Zocor
Dirk B. Robertson MD
- Professor of Clinical Dermatology, Department of Dermatology
- Emory University School of Medicine, Atlanta
https://atlantaskinsurgery.com/physicians/dr-robertson
Larger tumors cholesterol hdl ratio mmol l buy zocor mastercard, de-differentiated tumors ideal cholesterol ratio for an individual buy on line zocor, and recurrences predict a worse outcome high cholesterol foods beer purchase discount zocor on-line, with a 5-year control rate of cholesterol ratio readings uk buy zocor on line amex,35% cholesterol medication pravastatin generic zocor 10mg with amex. Recurrences may occur at the original tumor site or along routes of surgical access of the initial resection cholesterol rich foods purchase 40mg zocor otc, and there is a low rate of metastases to neck nodes and the lungs. Chordoma As chordomas arise from remnant (or ectopic) notochord tissue, the embryologic origin of the vertebral column, it is not surprising that chordomas can develop anywhere from the sella turcica superiorly, to the sacrococcygeal area inferiorly. About one-third of all of these rare (1:1,000,000) lesions occur near the spheno-occipital synchondrosis of the clivus, usually in patients between the ages of 50 to 70 years. Three histologic patterns of chordoma can be seen: classic, chondroid, and dedifferentiated. It may be difficult to distinguish the classic variant from the chondroid variant (with foci of cartilaginous matrix). The de-differentiated form is exceedingly rare in the skull base, exhibits more cytologic atypia and mitotic activity, and behaves as a high-grade sarcoma, with commensurate prognosis. These cells range from small, uniform oval cells with scant eosinophilic cytoplasm to cells with abundant glycogenrich vacuolated cytoplasm (so-called physaliphorous cells) with dense chromatin. Mucoid microcysts and fibrovascular strands and cords of eosinophilic syncytial cells are commonly seen. Like chondrosarcomas, chordoma shows immunoreactivity with Sarcomas Chondrosarcoma Chondrosarcomas of the skull base are cartilaginous malignancies that represent,5 to 15% of all skull base tumors. Radiographically and morphologically, they may be difficult to distinguish from chordomas. Unlike chordomas that typically arise in the clival midline, chondrosarcomas characteristically originate from the paramedian petroclival synchondrosis and often involve the petrous apex. Almost all skull base chondrosarcomas are well differentiated and not high-grade or dedifferentiated types. Cytokeratins and epithelial membrane antigen staining are not seen in chondrosarcomas but are present in chordomas. Podoplanin, on the other hand, may serve as a marker of chondrosarcoma; it was present in,80% of chondrosarcomas, but only 5% of conventional chordomas, and 21% of chondroid chordomas. Postoperative stereotactic radiosurgery or proton beam irradiation is usually recommended, similar to that in chordomas (see previous text), especially for incomplete resections as is common. Long-term survival is the norm, albeit with complications associated with surgery in difficult areas, especially in recurrent cases. Although far more common in metaphyses of long bones, in the head and neck region, the mandible, maxilla, and occasionally the bones of the ethmoid or sphenoid sinuses are sites of origin. The most common type of osteosarcoma is a central osteosarcoma, a high grade malignancy with frequent lung metastases. The primary osteosarcomas of the mandible and paranasal sinuses, in older adults or in children,67 which are not associated with prior irradiation or retinoblastoma, behave as low- or intermediate-grade malignancies and are treated by primary surgical resection. This group may not benefit from irradiation or chemotherapy, and hence may warrant a careful review of histologic grade and margin status. Other retrospective reports, however, suggest a poor prognosis, warranting consideration of irradiation and chemotherapy. It is far from clear that the treatment of osteosarcomas of the mandible, maxilla, or sphenoethmoid area in adults should be the same as for children. Treatment in children for osteosarcomas of long bones is focused on neoadjuvant chemotherapy followed by resection of the primary and metastases (lung metastases are the most common; 10 to 15% of patients have lung metastases at the time of primary evaluation), and then additional chemotherapy based on evaluation of initial response. The 5-year control rate of 70% for nonmetastatic disease has not improved in the past two decades. Patients with metastases or recurrent disease have less than a 20% 5-year control rate. The most common type of osteosarcoma is a conventional osteosarcoma, a high-grade malignancy with frequent metastases, especially to the lung. Irregularly distributed pale osteoid "tumor bone" is intermingled with malignant cells 560 Rhinology with hyperchromatic, large nuclei. Rare juxtacortical osteosarcomas include intermediate-grade periosteal and low-grade parosteal variants. Recognizing these rare variants is important as the prognosis is far better and surgery alone may suffice. Low-grade osteosarcomas, including parosteal and periosteal osteosarcoma,75 of the paranasal sinuses are exceedingly rare. Some of the factors that correlate with a poorer prognosis include positive surgical margins, size (. The 5- and 15-year control rates for the entire group of soft tissue sarcomas in adults is good, ranging from 70 to 90% for those with good prognostic parameters to ,50% for those, such as in the head and neck, with poor prognostic parameters. Limited lung metastases are best removed via videoassisted thoracoscopic resection. Local recurrences may be re-resected endoscopically, sometimes with supplemental irradiation such as stereotactic radiosurgery. There are fair 5-year survival rates even after the development of distant metastasis or local recurrence, reported to be,20% and 60%, respectively,98 although the development of bone metastasis is associated with a shorter median survival than that which follows lung metastases (21 versus 54 months). The maxillary sinus and nasal cavity are the most common sites, but perineural extension along V2 to the foramen rotundum and extension toward or through the foramen ovale is not uncommon. The spaces in the cribriform and tubular patterns contain pale basophilic or bright eosinophilic mucopolysaccharide-rich material. Varying proportions of the three patterns can be found in the same tumor, and the classification is based on the predominant pattern. In addition to histologic subtype, other factors such as anatomic site, margin status, clinical extent, and the presence of metastases affect prognosis significantly. However, 30 to 40% develop distant metastases Adenocarcinoma Nasoethmoid adenocarcinomas are seen less frequently in the United States than in Europe, where instead of accounting for 10% of sinonasal malignancies, they represent 25 to 75%. Moderately and poorly differentiated papillary types resemble colonic adenocarcinoma of similar grade and display increased cellular pleomorphism and mitotic activity. The low grade variant has an excellent prognosis and is treated by surgical resection. Five-year disease-specific survival