Management of Drooling

37min overview on Management of Drooling/Sialorrhoea.

Aimed at Otolaryngology Head & Neck Surgery Trainees.

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Choose to live well

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This coronavirus pandemic has changed the way we live drastically. This coronavirus is forcing us to choose. To choose to confront ourselves in the stillness and quietness of our homes. When all the bells and whistles have been removed, when our conferences, meetings and speaking engagements have been stripped away from us, we are forced to face our own selves when no one is looking. We have been forced to be still. How are you?

We are all in difficult places. But even in our various forms of difficulties, we can choose to be positive despite the negativity. We can still choose authenticity rather than authoritarianism. We can choose collaboration and connection when we have very little control over what is occurring. We may not change our situations but we can choose to change the way we respond to these difficulties. We cannot control every single thing that happens around us, but we can collaborate and connect to get through all this together.

We’re all in this together. Choose to live well.

The use of Povidone Iodine nasal spray and mouthwash during the current COVID19 pandemic

Evidence Based Medicine is the application of the best available evidence to the clinical problem at hand. We are living in a pandemic. We do not have the luxury of Randomised Controlled Trials. We do not have the luxury of prospective studies, time and resources. We use any good evidence we have, dissect it and see if it is fair and applicable. We rely on basic principles and extrapolate as necessary.

Here’s a paper that seems based on a good basic science foundation and appears to suggest a safe, cheap and readily available additional protection against the virus.

20200323 The use of Povidone Iodine nasal spray and mouthwash during the current COVID-19 pandemic Version 4.pdf

Your choice to take it up or not. You need to critique the evidence yourself.

Because of my front line exposure to examining and operating on patients whose noses and throats may be virus laden, I decided to do this simple nasal therapy.

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The mixture has to be diluted. Also, ensure the betadine you’ve got is cleared for oral use/gargle. There are some preparation with phenol mix that should be avoided. Get 1 ml of Betadine (10% Providone Iodine) add 20mls of sterile water. Put the solution into a small nasal spray bottle. 2 sprays each nose, three times a day (before the morning session, right after lunch, and before reaching home). Simple, safe and may well be protective. Stings a little but that’s all.

Tips on online presentations and meetings.

We do so many online meetings and talks now. Here are 3 little tips to help you do well in front of your phone or computer.

Lights.

Camera.

Action.

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Lights

Keep a forward light directed on to your face. No back light. Natural light is great, make sure it’s from in front not from behind you. You can use a simple study table light shining at your face.

Camera

Keep your phone or computer camera at the same level as your eyes. Our tendency is to look down at the computer. Double chins and nostril hair! Elevate the computer on a platform or a stack of books or lower your seat. Put the phone on a tripod or prop it up on a stand. It’s easy. Changing the angle makes you look 100 times better. Also, please don’t move the camera. The people on the other side watching you camera shakes might get dizzy with all the movements you make.

Action

Look at the camera. Looking at your own image as you talk make you look to your listeners like you’re staring at something else. Get used to focusing on the camera. It also helps you to focus your thoughts as looking at your own image on the screen distracts you.

Other tips

In an online meeting or presentation, mute your microphone unless you need to talk. When listening to a presentation, you may also switch your video off so your image doesn’t distract the presentation and reduces the load on the wifi/servers. If you switch off your video in a presentation, you can do other stuff while you listen. In a meeting I would encourage you to have the video on so your presence and contribution in a meeting will be acknowledged.

Choose words carefully. Do not ramble on. It’s not exactly a normal face to face.

If you’re doing a presentation, you need to continue with creating emotion and intonation with your voice, but remember that your listeners are listening to you in their office, lounge or transport vehicles, avoid yelling and screaming. Speak like you’re speaking to a small intimate gathering.

If you’re a host of a meeting set the rules clearly about speaking in turns and allowing everyone a chance to speak.

Watch your background. Choose a virtual background if you needed to protect your room privacy.

Keep the environmental noise to minimum. Use headphones or ear pods to improve sound quality and stop you yelling at a computer. This also reduces the noise feedback that sometimes happen as the computer microphone captures its own speakers.

This is the simple set up on my desk. A cheap study light, an iPhone tripod and an elevated platform for the laptop.

Any other tips you’d like to add?

Nasopharyngeal swab and nasogastric insertion.

