This document discusses malignant tumors of the nose and paranasal sinuses. It begins by covering the epidemiology, risk factors, and common histological subtypes of carcinomas in these areas. It then describes the natural history and spread patterns of tumors originating in different paranasal sinuses. Diagnostic workup, staging, and treatment options such as surgery, radiation, and chemotherapy are outlined. Surgical approaches like craniofacial resection are explained in detail. Prognosis and complications depend on tumor stage, size, and extent of involvement of surrounding structures.
Maxillectomy and craniofacial resection Mamoon Ameen
all maxillectomy types in detail and maxillofacial resection ,indications ,contraindications ,preoperative asssessment and detail techniques and rehabilitations
Maxillectomy and craniofacial resection Mamoon Ameen
all maxillectomy types in detail and maxillofacial resection ,indications ,contraindications ,preoperative asssessment and detail techniques and rehabilitations
Slides prepared and compiled by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal , for teaching undergraduate and postgraduate ENT students in the field of otorhinolaryngology.
A clear and concise explanation of the basic concepts in the subject matter concerned. He is the Head of department with a sound knowledge in the field of ENT to teach both undergraduate and postgraduate ENT students
Slides prepared and compiled by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal , for teaching undergraduate and postgraduate ENT students in the field of otorhinolaryngology.
A clear and concise explanation of the basic concepts in the subject matter concerned.
He is the Head of department with a sound knowledge in the field of ENT to teach both undergraduate and postgraduate ENT students.
This presentation gives a lucid idea about different neoplasms of nose like inverted papilloma, ca maxilla, ethmoid and so on.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
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
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
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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!
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.
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
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
6. SQUAMOUS CELL
CARCINOMA
• Squamous cell carcinoma remains the most
common sinonasal malignancy
• The majority probably arise in the maxillary
sinus
• Rarely the nasal septum or columella are the
primary site.
• These tumours have a particularly poor
prognosis due to the possibility of bilateral
metastatic spread to cervical nodes.
7. ADENOCARCINOMA
• Aout 30 per cent of patients with this condition
are woodworkers.
• These tumours usually arise in the middle meatus
and spread into the ethmoid
• Adenocarcinoma is generally rather radioresistant
but combined therapy is usually offered.
• Many patients require a craniofacial but in
selected cases have been treated successfully by
an endoscopic resection.
8. ADENOID CYSTIC
CARCINOMA
• Propensity to spread along perineural
lymphatics which compromises attempts at
excision.
• known to produce blood-borne metastases,
classically to the lung while lymphatic spread
is rare.
• Treatment is generally combined surgery and
radiotherapy
9. OLFACTORY NEUROBLASTOMA (OR)
ESTHESIONEUROBLASTOMA
• classically arises from olfactory epithelium in the upper
nasal vault
• The presence of a mass in the upper nasal cavity with
associated skull base erosion is typical.
• bimodal peak in the second/third and sixth/seventh
decades.
• Cervical metastases have been described in up to 23%.
• These are routinely resected in craniofacial approaches
• Endoscopic resection is being increasingly offered for this
tumour particularly when it arises from the middle and
superior turbinates.
• should always be combined with radiotherapy.
10. OHNGREN'S
LINE
· Line running from
medial canthus to
angle of mandible
· Prognosis of
suprastructure
tumors worse (This
was before advent
of craniofacial
resection)
13. NATURAL HISTORY & SPREAD –
CONTD…
Sphenoid sinus ca Frontal sinus ca
14. LYMPHATICDRAINAGE
• Usually sparse-10% incidence of cervical LNE
• If tumor extension into skin of face, nasal
cavity, NPX -> ↑ed incidence of LN->Assocated
with poor prognosis
• First echelon: submandibular nodes
• Second echelon: subdigastric nodes - same
side
• Contralateral mets. extremely rare
15. CLINICAL FEATURES
Maxillary sinus ca
• Facial swelling, pain, paresthesia of cheek
• Epistaxis, nasal discharge, obstruction
• Ill fitting dentures, alveolar/palatal mass
• Proptosis, diplopia, impaired vision, orbital pain
Ethmoid sinus ca
• Headache
• Referred pain to nasal, retrobulbar region
• SC mass at inner canthus, nasal
obstruction,dischargeD,r.Vi
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lopia & proptosis
16. WORK UP
• H & P
• Routine blood examination
• CXR- Adenocystic ca
• CT/MRI
• Dental evaluation
• Baseline ophthalmologic examn
• Baseline speech & swallowing assessment
• Fiberoptic endoscopic examination & Bx
17. COMPUTED
TOMOGRAPHY
• Bone erosion
– orbit, cribiform plate
– fovea, post max sinus wall
– sphenoid, post wall of
frontal sinus
• 85% accuracy
• ? Tumor vs. inflammation vs.
