Category: ENT

Big Cancer Cases

“You’re a bad ass” he said as I walked into his hospital room, making post op rounds from the previous day’s surgery.

Yesterday I spent five hours excavating this huge tumor from his neck. A local spread from a poorly differentiated squamous cell skin cancer previously removed from the back portion of his neck, just behind and below his left ear.

These poorly differentiated cells are the worst; wild cancer cells running amok in the lymphatic system, multiplying and invading locally, infiltrating into surrounding muscle and skin.

Pre op exam revealed an 8 x 5 x 3 cm mass, firm, fixed, right up under his ear. Big and stuck!

I told him there were no options other than cutting that monster out, and he gave a big thumbs up.

In the OR, I placed a nerve monitor with subcutaneous electrodes about his eye and mouth, just in case I needed to dissect around his facial nerve. We prepped and draped his neck for a big procedure.

I excised the scar from his previous skin cancer removal, cut in front and below his ear and looped the incision into his neck below his jaw line, raised skin flaps, and started dissecting the mass from surrounding tissue, including many lymph nodes in the neck below it and in front of it (technically what we call a supraomohyoid neck dissection). It had invaded the sternocleidomastoid muscle and totally compressed his jugular vein. Both of these structures needed to be removed along with the mass. I carefully preserved his carotid artery and vagus nerve (to the vocal cords), dissected the hypoglossal nerve (motor to the tongue) and the parotid gland from the superior extent of the tumor. I went through the deep fascia into the levator muscles which support the cervical vertebrae. Any further removal would have left his neck weak and unstable. This level of invasion could never be handled with surgery alone, and there was no surprise that microscopic remnants of the cancer were seen in the pathology specimen. Post op radiation therapy should be able to kill the residual tumor cells.

I put in a drain to collect tissue fluid post op for a few days, sewed him up nicely, using his own expanded skin from the tumor mass to cover the area excised, and then on to recovery. All nerves working fine, eating and drinking well with a good night, and then the next morning: “you’re a bad ass.”

So I had him clarify that statement. He had been seen at the VA, and referred to me, because “No one else there wanted to handle this. And you could, and you did!! I feel so much better with that goose egg thing out of my neck”. Actually more like an ostrich egg.

Years of study at Univ of Iowa, doing big tumor work. Years of experience taking care of federal inmates referred cross country with their large, growing tumors, had put me in a great place to help out this Vet.

Cut and sew right, preserve the vital important structures, and all will be well. Great anesthesia, experienced nursing crew. My team was ready, and we performed.

Shingles, or another virus demanding attention

While we are focusing so much attention on the coronavirus, we mustn’t lose focus on our other healthcare needs.

The need for my wife and me this week was our second shingles vaccine. That very nasty shingles attack is caused by the chickenpox virus (varicella zoster, a type of herpes virus different from the cold sore or genital type) that lives dormantly in our nerve roots, just waiting for who knows what conditions to break out along that nerve’s distribution and cause awful pain, blisters, loss of nerve function with facial paralysis (if it happens along the facial nerve), and possible post eruption pain (post herpetic neuralgia). That means when the virus attack resides and the blisters heal, you’re left with terrible pain along the area affected. It’s an anti gift that keeps on giving. Like that unwanted relative who is always coming for dinner or your neighbor who attacks his landscaping with any loud engine based device at any time (esp Sat and/or Sun at AM, or wine on the back porch time near dusk). But much worse, not just uncomfortable, I mean excruciating pain.

But, like with most viruses, there is a vaccine!!!! Several years ago (2006) a vaccine was developed that unfortunately was only about 50% effective. So another has been developed (2017) that is a 2-time shot, separated by 2 to 6 months, but 90% effective. Age 50 is the start date for this vaccine.

I like those numbers much better.