around 85 to 90% are reported, with,95% for selected tumors, such as those amenable to endoscopic resection. Neuroectodermal Tumors Tumors that exhibit neuroectodermal differentiation occur commonly in the sinonasal region, and can be confusing to an otorhinolaryngologist and pathologist alike. Many sinonasal tumors appear on light microscopy as small round blue-cell tumors that are largely undifferentiated. The differential diagnosis includes not only the broad group of neuroectodermal tumors and malignant melanoma, but also some carcinomas, sarcomas, lymphomas, and plasmacytoma. They arise in the nose and ethmoid sinuses, and frequently invade the orbit and skull base. Multimodality therapy is generally applied with functionally noncompromising surgery to the extent feasible; there is currently no consensus on specific irradiation fractionation or chemotherapy protocols. It is seen almost exclusively in the superior nasal cavity medial to the middle turbinate along the cribriform plate. There are reports of olfactory neuroblastoma occurring outside the superior third of the nasal septum, but without full availability of pathologic review, these represent another type of neuroectodermal tumor. On light microscopy, the cells of olfactory neuroblastomas form well demarcated nests or sheets, with high nuclear cytoplasmic ratios, small round nuclei with punctate chromatin, and small or absent nucleoli. Immunohistochemical reactivity with the neural marker synaptophysin is common; staining with neuronspecific enolase and chromogranin is more variable. S100 protein staining of the sustentacular cells at the periphery of cellular nests is characteristic, rather than diffuse S100 staining of malignant melanoma. Histologically, one sees intermediate-to-large (although occasionally smaller) polygonal undifferentiated cells with large ovoid nuclei and prominent nucleoli, numerous and often aberrant mitotic figures, and vascular invasion. As noted previously, the diffuse strong S100p reactivity of malignant melanoma differs from the S100 reactivity of sustentacular cells in the periphery of olfactory neuroblastoma. Clinically, sinonasal melanoma is associated with a poor prognosis, with most single institution retrospective series. An endoscopically harvested pericranial flap is a recently described alternative repair. Chemotherapy is reserved for advanced tumors (involvement of brain or orbit), for local recurrences after re-resection if feasible, or when the histopathologic diagnosis is not definitive. Although metastases are uncommon at presentation,10 to 15% will develop cervical nodal metastases. A neck dissection and irradiation would thus be indicated as they provide excellent tumor control. Distant metastases do occur rarely, and can be seen as late as a decade following the initial intervention. Local recurrences can be along dura and are amenable to stereotactic radiosurgery. Sinonasal Melanoma Sinonasal melanomas represent,1% of all melanomas, and are more commonly seen in the anterior nasal cavity and maxillary sinus than in the sphenoethmoid area. Re-resection is warranted if it can be achieved with limited morbidity, as this may help to maintain a patent nasal airway, reduce epistaxis, and lengthen, sometimes significantly, quality survival. In most cases, local recurrence precedes the development of subsequent nodal and distant metastases. This fact, plus the lack of highly effective systemic therapy, may diminish the zeal with which systemic tumor surveillance is pursued. It is likely that the sinonasal biopsy will be the first, and at times, only manifestation of the disease. Hence, long-term follow-up, both at the primary site and systemically, is important. About 80% occur in the upper aerodigestive tract, with the majority in the sinonasal area. Delineation from immunoblastic lymphoma or other plasmacytoid lymphomas requires careful histopathologic and immunohistochemical delineation. Malignant lymphoma represents,10% of nonepithelial malignancies of the paranasal sinuses. Diffuse large cell B cell lymphoma is most common,130 and usually presents as stage 1E. These have been previously classified as polymorphic or malignant midline reticulosis or lethal midline granuloma. The histopathologic features include a polymorphous population of atypical small and large lymphocytes, tumor cell necrosis, and numerous apoptotic bodies. Infiltration and destruction of blood vessels by lymphoid cells is observed (angiocentric/. Immunohistochemical staining for kappa or lambda light chain, not shown, showsamonoclonalproliferation,furtherassistingindiagnosis. Although some studies from Asia suggest a poorer prognosis, most patients survive. Familiarity with the pitfalls, nuances, areas of controversy, and clinical correlations of difficult dilemmas should improve accurate patient care. Growth factors and receptors in juvenile nasopharyngeal angiofibroma and nasal polyps: an immunohistochemical study. Drug insight: Cabergoline and bromocriptine in the treatment of hyperprolactinemia in men and women. Ultrastructure of fibrous dysplasia of bone: a study of its fibrous, osseous, and cartilaginous components. Juvenile aggressive psammomatoid ossifying fibroma: an interesting, challenging, and unusual case report and review of the literature. Aggressive psammomatoid ossifying fibromas of the sinonasal region: a clinicopathologic study of a distinct group of fibro-osseous lesions. Extracranial sinonasal tract meningiomas: a clinicopathologic study of 30 cases with a review of the literature. Olfactory groove meningiomas from neurosurgical and ear, nose, and throat perspectives: approaches, techniques, and outcomes. Low complication rates of cranial and craniofacial approaches to midline anterior skull base lesions. High efficacy of fractionated stereotactic radiotherapy of large base-of-skull meningiomas: long-term results. Sinonasal haemangiopericytoma-like tumour: a sinonasal glomus tumour or a haemangiopericytoma Is prophylactic neck irradiation indicated in patients with squamous cell carcinoma of the maxillary sinus Carcinomas of the paranasal sinuses and nasal cavity treated with radiotherapy at a single institution over five decades: are we making improvement Intensity-modulated radiation therapy for malignancies of the nasal cavity and paranasal sinuses. Brachyury, a crucial regulator of notochordal development, is a novel biomarker for chordomas. Emerging role of proton beam radiation therapy for chordoma and chondrosarcoma of the skull base. Treatment of chordomas with CyberKnife: Georgetown University experience and treatment recommendations. Chordomas and chondrosarcomas of the skull base: results and complications of surgical management. Patient outcome at long-term follow-up after aggressive microsurgical resection of cranial base chondrosarcomas. Primary osteosarcoma of the head and neck in pediatric patients: a clinicopathologic study of 22 cases with a review of the literature. Head and neck osteosarcoma in adults: the province of Alberta experience over 26 years. Sarcomas of nasal cavity and paranasal sinuses: chondrosarcoma, osteosarcoma and fibrosarcoma. Presentation, prognostic factors and patterns of failure in adult rhabdomyosarcoma.
