Daniela Gorduza, MD

• Consultant in Pediatric Urology,
• Claude-Bernard University, Lyon I,
• France
• Consultant in Pediatric Urology, H?pital M?re-
• Enfants?GHE,
• Bron, France

The shape of the node may also be helpful and some authors use the ratio of the length to the transverse diameter erectile dysfunction doctors albany ny order levitra plus 400 mg with mastercard, with reactive nodes being oval with ratios greater than two impotence vasectomy buy discount levitra plus 400 mg on-line, whereas malignant nodes tend to be rounded with a ratio less than two erectile dysfunction treatment in bangalore levitra plus 400mg on line. The nodes are homogeneous in the acute phase and enhance homogeneously erectile dysfunction otc meds buy levitra plus 400mg with amex, but develop low attenuation centres with peripheral enhancement later erectile dysfunction treatment natural order levitra plus uk. Chapter 138 Examination and imaging of the neck] 1761 may be involved does erectile dysfunction cause low sperm count discount levitra plus generic, there is minimal if any infiltration of the adjacent fat planes and this may help distinguish tuberculous from malignant nodes. Nodal staging is very important for the appropriate management of head and neck tumours. Tumour deposits tend to infiltrate from the cortex into the medulla of the node, which becomes lower in attenuation due to a mixture of tumour necrosis, interstitial oedema, fibrosis and viable tumour. The differential diagnosis of these apearances includes fatty hilar metaplasia (a response to chronic nodal infection) or a nodal abscess, and differentiation may be difficult. Extracapsular nodal spread of tumour indicates a poor prognosis with a reduction in overall survival of 50 percent with a ten-fold increase in the risk of neck recurrence compared with patients without extracapsular spread. Microscopic spread is found in 40 percent of nodes less than 2 cm, in 50 percent of nodes between 2 and 3 cm rising to 75 percent of nodes greater than 3 cm in diameter. Nodal metastases from papillary thyroid tumours may be homogeneous similar to reactive nodes, cystic or may show intense enhancement after contrast medium and may have punctate calcifications. Nodal calcification may be seen in tuberculosis or sarcoid and also in mucinsecreting tumours and treated lymphoma. Lymph nodes irregular soft tissue stranding indicating extracapsular spread (arrows). Magnetic resonance imaging Normal nodes are of similar signal intensity to muscle on T1W and slightly higher signal than muscle on T2W sequences. True necrosis is low signal on T1W and high signal on T2W; however, the central low attenuation seen in malignant nodes is not all due to necrosis and is made up of mixed components and therefore has heterogeneous signal on both T1 and T2W sequences. It may not be demonstrated on noncontrast T1W sequences, although it is seen as focal areas of high signal on T2W sequences. It is best shown using T1W contrast-enhanced sequences where there is central low signal with peripheral enhancement. This enhancement may be better appreciated against the high signal of the surrounding fat if fat suppression sequences are used and this also improves the visualization of extracapsular spread of tumour. The cystic nodes of papillary thyroid carcinoma are high signal on both T1 and T2W sequences. Using size, the false-negative and false-positive rate is between 10 and 20 percent. If size and internal architecture are combined, there is an improved diagnostic accuracy. Using a size of 1 cm or abnormal architecture to indicate a positive node, Curtin et al. Positron emission tomography Positron emission tomography is used to stage the primary squamous cell carcinoma including nodal involvement and distant metastases and for the detection of recurrent tumour. The use of positron emission tomography in patients with nodal metastases in the neck and no obvious primary is contentious. Positron emission tomography does appear to be the most sensitive method of detecting recurrent tumour, particularly following radiotherapy. Both of these techniques can identify the primary tumour, but the ability to identify nodal disease is limited. Ultrasound-guided fine needle aspiration cytology does not increase the sensitivity, but is 100 percent specific. Best clinical practice [Patients with an undiagnosed neck mass should undergo imaging. Magnetic resonance imaging versus clinical palpation in evaluating cervical metastasis from head and neck cancer. The new imaging-based classification for describing the location of lymph nodes in the neck with particular regard to cervical lymph nodes in relation to cancer of the larynx. Grey-scale sonography in assessment of cervical lymphadenopathy: review of sonographic appearances and features that may help a beginner. Diagnosis and staging of head and neck cancer: a comparison of modern imaging modalities (positron emission tomography, computed tomography, color-coded duplex sonography) with panendoscopic and histopathologic findings. Modern imaging techniques and ultrasound-guided aspiration cytology for the assessment of neck node metastases: a prospective comparative study. Ultrasonographic criteria for diagnosis of cervical lymph node metastasis of squamous cell carcinoma in the oral and maxillofacial region. Comparison of ultrasound-fine needle aspiration and computed tomography in patients undergoing elective neck dissection. Differential diagnosis of small round Deficiencies in current knowledge and areas for future research the aim of future research should be directed towards the detection of low volume metastic disease. The value of radical dissection of structures of the neck in the management of carcinoma of the lip, mouth, and larynx. Power Doppler sonography of cervical lymph nodes in patients with head and neck cancer. The incidence of micrometastases in neck dissection specimens obtained from elective neck dissections. Occult primary tumors of the head and neck: lack of benefit from positron emission tomography imaging with 2-[F-18] fluoro-2-deoxy-D-glucose. Update on 18F-fluorodeoxyglucose/positron emission tomography and positron emission tomography/ computed tomography imaging of squamous head and neck cancers. Positron emission tomography in the management of unknown primary head and neck carcinoma. There has been a distinctive paradigm shift from mandatory exploration, towards more selective, conservative management based on clinical evaluation and specialized investigations. Introduction of diagnostic tools such as flexible endoscopy, high quality oesophagography, angiography and duplex Doppler have improved nonoperative evaluation of aerodigestive and vascular injuries. The realization that certain injuries may be treated nonoperatively and given the management of selected arterial injuries by endovascular techniques, has further promoted the concept of selective exploration of the neck. There has been an increased awareness of carotid injuries in respect to blunt cervical trauma and the need to study the carotid artery by means of angiography and/or duplex Doppler in patients presenting with unexplained neurological signs. It focuses on factors such as hypoxia, hypovolaemia, tension pneumothorax and head injury. A cervical collar or sandbags should be used to stabilize the neck until cervical spine injury is excluded. Major facial fractures, in particular mandibular fractures, and large cervical haematomas may