Dr. Meier and Dr. Tolbert attend course on advanced endoscopic skull base surgery

Dr. Meier and Dr. Marshall Tolbert of Sierra Neurosurgery attended the University of Pittsburgh’s Endoscopic Endonasal Skull Base Course in December of 2018.  This four day course discussed the state of the art techniques involved in endoscopic management of cranial base disorders such as benign and malignant nasal tumors, CSF leaks, pituitary and other ventral skull base tumors.  The course involved lectures, prosections, live surgery and hands on dissections. This meeting was attended by dozens of rhinologists and neurosurgeons from around the world.  Dr. Meier and Dr. Tolbert are excited to return to Reno with the latest techniques to treat pituitary tumors in a minimally invasive fashion.

Is One Ear Better Than The Other?

When it comes to language, it may be true. According to recent research by audiologists at Auburn University, there could be an advantage to listening with our right ears, especially for children and noise-distracted adults.

The phenomenon is known as the right-ear advantage: Speech heard through the right ear reaches the part of the brain that processes it in about 20 milliseconds. Speech heard through the left ear, however, takes anywhere from 3 to 300 milliseconds longer to reach the same part of the brain.

Why? The speech we hear in our right ears can travel directly to the left hemisphere of our brains, which is generally thought to be where language is processed. Speech received by the left ear takes a less direct route, resulting in a lower processing speed. From the left ear, sound signals travel first to the right hemisphere of the brain. Then, they are relayed via the corpus callosum — a broad band of nerve fibers that connects the hemispheres — which finally passes them onto the left hemisphere. This means that, even though we can hear with both ears, our brains more efficiently process speech heard with the right ear because those signals arrive more quickly.

In children younger than 11, the right ear advantage is the most noticeable. A typical 7-year-old will correctly repeat information heard by the right ear about 70 percent of the time, compared to only about 55 percent of the time when the information is heard by the left ear. A 9-year-old is accurate about 80 percent of the time with their right ear and 75 percent with their left. An 11-year-old is about as accurate as most adults, which is close to 90 percent in both ears.

The right-ear advantage is more apparent in children whose myelin membranes are less developed. The myelin is an insulating sheath that facilitates faster impulse transfers through the corpus callosum. Because the myelin develops with age, the right-ear advantage tends to dwindle over time. In fact, for most adults this phenomenon isn’t noticeable unless we are processing complex information that exceeds our basic memory capacity.

When adults hear the same speech in both ears at the same time, there is no perceivable advantage with the right ear. Rather, problems occur when we receive signals that have to compete with each other. When adults are trying to pay attention to multiple sources of speech at the same time, memory capacity is quickly exceeded, and the right-ear advantage comes back into play. In these studies, distracted adults are shown to have anywhere from a 7 to 40 percent advantage when using their right ear.

With this in mind, the next time you lean in to talk to someone in a noisy room, check which ear you’re leaning towards — is it the right one?

Sources: http://online.wsj.com/public/resources/documents/print/WSJ_-A002-20180203.pdf

Excessive Tearing Caused by Nasolacrimal Duct Obstruction

The lacrimal apparatus is what is responsible for creating tears and moving them from the eyes to the nose. It is possible for the lacrimal system to become obstructed and prevent tears from draining naturally. This is known as nasolacrimal duct obstruction. When tears cannot drain, this can present as excessive tearing, or epiphora, and it can occur either intermittently or continuously.

Excessive clear tearing is the most common symptom of nasolacrimal duct obstruction. Occasionally it will also be accompanied by a mucus discharge from the eyes. Dacryocystitis is a less common symptom — this is an infection of the region between the eye and nose, and can occur repeatedly in those with a lacrimal blockage. Patients with dacryocystitis often report tenderness in the area between the eye and nose.

There are several possible causes for nasolacrimal duct obstruction. The most obvious is facial trauma, which can create scarring inside of the lacrimal apparatus or tear the nasolacrimal duct. In surgery to correct facial trauma deformities, injury to the lacrimal apparatus may occur unintentionally. Other types of facial surgery such as sinus surgery and head and neck cancer surgeries can also injure the lacrimal system.