‪The nasopharynx goes back, not up. ‬

‪When you take a nasopharyngeal swab or insert nasogastric tube, NEVER aim upwards towards the brain. ‬

‪Go LOW and go SLOW.‬

‪Correct direction follows the floor of your nose not up towards the roof. ‬

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All hands on deck for COVID19

Some data out there would suggest that 10-15% of people who are infected by the coronavirus are health care workers (HCW). Let’s do a numbers game here. One nurse treats up to 4 patients. They’re the absolute front line. They spend hours caring for patients in close proximity. One allied health clinician or one doctor may be responsible for a handful of patients, somewhere in the order of 10-15 on the ward or up to 30 in a day in clinics. Knock one nurse out or one physiotherapist out or one anaesthetist or surgeon out and see the domino effect on health care service provision? One less nurse or doctor or clinician means a handful of patients are not getting the treatment they deserve. In addition, the remaining staff needs to take up the slack, putting the patients and staff at risk. I can see how difficult this is already in the emergency department where staff members have to be quarantined. One General Practitioner quarantined for 2 weeks would mean loss of service to hundreds of patients.

Now think about the ventilator capacity. Increasing ICU capacity is increasing care for the sickest of the sick. A ventilator is a machine that keeps breathing for the patient while the patient is intubated in an induced coma. These are reserved for the really sick patient. And so far, the mortality rate for intubated patients is in the order of 60% or more based on several papers.

Can you now see where the upstream and downstream challenge is? If we had all the money and time in the world to prepare for this pandemic we would increase all supplies of Personal Protective Equipment (PPEs) and increase ICU capacity all at the same time. But we don’t have time and we don’t have resources.

Which challenge should we prioritise?

The high complex end of delivering ventilators or the mass protection of all health staff with masks, gowns, gloves and face shields? I wonder if specific technical industries can be mobilised to produce ventilators while general industries can be mobilised to mass produce masks, gowns, gloves and face shields? Protecting health care worker means protecting the health service means providing timely efficient care means protecting the community. It’s all connected. It’s not just about the HCW. Ultimately it’s about keeping the patients safe.

I know that it’s a complex world. I know that this is all very challenging for every institution around the world. I know that it seems an oversimplification of the problem. I know that many people are already working on the solutions. I know that I’m asking a question so obvious that many would already have the answer. But help me. In this simple oversimplification of the problem comes ethical, clinical, leadership and resource challenges. There’s probably no simple answer. It’s a question that will be answered differently by different people in different countries. The reality is what limits our answers.

The most important asset in healthcare is its people. Do not lose the people keeping the care going.

How would you prioritise the solutions? I’m just a simple surgeon I need some suggestions.

Be Kind

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This pandemic is changing the world and changing us. This coronavirus has slowed us down and taught us to live differently, to live carefully. Live CARE-full-ly.

Things I do NOT miss: meetings, KPI, goals, budgets, admin, shopping, competition, keeping up with the Joneses, parties, conferences, presentations.

Things I miss: people, people, people.

Online telehealth clinics have taught me that my facial expression matters and words are precious.

Virtual meetings have taught me that we can communicate with less words.

Having completely zero social events on the calendar taught me the good and bad of just simply being with family.

Having no new fancy restaurants to visit taught me that the family dinner table is the most important engagement of love and sharing.

I feel that the rhythm of the planet has slowed down and finally my body and mind are in tune again. No more running to places. No more hurry. No more rushing.

I am still committed to my patients and my team. Whenever my team is on the forward line operating on virus-laden oronasopharyngeal mucosa, I am fully committed to the wellbeing of the patient and the safety of my crew. The intensity of focus at work is balanced by the solitude of rest at home. We are all in this together.

How is this pandemic changing you?

 

Loss of smell and taste with COVID19

img_0842Here are a few fancy ENT words for you:

Olfactory (smell) disorder:

Anosmia: No smell (I can’t smell coffee)

Hyposmia: Reduced smell (I can smell coffee faintly)

Parosmia: Smelling a different smell (This coffee smells different)

Phantosmia: Smelling something that isn’t there (There’s a coffee smell but no coffee)

 

Gustatory (Taste) disorder:

Dysgeusia: dysfunction of taste

Parageusia: distortion of taste

Hypogeusia: reduced taste

Ageusia: No taste

ALSO, did you know that humans have 5 kinds of taste: sweet, salty, bitter, sour, umami (taste of MSG)

Read here from Europe the latest and so far the biggest study on smell and taste disorder in association with COVID19.

Key findings:

417 patients

85.6% had olfactory disorder, of which 79.6% of patients thought they were anosmic and 20.4% thought they were hyposmic. Phantosmia and parosmia concerned 12.6% and 32.4% respectively during illness.

The olfactory dysfunction appeared before (11.8%), after (65.4%) or at the same time as the appearance of general or ENT symptoms (22.8%).

The olfactory dysfunction persisted after the resolution of other symptoms in 63.0% of cases. For those who recovered their olfactory sense, 72.6% of these patients recovered smell within the first 8 days

88% gustatory disorder. Olfactory and gustatory disorders were constant and unchanged over the days in 72.8% of patients, whereas they fluctuated in 23.4% of patients.