compromise the airway. It should be converted to a formal tracheostomy subsequently, as the small tube is difficult to keep clean and in order to prevent subglottic stenosis. Tension pneumothorax presents with hypoxia, restlessness, hyper-resonance to percussion, decreased air entry, contralateral tracheal shift and elevated jugular venous pressure. It is decompressed by needle thoracocentesis with a large bore needle placed through the second intercostal space in the midclavicular line, followed by insertion of a chest drain. A large haemothorax is identified by dullness to percussion and decreased air entry, and is also managed with an intercostal drain. These are clinical diagnoses of lifethreatening conditions and immediate intervention is mandated before x-rays are obtained. A rectal examination to exclude a urethral injury should be performed prior to insertion of a urinary catheter. Haemo- or pneumothorax, pneumomediastinum (tracheal or oesophageal injury) and widened mediastinum should be excluded. Cervical spine x-ray is used to exclude spinal column injury and prevertebral air (pharyngeal or oesophageal injury). Secondary survey A detailed head-to-foot examination of the patient should be conducted. In firearm injuries, the entrance and exit wounds must be noted and the tract of the projectile determined to identify which anatomical structures may have been injured. If an exit wound is not present, then xrays are obtained (anteroposterior and lateral) to locate the bullet so that the tract of the bullet can be determined. Note the presence of large cervical haematomas, subcutaneous emphysema, the jugular venous pressure, the presence of blood in the nasogastric tube and tenderness over the mandible. Wounds should not be probed as this may result in massive bleeding from an arterial injury. The distal carotid and superficial temporal artery pulses should be examined and bruits should be listened for. The abdomen and pelvis should be examined, followed by a full neurological examination during which spinal cord and brachial plexus trauma are excluded. The patient should be log-rolled in order that the back can be examined for trauma. The line should not be inserted on the side of massive bleeding from a vascular injury, for if there is a venous injury, the fluids delivered will be bled out. In the shocked patient, start with 2 L of crystalloid and proceed to emergency blood (0 negative) if the blood pressure does not improve and crossmatch blood. A shocked patient with warm peripheries may have neurogenic shock secondary to spinal cord injury. Active bleeding from a cervical wound may be controlled with a compressive dressing or digital pressure. Failing this, a large Foley catheter may be inserted into the wound, the bulb inflated and the catheter crossclamped to stop blood pouring through the catheter. This can be a very effective form of haemostasis, particularly with bleeding from the subclavian and cervical vessels. Coupled with the introduction of antibiotics and tracheostomy, early exploration reduced the mortality rate to 7 percent. They concluded that all penetrating neck wounds that violated the platysma required surgical exploration. Mandatory exploration of the neck whenever the platysma muscle had been breached became common practice. Stone questioned the need for mandatory exploration for civilian injuries in 1963. The majority of trauma centres now advocate some form of selective conservative management. Both retrospective and prospective studies and review articles continue to compare results of studies without considering differences in the classification systems used. They point to the unreliability of clinical evaluation, that diagnostic studies do not have 100 percent sensitivity to detect oesophageal and vascular injuries, low morbidity associated with negative exploration, additional time and effort associated with expectant observation, and the significant morbidity and mortality associated with delayed detection and repair of oesophageal injury. Yet, vascular and oesophageal injuries can be missed when the neck is explored without the assistance of preoperative angiography, oesophagography and/or oesophagoscopy. Negative exploration in centres practising selective exploration ranges between 9 and 62 percent. With a selective approach, severe active bleeding, hypovolaemic shock not responding to resuscitation, a rapidly expanding haematoma, a large blowing wound and major haemoptysis are indications for emergency surgery. The remaining patients are assessed clinically and appropriate radiological and endoscopic investigations are undertaken if there is a suspicion of visceral injury. While the importance of early diagnosis of occult vascular injuries is debatable, delayed diagnosis of oesophageal perforations is accompanied by increased Demetriades et al. They advocate emergency exploration for the absolute indications for neck exploration noted previously, but do not consider soft signs such as shock responding to resuscitation, minor active bleeding, haematoma, dyspnoea, subcutaneous emphysema, hoarseness, dysphagia or minor haematemesis to be absolute indications for exploration. These patients are assessed individually, taking into account the direction of the injury tract and the severity of the signs. If the tract courses away from the larynx, trachea, oesophagus and carotid sheath, then no further investigations are undertaken. If the tract is directed towards the midline, then contrast oesophagography and/or endoscopy is carried out. They conclude that selection for exploration can be decided on the basis of careful initial and repeated clinical examinations. Although transcervical gunshots are twice as likely to have visceral/vascular injury as gunshots that do not cross the midline (79 versus 31 percent, p = 0. Flexible nasopharyngoscopy may reveal oedema, blood in the pharynx, or the perforation may be visible if located in the upper part of the hypopharynx. Oesophagography is unreliable, while direct pharyngoscopy should reveal all the injuries. They conclude that upper segment injuries can be managed nonoperatively as it is capacious, has a low intralumenal pressure and is enveloped by both the middle and inferior constrictor muscles. The lower segment funnels into the cricopharyngeus segment and is less capacious, has higher intralumenal pressure and is surrounded only by the inferior constrictor muscle and should be managed like oesophageal injuries by exploration, repair and drainage. Evidence of retropharyngeal air, retropharyngeal oedema, haematoma, tracheal deviation and pneumomediastinum may be revealed by x-ray. Because gastrograffin, if aspirated, may induce serious pulmonary Chapter 139 Neck trauma] 1771 problems, it should not be used in trauma patients. Delayed intervention of 412 hours for iatrogenic oesophageal injury has a mortality rate of 40 percent as opposed to 9 percent for o12 hours. They concluded that time delays in instituting active management incurred by investigations associated with selective exploration can lead to increased morbidity and mortality. Whether their conclusion applies to isolated cervical oesophageal injury is therefore open to question, particularly in view of reports of the successful outcome of small cervical oesophageal injuries treated conservatively. However, centres practising selective management of penetrating neck injuries should make rapid diagnosis and definitive repair a priority.

