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Posterior Epistaxis

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October 23  |  Blog, York ENT Blog  |   James Rejowski

Epistaxis, or nosebleed, is a common problem that we see and treat in our practice.  60% of the population will suffer a nosebleed at some time in their life.  Most the bleeding is anterior, or from the front of the nose.  This is usually treated in the office with simple cautery or packing.

Posterior epistaxis, or bleeding from the back of the nose, presents more of a problem.  It is frequently seen in older people with underlying health problems such as diabetes or vascular disease.  This type of bleeding can require admission to the hospital for treatment, but fortunately this occurs only in a small percentage of patients.

A recent study compared different modalities of treatment for posterior epistaxis.  Using a national data base of over 50,000 admissions, outcome results for nasal packing, surgical ligation of bleeding vessels, and endovascular embolization were obtained.  Nasal packing involves the placement of a Vaseline gauze, tampon, or balloon in the nasal cavity, leaving it in place for 48-72 hours.  Arterial surgical ligation is usually done with an operation done through a person’s mouth, in the area above the canine teeth.  Dissection proceeds through the maxillary sinus until the arterial feeding vessels are identified and clips are placed on them.  Arterial embolization is done by interventional radiologists, who will place a catheter through the arterial system from the groin and perform very selective occlusions of the vessels behind the nose in order to stop the bleeding.

The length of stay in the hospital for each of these treatments was quite comparable to each other.  The cost of treatment for the embolization group was highest.  There was an increased risk of stroke with the embolization procedures compared to packing, which is not surprising given the fact that particulate matter was injected into the arterial circulation in the former group.

The data in this study was extracted from the discharge diagnosis that was coded following these hospitalizations.  It was not actually done by a review of the individual charts, so it needs to be taken with a grain of salt.  None of the treatments is intrinsically better than the others.  Practically speaking, when we see patients presenting with bleeding it is more efficacious to place a pack and wait a bit to determine its success or failure, rather than go right to the operating room or the angiography suite with a bleeding patient.  The latter treatments are a fall back when the packing, a less invasive procedure, isn’t successful in controlling the bleeding, or if the epistaxis recurs following this initial treatment.

Reference: Recent Trends in Epistaxis Management in the United States 2008-2010, Drs. Vilwock and Jones, JAMA Otolaryngology/Head and Neck Surgery, 2013

Laryngeal Fractures and Lacrosse

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August 27  |  Blog, York ENT Blog  |   Dr James Rejowski

DSC_0427I was catching up on my reading recently and came upon an article of particular interest to me since my son John is a lacrosse player at the University of Iowa.

Drs. Kelley and French from the SUNY Department of Otolaryngology  in Syracuse N.Y. described three cases of fracture of the larynx which occurred when a player was struck with the ball.

Although lacrosse is an increasingly popular sport, to the point where my cousin’s son in Poland plays on a team there, some explanation to the uninitiated might be helpful. The lacrosse ball is made of hard rubber and it is propelled by a basket at the end of a stick at speeds up to ninety miles per hour. I have dents on my car to attest to this. The players wear a helmet with a face mask, protective gloves, and shoulder pads but for the most part their body is unprotected. The pace of the game is fast and they are very skilled at passing, catching, and shooting on the run, but just the same they still receive contact in unprotected areas.

The larynx has a framework composed of cartilage and fractures of it are usually associated with major trauma from motor vehicle accidents and assaults, not athletic injuries. They are characterized by the sudden onset of painful swallowing, change in the voice, bruising, and expectoration of blood from the throat. In the most severe cases difficulty breathing may occur. Immediate recognition of such an injury by players, coaches, and trainers is imperative. Prompt medical attention and consultation by an Otolaryngologist-Head & Neck surgeon is required. CT scanning of the neck, fiberoptic examination of the larynx, and evaluation under anesthesia may be required. Treatment ranges from careful observation to open surgical repair depending upon the severity of the injury.

These types of injuries are infrequent and are not unique to lacrosse. I myself have treated baseball and basketball players with similar injuries. In any sport it is important to recognize that there is a potential for untoward events, and to know how to recognize and address them.

Reference: Laryngeal Fractures in Lacrosse Due to High Speed Ball Impact; Christopher French, MD; Richard Kelley, MD; JAMA Otolaryngology-Head and Neck Surgery, Volume 139, Number 7, pages 735-738, July 2013.

