Spaces of middle ear and their surgical importanceDr Soumya Singh
one of the imp topics in ENT that should be understood very thoroughly if u want to pursue as an otologist.I tried to simplify the topic with simple diagrams and models for better understanding .
This is a presentation I used for my seminar on 'Phonosurgery' on 4th November, 2015. I hope they are useful to you. Constructive as well as Destructive criticism welcomed.
Spaces of middle ear and their surgical importanceDr Soumya Singh
one of the imp topics in ENT that should be understood very thoroughly if u want to pursue as an otologist.I tried to simplify the topic with simple diagrams and models for better understanding .
This is a presentation I used for my seminar on 'Phonosurgery' on 4th November, 2015. I hope they are useful to you. Constructive as well as Destructive criticism welcomed.
Myringoplasty is the closure of the perforation of pars tensa of the tympanic membrane. When myringoplasty is combined with ossicular reconstruction, it is called tympanoplasty. The operation is performed with the patient supine and face turned to one side.
Chronic Suppurative Otitis Media: Tubotympanic Type (CSOM TT)Dr Krishna Koirala
Chronic Suppurative Otitis Media: Tubotympanic Type (CSOM TT) is an important topic for MBBS and MS ENt students. Dr Krishna Koirala will be explaining this topic in a simplified way.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Mastering Wealth: A Path to Financial FreedomFatimaMary4
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2. Historical Background
Berthold (1878):
Myringoplastik
Full thickness skin graft
Nylen (1921): Monocular operating
microscope.
Holmgren, teacher of Nylen (1922):
Binocular operating microscope
In 1953, the Zeiss operating microscope:
Commercially available
3. Historical Background…..
Moritz (1952)
Zollner (1953, 1955) German,
Wullstein (1953,1956) Onlay skin graft
To restore or conserve hearing and promote
healing, after excision of disease from the middle
ear and mastoid.
4. Middle Ear Reconstruction
Not only the restoration of the anatomical or
mechanical components but also of the
physiology or function of the ear.
Tympanoplasty
Ossiculoplasty
Mastoidectomy:
Open or canal wall-down procedures
Closed or canal wall-up procedures
5. Tympanoplasty
Definition: Repair of the tympanic membrane
(TM) with inspection of middle ear & possible
ossicular chain reconstruction.
This is different than a myringoplasty
Aims:
Prevent recurrent disease
Improve hearing
Provide a dry ear canal
Enable patient to bathe & swim freely
24. Ossiculoplasty (OCR)
Appropriate candidates:
Resolved otorrhea with no middle ear disease
Conductive or mixed hearing loss
No Eustachian tube dysfunction (ideal)
Need enough middle ear space and aeration to allow for
prosthesis and function
Previous CWU for second-look
25. Ossicular grafts and implants
Autologous :
Ossicle grafts: Incus/ Head of the malleus
Cortical bone grafts: Mastoid cortex
Cartilage
Homologous human ossicles
Synthetic ossicular implants:
Porous high-density polyethylene (Plastipore) -
FBGCR
Plastic material -microdegradation
Bioactive glasses, aluminum oxide ceramic, carbon,
hydroxylapatite-polyethylene (Hapex)
26.
27. Ossicular chain defect
Austin’s classification
4 Common types: Incus absent in all cases and TM reconstruction
required in all cases.
Type A: M+, S+
Loss of part of incus or total loss of incus.
Type B: M+, S-
Loss of incus & stapes superstructure but the malleus handle still
present.
Type C: M-, S+
Loss of incus & malleus but the stapes superstructure still present.
Type D: M-, S-
Loss of incus, malleus & superstructure of stapes, but mobile
footplate still present.
33. Type D: TORP/ Autograft or homograft bone
Total Ossicular
Reconstruction Prosthesis
Footplate TM
Oval window (with graft)
TM
34. TORP
All OCRs are held in place by tension. When
placing a TORP, Gantz will frequently put a second
piece of cartilage to support the prosthesis.
35.
36. Ossicular chain defect…….
Rare ossicular chain defects
1)Isolated loss of the malleus handle: 2%
2) Isolated loss of the stapes superstructure: 1.7%
38. Defining Success
1995 guidelines of the AAO
Pre and postoperative air-conduction and bone-
conduction thresholds are measured at 4 designated
frequencies (0.5, 1, 2, and 3 kHz), then averaged
Success is defined as a mean postoperative air-
bone gap of less than 20 dB and is the main
outcome considered for this talk
39. Prognostic Factors
It is clear that optimal results depend not only on
the qualities of the prosthesis, but also on the
environment in which it is placed and the
surgical techniques used.
40. Prognostic Factors
Austin (1972) defined four groups in which the incus
had been partially or completely eroded:
Type A, malleus handle present, stapes
superstructure present (60% occurrence)
Type B, malleus handle present, stapes
superstructure absent (23%)
Type C, malleus handle absent, stapes
superstructure present (8%)
Type D, malleus handle absent, stapes
superstructure absent (8%)
41. Prognostic Factors
Kartush (1994) proposed a scoring system called
the middle ear risk index (MERI) to form an index
score to determine the probability of success in
hearing restoration surgery.
MERI is used to describe the preoperative middle
ear environment at the time of ossiculoplasty
44. All studies of prognostic factors identify middle ear
mucosal status and presence of malleus handle
as important predictors of successful hearing
restoration
45. Result of ossicular reconstruction
Incus/stapes assembly - air-bone gap closure with 10 dB
in 50% cases & under 20 dB in 70-80% cases.