Clinically erectile dysfunction drugs walgreens buy 400mg levitra plus overnight delivery, the characteristic forward bulging of the posterior pharyngeal wall can be difficult to recognize and in children differential diagnosis from epiglottitis is a priority erectile dysfunction medication new zealand levitra plus 400mg mastercard. The most common symptom is tender cervical adenopathy erectile dysfunction doctor cape town buy levitra plus 400mg on-line, usually accompanied by sore throat otc erectile dysfunction pills walgreens discount generic levitra plus canada. Airway obstruction in infectious mononucleosis may be aggravated by herpes infection erectile dysfunction shake drink purchase levitra plus 400mg with mastercard. Rare erectile dysfunction medications in india best 400 mg levitra plus, head and neck manifestations include periorbital oedema, especially of the lower lids, and cranial nerve mono- and polyneuropathies of which facial nerve weakness is the most common. Six cases of isolated clinical hypoglossal nerve palsy due to infectious mononucleosis have been described. A clinical presentation of infectious mononucleosis with facial palsy and a parotid mass, both of which resolved spontaneously, have been recorded in a child. The differential diagnosis of acute pharyngotonsillits from infectious mononucleosis can be aided by flexible nasendoscopy. Lymphoid tissue is present in the nasopharynx of 92 percent of patients with infectious mononucleosis and in none with acute tonsillitis. The white cell count may be normal in the first week but is usually raised in the second. The common serological tests depend on development of heterophile antibodies, the most useful being agglutinins to sheep and horse red cells, and these antibodies are the basis of the Paul Bunnell and monospot tests. False positive monospots can occur in healthy controls as well as in a variety of conditions including mumps, systemic lupus erythematosus, Mediterranean spotted fever and diabetes sarcoidosis. These tests are usually positive in the first week of the disease although approximately 10 percent never develop a positive test and this figure may be higher in children. Serological tests cannot distinguish between typical and atypical severe forms of infectious mononucleosis. Female patients without tonsillitis, and a white cell count o10 and an aspartate aminotransferase 4150 are at significant risk of complications and should be carefully monitored. This may be increasingly justified for some of the high-risk complications and prolonged fatigue syndromes. Acute upper airway obstruction secondary to infectious mononucleosis is an indication for steroid treatment. For those who fail to respond to intravenous steroids, acute tonsillectomy may be indicated. Patients who develop upper airway obstruction seem to be more prone to developing later recurrent tonsillitis and acute tonsillectomy has the incidental benefit of avoiding this complication. Rarely, tracheostomy may be required if tonsillectomy fails to relieve airway obstruction. In addition, a vaccine based on immunization with a structural antigen is under evaluation. Hopefully, these approaches will provide the impetus for cytotoxic T-cell vaccine development. Contact sports should be avoided for four to six weeks even in the absence of splenic enlargement because of the risks of splenic rupture. Sixty-four percent had atypical lymphocytosis, 90 percent had biochemical evidence of hepatocellular injury and 17 percent had evidence of immunological abnormalities. It causes severe vesicular and ulcerative stomatitis of the lips, tongue, gums, buccal mucosa and, occasionally, the oropharynx. The oropharyngeal involvement may be an isolated pharyngitis without ulceration or vesicles. Children are systemically unwell with pyrexia, tachycardia and cervical adenopathy. Occasionally, severe ulcerative pharyngitis may be due to type 2 herpes simplex infection contracted by heterosexual orogenital contact. In the virology laboratory virus from an unruptured vesicle can be identified using fluorescent antibody or be seen as intranuclear inclusions on scrapings. Secondary herpetic infection takes place when the herpes virus resides within the posterior root ganglion. Intercurrent illness then results in the appearance of herpetic vesicles, usually in the lips or the angle of the mouth, as a typical cold sore. Examination found hepatomegaly (25 percent), splenomegaly (23 percent), adenopathy (19 percent), pharyngitis (9 percent), jaundice (3 percent) and signs of meningeal irritation (1 percent). Fifteen percent had a gastrointestinal form of disease (hepatitis, jaundice, colitis, antral gastritis or cholecystitis), 7 percent a haematological form and less than 2 percent each had pericarditis, pneumonitis, thrombocytopenic purpura, polymyalgia rheumatica, cutaneous vasculitis and Herpes zoster is the virus that causes chickenpox. Herpes zoster pharyngitis probably arises from the reactivation of virus particles in the cranial nerve nuclei after a previous attack of chickenpox, thus it is analogous to shingles or cold sores. They may give rise to pain on swallowing, vesicles and shallow ulcers, which heal rapidly, may be seen on the soft and hard palate, tonsil or posterior pharyngeal wall. Treatment with antivirals should be started within 72 hours of onset of the lesions. Acyclovir has been the drug of choice in the past, but newer drugs such as valacyclovir Chapter 152 Acute and chronic pharyngeal infection] 2005 and famciclovir are equally effective and have more convenient dosing regimens and decreased incidence of post-herpetic neuralgia. A single dose of gabapentin reduces acute pain associated with herpes zoster infection. Herpes zoster vaccination markedly reduces the incidence and morbidity of this condition as well as the likelihood of developing post-herpetic neuralgia. Hand, foot and mouth disease this is usually caused by enterovirus 71 or Coxsackie viruses, but untypeable enteroviruses and mixed cultures may also be responsible. It is characterized by a vesicular eruption in the oral cavity and oropharynx causing dysphagia and dehydration, accompanied by vesicles on the hands and feet. The illness is short-lived and mainly affects young children but has been associated with mortality, for example in the 1998 epidemic in Taiwan. Fulminant enteroviurus 71 infection may lead to severe neurological complications, acute pulmonary embolus and cardiopulmonary decompensation. Age younger than three years has been associated with higher mortality as have larger families and kindergarten attendance. Hospital admission, careful staging and stage-based management reduces the fatality rate in those with cardiac complications. Currently, hand, foot and mouth disease is not susceptible to antiviral agents or vaccination and prevention of outbreaks in high-risk areas requires high-level surveillance and public health interventions. Treatment is symptomatic in straightforward cases but antiviral agents may be justified in the presence of systemic complications. These latter conditions only rarely involve the oropharynx without the oral cavity. The debris is of no significance except as an occasional possible