Benjamin J. Rejowski, M.D.

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May 12  |  Blog  |   James Rejowski

Our son Ben graduated this weekend from the Indiana University School of Medicine, receiving his M.D. degree. Being a physician is what he wanted to be from the time he was in grammar school, and now he is.

Ben graduated from the University of Notre Dame in 2009 and started at IU that same year. As a first and second year student he traveled to Honduras with fellow students and faculty to work in a university sponsored clinic in a remote rural village.

Making it through four years of medical school can present its challenges; the hours are long and the work is difficult. But Ben and his classmates will find out that the real reward will be a lifetime of having the opportunity to serve others and make a contribution to their lives.

Ben will be doing his residency at the Southern Illinois University School of Medicine in Springfield, Illinois, in General Surgery. All of us are very proud of him.

Good work, son. You did well.

Benjamin J. Rejowski, M.D.

York ENT Surgical Consultants has joined Adventist Health Partners

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February 2  |  Blog, York ENT Blog  |   James Rejowski

It’s hard for me to believe but in June of this year I will have completed thirty years in practice. When I completed my training at Rush, I joined Dr. Bulger at our current location in Hinsdale, and have been here ever since. Single specialty groups like ours were the norm at that time; multi-specialty or system owned groups existed but were uncommon around here.

A marked change has occurred over the past five to ten years. Physicians have increasingly looked for affiliation with larger entities. There are many reasons for this but basically such affiliations allow us to continue to practice as we have, in a patient focused and patient centered manner, while at the same time providing us with the information technology, electronic medical record, quality improvement and other supports that we need to go on.

Adventist Health Partners is a growing physician group of over 190 doctors with more than 50 locations within the western suburbs. Affiliated with Adventist Midwest Health, our goal is to emphasize education and preventative medicine, as well as the restoration of health when illness strikes. It was named as one of the fastest growing healthcare companies headquartered in the United States by Modern Healthcare magazine and is one of seven physician group practices who made the list. It was the only one named in the Chicago area.

We are all very excited about joining our medical and administrative colleagues within Adventist Health Partners. Our physicians, audiologists, staff, locations and hours of service remain unchanged. We look forward to having the opportunity to continue to provide comprehensive medical and surgical care in Otolaryngology/Head and Neck surgery to the people of our community.

Noisy Toys 2012

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December 9  |  Blog  |   James Rejowski

Noisy Toys 2012

Once again thanks to Dr. Dawn Violetto at Child’s Voice in Wood Dale, Il, and the Sight and Hearing Association, we are able to share the Association’s Noisy Toys list. It’s remarkable how loud these toys are. Here are some levels of comparison:

Vacuum Cleaner: 80 db

Walkman at Maximum Level: 100 db

Front Row at a Rock Concert: 110 db

Commercial Aircraft Jet Engine: 120-140 db

They should probably come with ear plugs.

CLICK PICTURE TO ENLARGE

 

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HPV Associated Oral Cancer

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May 23  |  Blog  |   James Rejowski

For years it has been known that heavy tobacco use is correlated with the development of oral and pharyngeal cancer. This is especially true when alcohol abuse is present as well.
In general the rate of smoking has decreased in this country over the past few decades, and one would expect a corresponding decrease in the prevalence of these tumors. Surprisingly, this is not the case. Although the rate of tobacco associated oropharyngeal squamous cell carcinomas (the proper name for such tumors) has decreased by 50%, down to 1 case per 100,000 individuals, the incidence of HPV (Human Papilloma Virus) associated lesions has increased 225% from 0.8 per 100,000 to 2.6 per 100,000. There are many types of papilloma viruses, but not all have pre-malignant behaviors. It is felt that 90% of HPV positive oropharyngeal cancers are associated with HPV type 16.
A study by Dr. Gillison and associates from Ohio State University published in JAMA in January 2012 looked at the incidence of oral HPV infection in the U.S. The overall prevalence of HPV infection was nearly 7% and was higher in men, those who currently smoked, and in individuals who had a history of multiple sexual partners. There was a significantly higher incidence of HPV infection in men from age 50-64 years, and this correlates with the higher rates of HPV associated oropharyngeal cancer in that age group.
The symptoms of an oropharyngeal cancer can be subtle and insidious. A persistent sore throat, especially if located on only one side and associated with an earache, definitely merits attention. Other presenting symptoms can include enlarged nodes in the neck, voice change, and swallowing trouble. Occasionally one might notice a growth in the back of the throat not previously seen. Any of these symptoms should prompt a careful examination in the office including an examination with a fiberoptic laryngoscope.
Treatment for small malignancies in this region usually consists of either surgical excision or radiation therapy. Larger tumors can respond very well to chemotherapy and radiation.

