This document discusses juvenile nasopharyngeal angiofibroma (JNA), a rare benign but invasive tumor that arises in adolescent males near the sphenopalatine foramen. JNA presents with nasal obstruction and epistaxis. Diagnosis involves imaging like CT and MRI to determine the extent of involvement. Treatment depends on staging and may include preoperative embolization, surgery such as endoscopic resection, or radiation for advanced cases. Complete resection aims to prevent recurrence while minimizing complications like bleeding, infection, and nerve damage.
Case presented in National ENT conference in serena hotel, Islamabad in Dec. 2015
Author
Dr. Ghulam Saqulain HOD
Dr. Jawad Ahmed Assoc. surgeon
Dr. Zaimal Shahan PGT
Case presented in National ENT conference in serena hotel, Islamabad in Dec. 2015
Author
Dr. Ghulam Saqulain HOD
Dr. Jawad Ahmed Assoc. surgeon
Dr. Zaimal Shahan PGT
Blood Supply of Nose
Little’s Area & Importance
Causes & Classification of Epistaxis
Management of Epistaxis
Angiofibroma and its Etiology
Pathology of Angiofibroma
Diagnosis of Angiofibroma
Treatment of Angiofibroma
Situated in the anterior inferior part of nasal septum.
Four arteries anastomose here to form a vascular plexus “Kiesselbach’s Plexus”
Usual site for Epistaxis in children & young adults.
Another plexus of veins is situated inferior to posterior end of inferior turbinate, called “Woodruff’s Plexus”. It is a site of posterior epistaxis.
Blood Supply of Nose
Little’s Area & Importance
Causes & Classification of Epistaxis
Management of Epistaxis
Angiofibroma and its Etiology
Pathology of Angiofibroma
Diagnosis of Angiofibroma
Treatment of Angiofibroma
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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.
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
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
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
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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2. DEFINITION
•JNA is a histologically benign , but locally invasive neoplasm which is
an uncommon and extremely vascular tumour that arises in the
tissues within the sphenopalatine foramen.
Synonyms: Angiofibroma, Juvenile angiofibroma, Juvenile nasal
angiofibroma(JNA).
3. HISTORY
• JNA was documented since the time of Hippocrates (4 BC).
•Shaheen in 1930 reported the first female patient with juvenile nasopharyngeal
angiofibroma.
• Hondousa recorded the youngest JNA patient (8 years)
• Figi and Davis (1950) emphasized the role of surgery in the management of JNA.
• Histopathological studies of JNA tissue was extensively done by Harma (1959).
4. INCIDENCE
•JNA accounts for less than 0.5 percent of all head and neck tumors
•JNA is more common in Americans and Middle east region.
•Exclusively adolescent males are affected.
• The reported rate of incidence varies from 1/6000 (Harma 1959) to
1/50,000 (Hondousa etal 1954).
5. AETIOPATHOGENESIS
•The exact nature of the tumor and its etiology is not well known.
•Various theories have been propounded to explain the
etiopathogenesis of JNA.
8. Recent studies shows other possible factors are,
◦ 75% of patients have androgen receptors present.
◦ VEGF found in endothelial and stromal cells.
◦ Over expression of IGF –II was found in JNA and also associated with
recurrence and poor prognosis.
◦ Mutations of beta catenin have found in sporadic and recurrent JNA.
◦ FAP have 25 times more chance to develop JNA.
THEORIES
9. SITE OF ORGIN
Earlier assumed that
◦ Vault of the Nasopharynx was the most likely site because of the broad
attachment to the skull
◦ Choana
Presently ,Tumor arises from the Posterior part of Nasal cavity-Close to superior
margin of the sphenopalatine foramen
10. HISTOPATHOLOGY
Macroscopic: Rounded, Spongy, Nodular
(nodularity increases with age), Non
Encapsulated tumour, red pink or tan grey in
appearance covered by nasopharyngeal
mucosa.
•The intact membrane covering the tumour is
deep red in color as usually seen in younger
patients.
11. Microscopic : vascular spaces of varying shapes and
sizes within a stroma of fibrous tissue.
•The relative proportions of the vascular and the
stromal components change with the age of the
swelling.
•whereas in long standing tumors collagen
predominates.
• In some cases pseudostratified columnar
epithelium is seen side by side with the
metaplastic squamous epithelium
HISTOPATHOLOGY
13. SPREAD OF TUMOR
JNA Spreads to
◦ Nasal cavity-Nasal Obstruction,Epistaxis,Nasal Dischage
◦ Nasopharynx-Pushes soft palate downwards
◦ Pterygopalatine fossa
◦ Maxillary,ethmoid,Sphenoid sinuses
◦ Middle cranial fossa and Anterior cranial fossa
14. CLINCIAL FEATURES
•The two cardinal symptoms of angiofibroma are NASAL OBSTRUCTION and
intermittent unprovoked EPISTAXIS.
•The nasal obstruction is so complete causing stasis of secretions and sepsis become
inevitable. Patients may even have hyposmia or anosmia.
•Chronic Anemia is thus a feature of an established JNA.