secretions
• Limitation-periorbital
involvement
• CT Chest for Adenocystic ca
19. AJCC- NASAL CAVITY &
ETHMOID SINUS
Tx - Primary tm cannot be assessed
To - no evidence of primary tm
Tis - carcinoma in situ
T1 - Tm restricted to any one subsite with or without bony
invasion
T2 - invading two subsite in a single region or extending to
involve an adjacent region within the nasoethmoidal complex
T3 - invade medial wall/ floor of orbit, maxillary sinus,palate/
cribiform plate
T4a - invade ant orbital contents, skin of nose /cheek, ant cranial
fossa, pterygoid plates,sphenoid/ frontal sinus
T4b - orbital apex, dura, brain,mid cranial fossa, cr nerves,
nasopharynx/ clivus Dr.Vinod M K
20. STAGING –
CONTD…
Dr.Vinod M K
Nx - regional nodal status cannot be assessed,
No - No regional lymph node metastasis
N1 - single I/L clinically +ve lymph node ≤ 3cm
N2 - metastasis in ipsilateral, bilateral, contralateral node
N2a - single I/L +ve LN >3cm <6cm
N2b - multiple, I/L +ve LN <6cm
N2c - B/L or C/L LN <6cm
N3 - any LN > 6cm
Mx - distant metastasis cannot be assessed
Mo - No distant metastasis
M1 -distant metastasis
21. STAGING –
CONTD…
• STAGE III – T3N0M0 OR T1-T3N1M0
• STAGE IV :
- IVA -T4N0-1M0
• ANY TN2 M0
- IVB ANY TN3M0
- IVC ANY T ANY N, M1
Dr.Vinod M K
Stagewise distribution
stage I
stage II
- T1N0M0
– T2N0M0
22. TREATMENT
OPTIONS
Dr.Vinod M K
Maxillary sinus ca
• Surgery
• Radiotherapy
- definitive
- pre op RT
- post op RT
• Combined modality ( Sx + RT)
• Chemotherapy
- Neo adjuvant
- Concomitant
25. SURGERY
Contraindications
- extension thr ant. Fossa
- involvement of both optic n.
- post. extension into sphenoid sinus
- invasion of middle cranial fossa
- extension into NPx
- inoperable neck node & distant mets
27. CRANIOFACIAL
RESECTION
• the ‘gold standard’ for tumours affecting the anterior
skull base.
CONTRAINDICATIONS
• Extensive frontal lobe and/or middle cranial fossa
involvement or bilateral orbital invasion/optic chiasm.
• Certain histologies, such as mucosal malignant
melanoma where extent of surgery does not influence
outcome
• those where surgery is not appropriate, such as
sinonasal undifferentiated carcinoma, lymphoma,
plasmacytoma.
• Distant metastasis.
28. INCISION
• Following bilateral temporary tarsorrhaphies,
an extended lateral rhinotomy is made on the
side of maximal tumour involvement
29. TECHNIQUE
• The soft tissues of the face are mobilized by subperiostial
elevation to expose the nasal bones, frontal processes of
the maxilla and frontal bone up to the hairline via an
extended lateral rhinotomy.