Sinusitis and Antibiotics

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March 7  |  Blog  |   James Rejowski

Sinusitis and Antibiotics

Acute sinusitis is one of the more common illnesses treated in physician’s offices. Antibiotics are frequently prescribed as treatment, but there is debate as to how much benefit this really offers in many cases.

A recent study published in the Journal of the American Medical Association by Dr. Garbutt and associates from the Washington University School of Medicine investigated this issue. Adults diagnosed with sinusitis were divided into two groups; one half was given amoxicillin and the others were not. Each patient was given acetaminophen for pain, guaifenesin to mobilize secretions, dextromethorphan for cough suppression, and pseudoephedrine for nasal congestion.

The results showed that there was no significant difference as far as improvement in symptoms between the groups when measured at three and ten days following the initiation of treatment. Approximately eighty percent showed significant improvement by day ten.

The study supports the case for making the initial approach to treatment a conservative one. This is in accord with the feelings of many patients who wish to utilize antibiotics only when necessary to avoid potential side effects such as allergic reactions, gastrointestinal upset, and the development of resistant bacteria.

It is important to keep in mind that the study really only looked at uncomplicated cases. Those infections associated with facial swelling or redness, orbital involvement, otitis media, or other illnesses such as asthma should be considered for more aggressive therapy using appropriate antibiotic treatments.

Incidental Thyroid Cancers

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January 24  |  Blog  |   Dr James Rejowski

Incidental Thyroid Cancers

The detected incidence of thyroid cancer has increased three fold over the past thirty years. Much of this is due to the wide spread use of imaging such as CT or MRI in the evaluation of musculoskeletal disorders, cardiac disease, or trauma. The thyroid abnormalities show up as incidental findings, or “incidentalomas”.

Interestingly, the probability of malignancy in these tumors is basically the same as those that are evident enough to be felt by the patients themselves or their physicians. It raises the question as to why such patients were not becoming ill or dying from the undetected tumors.

A study published in 2010 by Drs. Davies and Welch at Dartmouth Medical School reviewed records from over 35,000 patients diagnosed with papillary thyroid cancer over a twenty year period of time. Due to either patient refusal or the presence of other significant medical illnesses, 440 of these individuals did not have any treatment for their cancers. The tumor studied were not necessarily small, but were all confined to the thyroid and did not demonstrate spread to the regional lymph nodes.

The cancer specific survival, which means the chance of not dying from thyroid cancer, was basically the same in the two groups when measured at five, ten, and twenty year intervals. At twenty years, the cancer specific survival for the definitive treatment group was only 2% better than the non treated group (99% versus 97%).

This doesn’t mean that all the patients lived twenty years; it means that those who passed away did so from something other than thyroid cancer.

It appears that these undetected thyroid malignancies without evidence of spread are slow growing, and therefore do not present clinically,  but it would be inaccurate to conclude that incidental or overt thyroid cancers should not be treated. An untreated thyroid malignancy can advance and cause much morbidity, greatly reducing the quality of one’s life. There is a wide gap between having good health and just being alive.

Further research and study will hopefully clarify which groups of patients will benefit most from intervention, and those who would be best served by careful observation.

Noisy Toys

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November 26  |  Blog  |   James Rejowski

Each year at this time shoppers all over the country search the malls and the internet for the perfect toys for their young ones. Years ago when our boys were small we looked high and low for a Ghostbusters Firehouse, a rare commodity when Ray, Peter, Egon, and Winston were in their heyday. By a stroke of remarkable fortune our audiologist Nadine Reed found one on a trip home to Ohio, saving the day for us and making Santa look like a hero.

Last year another friend and colleague, Dawn Violetto, AuD, the audiologist at Child’s Voice in Wood Dale, Illinois (www.childsvoiceschool.org), a school for hearing impaired children, sent me a list of the ten noisiest toys of 2010. It was compiled by the Sight & Hearing Association (www.sightandhearing.org) in conjunction with the University of Minnesota.