The problem is this: those 2 shots kick your butt, with about 36 hours of feeling lousy, really lousy, headache, muscle pain, sore arm at the injection site, and ready to do nothing but stay in bed and take some Motrin. With the first shot, I was uninformed (even as a doc) and had a full day the next day. I made it through, but it wasn’t easy. So this time we planned a Friday evening shot, picked up comfort food from a local restaurant, and went home to chill. 36 hours later we are resurfacing to the living world.

Shingles stinks. The shingles vaccine stinks. But shingle stinks a whole lot more. Just be prepared to weather the prevention. Try a good book, it was Hamilton for me.

Sinus Balloon Procedure

Sinusitis  101

It is uncommon for sinus infections to spread outside of the sinus into the eye or brain, but certainly the possibility exists and must be treated urgently.

This week I was called to assess a patient with infection spreading into the eye and causing thrombosis (clotting) of the veins draining the eye. All from a sphenoid sinusitis. The sphenoid is located smack in the middle of your head, right below your brain and between the area that the optic nerves and eye blood vessels enter and exit the skull.

The eye was extremely swollen and could not move well in the socket.

The treatment was to drain the sinus by enlarging the sinus opening with a balloon, under image guided conditions. Watch this video!!

We went to the OR for anesthesia, and I carefully led a balloon catheter into the sinus (sort of like using in heart vessels) using previous CT scans which allowed me to know that the balloon had entered the sinus. After inflating the balloon, I then looked with an endoscope and suctioned out infected material. In the recovery room the eye pressure and headache from the infection was immediately greatly improved.

Techniques such as balloon sinuplasty, used routinely on an elective basis (not urgent or emergent), have become quite useful to these emergency conditions.
The more routine balloon cases performed, the more prepared is the surgeon is to handle these more challenging cases.

I use sinus balloons often, and am ready for any challenge.

Glomus Tumor Case

In the OR, working through a speculum with an opening the size of a BIC pen, I surgically raised up the right ear drum to view the middle ear, and there it was.

A rather large impressive bright red tumor, sitting on the bony medial wall of the middle ear, creating pulsating sounds that brought the patient to me.

“Doctor, I can hear my heartbeat in my right ear”.  Examination showed the reddish mass behind the translucent ear drum (tympanic membrane or TM for short).  Only surgical excision would relieve this condition, and only surgery would stop it from expanding and growing.

It would need excision, with laser ablation of its feeding vessels, all under microscopic dissection, with intense concentration and coordinated movements between surgeon, anesthesia, and OR tech.  (too much drama, but of course it does, all procedures do!!!)

But this is special. It’s really neat.  To flip up the TM and stare the beast in the eyes.  Large, red, full of blood and bleeding potential, this is why God made me a doctor.  (ok, a bit more drama).

In any case, this is exciting surgery.  Remove the vascular mass.  I was first introduced to these vascular anomalies while a medical student, on neurosurgery rotation, assisting in removing an AVM (arteriovenous malformation) in a teenaged girl.  It looked like a big red spider on the surface of the brain.  But that was a big open procedure, with a big bone flap removed and later replaced.  Nothing like ENT ear surgery (we ENT’s are the best, most delicate, etc, the saying should be: “it’s not ENT surgery”, no lie or exaggeration here).

So I introduced the CO2 laser fiber into the middle ear and coagulated feeding vessels from above and below, but there might also be some feeding the mass that I couldn’t see, underneath the mass.  The only thing to do was to remove the mass with cup forceps and deal with the bleeding.  And so I did.  But that’s not the additional lesson here.  Most younger surgeons in the face of bleeding here would have sucked and lasered and sucked and lasered without effect, but the senior surgeon (like me) would place a cotton ball with some type of vessel constrictor like epinephrine or Afrin ( I use afrin, it is safer) to initially stop the bleeding and then go back and laser.  So what does the surgeon do while waiting for the cotton soaked ball to work?  Absolutely nothing, and that is the hardest part!

I learned from my wonderful mentors during ENT residency at the University of Iowa, especially chairman Dr. Bruce Gantz, that there is great benefit to pushing back from the scope and taking a few moments to compose oneself, take a few deep cleansing breaths, and then carry on.