cause of halitosis or nasty taste in the mouth and should, on the whole, be ignored. Accumulation of debris in a crypt may form a tonsillar pseudocyst resulting in a cream-coloured epitheliumcovered lesion which can regress spontaneously and likewise be ignored. Sometimes patients may become extremely distressed by them, in which case tonsillectomy may be a reasonable option. Herpangina this is a self-limiting vesicular eruption that occurs in the oropharynx and a number of enteroviruses (30 and 71) and Coxsackievirus group A have been implicated. Its regular spread to the oropharynx distinguishes it from herpes simplex type 1 infection. Rare presentations include periorbital oedema and diverse cranial polyneuropathies. Asymmetrical adult tonsil with normal mucosa in the absence of cervical adenopathy and approximately 7 percent risk of malignancy, primarily B-cell lymphoma. Very rarely, isolated asymmetry of adult tonsils may be the only feature of sarcoidosis. Unilateral tonsillar enlargement in children in the absence of other suspicious clinical features, especially rapid tonsillar enlargement (within six weeks), dysphagia or night sweats, evidence of immunocompromise, lymphadenopathy, hepatosplenomegaly, history of previous malignancy or persistent acute tonsillitis with failure to respond to medical treatment, does not appear to warrant tonsillectomy. Infective causes presenting as unilateral tonsillar enlargement including invasive candidiasis and actinomycosis of the tonsil. In the absence of an obvious cause, treatment mainly consists of antihistamines, steroids and antibiotics or specific treatment for hereditary angioneurotic oedema. The clinician must always bear in mind the potential seriousness of this condition as a cause of upper airway obstruction. The differential diagnostic possibilities are: neoplastic: squamous carcinoma, minor salivary gland tumours. The patient complains of an onset Exclusion of malignancy is the most important aspect of managing these patients. This requires a careful history, in particular, enquiring about localized pain to one side and earache, progressive dysphagia, or weight loss and careful physical examination of the whole upper aerodigestive tract with a nasendoscope and otoscopy. Direct examination of the oral cavity and oropharynx, paying special attention to the tongue, floor of the mouth, Chapter 152 Acute and chronic pharyngeal infection] 2007 bucco-alveolar sulcus region and manual palpation of the tongue including its base, is required. Usually this is sufficient to exclude malignancy in the absence of unexplained otalgia or progressive dysphagia but, occasionally, further investigations, mainly rigid panendoscopy under general anaesthetic to take biopsies, may be required. If physical examination bears out evidence of postnasal drip or significant acid reflux, both should be treated appropriately with intranasal steroids and proton pump inhibitors although there is little documentation to support this practice. Strong advice is given about cutting out smoking and alcohol if these are involved and an appropriate dental referral may need to be initiated. In those patients where stress is deemed to be a significant factor, neck and throat muscle relaxation therapies are deemed to be beneficial. A large variety of nonspecific remedies has been used, such as gargles, antiseptic and analgesic throat spray, with no well-defined benefits. Surgery is of no demonstrable help in this situation and operations to remove excess extratonsillar lymphoid tissue are of no proven benefit. It is, therefore, very important to consider the possibility of primary syphilis in atypical oral or oropharyngeal ulceration. Secondary syphilis usually occurs several weeks (four to six) after the primary lesion and about 30 percent of patients at this stage will have a healing chancre. The features of the second stage are fever, headache, malaise, generalized lymphadenopathy, mucocutaneous rash and sore throat. The lesions are more commonly seen in the oral cavity than the oropharynx and are ulcerated lesions covered with a greyish white membrane, which when scraped off has a pink base with no bleeding. The secondary stage of the disease lasts a few weeks and, again, the lesions in the mouth and pharynx are infectious. This is a granulomatous necrotic lesion that begins as a nodule and then breaks down to form an ulcer. It can arise in the hard palate, nasal septum, tonsil, posterior pharyngeal wall or larynx. The disease progresses through primary, secondary and tertiary stages with the secondary stage being most likely to give rise to pharyngeal symptoms. The lesion of primary syphilis is at the site of initial inoculation and the organism can penetrate both normal and mucosal abrasions. In primary syphilis, the lesion is the chancre, which develops after an incubation period of 21 days. The most frequent extragenital sites for the chancre are lips, tongue, buccal mucosa and tonsil. The lesion begins as a papule that breaks down to form a painless ulcer with indurated margins. At the same time there may be non-tender unior bilateral cervical lymphadenopathy. The ulcer usually persists for two to six weeks and then heals spontaneously, often despite inappropriate treatment. While the primary lesion is present the patient is highly In the primary or secondary stage of the disease, spirochaetes can be identified by darkfield illumination microscopy in smears taken directly from the lesion. The spirochaetes can also be identified in biopsy specimens using silver stains or fluorescent-labelled antibody. A number of conditions give false positives for this test: other treponemal infections: yaws, bejel or pinta; other nontreponemal infections: atypical pneumonia, malaria, smallpox and leprosy; immunological disorders: systemic lupus erythematosus, rheumatoid arthritis; old age (occasionally). The absorbed antibody is identified by a fluorescein-labelled antihuman gammaglobulin. Occasionally, patients with systemic lupus erythematosus and rheumatoid arthritis will have a positive result. A new multiparametric assay for confirmation of the diagnosis of syphilis has been described. The pharyngeal lesions are secondary to coughing up heavily infected sputum and consist of multiple, painful shallow ulcers in the pharynx or oral cavity. Tuberculous otitis media is probably a blood-borne dissemination of the disease but, on occasion, can result from pharyngeal disease by spread from the Eustachian tube. Poverty, overcrowding and homelessness are the socioeconomic factors common to co-infection with both. Although less sensitive and specific than culture the sensitivity can be greatly improved by using phenol auramine stain as compared with the older ZiehlNielsen technique. It will, in principle, be treated at the same time as the pulmonary disease with triple therapy, usually isoniazid, rifampicin and pyrizinamide as first-line drugs. Management relies upon treatment with at least three drugs to which the isolate is susceptible. Directly observed treatment strategy should be used in adults and children where there is a significant risk of noncompliance and is vital to cut down transmission of disease in the community.