The sensitivity and specificity of high-resolution imaging in evaluating perineural spread of adenoid cystic carcinoma to the skull base cholesterol screening ratio buy zocor with mastercard. The role of skull base surgery for the treatment of adenoid cystic carcinoma of the sinonasal tract cholesterol levels 40 year old male buy cheap zocor 40mg on line. Clinicopathologic predictors and impact of distant metastasis from adenoid cystic carcinoma of the head and neck cholesterol test time frame order zocor discount. Salivary gland adenoid cystic carcinoma: a review of chemotherapy and molecular therapies cholesterol levels in salmon order 10mg zocor with amex. Adenocarcinoma of the ethmoidal sinus complex: surgical debulking and topical fluorouracil may be the optimal treatment cholesterol medication in homeopathy order zocor 20mg. Molecular and phenotypic analysis of poorly differentiated sinonasal neoplasms: an integrated approach for early diagnosis and classification q test cholesterol discount 20 mg zocor with visa. Neuroectodermal neoplasms of the head and neck with emphasis on neuroendocrine carcinomas. The cytologic features of sinonasal undifferentiated carcinoma and olfactory neuroblastoma. Combined proton radiotherapy with chemotherapy for advanced sinonasal neuroendocrine carcinoma [abstract]. Solitary extramedullary plasmacytoma of the head and neck-long-term outcome analysis of 68 cases. Primary extramedullary plasmacytoma: similarities with and differences from multiple myeloma revealed by interphase cytogenetics. Sethi and Hin Ngan Tay Located posterior to the nasal cavity, the nasopharynx is a unique structure involved both in deglutition and respiration. It connects with the nasal cavity anteriorly and with the oropharyngeal cavity inferiorly. Its inner surface is lined by various types of epithelium: keratinized and nonkeratinized squamous, pseudostratified, ciliated, and columnar. Diverse benign tumors arising from the epithelia, lymphoid, glandular, and connective tissue are occasionally encountered. Pharyngeal endoderm is closely associated with the notochord as it develops up to the fifth week. In later stages, connective tissue interposes between them except at an area caudal to the future position of the adenoids. This area of close contact or persistent attachment becomes the pharyngeal bursa as the notochord becomes incorporated into the skull base. The anterior boundary is a fixed air boundary, whereas the inferior boundary is variable, depending on the position of the soft palate, which lies lower at rest than on swallowing. The roof and posterior wall is a slope defined by the floor of the sphenoid sinus continuing onto the clivus and the craniocervical junction. The lateral wall is divided into two parts: the anterior part is limited by the medial pterygoid plate, whereas the posterior part is a soft tissue interface where the pharyngobasilar fascia separates the nasopharynx from the paranasopharynx. Anatomy of the Nasopharynx Embryology the nasopharynx is a derivative of the foregut. The cephalic part ends blindly at the buccopharyngeal membrane, which separates it from the ectodermally lined stomatodeum. Development of the pharyngeal arches and pouches has been extensively described and will not be fully elaborated here. Nasopharyngeal structures are largely derived from the first pharyngeal arch and pouch, with the eustachian tubes being the most recognizable feature. The eustachian tube is formed by the invagination of the first pharyngeal pouch laterally, which forms the middle ear cavity, terminating at the tympanic membrane by constituting its innermost layer. From the nasal cavity to the nasopharynx and the oropharynx, there is a gradual transition from Schneiderian membrane derived mucosa to the transitional zone and then endodermally derived squamous mucosa. The characteristic sagittal folds start appearing by the Bony Relations the nasopharynx is related to the sphenoid bone, the occipital bone, the ethmoid bone, and the palatine bones. In the midline, the body of the sphenoid and the clivus form the sloping roof and posterior wall, separating the nasopharynx from the sphenoid sinus and the posterior cranial fossa. The middle clivus is formed by the rostral part of the basiocciput and the lower clivus by the caudal part of the basiocciput. Located in the midline at the junction of the middle and lower clivus 1 cm above the foramen magnum is a small bony elevation termed the pharyngeal tubercle, which serves as the site of attachment of the pharyngeal raphe of the superior pharyngeal constrictor muscle. The bones of the nasopharynx above the pharyngeal tubercle are covered by mucosa, minimal submucosal tissue, and periosteum. The nasopharynx is bordered above by the posterior part of the sphenoid (Ss) and upper to middle clivus (c) and posteriorly by the lower clivus, atlas (a), and axis (A). The medulla (m) faces the lower clivus, the foramen magnum, and upper part of the dens (d). The nasopharynx is bounded above by the sphenoid sinus and laterally by the eustachian tube and is separated from the oropharynx by the soft palate. Laterally, the infratemporal fossa located below the greater wing of the sphenoid bone. The medial pterygoid and lateral pterygoid muscles occupy the infratemporal fossa. On the left side, the medial and lateral pterygoids have been removed to expose the internal maxillary artery and the mandibular nerve (V1) as it exits from the foramen ovale. Also seen are the internal carotid artery, the tensor veli palatini, levator veli palatini, and the muscles of the eustachian tube. Laterally, the medial pterygoid plates form the lateral boundaries of the nasopharynx. Attached to the posterior margins of the medial pterygoid plates is the thick dense pharyngobasilar fascia. The bony orifice of the posterior choana is formed by the vomer, the perpendicular plate of the ethmoid, and the palatine bone. The numerous bony foramina located within and near the nasopharynx are important routes of extension or invasion of both benign and malignant lesions. Anteriorly, the sphenopalatine foramen transmits the sphenopalatine artery and is commonly the site of origin of juvenile nasopharyngeal angiofibromas, which often expand the foramen and extend into the pterygopalatine fossa laterally. Thus, the nasopharyngeal roof extends down to the middle clivus in the midline, but is confined to the upper clivus by the longus capitis muscle on either side. The configuration of the nasopharynx is determined by the very tough pharyngobasilar fascia, which attaches to the base of the skull from the posterior margin of the medial pterygoid plate to the petrous part of the temporal bone immediately in front of the carotid foramina. The fascia forms an entirely closed and very resistant fibrotic chamber, which is perforated only by the passage of the eustachian