And that’s what I did to great success. After removal of the afrin cotton ball, all bleeding had stopped and the tissue was ready for further coagulation and ablation with the laser.

TM replaced intact, case closed.

Now for some coffee (none yet to prevent caffeine tremors under the magnification of the microscope), talk with the family, and a little post-op EMR computer work.

Can You Hear Me Now? If You Can’t Make That ENT Appointment

Around 18% of adults report that they struggle with some type of hearing difficulty. An ENT (ear nose and throat doctor) is an expert that can help. Improving your hearing starts with an accurate diagnosis.

Using state of the art hearing tests an ENT doctor can quickly diagnose hearing problems and provide you with the tools to improve your hearing. A Raleigh ENT doctor is the specialist you need to see for all your ear, nose, and throat needs.

Your Ears, Your Nose, And Your Throat

Many people do not realize that the ears, nose, and throat are all one system. They are part of the upper respiratory system and share one membrane. There is a wide range of conditions and illnesses that will affect the ENT system that can cause hearing problems, headaches, and more.

Seasonal allergy sufferers know during allergy season exactly how relative each part is to the other. When one part is affected by allergies all parts are affected. The same is true of a sinus infection or a disease of the throat. Each part affects the other parts’ ability to function.

An ear nose and throat medical practice focus on treating disease and dysfunction of this system including providing corrective action for hearing loss. ENT care for both children and adults is available.

Hearing Loss

There are several different types of hearing loss that an ENT doctor can help to correct. Congenital hearing loss is hearing loss that you are born with. This type of hearing loss is largely related to malformations in the ear.

Infections can also cause hearing damage that can result in hearing loss. For older people, exposure can cause hearing loss. Aging in and of itself can cause hearing loss.

What Can You Do About Hearing Loss

The good news is that hearing loss can be correctable. Using digital technology customizing your hearing aid can be an easy way to improve your hearing. Hearing loss can make you feel isolated, impact your social life and personal relationships.

An ENT doctor can help to improve your hearing. Make your appointment today and learn more about hearing loss correction.

How Can Hearing Aid Customization Help You?

No one wants to wear a hearing aid but, like glasses, this can be a necessary aspect of life. Hearing loss is actually a very common problem that can affect people of any age. Sometimes, it’s caused by illness or disease. Sometimes, it’s caused by years of exposure to loud noises. It may even be an occupational hazard. In fact, around two to three out of every 1,000 children in the U.S. have a detectable hearing loss in one or both ears when they are born. Hearing aid customization makes it much easier for anyone to comfortably wear hearing aids. They make it possible to hear perfectly without discomfort and sometimes, without others even being able to see the hearing aids.

What’s Possible With Hearing Aid Customization?

Hearing aids have a bit of a bad reputation because of their past. Older hearing aids made years ago were big, clunky devices that were difficult to wear. They were unwieldy, uncomfortable and highly visible. But hearing aids have changed a great deal in more recent years. They have become streamlined, comfortable, easy to wear and sometimes, even invisible to others. Individual hearing aids and comfortable hearing aids are possible with customization.

Customizing your hearing aid isn’t that much more difficult or expensive than buying a generic model. In fact, it’s easier to get hearing aid customization than most people even realize. Today’s modern hearing aids are carefully designed based on very precise measurements of your ears. They can fit into the ear canal or right behind the ear, depending on the specific style you choose.

Hearing aid customization is actually necessary when it comes to getting aids for children. They have small ears and don’t want to wear something that’s uncomfortable. You don’t want a very young child to reach up and pull out their hearing aids, for example. Luckily, there are doctors who specialize in creating pediatric hearing aids that are made for children to wear comfortably.

Should You Be Wearing Hearing Aids?

Do you suspect that you have some form of hearing loss? Even a little hearing loss probably isn’t going to get better and will, in fact, probably get worse over time. Don’t wait for that to happen. Get your hearing checked immediately and find out if you’re a candidate for hearing aids.