Inconsistencies impotent rage quotes safe 400 mg levitra plus, observer variability and differences in stage method contribute to potential bias causes for erectile dysfunction and its symptoms purchase line levitra plus. Review of the literature has been performed to incorporate new information and/or new data impotence curse buy generic levitra plus 400mg line, which may impact upon revisions on the staging process causes of erectile dysfunction in young adults purchase levitra plus in united states online. In 1958 impotence define purchase levitra plus 400 mg on-line, laryngeal and breast cancer were the first cancers to be assigned recommendations on clinical stage and presentation of results erectile dysfunction zyrtec buy levitra plus 400mg line. They reviewed the available literature of that time and added their own experiences to devise the initial staging system. Subsequent revisions were also implemented based on the observations of the committee members on information available in the literature and from institutional experiences. This is maintained by the Commission on Cancer of the American College of Surgeons and supported by the American Cancer Society as well as data from Surveillance, Epidemiology, and End Results Reporting (a database maintained by the National Cancer Institute which represents 14 cancer registries). The clinical stage is essential to select and evaluate therapy, while the pathological stage provides the most precise data to estimate prognosis and calculate end results. It should be remembered that if there is doubt concerning the correct T, N or M category to which a particular case should be allotted, then the lower. Histopathological grading the histological grading of squamous cell carcinoma represents estimation by the pathologist of the expected biological behaviour of the neoplasm. It has been suggested that such information in conjunction with other characteristics of the primary tumour would be useful in the rational approach to therapy. In a systematic review of 3294 patients, it was found that 46 percent of patients with poorly differentiated tumours had a nodal metastasis at presentation compared with only 28 percent of differentiated tumours. Primary and nodal recurrence rates rose and survival fell significantly for poorly differentiated tumours. It was found that patients with welldifferentiated tumours are at low risk of metastases and patients with poorly differentiated tumours are at high risk of distant metastases. C1 is evidence from standard diagnostic means whereas C5 is evidence from autopsy. Generally speaking, pretherapeutic clinical staging of head and neck cancers should be based on a C2 factor. That would be evidence obtained by special diagnostic means such as radiographic imaging. The grouping adopted is designed to ensure, as far as possible, that each group is more or less homogenous in respect of survival and in addition, that the survival rates of these groups for each cancer site are distinctive. The exception to this grouping is for nasopharynx and carcinoma of the thyroid (Tables 181. The sex and age of the patient, the duration and severity of symptoms and signs, and the presence and severity of intercurrent disease should all be documented. For further information, refer to Chapter 163, Assessment and examination of the upper respiratory tract and Chapter 138, Examination and imaging of the neck. Not every patient requires a scan but they are useful in delineating the extent and size of the primary tumour, determining the presence (particularly when risk of occult nodes is 420 percent), number and position of cervical lymph nodes, searching for an occult primary and locating a synchronous primary or distant metastases (particularly the chest). Appropriate screening for synchronous tumours and distant metastases is particularly important in advanced tumours. Endoscopy and biopsy should be performed by a senior surgeon and in all cases by the head and neck surgeon responsible for any future procedure. For each tumour this should include a description, diagrammatic representation and preferably also photographic documentation. Proponents point out that these procedures require very little time, and may be performed easily during planned, direct laryngoscopy. A large meta-analysis found a small advantage to panendoscopy in detection of second primary tumours during analysis of multiple prospective studies. There is a natural desire to confer a stage on the tumour at presentation in the clinic and, certainly, after endoscopy. It is better to rely on descriptive text to avoid changing the stage as more information becomes available. Chapter 181 Staging of head and neck cancer] 2363 based on examination, imaging, endoscopy and biopsy should be clearly documented in the case file only when all of the above information is collated. Regional lymph nodes the status of the regional lymph nodes in head and neck cancer is of such prognostic importance that the cervical nodes must be assessed for each patient and tumour. Lymph nodes are described as ipsilateral, bilateral, contralateral or midline; they may be single or multiple and are measured by size, number and anatomical location (Table 181. Direct extension of the primary tumour into lymph nodes is classified as lymph node metastasis. Lymph nodes are now subdivided into specific anatomical sites and grouped into seven levels for ease of description (Table 181. Survival is significantly worse when metastases involve lymph nodes beyond the first echelon of lymphatic drainage. It recommends that each N staging category be recorded to show, in addition to the established parameters, whether the nodes involved are located in the upper (U) or lower (L) regions of the neck, depending on their location above or below the lower border of the thyroid cartilage. On each side the medial border of the carotid sheath forms the lateral border Contains the lymph nodes inferior to the suprasternal notch in the upper mediastinum Reproduced from Ref. The natural history and response to treatment of cervical nodal metastases from the nasopharynx are different, in terms of their impact on prognosis, thus they justify a different N classification. Regional lymph node metastases from well-differentiated thyroid cancer do not significantly affect the ultimate prognosis and, therefore, also warrant a unique system. Pathological classification the pT, pN and pM categories correspond to the T, N and M categories. The extent of the tumour in terms of the location and level of the lymph nodes should be documented. In addition, the number of nodes that contain tumour and the presence or absence of extracapsular spread of the tumour should be recorded. Histological examination of a selective neck dissection specimen usually includes six or more lymph nodes; a radical or modified radical neck dissection specimen includes 10 or more lymph nodes. T Definition Tumour 2 cm or less in greatest dimension Tumour more than 2 cm but not more than 4 cm in greatest dimension Tumour more than 4 cm in greatest dimension Lip: tumour invades through cortical bone, inferior alveolar nerve, floor of mouth or skin (chin or nose) Oral cavity: tumour invades through cortical bone, into deep/extrinsic muscle of tongue, maxillary sinus or skin of face Lip or oral cavity: tumour invades masticator space, pterygoid plates or skull base, or encases internal carotid artery Reproduced from Ref. Superficial erosion alone of bone/tooth socket by gingival primary is not sufficient to classify a tumour as T4. Chapter 181 Staging of head and neck cancer] 2365 surface of the hyoid bone (or floor of the vallecula) (Table 181. It includes: anterior subsites (glossoepiglottic area); base of tongue (posterior to the vallate papillae or posterior third); vallecula; lateral subsites; lateral wall; tonsil; tonsillar fossa; tonsillar pillar; posterior wall; superior subsites; inferior surface of soft palate; uvula. T T1 T2a T2b T3 T4 Definition Tumour confined to nasopharynx Tumour extends to soft tissues of oropharynx and/or nasal cavity without parapharyngeal extensiona Tumour extends to soft tissues with parapharyngeal extensiona Tumour invades bony structures and/or paranasal sinuses Tumour with intracranial extension and/or involvement of cranial nerves, infratemporal fossa, hypopharynx, orbit or masticator space a