tube. Eustachian Tube System and Soft Palate the eustachian tube is a prominent anatomic feature on the lateral nasopharyngeal wall. It connects the nasopharynx to the middle ear, is 3 to 4 cm long, and opens into the lateral wall of the nasopharynx immediately behind the medial pterygoid plate by an inverted J-shaped protuberance called the torus tubarius. Associated with this mucosa is a variable amount of lymphoid tissue, known as the nasopharyngeal tonsils or adenoids. The nasopharynx can be thought of as a fibromuscular sling suspended from the basisphenoid. The inner longitudinal layer consists of the salpingopharyngeus, palatopharyngeus, and stylopharyngeus. The tensor and levator veli palatini, which are muscles of the soft palate, also contribute to this layer at their superior ends. The outer circular layer at the level of the nasopharynx is formed by the superior constrictor, with the superior aspect of the middle constrictor overlapping it inferiorly. The median raphe of the superior constrictor is attached to the pharyngeal tubercle superiorly. Lateral to the pharyngeal tubercle on each side, the longus capitis muscle is attached to the middle and the lower clivus. The anterior surface of this muscle, which is convex forward on each side of the midline, also furnishes attachment to the pharyngobasilar fascia and the prevertebral fascia on the middle clivus. The border between the roof and posterior wall of the nasopharynx is sited at the. The torus tubarius is formed by the medial end of the cartilaginous tube elevating the overlying mucosa. The medial or posterior limb of the cartilage is longer than the lateral or anterior limb. The eustachian tube is bounded anteriorly and laterally by the tensor veli palatini and posteriorly and inferiorly by the levator veli palatini. The levator veli palatini originates from the quadrate area of the petrous bone and partly from the short limb of the cartilaginous eustachian tube and runs almost parallel to it. Along with the cartilaginous portion of the eustachian tube, the levator veli palatini passes directly to the soft palate through the sinus of Morgagni. Isotonic contraction of this muscle elevates the soft palate and expands the tubal orifice as it splays open the medial and lateral limbs. The tensor veli palatini originates from the scaphoid fossa of the sphenoid bone anterolateral to the levator veli palatini muscle. The tensor veli palatini muscle reaches the palate indirectly by hooking around the hamulus of the medial pterygoid and inserts into the median raphe. It opens the tube by traction on the lateral tubal membrane and the lateral limb of the cartilage. The recess is bounded anteriorly by the levator veli palatini, posteriorly by the longus capitis muscle, and its roof is attached to the thick connective tissue covering the foramen lacerum above. The posterolateral depth of the recess is separated from the cervical internal carotid artery by only a layer of fibroconnective tissue. The motor supply is derived from the nucleus ambiguous, by way of the pharyngeal branch of the vagus nerve, which supplies all pharyngeal muscles except the stylopharyngeus, which is the only muscle controlled by the glossopharyngeal nerve. Sensory innervation is supplied by the glossopharyngeal nerve, with the exception of a small patch behind the eustachian tube, which is supplied by the pharyngeal branch of V2. The cell bodies of these afferent fibers are located in their respective ganglia, with central connections to the nucleus of the tractus solitarius and the spinal tract of V. The parasympathetic secretomotor supply arise from the superior salivary nucleus, whose fibers travel from the brainstem via the nervus intermedius, through the geniculate ganglion, proceeding anteriorly in the greater superficial petrosal nerve, and reaching the pterygopalatine ganglion via the nerve of the pterygoid canal. Sympathetic fibers, as in the rest of the body, travel together with the blood vessels. The preganglionic cell bodies arise from the lateral column of T1 through T3, traveling up the sympathetic trunk to synapse in the superior cervical ganglion. Histology the epithelium of the nasopharynx is mainly pseudostratified ciliated columnar type near the choanae and adjacent part of the roof of the nasopharynx, becoming stratified squamous in the lower and posterior regions. Almost 60% of the nasopharynx is lined by stratified squamous epithelium derived from endoderm. Areas of transitional epithelium are encountered in the junctional zone of the roof and lateral walls. The transitional zone between the nasopharynx and oropharynx is lined by stratified columnar epithelium, which changes to the nonkeratinizing stratified squamous epithelium of the oropharynx. Typical of respiratory mucosa, mucus production is by goblet cells, although there are seromucinous glands in the submucosa. Deep to the mucosa lies the lamina propria, which is frequently infiltrated by lymphoid tissue, which, in the child, forms a midline aggregation posteriorly of varying size, termed the adenoid (nasopharyngeal tonsil). These lymphoid aggregates, although found mainly in the lamina propria, may extend into the submucosa if hypertrophic. Branches are given off to supply the pharyngeal wall as it ascends, with a palatine branch passing over the superior edge of the superior constrictor, which supplies the soft palate and mucosa. The ascending palatine branch of the facial artery and the greater palatine and pterygoid branches of the internal maxillary artery also contribute. The sphenopalatine artery and its posterior septal branch contribute to the blood supply of the roof and choanal aspects of the nasopharynx. Venous drainage of the nasopharynx consists of two layers of venous plexuses, namely the submucous layer and the external pharyngeal plexus. These plexuses are continuous from the nasopharynx inferiorly into the oropharynx. The pharyngeal plexus of the nasopharynx drains laterally into the pterygoid plexus and downward into the internal jugular vein. Imaging Radiologic Anatomy Conventional radiographs yield limited information about the nasopharynx. These modalities are complementary and are often used together to demonstrate the full disease extent. A discrepancy of more than 5 mm between sides should prompt suspicion of a lesion. The cartilaginous end of the eustachian tube is usually of similar or lower signal intensity than surrounding muscle. Tubular tonsillar tissue present in this area may give a fairly intense signal depending on the amount of lymphoid tissue present and the effects of volume averaging. The signal of lymphoid tissue is always more intense than that of muscle because it is normally located submucosally and it never obliterates the deeper tissue planes of the nasopharynx. The medial and the lateral pterygoid muscles fill the bulk of the infratemporal fossa.
