 3:
CT Sinus scan to evaluate the extent of the sinus disease.

Step 4:
If medical management not working, sinus surgery is performed. Intra-operative cultures are obtained.

Step 5:
If sinus infections persist in spite of sinus surgery, more aggressive antibiotic treatment is performed via:

1) Adding antibiotics to the saltwater which is than flushed into the nose twice a day.
2) Injecting a thick gel impregnated with antibiotics and steroids into the sinus cavity filling it up. This will stick around for 2-4 weeks.

Step 6:
Potentially start a workup for potential autoimmune issues that may be contributing to the sinus infections (ie, Wegener's Disease, Churg-Strauss Syndrome, etc).

Step 7:
Ultimately, manage the sinus infections as a chronic illness, just like hypertension or diabetes.

December 03, 2017

Types of Medical Animations and Cost Implications

I've received numerous inquiries from physicians over the years regarding my experiences with medical animation development and cost given I've produced close to 30 animations thus far. Rather than going over the same materials each time I get a new inquiry, I wrote this blog article that addresses many of the questions I get.


There are essentially 4 types animations currently out there. There are both strengths and weaknesses for each animation type, but for the individual who will be paying for everything, cost is the main differentiator.

Some companies specialize in only one type of animation whereas others like O2Labz can accommodate any style.

Realistic 3D Animation - Very Expensive

This type of animation provides the wow factor and is akin to the CGI you would see in a hollywood blockbuster movie. Of course, you also pay orders of magnitude more. The rhinoplasty animation below is an example of 3D animation. Note that perspective is maintained even through different camera angles as well as realism of surface textures and appearances.

Semi-Realistic 3D Animation - Expensive

This type of animation is still 3D, but realism is sacrificed in order to save on cost.

2D Animation - Less Expensive

Note that the animation is much more cartoonish in appearance. Also note that only a single camera angle is used at all times.

Whiteboard Animation (aka, Explainer Videos) - Least Expensive

Typically, animation is in black and white, though elements of color can be added. Movement is also limited in nature.


Although others may follow a different plan, the steps that I take to make the best possible animation with the least amount of money are as follows.

1. Create a VERY detailed storyboard. The storyboard is basically making a cartoon that describes what the scene will look like, lighting, camera angle, camera zoom, and duration every single moment of the imagined animation from start to finish. For example,

"At 0 seconds, start out showing the front of a woman's face filling the screen. The background is a light grey. Lighting is diffuse and even. Over the next 5 seconds, slowly zoom into the woman's face such that the nose fills 75% of the screen. Once zoomed in, over the next 3 seconds, turn the camera angle 30 degrees to the left such that the side of the nose is centered."

The storyboard should include reference illustrations and videos to try and explain to illustrator what you envision. I typically get such reference images from Google Images, YouTube, and textbooks.

Cut out anything that is not necessary since every additional second/minute adds significantly to the cost.

2. Based on the storyboard, decide which type of animation style would work best at conveying the information you have. Although 3D animation for everything would be great if you have an unlimited budget, it is not always technically necessary. For example, I decided on 2D animation to describe how allergy vials are made above as 3D really would not have added to the information I was trying to convey. However, for the rhinoplasty video, 3D was extremely important as nasal appearance in all dimensions is something patients like to see as it may be hard to visualize such information in 2D only.

Once you pick an animator, work can begin, but here's a few things to keep in mind to prevent surprise expenses and minimize annoying your animator.

• ALWAYS respond promptly to questions. The animator can not continue working on the animation without constant feedback and approval to go on to the next step in the storyboard. If it takes 24 hours for you to respond, the animator will have to wait 24 hours before continuing to work on your animation. This wastes their time.
• Have the animator create still shots of storyboard scenes first for your approval before they animate anything.
• When animation finally created, keep the amount of detail to a minimum initially. Make sure that the camera angles, sequence of events, zoom, etc are all looking good first. Once draft animation approved, final animation with full rendering of textures and details can be produced as the last step. Why? Because it takes time for a computer to create the movie with full detail whereas "draft" animations can be produced quickly.
• Try to avoid requesting changes AFTER you have already approved something. The biggest faux pas is to request a change after you have already approved of an animation sequence. Why? Because even a small insignificant change may require the animator HOURS of work to implement. To use an analogy, it's like a homeowner asking a builder to make the basement slightly bigger after the first and second floors have already been built. Or deciding to change the color of a yarn pattern after the sweater has already been knit.

If you request changes after initially approving something, you might be charged extra for additional work that needs to be redone. Most animators will forgive one or two such changes, but WILL charge extra if you keep making changes beyond that.

Typically, the animator is paid in thirds: 1/3 of the project cost immediately or after stills approved; 1/3 after first animation draft; and 1/3 after project completion.


Once an animator has created something for you... additional animations based on the same model can be made for much less. For example, using the same nasal hump rhinoplasty model above, I was able to create a different rhinoplasty video shown below for significantly less.

I also would not worry about how fast or slow the animation is in certain scenes. That's something you can easily change in any video editing program like iMovie or Final Cut Pro X (which I use). No need to pay an animator to do this. Needless to say, you can save money by doing things yourself where you can. This includes narration, background music, title screens, credit screens, etc.

Just FYI, copyright free background music and sound effects are available through YouTube's Creative Studio.

I personally ALWAYS credit the animator in videos I publish because I feel it is the right thing to do. But when negotiating cost with an animator, do NOT bother to ask for a discount if you provide such credit. Providing credit is not a particularly big carrot for animators because there's no guarantee that your video will actually be popular enough to warrant giving you a discount. Perhaps if you have already established a track record for creating popular videos, the animator might provide a small discount, but don't count on it.

For those curious, the animation company I have worked most extensively with is O2Labz.

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