Parapharyngeal extension denotes posterolateral infiltration of tumour beyond the pharyngobasilar fascia. The nasopharynx begins anteriorly at the posterior choana and extends along the plane of the airway to the level of the free border of the soft palate (Table 181. It includes the following: superior wall; posterior wall: from the level of the junction of the hard and soft palates to the superior wall; lateral wall: including the fossa of Rosenmuller; floor: superior surface of the soft palate. The margin of the choanal orifices, including the posterior margin of the nasal septum is included with the nasal fossa. It includes the piriform sinuses, the postcricoid area and the lateral and posterior pharyngeal walls. Postcricoid area (pharyngo-oesophageal junction) extends from the level of the arytenoid cartilages and connecting folds to the inferior border of the cricoid cartilage, thus forming the anterior wall of the hypopharynx. Piriform sinus extends from the pharyngoepiglottic fold to the upper end of the oesophagus. It is bounded laterally by the thyroid cartilage and medially by the hypopharyngeal surface of the aryepiglottic fold and the arytenoid and cricoid cartilages. Posterior pharyngeal wall extends from the superior level of the hyoid bone (or floor of the vallecula) to the level of the inferior border of the cricoid cartilage and from the apex of one pyriform sinus to the other. Nasal cavity and paranasal sinuses the anatomical sites and subsites are: nasal cavity (Table 181. Definition Tumour limited to one subsite of supraglottis with normal vocal cord mobility Tumour invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis. T3 T4a Stage grouping Separate stage groupings are recommended for papillary and follicular, medullary, and undifferentiated carcinomas (Table 181. Definition Tumour limited to one vocal cord (may involve anterior or posterior commissure) with normal mobility Tumour involves both vocal cords (may involve anterior or posterior commissure) with normal mobility Tumour extends to supraglottis and or subglottis, and/or with impaired vocal cord mobility Tumour limited to larynx with vocal cord fixation and/or invades paraglottic space, and/or with minor thyroid cartilage erosion (inner cortex) Tumour invades through thyroid cartilage or invades tissues beyond the larynx. Definition Tumour restricted to one subsite of nasal cavity or ethmoid sinus without bone erosion Tumour involves two subsites or extends to involve an adjacent site within the nasoethmoidal complex, with or without bony invasion Tumour extends to invade the medial wall or floor of the orbit, maxillary sinus, palate or cribriform plate Tumour invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses Tumour invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve, nasopharynx, clivus Reproduced from Ref. Definition Tumour limited to the antral mucosa with no erosion or destruction of bone Tumour causing bone erosion or destruction, including extension into hard palate and/or middle nasal meatus, except extension to the posterior wall of maxillary sinus and pterygoid plates Tumour invades any of the following: bone of posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa or ethmoid sinuses Tumour invades any of the following: anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, and sphenoid or frontal sinus Tumour invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve, nasopharynx, clivus Reproduced from Ref. It is, however, well recognized that T stage alone is of limited prognostic significance in many head and neck carcinomas. Patients with larger tumours are more likely to have nodes than those with smaller tumours. If nodal metastases are removed as a confounding factor then T stage per se does not influence prognosis. For example, a large 3-cm tumour of the supraglottis may still remain T1, whereas in the glottis this will almost certainly be a T3. In addition, depth of invasion is not measured, but is of prognostic and therapeutic importance. The same tumour may be deeply infiltrating into vocalis muscle and yet the stage will still remain T1a. In the oral cavity, in particular the oropharynx, the size of the tumour is not always easily measured. Definition Tumour Tumour Tumour Tumour Tumour 2 cm or less in greatest dimension without extraparenchymal extensiona more than 2 cm, but no more than 4 cm in greatest dimension without extraparenchymal extensiona more than 4 cm and/or tumour with extraparenchymal extension invades skin, mandible, ear canal or facial nerve invades base of skull, pterygoid plates or encases carotid artery Extraparenchymal extension is clinical or macroscopic evidence of invasion of skin, soft tissues or nerve, except those listed under T4a and T4b. Definition Tumour 2 cm or less in greatest dimension, limited to the thyroid Tumour more than 2 cm, but not more than 4 cm in greatest dimension, limited to the thyroid Tumour more than 4 cm in greatest dimension, limited to the thyroid or any tumour with minimal extrathyroid extension. Tumour (any size) extends beyond the thyroid capsule Multifocal tumours of all histological types should be designated (m) (the largest determines the classification). Furthermore, increasing severity with a T4 tumour is reflected in deep invasion into muscle, bone or adjacent structures. The depth of invasion of lesions of the floor of the mouth has been shown to be of prognostic significance and this is similarly difficult to assess by either clinical or radiographic means. The anatomical boundaries of the hypopharynx have been in the past contentious and it is occasionally difficult to be certain of the exact origin of some of the larger tumours. The dual listing of the aryepiglottic fold in both the supraglottis and hypopharynx sites, in particular, invokes a problem in trying to classify the site of origin in some situations. Various studies have confirmed the importance of this factor17 and it is now included in the current classification (engaging the Memorial Sloan-Kettering system of lymph node levels). Many authorities have concluded that problems exist with the current staging system. During clinical examination, the size of the node should be measured with callipers, and allowance made for the intervening soft tissues. The subgroups defined by the T, N and M that make up a given group within a stage grouping scheme have similar survival rates (hazard consistency). The distribution of patients across the groups is balanced (thereby maximizing statistical power in each group). The main disadvantage is that the concept of T and N equivalence does not hold true. Many studies have confirmed the more significant impact of N status over T status. It is also apparent that by pooling groups because there is little difference in survival between them (attempting to improve hazard discrimination), there is an implicit trade-off with hazard consistency. They observe that one of the main disadvantages is that the systems are not intuitive and would require a chart for most clinicians to stage their patients. Therefore, because the system was created from the database, it would naturally perform well. The true test is whether the results from an independent database would yield similar results. The five major sites of the head and neck (oral cavity, oropharynx, larynx, hypopharynx and paranasal sinuses) share the same system. Different systems are in use for the nasopharynx and thyroid, which are considered to be sufficiently different with respect to risk factors, behaviour and treatment. They are of the view that any new system should be comprehensive and easily applicable to all the major sites. It is meant to facilitate an estimation of prognosis and provide useful information for treatment decisions. Radiological investigations to evaluate the primary site should be performed prior to biopsy to avoid the effect of upstaging from the oedema caused by biopsy trauma. The sex and age of the patient, the duration and severity of symptoms and signs, and the presence and severity of inter-current disease should all be documented. Assessment by endoscopy and biopsy should be performed by a senior surgeon and in all cases by the head and neck surgeon responsible for any future procedure. Meta analysis of second malignant tumours in head and neck cancer: the case for an endoscopic screening protocol.