•The voice of the patient acquires a nasal intonation. If the swelling enlarges to force
the soft palate down, the voice may become plummy. Blockage of Eustachian
tube orifice is also common causing deafness and otalgia.
•Headache is not uncommon in long standing cases. If present it could be
15. CLINCIAL FEATURES
•Diplopia may occur secondary to the erosion of the mass into the
cranial cavity and causing pressure on the optic chiasma.
•Proptosis and “frog-face”.
•Failing vision -tenting of the optic nerve by the tumor.
•Swelling of the cheek,Hearing loss, Broadening of nasal bridge
16. •Anterior rhinoscopy: shows the presence of abundant purulent
nasal secretions together with bowing of nasal septum to the
uninvolved side.
•Posterior rhinosocpy: in a cooperative patient shows a pink or red
mass filling the Nasopharynx. Due to the bulk of the lesion it may
not be always possible to ascertain the site of origin accurately.
•Probing should not be done
CLINCIAL FEATURES
17. Andrade NA, Andrade JSC, Silva PDM, Oliveira VB, Andrade BB. Nasopharyngeal Angiofibroma: Review of the Genetic and
Molecular Aspects . Int. Arch. Otorhinolaryngol. 2008;12(3):442-449
18. Surgical Approaches to Juvenile Nasopharyngeal Angiofibroma - Case Report and Literature Review, Journal of Otolaryngology,
2006 Vol. 10 Num. 2.
20. STAGING OF THE TUMOR
FISCH STAGING CLASSIFICATION:
TYPE 1 : Tumour limited to the nasopharyngeal cavity; bone destruction negligible or limited to the
sphenopalatine foramen
TYPE 2 : Tumor extension into the pterygopalatine fossa, or maxillary, sphenoid or ethmoid sinuses with
bone destruction.
TYPE 3: Tumour invading the infratemporal fossa or orbital region:
◦ 3a without intracranial involvement
◦ 3b with intracranial extradural (parasellar) involvement
TYPE 4: Intracranial intradural tumour:
◦ 4a without infiltration of the cavernous sinus, pituitary fossa or optic chiasm
◦ 4b with infiltration of the cavernous sinus, pituitary fossa or optic chiasm
23. X-RAY
•Xray of the nasopharynx (lateral view) and paranasal
sinuses (occipito-mental view) will show the presence of
soft tissues mass.
•Holman Miller Sign/Antral Sign-seen in the plain Xray -
lateral skull that would show anterior bowing of the
posterior wall of the maxillary sinus
24. CT SCAN
•CT SCAN is particularly helpful to find the extent of the tumor. In addition CT
scan with contrast will show the vascularity of the tumor.
•Showes a dumbell shaped mass extending from Nasal cavity /NP to PTF
25. MRI
•Helpful especially to see the extension
of the soft tissue tumour into the
cranium, orbit and infra-temporal
fossa.
28. SURGERY-PRE OP
Preoperative Embolization
◦ In surgical management is controversial.(Complications)
◦ Blood supply is predictable(usually Internal maxillary artery).
◦ Recurrence rate is more in case of Preoperative Embolization.
Preoperative chemotherapy
◦ Estrogens have been reported to induce shrinkage.(But effects are variable)
◦ Estrogen therapy delayes sugery and secondary feminizing in boys.
◦ Non steroidal androgen receptor blocker FLUTAMIDE is also used.
29. APPROCHES
•Endoscopic Resection
•Transpalatal
•Le Fort 1 osteotomy
•Lateral rhinotomy
•Midfacial degloving
•Maxillary swing
•Infratemporal fossa(1980s)
•Extensive JNA are resected through skull base with
combined approach with Neurosurgeons.
31. ENDOSCOPIC ENDONASAL APPROCH
•After induction of general anesthesia nose packed with vasoconstrictor solution.
•The anterior end of middle turbinate is resected.
•Uncinectomy and wide middle meatal antrostomy
•An Anterior ethmoidectomy together with removal of the medial wall of
maxillary sinus gives access to posterior wall of antrum.
•Then removal Posterior wall will expose the tumor.
•Through out the procedure Bipolar diathermy or ligaclips to control bleeding
from feeding vessels.
34. COMPLICATIONS
Recurrence
◦ The age of patient, younger will develop recurrence
◦ In advanced disease and in experienced surgeons
◦ Invasion of the basisphenoid
Pain, bleeding, infection, hyposmia, synechiae, orbital injury, loss of vision, cerebrospinal
fluid leak-Endoscopic Approch
Infra orbital nerve deficit-Mid facial degloving
Radiotherapy
◦ Growth retardation ,Temporal bone necrosis,Catracts
◦ Thyroid malignancy
Holman Miller Sign/Antral Sign-seen
Schwanoma
3) Fibrous dysplasia
4) Nasopharyngeal Carcinoma
5) Tumours of infratemporal fossa
Submento Vertical View of X-Ray PNS
1) S-Shaped line represents the Posterior wall of the Maxillary sinus. Erosion – into the Subtemporal fossa.
2) Upper curvilinear line represents lateral wall of orbit. Erosion – into the orbit.
3) Lower curvilinear line represents lesser wing of the Sphenoid. Erosion – Skull base.
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