This document provides information on juvenile nasopharyngeal angiofibroma (JNA), including its epidemiology, pathology, theories of origin, clinical features, diagnosis, staging systems, treatment options, surgical approaches, and complications. JNA is a benign but locally aggressive tumor most commonly seen in adolescent males. Surgical removal is the primary treatment, with endoscopic approaches used for early-stage tumors and open approaches for more advanced cases. Recurrence rates remain high due to the tumor's vascularity and location near vital structures, so adjuvant therapies may also be used.
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
Sinus tymapni shape and depth can influence surgical approach in cholesteatoma surgery. In the case of a shallower ST, an exclusive endoscopic exploration is chosen; while in the case of a deeper ST, a retrofacial approach is usually preferred.
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 .
Sinus tymapni shape and depth can influence surgical approach in cholesteatoma surgery. In the case of a shallower ST, an exclusive endoscopic exploration is chosen; while in the case of a deeper ST, a retrofacial approach is usually preferred.
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 .
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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
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
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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
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.
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Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
1. JNA : SURGICAL APPROACHES & NEWER
TREATMENT OPTIONS
DR UTKAL MISHRA
AIIMS, BHOPAL
2. JUVENILE NASOPHARYNGEAL ANGIOFIBROMA
Most common benign tumor of nasopharynx.
Seen almost exclusively in Adolescent Males of 10-20 years
It is encapsulated , slow-growing ,vascular tumor
Although benign it is locally aggressive and has a high recurrence
rate
3. EPIDEMIOLOGY
Accounts for 0.05 to 0.5% of all head & neck tumours.
Intracranial extension found in 20 % cases.
Incidence – 1/6000 Harma et al to 1/50,000 Hondousa et al
In India incidence is increasing.
4. PATHOLOGY
Gross : - Sessile, Firm, Lobulated, Pink – Red in colour
Histology : -
1. Encapsulated, composed of vascular tissue & fibrous stroma.
2. Vessels are thin-walled, endothelium lined with no muscle or elastic coat.
5. THEORIES OF ORIGIN
Ringertz theory: JNA always arose from the periosteum of the skull base.
Bensch & Ewing (1941): Origin from embryoninc fibro cartilage between the basi occiput and basi sphenoid.
Brunner (1942): Origin from conjoined pharyngobasilar and buccopharyngeal fascia.
Marten (1948): Tumors resulted from deficiency of androgens or over activity of estrogens
Sternberg (1954): Hamartoma
Osborn (1959): Hamartomatous origin
Girgis & Fahmy (1973): They considered JNA to be a paraganglionoma.
Mild & Mauris theory: Origin from midline erectile tissue/ androgen dependent hamartoma
6. SITE OF ORIGIN
Most common site - Superior Margin Of Sphenopalatine Foramen
Pterygoid wedge
Vidians canal
Basisphenoid
7. EXTRANASOPHARYNGEAL ANGIOFIBROMA
Do not originate from the area around the sphenopalatine foramen.
Common in older Females
Less vascular
Commonest site – Maxillary sinus
Other sites – Ethmoid sinus, Inferior Turbinates, Frontal Recess, Tonsil, RMT
8. MOLECULAR ANALYSIS
Androgen receptors - 75%
VEGF – 80%
Progesterone receptors
SOMATOSTATIN Receptor (SSTR 2)
IGF II
APC gene - 25 times more frequent in FAP patients
ß catenin
CD 34
Loss of expression of GSTM 1
9. CLINICAL FEATURES
Commonest Symptom - Profuse, Unprovoked, Recurrent and Spontaneous
Epistaxis.
Progressive nasal obstruction and denasal speech
Conductive hearing loss and otitis media with effusion.
Mass in the nasopharynx, Palatal Bulge
Broadening of Nasal Bridge, Proptosis, Swelling of Cheek
10. EXAMINATION OF NOSE
Smooth Reddish Lobulated mass filling the nasal cavity & choana at times.
Accumulations of secretions anterior to mass – CHOANAL BANKING EFFECT
DNS to contralatertal side may be present.
12. SIGNIFICANCE OF PTERYGOID WEDGE
It is defined as the anterior junction of the medial & lateral pterygoid plates.
Involvement of pterygoid wedge is found in 99% cases.
Pterygoid wedge is the Epicenter of tumour.
Most common site of residual & recurrent disease – pterygoid wedge (45%)
Most important step in JNA surgery to prevent recurrence - Drilling of pterygoid wedge
23. CHOP STICK SIGN
CHOP STICK SIGN – Post op appearance of medial & lateral pterygoid plates as
two separate sticks due to drilling & removal of pterygoid wedge.
24. MRI
Characteristic – Salt & Pepper appearance due to flow voids
It aids in differentiation of tumour in – Orbit , Cavernous sinus , Middle cranial fossa , Infratemporal
region
28. EMBOLIZATION
Planned 24-48 hrs before surgery to avoid revascularization.
No anesthesia required for cooperative patients
Done under DSA guidance.