Inherited causes of white patches treatment of erectile dysfunction in unani medicine cheap levitra plus line, such as white sponge naevus and dyskeratosis congenita impotence medications buy discount levitra plus 400mg on-line, are rare impotence existing at the time of the marriage buy 400 mg levitra plus with visa. Telangiectasia may be a manifestation of hereditary haemorrhagic telangiectasia impotence mental block order levitra plus discount, primary biliary cirrhosis erectile dysfunction treatment atlanta safe levitra plus 400 mg, systemic sclerosis erectile dysfunction questionnaire discount levitra plus online, or may follow radiotherapy. Swelling Localized gingival swellings (epulides) may be of local aetiology (irritation) or can be manifestations of pregnancy, a neoplasm or systemic disease (Table 142. Chronic periodontitis may be a sequel of gingivitis but smoking is also a risk factor. The gingiva detaches from the tooth neck, the periodontal membrane and alveolar bone are damaged, and an abnormal gap (pocket) Table 142. Management comprises improved oral hygiene but, since the plaque accumulates within periodontal pockets below the gumline, surgical removal of the pocket wall and removal of diseased tissue may be needed to facilitate future cleansing. Attempts to regenerate lost periodontal tissue (such as guided tissue regeneration) may be indicated. Acute pericoronitis Inflammation of the operculum over an erupting or impacted tooth is common, especially surrounding the lower third molar and presents with pain, trismus, swelling and halitosis, sometimes fever and regional lymphadenitis, and a swollen, red and often ulcerated operculum. Chronic periodontitis is typically seen in adults, is painless but may be associated with bleeding, halitosis and a foul taste. Debris and pus may be expressed from the pockets (pyorrhoea), and there may be increasing tooth mobility. Anaerobes, particularly bacteroides porphyromonas species, have been implicated, and the condition is especially seen in resourcepoor areas such as the developing world, or war zones. Malignant neoplasms Cutaneous disease Blood disorders Vesicles may be seen in viral infections, especially in herpes simplex stomatitis, chickenpox, herpangina and hand, foot and mouth disease. Blisters may result from burns or vesiculobullous disorders such as pemphigoid and pemphigus. Mucocoeles typically remain intact but most other mouth vesicles and blisters break down rapidly to form ulcers, see also Table 142. Gastrointestinal disease Rheumatic diseases Pigmentation Mucosal pigmentation is most usually seen in darkskinned races (but may be seen in white people). Iatrogenic causes Disorders of uncertain pathogenesis Redness Red lesions may be inflammatory or represent erythroplasia, atrophy, petechiae, telangiectasia, haemangiomas or neoplasms. Candidiasis is a common cause as are primary herpes simplex stomatitis, lichen planus or mucous membrane pemphigoid. Lingual depapillation in deficiencies of iron, folate or vitamin B12 may produce a red tongue, termed glossitis, the geographical tongue may also produce red patches. Telangiectasia may be seen in hereditary haemorrhagic telangiectasia, primary biliary cirrhosis or systemic sclerosis, or may follow radiotherapy. Chapter 142 Benign oral and dental disease] 1823 Haemangiomas are usually isolated but may occasionally be part of a wider syndrome. Approximately half are of the intradermal (intramucosal) type; one third are blue naevi, many others are compound naevi and some are junctional. They are usually brown, macular, do not change rapidly in size or colour and are painless. There is no evidence that most naevi, except junctional naevi, progress to melanoma. However, they may resemble melanomas and if early detection of thin oral melanomas is to be achieved, all pigmented oral cavity lesions should be excised for histology. Malignant neoplasms, drugs, irradiation, infections or disorders of blood, gastrointestinal tract or skin, also produce mouth ulcers (see list above under Blisters and Table 142. White patches White patches can be caused by debris, burns, infections (candidiasis, hairy leukoplakia), skin diseases (lichen planus mainly), carcinoma, drugs, friction or smoking, but many cases are idiopathic (Table 142. Those affected have discrete, brown to bluish black macules mainly around the mouth, nose and eyes. There is a slightly increased risk of gastrointestinal carcinoma and carcinomas of the pancreas, breast and reproductive organs. Dental hypoplasia and other defects and delayed tooth eruption may also be a feature. Haemangiomas are usually deep red or blue-purple, blanch on pressure and are fluctuant to palpation. Oral haemangiomas are left alone unless causing symptoms when, if small, they are best treated with cryosurgery or laser, or if large by ligation or embolization of feeding vessels. Fordyce spots are totally benign, although the occasional patient or physician becomes concerned about them or misdiagnoses them as thrush or lichen planus. Obstruction of the airway is a constant threat with a mortality as high as 30 percent in some families. In most cases the plasma C1 esterase levels are reduced, the plasma C4 level falls but the C3 levels are normal. Painless, shaggy or folded white lesions typically affect the buccal mucosa bilaterally but may also involve other areas, the upper respiratory tract, genitalia and anus. Family history and clinical examination are usually adequate to differentiate this from other more common causes of white lesions. Oral papillomas, dental anomalies (hypodontia, enamel defects and taurodontism) and occasional cleft lip and palate are the main oral features. Although approximately 10 percent of cadaver tongues contain thyroid tissue, clinical presentation is much less common. Typically, there is an asymptomatic smoothsurfaced lump in the midline of the base of tongue, between the sulcus terminalis and epiglottis. Occasionally, a lingual thyroid may produce dysphagia, cough, pain or rarely airways obstruction. Not all lingual thyroid tissue is functional, and function tends to decline with age. Where thyroid-stimulating hormone levels are high, thyroid hormone supplements are indicated. Malignant change is rare in lingual thyroids though follicular carcinomas have been recorded. White or yellow lesions There are a number of genetically determined white lesions but most are rare. Superficial extravasation mucocoeles of the minor salivary glands in the palate, buccal mucosa or labial mucosa are not uncommon, especially associated with oral lichen planus. Blisters may result from burns or vesiculobullous disorders such as pemphigoid and pemphigus or angina bullosa haemorrhagica (see list above under Blisters and Table 142. Recurrent herpes labialis is the most common cause of lip blisters: acyclovir has been the standard treatment used as a 5 percent cream, but pencyclovir 1 percent cream is reportedly more effective. The tongue is often discoloured due to superficial staining from foods, drinks or habits such as tobacco or betel use (the teeth are also usually discoloured). Various medicaments such as chlorhexidine