Celebrated Physician: Norman Lester, MD

­­For as long as he can remember, Norman Lester, MD, wanted to become a physician. Choosing a specialty, however, took a little longer.

It wasn’t until his third year at the University of Maryland School of Medicine that he discovered otolaryngology—more familiarly known as the diagnosis and treatment of ear, nose and throat (ENT) disorders.

Why Otolaryngology?

“Honestly, I thought an ENT might just take out tonsils,” Dr. Lester says with a laugh. “I quickly learned that head and neck anatomy is fantastically complicated. There a lot going on in a small space.”

Dr. Lester remains fascinated by otolaryngology’s sheer breadth of conditions and diseases, with surgical treatments that range from intricate oncology procedures to, yes, routine tonsillectomies.

Otolaryngology also affords Dr. Lester the opportunity to cultivate lasting relationships with a variety of patients. Many of them have referred their children to him when they needed treatment.

“Now, the occasional grandchild is showing up,” he says.

Team-Based Treatment for Specialized Patient Care

While Dr. Lester considers himself a generalist, he enjoys a close relationship with MedStar Washington Hospital Center’s otolaryngologists who have specialty expertise in various head and neck conditions.

“If our initial diagnosis indicates they need additional help, we can refer the patient to a sub-specialist, who will prescribe the treatment, then we handle the follow-up,” he says. “It’s a really good system.”

Variety may be the “spice” of otolaryngology, but Dr. Lester has noticed some trends in his cases, including a rise in sudden sensory hearing loss (SSHL), an urgent, yet sometimes difficult-to-diagnose condition that typically affects only a few thousand people a year.

“In the last four months, I’ve treated 15 to 20 SSHL patients—as many as we used to see during an entire year,” he says.

The need to quickly address SSHL is not lost on Dr. Lester, who has experienced the condition a few times himself. When other issues began accompanying his hearing difficulties, however, he suspected the presence of an acoustic neuroma—a slow-growing, noncancerous tumor that develops on the main nerve of the inner ear. The condition was verified by a colleague, and successfully treated with surgery.

“I’m probably the only ENT who diagnosed his own acoustic neuroma,” Dr. Lester says. “Experiencing things from the patient’s perspective was interesting.”

Outside the Hospital

It should come as no surprise that someone so closely associated with hearing as a professional would also be a musician. In addition to occasionally playing bass with a friend’s band (“mainly alternative rock,” he says; “loud and obnoxious.”), Dr. Lester builds custom guitars on a semi-professional, word-of-mouth basis. He’s crafted instruments for several area musicians, including legendary “power-pop” guitarist and Bethesda native Tommy Keene.

Never harboring any illusions about his own musical talent, Dr. Lester finds plenty of satisfaction in a field that he once misunderstood, but has since come to love.

“Each week, I can point to something where what I did made a difference—where I did something important for a patient,” he says.

Putting Sleep Apnea to Bed

An estimated 50 to 70 million Americans suffer from serious chronic or intermittent sleep disorders that undermine the quality of their sleep and, more importantly, their health. Sleep apnea, the most common disturbance, is also potentially the most serious, raising the risk of high blood pressure, arrhythmias, diabetes, heart failure, heart attack and stroke. At its most severe, it can even cause death.

Fortunately, modern medicine can diagnose and treat obstructive sleep apnea before it ever reaches such dangerous stages. Key to our success was the development of the continuous positive airway pressure device known as CPAP. The front-line therapy for nearly 30 years now, CPAP is a safe, non-invasive and highly effective treatment for the disorder, when used as directed. However, compliance can be a problem.

Tune in to the full podcast with Dr. Stanley Chia.  

Why?  

Some people find the devices noisy and uncomfortable. Those with claustrophobia have problems adjusting to a mask that covers the nose and, with some models, also the mouth.  And restless sleepers have trouble keeping them on.  

As a result, only between 30 and 60 percent of patients with the devices actually use them regularly and for the prescribed amount of time each night.  

So clinicians and researchers have come up with new methods to tackle the problem. 

Understanding Obstructive Sleep Apnea

First, it helps to understand the mechanics behind sleep apnea, which is marked by pauses in breathing called apnea episodes, or shallow breathing called hypopnea episodes, during sleep. When you sleep, the throat muscles that normally keep your airway stiff and open relax, narrowing the passageway. That’s normal.  However, certain conditions or even the physical structure of your mouth can momentarily prevent enough air from getting to your lungs. A partial blockage produces loud snoring or irregular breathing, while a complete obstruction usually results in a sudden snort or gasp as the oxygen-starved brain startles the body awake.

These breaks in breathing can last from a few seconds to minutes, and have been recorded over 100 times an hour.  

Among the causes of sleep apnea are age, sex (with males at a higher risk) and, increasingly, obesity as excess fatty tissue can thicken the wall of the windpipe, narrowing the opening.  

Finding the Right Fix

Beyond lifestyle changes and CPAP, specialists have a range of other approaches to treat sleep apnea. Choosing the right therapy depends upon determining the source of the problem and on patient preference. We start with a careful and thorough evaluation, including physical examination, a detailed medical history, an overnight sleep study and an endoscopy to look at the airways and arrive at the correct diagnosis.  

For patients with large tonsils or an elongated soft palate, treatment can include removing the tonsils and shortening the palate. Another approach, especially when patients have excess or enlarged tissue at the back of the tongue, is transoral robotic surgery to remove the excess tissue, or radio frequency ablation which shrinks the tongue or soft palate.

In other cases, the very structure of the upper or lower jaw is the culprit. To eliminate the condition, oral surgeons can actually advance the upper and lower jaws to open up the airway.  These procedures have a high success rate, sometimes accompanied by an unintended consequence: a better-looking jaw line!