29. DISADVANTAGE
Advantage – Reduction in blood loss, Less operative time, Improved visualisation of tumour margins
Disadvantage –
1. Neurological complications, - Stroke, Cranial N. palsy, Blindness
2. Recurrence
3. Friable
4. Obscure tumour front in cracks & crevices.
30. TYPES
2 types –
1. TRANSARTERIAL EMBOLIZATION WITH PVA
2. DIRECT PERCUTANEOUS EMBOLIZATION WITH ONYX –
Advantage : Solidifies slowly & infiltrates small vessels with excellent penetration of parenchyma
33. PRINCIPLES OF JNA SURGERY
Analyze the coronal CT thoroughly & plan the approach.
Adequate tumour exposure.
Don’t touch the tumour until feeding vessels are controlled.
Drilling of pterygoid wedge is must.
34. ANAESTHETIC CONSIDERATIONS
TIVA – Ramifentanyl + Propofol
Controlled hypotension by Nitroglycerine infusion
Maintain MAP → 60 – 70 mm Hg
Positioning – Reverse Trendelenberg position
38. BINOSTRIL 4 HANDED SURGERY
1 st described by – MAY et al in 1990.
Posterior septectomy done as 1st step.
Requires 2 surgeons
Surgeon 1 – Holds endoscope at 11 o clock position + Irrigation
Surgeon 2 – Suction same nostril + Instruments opposite nostril
39. ENDOSCOPIC ENDONASAL TECHNIQUE
Nose is prepared with 4% Cocaine & adrenaline 1:10,000
Resection of anterior end of middle turbinate
Anterior ethmoidectomy + Removal of medial wall of maxillary sinus
Removal of posterior wall of maxillary antrum to achieve complete lateral exposure of tumor
Ligating SPA + DPA
Dissection continues till rostrum of sphenoid
Tumor is peeled inferiorly
Drilling of basisphenoid & pterygoid wedge to remove residual tumour.
41. THE FOUR-PORT BRADOO TECHNIQUE
4 ports –
(A) The ipsilateral nostril.
(B) The contralateral nostril after doing a posterior septectomy.
(C) An antral window in the canine fossa.
(D) An incision of one inch in the gingivobuccal sulcus adjacent to the last molar.
Advantage – Avoids removal of frontonasal process of maxilla
42. POST OP MANAGEMENT
Merocel pack removed after 48 hrs.
Saline irrigation started after pack removal
Endoscopic cleaning of nose every weekly until crusting subsides.
CECT done after 36 hrs to rule out residual disease.
43. FOLLOW UP
Endoscopic examination of nose every 3 months
Routine CECT every year for at least 3 years
53. HEMOSTASIS IN JNA
Reverse trendelenberg position with 200 head elevation – Improves venous drainage from brain.
Direct pressure
Liga clips
Bipolar forceps
Warm saline irrigation 400c
1:1000 topical adrenaline
Surgicel
Floseal – Bovine Collagen + Human Thrombin
54. MANAGEMENT OF ICA INJURY
Don’t panic Don’t pack
Use 2 suctions
1 – 2 cm3 muscle harvested from thigh or abdomen
Crushed & placed over bleeding point for atleast 3-5 min. → Activates platelet fibrin plug
Reinforce with surgicel
If still not controlled → Endovascular intervention by angiography team
55. TRIGEMINO-CARDIAC REFLEX
Characterized by –
1. Bradycardia / Asystole
2. Hypotension
3. Apnea
4. Gastric Hypermotility
Incidence – 4 %
Cause – Manipulation of PPF, ITF, NP Mucosa
To prevent – 4% Xylocaine pack in PPF , ITF
If occurs – Stop all manipulation, IV Crystalloids, wait for 10-15 min
56. EARLY POST OP
Nasal Crusting
Orbital hematoma
Infraorbital nerve paraesthesia
57. LATE COMPLICATIONS
Alar collapse – Modified denkers due to drilling of pyriform aperture
Vestibular stenosis
Fistula of palate
Caroticocavernous fistula
Recurrence
58. RECURRENCE
Defined as subsequent tumour after negative immediate post op scan at 36 hours
Incidence – 32 %
Factors responsible-
1. Extensive Disease
2. Young Age
3. Pre op Embolization
4. Inexprienced Surgeon
MOST IMPORTANT STEP TO PREVENT RECURRENCE – Drilling the cancellous bone of pterygoid wedge
62. DOSE
3000 to 5500 cGy in 15–18 fractions is delivered in 3–3.5 weeks.
Tumour regression is very slow (over 2-3 year).
Tumor regression by radiation vasculitis and occlusion of vessels by perivascular fibrosis.
63. COMPLICATIONS
Occular – Cataract, Glaucoma, Endophthalmitis, Optic N. Atrophy
Cranial N. Palsy
Pan Hypopituitarism
Temporal lobe necrosis
Malignant transformation of JNA
Xerostomia, Hyposmia, Crusting
64. HORMONAL THERAPY
Flutamide - 10mg/kg/day in 3 divided doses x 6 weeks – 44% tumour shrinkage
Diethylstilbestrol – 5 mg TID
Bevacizumab – Mab against VEGF
Sirolimus / Rapamycin