Another cause of nasolacrimal duct obstruction is bacterial infection, which leads to inflammation within the duct. Infection and inflammation can lead to scarring, which can reduce passage within the duct or block it entirely. Autoimmune diseases can also cause inflammation in the nasolacrimal duct, which can create a blockage without any infection.

Although the above causes are easy to understand, more often than not, nasolacrimal duct obstruction occurs without any apparent cause. Middle-aged individuals are most likely to experience it, and some researchers believe osteoporosis and hormone changes may play a role.

To determine if you have an obstruction in your nasolacrimal duct, a rhinologist may apply fluorescent dye in the corner of an eye to see if saline is transferring into your nose. If the dye is not noticeably passing through your lacrimal apparatus, an injection of the same substance may be attempted into the tear duct. If the duct still appears obstructed, an x-ray can be used to determine the location of obstruction.

If there is a physical obstruction, your rhinologist may perform a dacryocystorhinostomy (DCR) to remove it. A DCR creates a direct opening from the lacrimal sac (within the lacrimal apparatus) to the nasal cavity. The opening is held open with either sutures or stents, and it allows the tears to drain naturally into the nasal cavity. The procedure can be done externally, through an incision between the nose and eye, or endoscopically, which can be less painful and won’t leave any visible scarring. DCR is a procedure with minimal risks and postoperative effects. Patients can expect minimal bleeding and some scarring within the nose, and those who have the procedure enjoy a 90 percent success rate.

If you are having issues with excessive tearing, please call and make an appointment with one of the specialists at Nevada ENT and the Reno Tahoe Sinus Center. We can help determine the source of your symptoms and give you information on treatment options individually tailored to your situation.

Sources: Epiphora, American Rhinologic Society

Kevin C. Welch, MD


Dacryocystorhinostomy (DCR), American Rhinologic Society

Vijay Ramakrishnan, MD
Todd Kingdom, MD



How to Handle Your Summer Allergies

Allergies can make you miserable. With itchy eyes, a runny nose, sneezing and congestion, enjoying yourself during beautiful summer months can be difficult. Try these simple tips to keep your summer allergies under control and have fun this summer!

Keep Indoor Air Clean

Unfortunately, there isn’t a product that can magically eliminate all allergens in your home. However, when using the air conditioning in the house or car regularly, changing the air filters and keeping the indoor air dry with a dehumidifier can greatly help.

Reduce Exposure

Try and reduce your exposure to things that can activate your allergies like staying indoors on dry or windy days. Understanding that spending all summer indoors is impossible, plan ahead and look at local weather or pollen levels.

If outside chores are calling your name, either wear a pollen mask or delegate the chores like lawn mowing or weed pulling. After outdoor chores or activities, remove the clothes you wore outside and shower to remove all the pollen from your hair and skin.

Rinses Those Sinuses

Rinsing your sinuses, or nasal irrigation, is a beneficial way to relieve symptoms for those who struggle with allergies or just general nasal congestion. Nasal irrigation is flushing out your nasal cavity with a saline solution. The solution is a simple mixture of purified water and salt, used in combination with a squeeze bottle or a neti pot. Directly rinsing your sinuses or nasal passages will flushes out mucus and allergens in your nose.

Over-the-counter remedy

If the tips above aren’t cutting it, there are several types of nonprescription medications that can alleviate your allergy symptoms.

  • Oral antihistamines can help relieve sneezing, itching, a runny nose and watery eyes
  • Decongestants, such as pseudoephedrine, can provide temporary relief from nasal stuffiness
  • Nasal spray can ease allergy symptoms and doesn’t have serious side effects, though it’s most effective when you begin using it before your symptoms start

Consult a Doctor

For some, taking precaution or using over-the-counter medications isn’t enough to alleviate their allergy symptoms. So, consult your doctor to determine the best course of action for your allergies, whether they are seasonal or year around.