But a newer approach is proving to be even better for some individuals.   

Novel Approach Offers Improved Solution

Approximately two years ago, the FDA approved a promising new technology to treat sleep apnea called the hypoglossal nerve stimulator. (Full disclosure:  I sat on the final FDA review board.) Basically, the technology acts like a pacemaker, helping to synchronize the intake of air with the action of the tongue.  The pacemaker apparatus is implanted in your right chest, and connected to a wire that is wrapped around the nerve that controls tongue movement. A second wire implanted in the side of the right chest senses when you breathe in, causing the pacemaker to signal to the tongue to move forward and out of the way, opening the airway. The device is turned on and off by the patient, so daytime breathing is not affected.  

To date, the stimulator has been used in hundreds of patients with very good success. I’ve personally used it on about 15 patients with an 85% success rate. However, not everyone is a candidate for the approach.  Patients must have moderate to severe sleep apnea, as indicated by a sleep apnea severity score (Apnea Hypopnea Index or AHI) between 20 and 65, and a body mass index (BMI) less than 32. The latter, in particular, rules out many who could benefit from the procedure. As a result, I often refer my obese patients for consideration of bariatric surgery to help lose weight instead.

But for those who fit the criteria, the hypoglossal nerve stimulator is an important breakthrough. And for specialists, it’s a nice complement to the range of other treatments available and yet another tool to give patients what they need to put sleep apnea to bed.   

Listen to the full podcast with Dr. Chia.

 

The dangers of loud–and dirty–earbuds and headphones

We live in a noisy world. The ear-splitting sounds of rush-hour traffic, the drone of a lawn mower, loud washing machines and vacuum cleaners, blaring TVs and computers—all of these loud noises and more can blast at us wherever we go. 

These everyday noises can do more than annoy us. They can put us in danger of hearing loss. Until recently, most researchers believed work-related exposure to loud noises was the greatest risk for noise-induced hearing loss, or hearing loss caused by loud noises. But as Centers for Disease Control and Prevention reported in February 2017, more than half of people who had noise-induced hearing loss reported no exposure to loud noises at work. Schedule regular hearing checkups to minimize your risk for hearing loss.

These findings mean hearing damage is coming from other environmental factors. And it’s not just unpleasant sounds that can damage our hearing. Standard headphones and earbuds at full volume are about as loud as a chainsaw. Just like other loud noises, we need to limit our exposure to loud sounds from earbuds and headphones to protect our hearing.

The science of sound

The subject of earbuds and headphones is controversial among hearing health specialists like me. Some people believe earbuds are more dangerous than headphones because earbuds rest inside the ear, while earphones rest over the ear.

It’s not an issue of the earbuds being more dangerous. What matters is the intensity of the sound the ear is exposed to. We measure the intensity of sound in decibels. Higher decibel levels mean sound is more intense. And more intense sounds are more dangerous to your ears.

Normal, comfortable sounds range from about 30 to 60 decibels. A 60-decibel sound is about the same as a normal conversation. Sounds at these levels don’t pose a threat to your hearing. But sounds that are higher than this on the decibel scale get much more intense very quickly—and much louder.

Each 10-level jump in decibels translates to sound intensity that’s 10 times as strong and about twice as loud. Music at 100 decibels is 10,000 times more intense and 16 times louder than a 60-decibel conversation

Regular exposure to sounds with a high decibel level can have a damaging effect to your hearing over time. Sounds at or above 85 decibels can cause hearing loss, particularly if you’re exposed to them for long periods.

Many commercially available earbuds and headphones, even those marketed for children, go above these levels. In fact, some are capable of producing sounds that are 100 decibels or higher. Sounds at 115 decibels can permanently damage hearing after just 15 minutes of exposure.

Turn the volume down when using earbuds or headphones

Keep your devices at 50 percent volume or less when using earbuds or headphones. That’s usually a safe area below the decibel level that can cause hearing loss. While listening to your earbuds or headphones, you should be able to hear and participate in a conversation. If you can’t hear the other person, your device probably is too loud.

Most sets of earbuds or headphones will list their maximum decibel level on the package or in the instruction manual. If you don’t have the packaging or instructions for your device anymore, search for your particular model online to find details about its maximum decibel level. However, keep in mind that these published or posted figures may not have the most accurate information. A December 2016 report in The New York Times noted that 30 sets of children’s headphones in a product analysis failed to restrict their volumes to the posted limits.

Be particularly mindful of children’s exposure to loud noises. As smartphones and other devices have become a part of everyday life, children are exposed to loud music and other sounds more often than we might realize. Make sure your children know to keep the volume down on their devices. One alternative for kids: Get them reading! Reading, of course, is perfectly safe for the ears—just watch the volume levels on audiobooks.

The dirty danger of earbuds and headphones

Perhaps just as important as the decibel levels of our devices is keeping our devices clean. Most people never think about cleaning their earbuds or headphones despite putting them in or on their ears several times a day.

Consider this: Your smartphone is likely one of the dirtiest things you own. You may carry it with you all the time, wherever you go, even in the bathroom. Then you plug the earbuds into the phone to listen to music, and put the earbuds in your ears. The bacteria from the phone now have a direct path into your ear canals.

Luckily, there’s an easy fix for this dirty dilemma. Clean your earbuds or headphones with alcohol at least once a day to reduce the risk of bacterial contamination. Make sure you don’t get the alcohol near the headphone jack or other sensitive electronic contact points. You also can use antibacterial wipes that are specially designed for electronic equipment to clean your phone, earbuds and headphones.

Headphones and earbuds are great tools while we’re hard at work, working out or just relaxing with our favorite tunes. But just like anything else, they’re best when used in moderation. Keeping the volume down now may mean you don’t have to turn it up so loud to hear later in life.