A modified radical neck dissection is recommended for resectable nodal recurrences cholesterol comparison chart order zocor 40mg free shipping. Local recurrences amenable to endoscopic skull base resection with intraoperative navigation (or an open approach cholesterol range chart pdf buy generic zocor 40mg on-line, depending on surgeon 557 cholesterol and crp test purchase cheap zocor on-line. Resection may be selectively indicated for re-recurrences following reirradiation as well cholesterol levels daily buy discount zocor 40 mg online, despite greater risk of wound healing problems cholesterol test tips generic zocor 10mg with visa. The tumor may be quite large at presentation and may abut or encase the cavernous segment of the internal carotid artery cholesterol binding drug definition cheap zocor, or abut the basilar artery. Although imaging is sufficiently characteristic that a presumptive diagnosis can be suspected, a confirmatory intraoperative biopsy is obtained early in a planned endoscopic resection. Treatment is as complete a resection as possible by an appropriate approach, usually transsphenoidal (endoscopic54,55 or sublabial56), or transoral or subfrontal (depending on extent) with intraoperative navigation, followed by high-dose irradiation. Surgery and postoperative charged particle irradiation57 to 65 to 70 Gy is associated with 5-year control rates of,75% in previously untreated tumors smaller than 75 cm3, depending in part on the extent of resection. Local control after intensity-modulated radiotherapy for headand-neck rhabdomyosarcoma. Pathologic aspects and proposal for a new classification-an Intergroup Rhabdomyosarcoma Study. Updates on cytogenetics and molecular genetics of bone and soft tissue tumors: Ewing sarcoma and peripheral primitive neuroectodermal tumors. Prognostic factors for patients with localized soft-tissue sarcoma treated with conservation surgery and radiation therapy: an analysis of 1225 patients. From Radiologic Boundaries of the Nasopharynx As a prelude to understanding the radiologic anatomy of the nasopharynx, it is important to identify its radiologic boundaries. A line connecting the posterior wall of the maxillary sinus bilaterally is taken as a landmark for the posterior choana, which forms the anterior boundary of the nasopharynx. The retropharyngeal and prevertebral spaces lie anterior to the arch of the atlas and the body of the axis. The inverted J configuration of the torus tubarius results in the fossa appearing posterior (on axial images) and superior (on coronal images) to the eustachian tube orifice. A line from the medial pterygoid plate (m) to the internal carotid artery (c) defines the lateral limits of the nasopharynx. The infratemporal fossa is lateral to a line drawn from the lateral pterygoid plate (1) to the styloid process (s). Note the tissue interface between the mucosa and the underlying longus capitis (L) muscle situated immediately deep to the mucosa of the posterior nasopharyngeal wall. The white asterisk indicates the eustachian tube orifice on the lateral wall of the nasopharynx. Lymphoid tissue (L) enhances well demonstrating the "crypt enhancement pattern" and shows good demarcation from the prevertebral muscles (M). The asterisk indicates the lateral pharyngeal recess which shows good symmetry bilaterally. Together with the internal jugular vein and the vagus nerve, it lies within the carotid sheath, which forms the posterolateral compartment of the nasopharynx. The cortical margins of the clivus and the basisphenoid show no signals; however, the fatty marrow within gives a characteristic high signal. Epithelial Nasopharyngeal Carcinoma Pathology of the Nasopharynx Pathology in the nasopharynx may arise from any of its constituents, including the epithelium, soft tissue, neural, vascular, etc. It has a distinctive geographic distribution, clustering in the south of China and southeast Asia, with increased incidence also 576 Rhinology Table 43. The highest rates are found in Hong Kong, followed by Singapore and Chinese-Americans. It is the fifth and seventh most common cancer in males and females, respectively. The peak incidence is between 40 and 60 years with a two to three times male predilection. An association with preserved foods like salted fish, particularly when exposure is very early in life. This accounts for the late stage of the disease at initial diagnosis in most cases. Nodal metastasis shows an orderly inferior spread, and the affected nodes are larger in the upper neck. Because this muscle is responsible for opening the eustachian tube orifice during swallowing, dysfunction leads to disequilibrium in the air pressure within the middle ear and the nasopharynx. Unilateral or bilateral nasal obstruction may result from a large nasopharyngeal tumor obstructing the nasal airway. Diplopia due to sixth cranial nerve palsy may be the presenting symptom in some patients. With locally advanced tumors, 43 the Nasopharynx other problems may arise due to invasion of surrounding structures, such as cranial nerve palsies, facial pain due to trigeminal nerve involvement, and headaches due to meningeal involvement. Examination of the nasopharynx with flexible or rigid endoscopes often reveals the diagnosis. Rarely, the disease may be a submucosal lesion, and the overlying mucosa may appear normal. Any mucosal irregularity in this situation is treated with deep suspicion, and a biopsy of the region performed. The lateral pharyngeal recess on the right is effaced by a large tumor extending laterally to the parapharyngeal space and posteriorly to the prevertebral muscles (m) and around the occipital condyle (oc). Tan Tiong Yong, Chief of Radiology, Changi General Hospital, Singapore; F, courtesy of Dr. Posteriorly, the tumor may extend along the foramen rotundum and the vidian canal, laterally into the infratemporal fossa, and superiorly to the inferior orbital fissure, superior orbital fissure, and the orbital apex. From the superior orbital fissure, tumor spread may continue posteriorly into the cavernous sinus. Posterolateral spread into the retrostyloid compartment may result in the infiltration of the carotid space. Destruction of the vertebral bodies and