Among the cured patients who had residual olfactory and/or gustatory dysfunction, 53.9% had isolated olfactory dysfunction, 22.5% had isolated gustatory dysfunction and 23.6% had both olfactory and gustatory dysfunctions.

What does this mean for us?
Keep an eye out for loss of smell as a possible early indicator prior to other symptoms. Resolution takes time. There’s still a lot we have yet to discover. Keep an open mind. This is not a protocol or policy. This is something we all should think about. Signals.

ENT Tips:

Check smell with coffee, mint, vinegar, chocolate lip balm, strawberry lip balm, etc. Check taste with salt, sugar, soya sauce (umami)

COVID19 affects everyone

Here’s a report from the Center for Disease Control and Prevention looking at the first 4000+ COVID positive patients in the United States.

https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6912e2-H.pdf

There are 2 graphs in that article that concerns me. This is the first one.

This tells me clearly that people of all age groups get admitted to hospitals. In fact, the big hospital admission burden is in the group between ages 20-74. This is important as we prepare for the incoming surge of patients. Many young people will require hospitalisation. Your youthfulness does not protect you from becoming ill enough that you need to be admitted to the hospital. Hospitalisations are expensive and labour intensive. We need to work hard at preventing these admissions. Community priority: social distancing to prevent spread and admission to hospitals. We can’t just use the number of ventilators as a measure of readiness. We need to look at the big picture of bed management across the service.

Let’s dump that myth suggesting that COVID19 is an elderly person’s disease. No. It affects all age group.

The second table is this.

It’s proving what we have heard from China , South Korea, Italy and the UK. Mortality rate goes up with age. In the oldest group of 85 and above, it appears that there is a case fatality rate of 10-27%. Now that’s a very high mortality risk. It’s critical that we have a frank discussion with patients and their families regarding advanced care plans even before entering the ICU.

Stay the course, friends. We’re all in this together.

3D printed ENT-modified face shield

Speed trumps perfection. Safety is a priority. This coronavirus pandemic has created a tsunami of innovation and collaboration. New problems are identified and creative solutions are offered across specialty lines. Many Ear Nose and Throat Surgeons in Australia and New Zealand use a special spectacle-mounted headlight magnifying loupes to look into ears, noses & throats (Vorotek). Standard face shields are not compatible as the visor hits the headlight. I shared this problem with an orthopaedic surgeon Dr Claudia di Bella who then connected me immediately to the BioFabrication 3D Lab in Melbourne. Ten minutes of discussion of the challenges led to some simple solutions to bring the shield forward. Within 2 days, we have a prototype which was then simplified and refined. Two days after that we have a good solution to the problem. You can put this on with optical loupes up or down, which make patient examination easier. Glare from plastic is minimal and acceptable. The plastic can be detached from the frame easily to be regularly cleaned and washed. Watch it here.

Note: this face shield is a layer of splash/droplet protection over your vorotek. You still need to don other protective measures such as surgical mask (or N95 in an AGP), gowns and gloves. User feedback will improve the design and functionality for the next generation of shields we’re working on.

This is an example of how 3d printing skills are making an immediate difference to clinicians at the front lines facing the patients. Simple, cheap, scaleable solution.

Materials:

1. 200Micron thickness A4 overhead projector sheet from your local stationery shop. You can cut the length and width to size. This sheet can be wiped down with alcohol or soap at every patient encounter.

2. Hair ties, hair elastic band or velcro straps from your local shops. Velcro straps will give a bit more security if you preferred.

3. 3D printed ENT-modified frame. Drop a line at BioFab3d. They can send you the open-sourced file that has been refined by the team at RMIT and BioFab3D. Take the file to your nearest 3D printing facility. If you live in Melbourne, you can pick up the frame from the Lab situated within the campus of St.Vincent’s Health Melbourne. Cathal O’Connell is the man you want to speak to. This is his page at COVID SOS.

Click on this video on how to assemble the face shield. Too easy!

They also have the standard face shield (not modified to allow headlight. The shield sits closer to the face). They are going into production asap.

The stl file for Vorotek modified faceshield to download is here.

For the standard face shield that sits closer to the face, the file is here.

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I’m grateful for innovation and collaboration. We’re all in this together.

CATHAL O’CONNELL of 3d Fabrication Lab, PAUL SPITHILL from RMIT Advanced Manufacturing Precinct & Prof MILAN BRANDT, Director of RMIT Advanced Manufacturing Precinct have donated their expertise, time and effort for free. RESPECT TO THEM. Also catch this development on SBS News. Their website here.