For more information on all Rhinology questions or to schedule an appointment with one of our physicians, please visit https://nevada-ent.com/ or call 775.322.4589.


How to Protect Hearing During Summer Outdoor Activities

Summer; the best time for outdoor activities like swimming, live concerts, fireworks and even yard work. To get the most out of your summer but also to protect your hearing, here are some preventative measures to keep in mind during these summer activates.

Live Concerts

Outdoors concerts are the best during the summer but can be just as harmful because of the high volume of decibels during the concerts.

Decibels are a unit used to measure the intensity of a sound or the power level of an electrical signal by comparing it with a given level on a logarithmic scale.

The typical person can generally accept 85 decibels for a maximum of eight hours a day, followed by at least a couple hours of recovery time. Most live concerts are at a volume of 100 to 110 decibels which decrease the length of exposure time.

There are two options for all concert goers, placing oneself as far away from speakers as possible or wearing ear plugs. Earplugs can decrease the noise by 20 to 30 decibels.

Both are good options to avoid ringing in the ears after the concert has ended.


Between Fourth of July, baseball games and local events, fireworks are a staple during the summertime. Although fireworks produce between 140-150 decibels, they generally do not cause problems because the explosions are short-lived and happen in the sky.

However, it’s always better to be safe than sorry. Keeping your distance, around 500 feet, is an easy way to still enjoy the beautiful show but also keep your hearing safe.

Using earplugs is an inexpensive and efficient way to protect your hearing. Various types of earplugs are able to reduce different level of decibels.

Water Activities

The best way to cool off can also be the most common cause of ear trouble during the summer. Swimming in any type of water can cause water to get trapped in the middle ear.

The middle ear is the part between the eardrum and the oval window. It transmits sound from the outer ear to the inner ear. Getting water trapped in the middle ear can cause an infection to develop.

Wearing earplugs or custom-molded ones can prevent trouble or pain.

Outdoor Equipment

Equipment like lawnmowers and weed whackers can produce up to 100 decibels so wearing earplugs is a key protective measure. Some people prefer to listen to music through headphones while doing yard work, this isn’t the same as using earplugs and can be harmful.

Listening to music requires the music to be louder and drown out the sound of the equipment.

Be aware of your proximity to the loud sound and remember to use ear plugs if you need to. There are a variety of earplugs that are best for different types of activities including swimming and attending concerts.

For more information on all Otology questions or to schedule an appointment with one of our physicians, please visit https://nevada-ent.com/ or call 775.322.4589.



Congratulations to Dr. Van Duyne!

We’d like to congratulate our very own Dr. Van Duyne for competing in the 14th Annual Reno-Tahoe Odyssey. Dr. Van Duyne and the rest of “Outrunning 50” won and set a new record for the Senior Women division.

Congratulations to Dr. Van Duyne who participated!

Septal Deviation and Septoplasty

Septal deviation is a common condition, with a significant portion of the population having their septum deviate to one side or the other. Commonly some degree of nasal trauma may cause a deviated septum. Many people are asymptomatic from this, however a few can have nasal obstruction symptoms on the side that is deviated. In these patients, septoplasty (i.e straightening the septum), can be performed. It is usually an outpatient procedure, performed under general anesthesia. After the operation, the patient can breathe better on the affected side. If the deviated septum is more posteriorly placed, endoscopic septoplasty is a good option for the patient. This approach can be done without packing or splints afterwards, and the recovery is easier. Commonly an inferior turbinoplasty is performed concurrently because the turbinates can be swollen due to allergies, or to compensate for the extra space on the non deviated side.

Josh Meier, M.D. F.A.R.S

Nasal Rinsing, or the Use of Neti Pots

The use of neti pots and similar methods of irrigating the nasal cavity is an old homeopathic remedy for sinus pressure and high levels of sinus mucus. Though the neti pot stems from ancient Indian Ayurvedic hygiene and wellness practices, doctors have recently been paying more attention to the method. What they have found is that it is both a safe and effective method for clearing the sinuses of mucus, and may also help to reduce inflammation by flushing small, irritation-causing particles out of the sinuses, as well as viruses and bacteria.