involvement of the spinal canal is occasionally observed in late cases. Superior Spread Skull base erosion may be detected in up to one-third of patients. Tumor may also infiltrate the mandibular nerve, gasserian ganglion, trigeminal nerve, and pons. The most common site of metastasis is bone (20%), followed by lung (13%) and liver (9%). Histologically, nonkeratinizing tumors comprise solid sheets, irregular islands, dyscohesive sheets, and trabeculae of carcinoma intermingled with lymphocytes and plasma cells. In the undifferentiated subtype, syncytial-appearing large cells with indistinct borders and vesicular nuclei may be crowded with overlapping. In the differentiated subtype, there is cellular stratification and pavementing, often with a plexiform growth pattern. An abundance of infiltrating lymphocytes and plasma cells may appear to break up the epithelial component into small clusters, aptly termed in these cases, lymphoepithelial carcinoma. The prognosis for both the differentiated and undifferentiated subtypes is similar. Their prognosis is worse than nonkeratinizing tumors with poorer response to radiation with or without chemotherapy. The acute side effects of radiotherapy include xerostomia, mucositis, and dermatitis. Late effects of irradiation may include endocrine sequelae, radiation caries, and soft tissue fibrosis. The most severe complications of radiation are the neurologic sequelae, including cranial nerve palsies and temporal lobe necrosis. Excellent tumor control with the added advantage of sparing normal tissues like the parotid glands have been consistently reported. They may be classified by their morphologic features and clinical behavior into two main categories: the mucosal surface origin type20 and the salivary gland type. The mean age of patients is 38 years and incidences are higher in females than males. Patients with these tumors are generally older (mean age of 51 years), and incidence is slightly higher in males than in females. Examples include adenoid cystic carcinomas, mucoepidermoid carcinomas, and adenocarcinomas not otherwise classified. The behavior of this tumor entity is unpredictable, which makes an individually tailored therapeutic approach difficult. This patient underwent an endoscopic nasopharyngectomy with adjuvant postoperative radiotherapy. Note the high signal area (asterisk) indicating the fatty component of the lesion. These tumors exhibit aggressive local invasion with perineural and vascular spread distant from the primary tumor. Nasopharyngeal Cysts Nasopharyngeal cysts are an uncommon entity, often encountered as an incidental finding. These cysts may remain asymptomatic or may cause symptoms like nasal obstruction, headaches, postnasal discharge, and eustachian tube dysfunction when the cyst is inflamed. The signal intensity is bright on both T1- and T2-weighted images because of either high protein content of the cyst or a hemorrhage within the cyst. These tumors are believed to arise in the fibrovascular stroma present in the posterolateral wall of the nasal roof where the sphenoidal process of the palatine bone meets the horizontal ala of the vomer and the pterygoid process. Initially, the tumor grows in the submucosa of the nasopharyngeal roof, reaching the septum and posterior aspect of the nasal space, and creating a mass effect that may cause nasal airway obstruction. As the process continues, the anterior face of the sphenoid sinus is eroded and invaded. The tumor may grow forward into the nasal fossa and may expand the posterior end of the middle turbinate, which 582 Rhinology. An endoscopic wide excision (partial nasopharyngectomy) was performed for this patient. Laterally, angiofibroma may extend to the pterygomaxillary fossa and may cause bowing of the posterior wall of the maxillary sinus and distortion and posterior displacement of the pterygoid plates. Eventually, the tumor may involve the infratemporal fossa, orbit, and middle cranial fossa. Patterns of spread to local structures may be widely unpredictable and do not always follow a stepwise progression. Angiography is useful as an adjunct to diagnosis but, more importantly, to decrease tumor vascularity during surgery by embolization. Many surgical approaches have been used, including transpalatal, transzygomatic, transmandibular, transhyoid, and transantral approaches; lateral rhinotomy; midface degloving; and concomitant craniotomy. In the past decade, endoscopic transnasal surgery for confined lesions has generated interest. Whether the approach is open or endoscopic, the complete surgical resection should be attempted. This patient underwent an endoscopic nasopharyngectomy for the removal of the residual angiofibroma. They usually occur in patients between 50 and 60 years of age, and they are more common in men. Treatment of skull base plasmacytomas relies on the radiosensitivity of the tumor. When complete removal is possible, surgical intervention is an excellent treatment option. For patients with a diagnosis of multiple myeloma and skull base plasma cell tumors, chemotherapy for systemic disease takes precedence. In the West, the majority of cases are B cell lymphomas with a median age of 63 years and a male to female ratio of 1. Bone and Cartilage Tumors: Chordoma Chordomas are low grade malignant tumors associated with the primitive notochord. Radiology demonstrates lytic destruction of the clivus and patients may have nonspecific symptoms like a headache and nasal obstruction and, with involvement, cranial nerve palsies. Treatment is with resection where possible and radiation for residual or unresectable disease. Neuroectodermal Tumors: Paraganglioma Paragangliomas include schwannomas, neurofibromas, and glomus tumors. Paragangliomas more commonly involve the structures within the carotid sheath and may extend to the nasopharynx. Although benign, paragangliomas may cause significant local morbidity due to mass effect and erosion. Patients may present with cranial nerve palsies due to skull base involvement caused by the erosive nature of these tumors. Endoscopic examination showed a large cystic mass (asterisk) obstructing the posterior choanae bilaterally and extending anteriorly into the nasal cavity.