Although the toys themselves still appeal to the inner child still present in many of us, the stated noise levels listed are really a bit excessive, to be kind about it.

Here is the list:

2010 Ten Noisiest Toys

  1. Bell Riderz Block Blaster from Bell Sports, Inc.- 129.2 dB
  2. Cars Shake ‘N Go Ramone from Mattel, Inc.-119.5 dB
  3. Transformers Optimus Prime Cyber Sword from Hasbro- 110.1 dB
  4. True Heroes Sonic Battle Blasters from Geoffrey, LLC- 110 dB
  5. CAT Mini Mover from Toy State Intl Ltd.-104.8 dB
  6. Rocket Boost Iron Man 2 from Hasbro- 103.2 dB
  7. Road Rippers Rush & Rescue Fire Truck from Toy State Intl Ltd.- 101.6 dB
  8. Interaction Morris from Learning Curve Brands, Inc.- 98.7 dB
  9. Proto Bat-Bot Figure from Mattel, Inc.- 98.6 dB
  10. CAT Honk and Rumble Wheel from Toy State Intl Ltd.-96.6 dB

The Occupational Safety & Health Administration website publishes a table that lists the amount of time that a worker can be exposed to a given level of sound before an effective hearing conservation program must be implemented. For 115 dB, it is fifteen minutes or less; for 110 dB, thirty minutes; for 100 dB, two hours.

Noise induced hearing loss can be permanent. Concerns exist regarding this given the widespread use of portable devices and MP3 players, and noisy toys raise this issue at an earlier age.

It’s just another thing to keep in mind when shopping for the ones we love. Maybe Santa should pack a few extra sets of earplugs into the sleigh.

Happy Holidays!

Dr. James Rejowski
York ENT Surgical Consultants
Hinsdale, IL

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Bolingbrook Hospital Foundation’s inaugural golf outing planned

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September 12  |  Blog  |   James Rejowski

Bolingbrook – Bolingbrook Hospital Foundation will host its inaugural golf outing Sept. 22 at Bolingbrook Golf Club, 2001 Rodeo Drive, Bolingbrook.

Registration begins at 11:30 a.m. Lunch will be served at noon. A shotgun start will take place at 1 p.m. with best ball format. Dinner and an awards presentation will take place at 6 p.m.

The Bolingbrook Hospital Foundation raises funds to advance Adventist Bolingbrook Hospital’s mission of extending the healing ministry of Christ. Proceeds from the outing will be directed to benefit the hospital’s Breast Center, which provides a full array of services for women using an integrated approach to the evaluation and treatment of breast abnormalities. Services include digital mammography, ultrasound, breast MRI, breast biopsies, reconstructive surgery and radiation oncology referral.

“The golf outing will be a day for all to enjoy,” said Ron Hawkins, Bolingbrook Hospital Foundation board chairman and event chairman. “The foundation is truly grateful for the continued support from the committee members and the community.”

Packages including golf, lunch and dinner are $800 per foursome, $450 per twosome or $225 per individual. The packages include 18 holes, lunch, beverage coupons, a buffet dinner, a two-hour open bar at the dinner reception and photos. The dinner only option is $50. Hole sponsorship is $200 and includes recognition on the course. Get a hole in one for a chance to take home $1 million or a new car.

For more information, contact Lynne Vehlewald at 630-312-6084.

The foundation would like to recognize Capstone Financial Advisors as the event’s premier sponsor. Sponsorships, ranging from $500 to $10,000, are still available.

The foundation also would like to recognize the 2011 Golf Committee members: Ron Hawkins, Eric Aldrich, Tom Castagnoli, Derek Cazeau, Michael Evans, Jim Galbraith, Bob Jaskiewicz, Linnea Jaskiewicz, Kris Kuchler, Herman McKenzie, Craig Parker, Cesar Pinzon, Jr., Keith Plywaczynski, Dr. James Rejowski and Pat Wallace.

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Adventist Midwest Health includes Adventist Bolingbrook Hospital, Adventist GlenOaks Hospital, Adventist Hinsdale Hospital and Adventist La Grange Memorial Hospital. To find a physician, visit www.keepingyouwell.com.

Contact: Lynne Vehlewald , 630-312-6084

http://www.keepingyouwell.com/abh/Donate.aspx