or iron can also cause a black or brown superficial staining of the tongue (and teeth). The condition typically improves if patients avoid habits or drugs that stain the tongue, increase their oral hygiene, brush the tongue with a toothbrush, use sodium bicarbonate mouthwashes, chew gum or suck a peach stone. Drugs which cause intrinsic staining include antimalarials, minocycline, busulphan and gold. Biopsy may be indicated to exclude a melanoma but otherwise these innocuous lesions can be left alone. Dentures worn throughout the night, or with a dry mouth, favour development of this infection with Candida and bacterial species. There is an accumulation of microbial plaque on and in the fitting surface of the denture and the underlying mucosa. Denture-related stomatitis is not exclusively associated with candida however and, occasionally, other factors such as bacterial infection, or mechanical irritation may be at play. Complications are uncommon, but include: angular stomatitis; papillary hyperplasia in the vault of the palate. Since the denture fitting surface is infested, usually with Candida albicans, this must be disinfected and plaque must be removed regularly. Dentures should be left out of the mouth at night and stored in an antiseptic such as chlorhexidine or hypochlorite. The mucosal infection is eradicated by brushing the palate and using antifungals (usually topically) for four weeks. Acute candidiasis Acute oral candidiasis may complicate long-term corticosteroid or antibiotic therapy, producing widespread erythema and soreness, sometimes with thrush. There can be an associated angular stomatitis which is a well-recognized feature of T-cell immunodeficiencies. Some patients have atopic allergies such as hayfever and a few relate the oral lesions to a particular food, for example cheese, or to stress. Clinical examination usually suffices to differentiate the condition from lichen planus, candidiasis or deficiency glossitis. Blood and urine examination may occasionally be necessary to exclude anaemia and diabetes. In those with no systemic disorder, no effective treatment is available except reassurance. It occurs only beneath a denture or other this is an uncommon red, depapillated, rhomboidal area in the centre line of the dorsum of tongue, anterior to the sulcus terminalis, thought to be associated with candidiasis. Median rhomboid glossitis is usually diagnosed on clinical grounds, although biopsy may be indicated since some lesions are nodular and may simulate a neoplasm both clinically and histopathologically. Miconazole may be a preferable treatment for candidiasis (cream applied locally, together with the oral gel) as it has some Gram-positive bacteriostatic action. Any staphylococcal infection should be treated with fusidic acid ointment or cream. Most cases are in adults and due to mechanical and/or infective causes but, in children, nutritional or immune defects are more prominent causes. Mechanical factors may contribute in edentulous patients who do not wear a denture or who have inadequate dentures and, also as a normal consequence of the ageing process, produce an oblique curved fold and keep the small area of skin constantly macerated. Nutritional deficiencies, in particular deficiencies of riboflavin, folate, iron and general protein malnutrition, may produce smooth, shiny, red lips associated with angular stomatitis, a combination called cheilosis. Linear furrows or fissures radiating from the angle of the mouth (rhagades) are seen in the more severe forms, especially in denture wearers. Dentures should be kept out of the mouth at night and stored in a candidacidal solution such as hypochlorite. Most intraoral abscesses are odontogenic in origin and discharge in the mouth but they can cause diagnostic Table 142. In primary amyloidosis, the tongue is enlarged and firm with yellowish submucosal nodules, lumps or petechiae. Secondary amyloidoses rarely involves the mouth, except in the case of multiple myeloma or haemodialysis-associated amyloid, which may occasionally produce oral nodules. Ulcers classically involve the buccal sulcus where they appear as linear ulcers, often with granulomatous masses flanking them. The lips or face may swell and there may be splitting of the lips and angular stomatitis. Some patients develop similar oral lesions because of an adverse reaction to food additives such as cinnamaldehyde or benzoates, butylated hydroxyinosole or dodecyl gallate (in margarine), menthol (in peppermint oil) or to cobalt. Topical or intralesional corticosteroids may effectively control the oral lesions. Oral allergy syndrome is the combination of oral pruritus, irritation and swelling of the lips, tongue, palate and throat, sometimes associated with other allergic features such as rhinoconjunctivitis, asthma, urticaria-angiooedema and anaphylactic shock, precipitated mainly by fresh foods such as fruits and vegetables, sometimes by pollens because of cross-reacting allergens. Chronic oral soreness may be particularly caused by ulceration, or by atrophy, geographical tongue (see above under Benign migratory glossitis), lichen planus (see below under Lichen planus), or deficiency states. Deficiency glossitis Glossitis may be related to deficiency of iron, folate or vitamin B12, and is associated with angular stomatitis and/or ulcers. A full blood picture and assays of iron, Chapter 142 Benign oral and dental disease] 1829 folate and vitamin B12 are indicated. The cause of any deficiency should be sought before replacement treatment is given. Patients are often middle-aged or older and more than 70 percent of patients are women. The four main groups of patient appearing to suffer from this type of psychogenic pain are those who have: 1. Clinical features include a constant chronic discomfort or pain, often of a deep, dull boring or burning type and mainly in the upper jaw. The location of pain is unrelated to anatomical distribution of trigeminal nerve innervation, the pain is poorly localized, and sometimes crosses the midline to involve the other side or moves to another site. Pain persists for most or all of the day but does not waken the patient from sleep. There is no tenderness or swelling in the area, nor any obvious odontogenic or other local cause for the pain. There is a total lack of objective physical (including neurological) signs and all blood investigations and radiographic studies are negative. There are often multiple oral and/or other psychogenic-related complaints and a high level of utilization of health care services. The pain reduction achieved with antidepressants exceeds that produced by placebos. A monosymptomatic hypochondriasis, or an underlying anxiety about cancer or other disease with perhaps excessive tongue activity, appear to be the basis for the complaint in many patients (Table 142. Although the tongue is most frequently involved, the patient may also occasionally complain of burning lips, gums or palate. Once organic disease has been excluded, reassurance and, occasionally, psychological treatment, antidepressants or psychiatric care, are indicated.

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