A nasobronchial reflex cholesterol ratio pdf buy generic zocor 5mg on line, releasing neuropeptides in the lower airway good cholesterol chart levels generic 20 mg zocor visa, which induces inflammatory reactions d cholesterol lowering functional foods zocor 10 mg. Dissemination of inflammation-related substances via the systemic circulation Review Questions 1 cholesterol medication no grapefruit purchase genuine zocor. Atopy acquired later in life is associated with the development of allergic rhinitis cholesterol lowering foods in hindi discount zocor 40 mg otc. Atopy acquired later in life is associated with the development of allergic asthma cholesterol levels on low carb diet zocor 5 mg generic. Atopy acquired early in life is not associated with the development of allergic rhinitis. Atopy acquired early in life is not associated with the development of allergic asthma. Patients with seasonal allergic rhinitis have greater bronchial hyperreactivity than patients with perennial allergic rhinitis. Patients with perennial allergic rhinitis have greater bronchial hyperreactivity than patients with seasonal allergic rhinitis. Patients with intermittent allergic rhinitis have greater bronchial hyperreactivity than patients with persistent allergic rhinitis. Patients with intermittent nonallergic rhinitis have greater bronchial hyperreactivity than patients with persistent nonallergic rhinitis. In occupational asthma and rhinitis, adequate pharmacological treatment is the most effective treatment. In occupational asthma and rhinitis, removal from exposure is the most effective treatment. In the majority of patients with occupational asthma, bronchial hyperreactivity and the need for antiasthma medication disappear after avoidance of sensitizing agents. Exacerbations of asthma are mostly associated with exposure to relevant allergens. Bousquet J, Van Cauwenberge P, Khaltaev N; Aria Workshop Group; World Health Organization. Absence of pulmonary aspiration of sinus contents in patients with asthma and sinusitis. Segmental bronchoprovocation in allergic rhinitis patients affects mast cell and basophil numbers in nasal and bronchial mucosa. The impact of asthma and aspirin sensitivity on quality of life of patients with nasal polyposis. Longterm outcomes from the English national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis. Rhinitis therapy and the prevention of hospital care for asthma: a case-control study. Fluticasone propionate nasal spray is superior to montelukast for allergic rhinitis while neither affects overall asthma control. Combined antagonism of leukotrienes and histamine produces predominant inhibition of allergen-induced early and late phase airway obstruction in asthmatics. Cetirizine in patients with seasonal rhinitis and concomitant asthma: prospective, randomized, placebo-controlled trial. Terfenadine, a potent histamine H1-receptor antagonist in the treatment of grass pollen sensitive asthma. Levocetirizine in persistent allergic rhinitis and asthma: effects on symptoms, quality of life and inflammatory parameters. Desloratadine reduces systemic allergic inflammation following nasal provocation in allergic rhinitis and asthma patients. Safety and efficacy of desloratadine 5 mg in asthma patients with seasonal allergic rhinitis and nasal congestion. Comparative effects of desloratadine versus montelukast on asthma symptoms and use of beta 2-agonists in patients with seasonal allergic rhinitis and asthma. Efficacy of beclomethasone nasal solution, flunisolide, and cromolyn in relieving symptoms of ragweed allergy. Influence of intranasal steroids during the grass pollen season on bronchial responsiveness in children and young adults with asthma and hay fever. Effect of an intranasally administered corticosteroid (budesonide) on nasal obstruction, mouth breathing, and asthma. Nasal inhalation of budesonide from a spacer in children with perennial rhinitis and asthma. Effect of nasal triamcinolone acetonide on lower airway inflammatory markers in patients with allergic rhinitis. Efficacy of sublingual immunotherapy in asthma: systematic review of randomized-clinical trials using the Cochrane Collaboration method. Protective effect of montelukast on lower and upper respiratory tract responses to shortterm cat allergen exposure. Metaanalysis of the efficacy of sublingual immunotherapy in the treatment of allergic asthma in pediatric patients, 3 to 18 years of age. Local nasal immunotherapy and bronchial hyperreactivity in seasonal allergic rhinitis: an observational pilot study. An important subgroup of nonallergic rhinitis is idiopathic rhinitis, formerly called vasomotor rhinitis. The patient history is the most important part of the diagnosis of nonallergic rhinitis. Asking for trigger factors that provoke symptoms, such as physical and chemical stimuli, strong emotions, alcoholic beverages, changes in hormone levels (menstrual period), certain medications, and occupations, can lead to a solution for the problem. There are several available therapies for nonallergic rhinitis, both surgical and pharmacotherapeutic, all claiming partial success. With the exception of rhinitis in the elderly, where ipratropium bromide is the first treatment of choice, there is no obvious best treatment in nonallergic rhinitis. It generally proves to be a self-limiting disease, disappearing in 1 or 2 weeks without specific treatment. This in contrast to chronic rhinitis, affecting up to 20% of the general population. Therefore, the term rhinitis in daily practice is used for nasal dysfunction causing such symptoms as nasal itching, sneezing, rhinorrhea, and nasal blockage. Definition and Differential Diagnosis Rhinitis Classification Chronic rhinitis can roughly be classified as allergic, infectious, or nonallergic, noninfectious. The diagnosis of allergy is based on diagnostic tests for allergy, such as skin prick tests and measurement of serum-specific IgE. The disease is nonallergic when allergy has not been proven by proper allergy examination (patient history, skin prick testing, and measurement of serum-specific IgE antibodies). Rhinitis is considered noninfectious when the nasal discharge is clear and watery, not purulent. Detection of microorganisms (viruses, bacteria, and fungi) is generally not used as a diagnostic criterion. Most agents inducing occupational nonallergic rhinitis are small molecular weight compounds, such as isocyanates, aldehydes, ninhydrin, and pharmaceutical compounds. Some compounds, such as chlorine, can induce irritant rhinitis in 30 to 50% of exposed workers. Drug-induced Rhinitis Rhinitis Medicamentosa Long-term use of topical nasal vasoconstrictors. Rhinitis medicamentosa can be defined as a condition