• Through the lateral rhinotomy, the upper lateral cartilage is
separated from the nasal bone to allow complete retraction
of the nasal ala.
• The orbital periosteum is elevated to expose the lacrimal
fossa and the medial orbital wall. The nasolacrimal duct is
often transacted obliquely at this point
• anterior and posterior ethmoidal arteries are divided after
bipolar coagulation.
• If the lamina has been eroded by tumour, the adjacent
periorbita should be resected for frozen section assessment
30. • A shield-shaped craniotomy is performed above the
level of the supraorbital rim to include the frontal
sinus. usually approximately 3x3x3.5 cm size.
• The frontal sinus which has been opened by this
manoeuvre is cleared of its mucosa and the posterior
wall removed combined with a wide dissection of the
dura.
• Dissection around the cribriform plate and crista galli is
facilitated by the use of the operating microscope.
• This dissection continues until the cribriform plate is
exposed and continues on to the jugum of the
sphenoid.
• In cases of olfactory neuroblastoma routinely the
olfactory bulb and tracts are removed in continuity.
• The anterior and posterior ethmoidal arteries are
coagulated with the bipolar diathermy although care
must be exercised as the
Dr.V
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ino
p
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c nerve is approached.
31.
32.
33. • Osteotomies are performed around the cribriform plate
through the ethmoidal and sphenoid roofs.
• The posterior osteotomy crosses the planum sphenoidale to
include the anterior face of the sphenoid and the nasal
septum is separated by quadrilateral cuts.
• The specimen is mobilized this can be removed, haemostasis
achieved and the cavity inspected for further resection.
• fashion a large middle meatal antrostomy to prevent
subsequent infection.
• dura has small defects which can be repaired primarily but
more with fascia lata held in place with fibrin glue to which a
split-skin graft taken from the thigh is applied inferiorly.
• The frontal bone flap is replaced and secured with miniplates.
• The periosteum and subcutaneous layer is closed with
absorbable sutures and skin with clips or fine skin sutures. A
pressure dressing is appliedD
r
.
V
ti
n
oo
d
bM
oKth the head and leg.
34. POST OP CARE
• Patients are kept in a neutral position of
approximately 15 degree for the first 2 or 3
days and then gently elevated.
• The urinary catheter is removed on the
second or third day and facial sutures after 5–
7 days.
• The anticonvulsant is continued for 6 weeks
following the operation and patients must
douche the nose long term.
36. MIDFACIAL DEGLOVING
Dr.Vinod M K
• The degloving approach affords excellent access to the middle third of the
face.
• Indicated in malignant tumours affecting the nasal
cavity,maxilla,ethmoids,sphenoid, pterygopalatine and infratemporal
fossae.
INCISION
• After temporary tarrsoraphies, a bilateral sublabial incision is made from
maxillary tuberosity to tuberosity down to bone
• Routine rhinoplasty intercartilaginous incisions are made extending into a
transfixion incision along the dorsal and caudal borders of the
cartilaginous septum,separating it from the medial crura of the lower
lateral cartilages.
• The circumferential incisions are joined across the floor of the nose just
anterior to the pryriform aperture.
38. Dr.Vinod M K
• The soft tissues of the midface are elevated
subperiosteally up to the infraorbital nerve on each
side to display the pyriform aperture.
• The soft tissues over the nasal bridge are elevated as
far as the root of the nose and laterally to complete the
mobilization from below so that the mid-third of the
face is completely elevated and can be lifted superiorly
over the nasal skeleton.
• nasal cavities and maxillary sinuses can be opened
using drills, hammers and osteotomes.
• maxillary and sphenopalatine arteries accessed and
ligated
39.
40.
41. • ethmoids, sphenoid, nasopharynx and structures
posterior and lateral to the maxillae are reached
for further resection.
• Closure of the incisions must be done with care
to avoid complications, using absorbable suture
material.
• The bridge of the nose may be taped or a
rhinoplasty dressing applied for a few days.
• After pack removal patients advised to use saline
douching daily until crusting settles.