Malleus/stapes assembly –
0-10 dB 50% cases
0-20 dB in 80% cases
Malleus/footplate assembly-
20 dB in 35- 60% cases.
Use of PORP – air-bone gap closure < 20 dB in 77%
cases.
Use of TORP – air-bone gap closure < 20dB in 52%
cases.
expert surgeon
51. Obliteration techniques…………..
Autologous cancellous iliac crest bone graft
(Schiller & Singer, 1960)
Allogenic femoral cortical bone chips
(Shea, Gardner and Simpson, 1972)
Bone chips/ dust
Autogenous cartilage (chondral part of pinna)
Hydroxylapatite ceramic powders &
particles.
52. Obliteration techniques…………..
The muscle obliteration techniques:
(more popular)
Local random pattern muscle periosteal transposition
& rotation flaps of sternomastoid muscle( Meurman
and Ojala, 1949)
Temporalis muscle (Rambo, 1958)
Postauricular muscle periosteal flaps based on the
SCM muscle (Hilger and Hohmann, 1963)
Anteriorly based postauricular muscle-periosteal
transposition flaps together with bone pate (Palva,
1963,1982,1993)
53. Obliteration techniques…………..
Local axial pattern flaps:
Temporoparietal fascia flap, based on the
superficial temporal vessels (Byrd, 1980; East,
Brough and Grant, 1991)
The temporalis fascia flap; ‘Hong Kong flap’ ,
(van Hasselt, 1994)
Free grafts: Fascia (temporalis), fascia lata,
abdominal fat, local muscle and periosteal grafts
54.
55.
56. B: Posterior canal wall and outer attic
reconstruction-
Alternative to cavity obliteration.
Autologous material
> Bone dust & chips
> Cortical bone graft
> Tragal cartilage/Scaphod cartilage
Allogenic
> Bone graft
> Tragal cartilage
Hydroxylapatite
57.
58.
59. Tympanoplasty with mastoidectomy
1) Closed cavity mastoidectomy with tympanoplasty.
2) Open cavity mastoidectomy with tympanoplasty.
3) Obliteration of open mastoid cavity with
tympanoplasty.
4) Reconsturction of the outer atlic wall or posterior
canal wall of open mastoid cavity with
tympanoplasty.
60. Ossicular chain reconstruction
1) When incus is eroded but malleus handle & stapes
is present.
Malleus/stapes assembly by –
> Autologous & allogenic malleus head or incus body
to fit between the malleus handle & stapes head.
> Artifical prostheses are also available to perform
the same task.
61. Continue…
2) When loss of incus & stapes superstructure but
handle of the malleus present.
Malleus/footplate assembly by-
> Autologous or homologous bone can be used.
> Artifical prostheses are also available.
3) When loss of incus & malleus but stapes
superstructure present.
TM/ stapes head assembly by-
> Autograft or homograft bone can be used .
> Artfical prostheses are also available.
62. Continue….
4) When loss of incus, malleus & stpaes
superstructure
but mobile footplate.
TM/ footplate assembly by-
> Autograft or homograft bone can be used.
> Artifical prostheses are also available.
63. SURGICAL APPROACHES
A. Post Aural (William Wilde) Incision: A cured incision is wade in the natural Post aural
gulcus. Starting nt the 12 o’ clock Position sumperorly and terminatiog at the 6 o’clock
position just behing the ear lobule
Used
Myringoplasty & Tympano Pasty ( Comsined At)
Masteidectomy (All)
Cochler Implant
Exposove of CN VII in vertical sac.
B. End aural inusion: i) incision in the canal and icisuratermials
Lempert I: It is semicircular incision made from 12 ‘o clock to 6 o’ clock Position in the
posteromeatul wall at the bony Cartilaginous function.
Lempert II: Starts from the 1st incision at 12 o clock and them pome upwords in a cuvilinear
fashion btween tragus and crus of helix. It pases though the incisura terminals and them
doen not cut hte cartilage. Both masterd and external canal surgery can be done
Indication:
Lage tympanic membrane perforations.
Attic cholesleatonas with limited extension into the andrum.
Excesion of osteona or exostosis of earcanal.
Modified radical mastordectomy where disane is limited to attic, antrum and part of
masted.
64. C. Permeatal approacho ( tramcanal) (Endomeatal)/
Rosen incision ( Lateral Tympanotomy)
Resn’s incisim in the most commonly used for stapectechomy It comnts of two
parts
a) A Small vertical inlision at 12’ o Clock Position near the annulus and
Acarvilinear incirion storting at 6 o’ clock Position to meet the 1st incision in the
poster superior region of the canals, 5mm-7mm away from the annulus.
Indication:
Stepes surgery
Myrugplasty
Omicnler chain reconstruction
Exporatory tumpanotomy Examination of omcular chain in congenital conductive
defames.
Success rate in achieving tympanoplasty?
Ans: In expert hand armed -95%
Trainee – 74%
Most out patiant methods have a success rate of between 30 and 80 percent
depending on pathology technique and operator Patience Minor surgery for small
defects can be successful in 80% or More Myringoplasty can be expected to
close 90% of Perforndim with a follow up of 12 months in experiorud hands.