Hearing tests can be done by many types of doctors. Sometimes, you can even find clinics and mobile medical facilities that test hearing. The tests are pretty standard. Sometimes, you can even get your hearing checked by a mobile booth at a fair or carnival! For children’s hearing tests, you may want to consult with a pediatrician or pediatric audiology specialist.

After your hearing evaluations are over, consult with a specialist to find out if you’re a candidate for hearing aids. Be sure to bring the results of your hearing tests so they have all the information about your hearing loss. Once you determine that you’re a candidate to wear hearing aids. you can find out more about customizing your hearing aid to perfectly suit your ears. With hearing aid customization, you can begin hearing perfectly again.

Pediatric ENT -What You Need To Know About Hearing Loss In Children

Every year around 3 out of 1000 children are born with some type of detectable level of hearing loss. In many cases, hearing loss is missed or not diagnosed. A pediatric ENT specializes in hearing evaluations, hearing tests, and hearing aids for children.

The first step in treating hearing loss is an accurate diagnosis. Hearing loss in children can affect everything from speech development to their ability to learn. It is important that you are able to recognize the signs of a child struggling with hearing problems.

What Causes Hearing Loss in Children?

There are several things that can cause hearing loss in children including:

  • Congenital hearing loss is when a child is born with hearing loss. It can stem from a wide range of reasons.
  • Hearing loss that is acquired through infections, ototoxic medications, injury to the ear, exposure to noise, and other incidents that damage the hearing.
  • Transient loss of hearing occurs due to infection of the middle ear. Transient means it can come and go and can resolve itself without the intervention of a hearing device. In some cases, it does evolve into permanent hearing loss.

There are many risks to hearing in children. From untreated infections to injuries to listening to headphones, there are many risks out there.

Recognizing the Signs of Hearing Loss In Your Child

Many parents are not aware of what to look for to determine if they need to make an appointment with a pediatric ENT. Hearing tests are the only way to confirm the hearing loss. Symptoms of hearing loss can include:

  • Speech delays, speech impediments
  • Often inattentive, non-responsive when being spoken to
  • Learning delays

There are other signs that your child may be struggling with hearing loss that your pediatric ENT will review with you. If you suspect that your child cannot hear or is experiencing some level of hearing loss, it is time to make an appointment for hearing tests. A hearing test Raleigh NC parents have found can be a very helpful diagnostic tool in making sure their child is getting the right care.

If you suspect there is a problem the best way to find out for sure is by making an appointment for an evaluation. Once you have an accurate diagnosis you can get the care that your child deserves.

How to Care for Ear, Nose, and Throat Issues in Your Child

The ear, nose, and throat are common areas of trouble for children. To avoid further complications down the road, it’s often to handle problems with these areas as quickly and accurately as possible. Finding the right ENT for children is an important part of overall health and wellness. Follow our simple tips and you should be well on your way to establishing quality care.

In addition to assessing the health of your child’s nose and throat, ENT care facilities perform hearing tests. Hearing loss is a common affliction among children and adults alike. In the United States, about 2 to 3 out of every 1,000 children are born with a detectable level of hearing loss in one or both ears. A lot of hearing issues can be mitigated if they are detected and addressed early on in life. When you choose your ENT doctor, they will administer comprehensive hearing evaluations, and if necessary, provide recommendations on hearing aids. If hearing aids are needed, a reliable ENT can help you in customizing your hearing aid and providing ongoing care to monitor progress.

ENT for children also covers ear infections. Infections of the ear are one of the more common conditions that arise in children. There are many strategies for dealing with infections, as well as many factors that can cause them. Exposure to other viruses, such as respiratory viruses will be considered by your doctor, as well as environmental factors, family history, and the potential of infections that were experienced in the early life of your child.

Searching for the right ENT care provider does not have to be a complicated process. Begin by consulting with trusted friends and family, as word of mouth suggestions can often provide all the assurance you need. You can also reference the wealth of information and reviews available online. By establishing a relationship with a quality ENT care facility, you are taking the right steps toward providing your child with a happy, healthy life as they grow, learn, and develop.