of nasal hyperreactivity, mucosal swelling, rebound nasal congestion, and tolerance that is induced, or aggravated, by the overuse of topical vasoconstrictors. Generally, these patients can be adequately treated by lucid exposition, vasoconstrictor withdrawal, and a topical corticosteroid spray and in very severe cases prednisone to alleviate the withdrawal process. It is not advisable to start treatment of an underlying disorder before 6 months of complete withdrawal of the vasoconstrictors because the mucosa that is severely damaged needs a considerable time to repair. However, we can assure our patients that full recovery occurs after withdrawal, even after long abuse. Other Drugs Inducing Nonallergic Rhinitis Several different types of medications are known to cause nasal symptoms. Nonallergic Noninfectious Perennial Rhinitis Nonallergic, noninfectious perennial rhinitis can be divided into disorders with known and unknown pathology. Occupational Nonallergic Rhinitis Occupational rhinitis arises in response to an airborne agent present in the workplace. Many occupational Hormonal Rhinitis Changes in the nose are known to occur during the menstrual cycle, puberty, and pregnancy and in specific Definition and Differential Diagnosis 231 endocrine disorders, such as hypothyroidism and acromegaly. Persistent hormonal rhinitis may develop during pregnancy in otherwise healthy women. Rhinitis in the Elderly Rhinitis in the elderly, or senile rhinitis, is a characteristic clinical picture of the elderly patient suffering from a persistent clear rhinorrhea without nasal obstruction or other nasal symptoms. The first treatment option is intranasal ipratropium bromide (generally with good clinical result when given up to 6 times daily). The technique of vidian neurectomy has been reassessed with the use of the endoscope and better understanding of the nasal and sinus anatomy. It has been attributed to infection with Klebsiella ozaenae, although its role as a primary pathogen is not determined. Secondary atrophic rhinitis can be associated with chronic granulomatose conditions, radiation, and trauma. Some patients develop postsurgical disease comparable to secondary atrophic rhinitis, but the reasons why this happens in a subpopulation of patients who had surgery is not clear, and there does not seem to be a relation to the extent of the surgery. Trigger factors associated by patients with the acute onset of nasal symptoms were none or unknown (42%), weather changes (31%), odors (15%), and noxious or irritating substances (12%). The same sort of patient group with perennial symptoms of nasal hyperreactivity involving sneezing, rhinorrhea, nasal obstruction, pruritus, and frequent hyposmia was later described by others. Smoking Rhinitis Smoke, in particular cigarette smoke, is known for its irritative effect on mucosa of the respiratory tract. Because smoking results in the same clinical picture of rhinitis with rhinorrhea and nasal obstruction, it has to be viewed as a cause of rhinitis in its own right. Characteristically, excessive rhinorrhea occurs exclusively during food ingestion and begins within a few minutes of eating the involved food, usually with no associated sneezing, pruritus, congestion, or facial pain. Gustatory rhinitis is classified in four subcategories: idiopathic, posttraumatic, postsurgical, and gustatory rhinorrhea associated with cranial nerve neuropathy. Idiopathic gustatory rhinitis is always bilateral, whereas the other types may be unilateral or bilateral. Epidemiology Nonallergic rhinitis is common and is estimated to affect more than 200 million people worldwide. However, its exact prevalence is unknown, and its phenotypes need to be evaluated using appropriate methods for diagnosis and management. The prevalence of allergic and nonallergic rhinitis is reported to be between 10 and 50% of the population. Of these patients, about onequarter to one-half of cases is reported to be nonallergic. If nonallergic rhinitis is present in the pediatric population, it is more likely to be anatomical in nature and to be caused by either adenoid or turbinate hypertrophy, leading to persistent nasal obstruction. In adults, most studies report a clear female predominance, with estimates ranging from 58 to 71% of those affected being female. In a Danish study classifying a population of both adults and adolescents, female predominance held true, with approximately double the prevalence of nonallergic rhinitis in women. Idiopathic Rhinitis If we exclude all of the possible causes given above, a significant proportion of the nonallergic, noninfectious rhinitis patient group persists. Other terms, such as noninfectious, nonallergic rhinitis, are also purely descriptive. It is unrelated to allergy, infection, structural lesions, polyposis, and other systemic diseases (as mentioned above). Mixed Rhinitis Some patients with allergic rhinitis, especially those sensitized to pollen, have symptoms outside the pollen season. Also, recently nonallergic rhinitis in some patients was found to develop into allergic rhinitis over a period of 3 to 6 years. Note Nonallergic rhinitis is uncommon in children; allergic rhinitis or anatomical factors are much more often the source of rhinitic symptoms. Chronic Rhinosinusitis with or without Nasal Polyps Considerations on Possible Pathophysiologic Mechanisms Despite trying to form a nonallergic rhinitis patient group as homogeneous and uniform as possible, it still has to be anticipated that nonallergic rhinitis is a group of different pathophysiologic entities. With the limited data available at the moment, we will speculate which pathophysiologic mechanisms may play a role in nonallergic rhinitis. Whether the roles of these mechanisms are major or minor and which are important for many or a few patients with nonallergic rhinitis have to be further elucidated. In symptomatic allergic rhinitis patients, an increase of inflammatory cells has been observed in the nasal mucosa; this increase is positively correlated to nasal complaints. In patients with idiopathic rhinitis, no differences could be found in inflammatory cells in nasal biopsies compared with controls. Also, there was no relation between the number of immunocompetent cells and nasal complaints in patients with nonallergic rhinitis. The anatomically defined sensory, parasympathetic, and sympathetic neural systems contain heterogeneous populations of nerve fibers, often with unique combinations of neurotransmitters and neuropeptides. Normally, base line sympathetic tone provides a constant - and -adrenergic receptor stimulation.
Buy generic zocor 10mg online. Lipid Profile test Kya hota hai?|Cholesterol nuksaandaayak kyon hota hai?|Shaun Tips(2019).