Usually a nasal rinse is some form of saline concentration. It is recommended that patients use an isotonic concentration, or a concentration that has saline levels similar to those in the human body. Patients can either purchase premixed salt packets for this or make their own at home. One common recipe calls for 2-3 teaspoons of iodine-free salt and 1/4-1/2 teaspoons of baking soda for one liter of sterile water. Including a small amount of baking soda in the rinse has been shown to yield better results than saline alone. Some patients prefer higher levels of saline concentration, but studies have shown that this can damage the nose’s cilia. Cilia are small, waving hairs that keep the nose clean. Increased salt levels in your nasal rinse can lead to increased nasal congestion and nasal swelling.

It is very important when flushing your nasal cavities that you use sterile water. Boiled, distilled, or well-filtered water are recommended. Do not use water from a wild or questionable source without appropriate filtration and sterilization. In very rare instances, amoeba present in a municipal water source has caused encephalitis in neti pot users. Encephalitis is a deadly brain infection. It is not common to find such amoeba outside of untreated water supplies, but the results are serious, so use caution and ensure your water is safe before using it in your sinuses.

In addition to sterile water, it is also important to use sterile equipment. To sterilize the bottle you are using, microwave it for two minutes in cold water. One study found this method more effective than a boiling water rinse. Using Milton’s antibacterial solution was also found to be an effective sterilization method.

Ideally, an effective nasal rinse will reach as much of the nasal lining as possible. There are a couple of factors in application that may improve the rinse’s effectiveness. First, when applying the rinse, place your head down. This can help the irrigation reach the top of the nose and forehead sinus. Second, a high volume of delivery tends to be more effective than a lower volume of delivery. The increased volume tends to result in the optimal coverage of the nasal lining.

There are a couple of treatments that can work in conjunction with nasal rinsing to improve patient results. One is sinus surgery. If there are nasal blockages present, surgery can lead to improved delivery and effectiveness of a nasal rinse. Another is medicated irrigation. In patients with chronic sinusitis who were using topical antibiotics or nasal steroid sprays, high volume rinses with diluted steroids improved their symptoms.

If you are having nasal issues, please call and make an appointment with one of the specialists at Nevada ENT and the Reno Tahoe Sinus Center. We can help determine the source of your symptoms and give you information on treatment options individually tailored to your circumstances.

Source: Nasal/Sinus Irrigation by Benjamin S. Bleier, MD

Award Winning Research

Nicholas Weseley, UNR 2nd year Medical Student, presented his summer research project “A Validated Model for the 22-item Sinonasal Outcome Test Subdomain Structure in Chronic Rhinosinusitis” at the Regional American College of Physicians Meeting on September 27th at the VA Hospital in Reno. He won first prize for the summer project he headed up in collaboration with Mass Eye and Ear and Harvard Medical School. He will present again October 13-14th at the Nevada State ACP Meeting in Las Vegas. Congrats to Nic on his win and all of his hard work! This research has furthered understanding of quality of life effects in patients with chronic sinusitis.

Josh Meier, M.D. F.A.R.S.

Nevada ENT and Reno Tahoe Sinus Center Collaborate with Harvard Medical School

Dr. Meier recently returned from Chicago where the paper “A Validated Model for the 22-item Sinonasal Outcome Test Subdomain Structure in Chronic Rhinosinusitis” was presented at the American Rhinologic Society’s Annual Meeting. This paper demonstrated that the 22 questions found in the SNOT-22 can be grouped into 4 subdomains (sleep, nasal, otologic/facial pain and emotional). Data was provided from 400 patients from Nevada ENT / Reno Tahoe Sinus Center and 400 patients from Harvard / Mass Eye and Ear. Dr. Meier and Dr. Killeen enjoyed collaborating without colleagues from Boston and look forward to future projects. Special thanks to our hard working, 2nd year UNR medical student, Nicholas Weseley, who performed the data collection.