42. LATERAL
RHINOTOMY
• Indicated in any malignant tumour affecting the
nasal septum,lateral wall and extending into
ethmoid, sphenoid, maxillary sinuses and up to
the anterior skull base
INCISION
• After a temporary tarrsoraphy, the incision runs
from the level of the medial canthus, midway
between the canthus and nasal bridge in the
nasomaxillary groove, curving round the lower
ala into the nasal cavity
43. TECHNIQUE
• Through the incision, the orbital periosteum can be
dissected from the lamina and the nasolacrimal duct
mobilized.The duct can be transected obliquely adjacent to
the sac.
• Anterior and posterior ethmoidal arteries ligated
• An en bloc or piecemeal removal of lateral nasal wall done
including the pyriform aperture,nasal bone,frontal process
of maxilla,anterior maxillary wall,medial orbital wall and
rim,ethmoids lamina pipyracea and lacrymal fossa
depending upon extend of tumour.
• The sphenoid sinus can be opened,frontal can be
accesed,orbital periosteum can be resected if required
44. MAXILLECTOMY
• Malignant tumors of maxilla involving all walls
with/without orbital extension.
INCISION
-Weber-Fergusson incision extends 1cm lateral to the lateral
canthus and medially 3mm below the lower eyelash.at medial
canthus incision curves inferiorly into nasomaxillay groove
down to alar margin.it continues medially to the midline
where it turns at right angle dividing the upper lip.
-incision extends round the upper alveolus in the
gingivobuccal sulcus upto maxillary tuberosity.medially
incision pass to hard palate between the central incisors as far
as junction of hard and soft palate,then crosses laterally to the
poserior aspect of maxillary tuberosity
45.
46. TECHNIQUE
• The entire soft tissue of cheek are raised subperiosteally off
the maxilla from the pyriform apperture to the zygomatic
arch including buccinator
• The orbicularis oculi left intact around the eye but the
orbital periosteum is incised at the bony rim allowing
dissection of orbital contents.infraorbital neurovascular
bundle is cut at the infra orbital foramen.
• Osteotomies are made through the zygoma beneath the
infraorbital rim,across the frontal process of maxilla,into
pyriform fossa,inferiorly through the central upper
alveolus.lateral nasal wall divided below the superior
turbinate.
• Mobilization of maxilla completed by seperating the
tuberosity from the pterygoid plates.
47.
48.
49. • A variety of reconstructions are available.
• At its simplest,a split skin graft can be applied to the
cavity wall held in place with quilting
incisions,biological glues,and a temporary gutta percha
prosthesis.
• Alternatively a free flap can be utilized, e.g. rectus
abdominis, latissimus dorsi, radial or fibula
osteocutaneous flaps with osseointegration
• Repairing lost orbital support decreases the risk of
globe malposition, diplopia and disturbance of
extraocular muscle function.
• Small defects in the floor can be left, larger ones can be
repaired using a fascia lata sling secured to the margins
of the bony defect
50. • Extensive spread of the tumour anteriorly into
the facial skin may necessitate sacrifice of this
with repair using a local pedicled or free
microvascular flap.
• More frequently, extension occurs posteriorly
into the pterygoid region which adversely affects
prognosis.
• Limited areas of pterygoid muscle can be
removed.
• clearance of the pterygopalatine and
infratemporal fossae can be undertaken.
51. Reconstruction and Prosthetic Rehabilitation
Aim :
• - prevent contracture of the check
• -to separate oral & nasal cavities
• -to provide support for the globe .
• -An obturator should be made preoperatively
from an impression of the hard palate
52.
53. Tumours with bad prognosis
1 Advanced maxillary cancer .
2lesions involving pterygoid plates or
pterygopalatine fossa .
3lesions involving brain , dura , nasopharynx ,
sphenoid .
4 lesions involving orbital contents
54. FOLLOW UP
• 3 mths after Rx
- baseline physical examn
- CT, MRI or PET CT
• 1st 3 yrs – every 4 mths
• 4th & 5th yr – every 6 mths
• Then - annually