Sublingual Immunotherapy – Alternative to Allergy Shots

Less than five percent of US allergy sufferers receive immunotherapy. The other 95% take medications to temporarily reduce symptoms, try to avoid their allergens, or just continue to suffer.

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Tinnitus Evaluations

tinnitus-evaluationWhat is a Tinnitus Evaluation?

It is important to have your tinnitus evaluated by a professional who can help you manage the irksome symptoms. Primary Tinnitus is a medical symptom that is characterized by persistent noise in one or both ears that can only be heard by the affected individual.

Read More »

Are Sinus Infections Contagious?

If It looks like a cold, it feels like a cold, and it sounds like a cold, then you should avoid it like a cold, right?
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What is Sleep Apnea?


Over the past decade, Obstructive Sleep Apnea (OSA) has become more well-known due to the associated health risks and deaths associated with untreated sleep apnea. Almost fifty percent of healthy adults snore occasionally, while half of them are habitual snorers. Many times, the problem afflicts individuals who are overweight. If the problem is not treated it typically gets worse with age. Douglas Holmes, MD, founder and medical director of ENT and Audiology Associates in Raleigh has been helping treat patients who suffer from snoring and sleep apnea for the past 15 years.

Sleep apnea is a common disorder that causes affected individuals to stop breathing for short periods of time while asleep. While the effects are the same, there are two primary varieties of the condition: obstructive sleep apnea (OSA) and central sleep apnea (CSA), which differentiate in their root causes. Regardless of the type of sleep apnea from which you suffer, it is important to be professionally diagnosed and treated to avoid further complications.

What happens when you fall asleep?

When you fall asleep your body undergoes many physiological changes during your sleep cycle including changes that affect your breathing. Obstructive sleep apnea (OSA) occurs when the soft palate sags and the tongue relaxes while sliding back, which can partially obstruct the upper airway. When the obstruction is severe enough to decrease the amount of air obstructing the lungs, it is called hypopnea. If the upper airway collapses, blocking the airflow by 80% or more, it is called an apnea. Hypopnea and apneas last 10 seconds or more and can greatly reduce the amount of oxygen in your blood despite your continued efforts to breath.

What are some symptoms of sleep apnea?

The most noticeable symptom of OSA is loud, chronic snoring. During an apneic episode, there is an increase in the level of carbon dioxide in the blood. This build up triggers a defense mechanism in the brain which jolts the body into resuming normal breathing. In mild sleep apnea, the number of apneas is 10 per hour on average. In severe sleep apnea, it can be 40 or more per hour.

Are there any risks to not treating sleep apnea?

Sleep disorders, like sleep apnea, have become a significant health issue in the United States. It is estimated that 22 million Americans suffer from sleep apnea, with 80 percent of the cases of moderate and severe obstructive sleep apnea undiagnosed.

If left untreated, sleep apnea can lead to a higher risk of life-threatening conditions such as high blood pressure, heart disease, stroke and type 2 diabetes. and is a factor in many traffic accidents and accidents with heavy machinery, owing to the persistent drowsiness suffered by many sleep apnea patients before the disease is recognized and treated.

What treatment options are available for snoring and sleep apnea sufferers?

Until recently, treatment options have been limited to painful and invasive nose and throat surgeries and bulky CPAP and oral appliances which require patients to wear every time they sleep. At ENT and Audiology Associates, Douglas Holmes, MD will meet with you to individualize a treatment plan that is right for you and your condition. At ENT and Audiology Associates, we believe in finding the least invasive ways to help improve a patient’s quality of life. One procedure, Radiofrequency Ablation of the Tongue Base, has been found to be superior to any other treatment for sleep apnea. The procedure was developed 10 years ago and continues to be performed with great success.

What is Ear Wax?


Ear wax is not really a “wax” but a water-soluble mixture of secretions, plus hair and dead skin. Most of the time the ear canals are self-cleaning; that is, there is a slow and orderly migration of ear wax and skin cells from the eardrum to the ear opening. Old ear wax is constantly being transported, assisted by chewing and jaw motion, from the ear canal to the ear opening where it usually dries, flakes, and falls out.

Unfortunately, many people mistakenly believe that ear wax should be routinely removed for personal hygiene. This is not so. In fact, attempting to remove ear wax with cotton-tipped swabs or other probing devices can result in damage to the ear, including trauma, impaction of the ear wax, or even temporary deafness. These objects only push the wax in deeper, and can block the ear canal entirely.

Under ideal circumstances, the ear canals should never have to be cleaned. However, that isn’t always the case. The ears should be cleaned when enough ear wax accumulates to cause symptoms or to prevent a needed assessment of the ear by your doctor. This condition is called cerumen impaction, and may cause one or more of the following symptoms:

  • Earache, fullness in the ear, or a sensation the ear is plugged
  • Partial hearing loss, which may be progressive
  • Tinnitus, ringing, or noises in the ear
  • Itching, odor, or discharge
  • Coughing


If you or a loved one are experiencing any of these ear wax symptoms, please call the ENT & Audiology Associates in Raleigh at 919-782-9003 to confirm that ear wax is the cause. Do not attempt to remove the wax yourself.

Changing Perspectives

I recently had a unique experience in the ENT & Audiology Associates office, as I went from being a clinician, to being a patient.  While I can talk all day about how great it is to work here with Dr. Holmes and our amazing staff, I didn’t fully understand how amazing this practice is until last week.

I had just returned from a whitewater kayaking trip in northern California.  It took me three flights to get back home, flying overnight and coming straight to work Monday morning.  I had a sore ear at work on Monday, but attributed it to sleep deprivation, the black eye I had gotten from paddling, and all the pressure changes on the flight, so I didn’t think much of it.  The next day though, the pain had increased.  I did a tympanogram on myself, saw that my eardrum was still moving normally, so tried to still brush it off.  Later in the day however, it had gotten worse, and I asked Dr. Holmes to look in my ear.  He noted IMG_0374that my eardrum on that side was red and inflamed, and gave me some drops for what looked like the start of an outer ear infection (made sense, as I had just spent a week on a river).  Unfortunately, what looked like the beginning of an external ear infection was actually the onset of acute otitis media, and that night my middle ear filled with fluid, so that by the time I got to the office on Wednesday, my eardrum was bulging.  (I have never had an ear infection my whole, life, and now that I’m almost 30, I get my first one!)  Dr. Holmes came to my side of the office first thing in the morning, to see how I was doing, immediately diagnosed the problem, he and the nurses were able to call me in an antibiotic to start right away.

Later in the day, it had gotten to the point where it was so painful and there was so much pressure, it was determined that a myringotomy was the best option to relieve the pressure and remove the fluid.  While I was nervous (as I was about to have a incision cut into my eardrum), I tried my best to act tough, knowing that some of my colleagues wanted to watch.  The nurses were incredibly empathetic, and made me feel very comfortable.  Dr. Holmes talked me through the whole procedure (all two minutes of it), and I was immediately feeling better.  That night I slept better than I had all week, and by the next day, I was feeling completely healthy again.  Every time I saw a nurse in the hallway, they would ask to make sure I’m feeling better.  I felt so supported and cared for by everyone in the office. DrKymanPic  I definitely have new empathy for the patients I see, and can say without hesitation that Dr. Holmes and the staff at ENT & Audiology Associates provide excellent care, difficult to find elsewhere.  My eardrum is already healed, and I’ll be back on the water in no time thanks to Dr. Holmes.
Lena Kyman is a clinical audiologist at ENT & Audiology Associates, and patient of Dr. Holmes’.



We Love Hearing From Our Patients


We love hearing feedback from our patients!  While Twitter is a very public forum and not everyone will want to share a hospital recover picture there, we still love engaging with our patients on social media.  So please, ‘Like’, ‘Share’, and ‘Tweet’ with us!