*Important Notice : Guided tours to the Parliament Chamber are suspended until further notice as a preventative measure in response to Covid-19


J. Stephen Dummer, M.D.

  • Professor
  • Departments of Medicine and Surgery
  • Vanderbilt University School of Medicine
  • Chief
  • Transplant Infectious Diseases
  • Vanderbilt University Hospital
  • Nashville, Tennessee

Quality of life issues are a very important concern for individuals (especially teenagers) with acne hypertension and stroke exforge 80mg with amex. The follicular wall ruptures and bacteria arrhythmia kardiak order genuine exforge on line, sebum, and other follicular components are released in to the dermis creating an inflamed nodule. Several other factors such as genetics and emotional stress and affect the development and severity of acne. Inflammatory papules and/or pustules may develop in early to mid-teen years and are usually confined to the face, but the neck and back may be affected. Acne is typically a chronic disorder that does not begin to resolve until the late teens. Physical Examination Acne typically presents with 4 types of lesions, comedones, inflammatory papules, pustules, and nodules. In the past the term "cystic acne" was used, but acne does not have true cysts with an epithelial lining. These are usually the first lesions of acne seen in early adolescence and are typically on the central face. Acne lesions are usually primarily on the face, but can also occur on the neck, upper trunk, and shoulders. As acne lesions resolve they may leave pink macules that may persist for many weeks or areas of hyperpigmentation that may last for months. These macular lesions are often as cosmetically bothersome to a patient as the active acne lesions. Inflammatory lesions may leave permanent scars that may be indented (ice pick scars), atrophic, or hypertrophic. Acne may be classified as mild, moderate or severe depending on the number and/or size of the lesions and the extent of the lesions. Management There are many factors to consider in the treatment of acne including the following. Bacterial cultures of pustules could be done if gram-negative folliculitis is suspected. In general generic dermatologic medications are much more affordable than branded medications. Diagnosis the key diagnostic findings are the presence of comedones and inflammatory papules, pustules or nodules typically on the face, neck, or upper trunk. Differential Diagnosis Milia: Resemble closed comedones and have the appearance of a tiny, white, firm bead. Keratosis pilaris: Very common finding in prepubescent children and may persist in to adulthood. It presents with 1- to 2-mm keratotic papules typically on the cheeks and upper arms. Table 15-2 lists formulations and brand names of several of the more commonly used topical medications. Table 15-3 lists dosage, dosing, and some of the adverse effects of oral antibiotics that are commonly used as first-line treatment for acne when oral antibiotics are indicated. Medication used for the Treatment of Acne Topical retinoids decrease the cohesiveness of the keratinocytes in the follicular opening, reduce the number of visible comedones, and inhibit formation of microcomedones. They are effective as monotherapy for comedonal acne and in combination with other medications for all other forms of acne. Dryness, redness, and peeling are common side effects with initial use, but these often resolve or improve with continued use. It is best to start with a low concentration of a retinoid and increase as tolerated. Disease Acne Clinical Findings Comedones, inflammatory papules, and/or pustules or nodules typically on the face. May also occur on neck and upper trunk Erythema, telangiectasia, inflammatory papules, and/or pustules on central face. No comedones Perioral erythema with or without scale with papules and/or pustules Perifollicular inflammatory papules or pustules in hair-bearing areas Inflammatory papules and abscesses in axillae and inguinal areas. Sinus tracts and scarring may be present Notes Onset after puberty, but may persist in to adulthood Rosacea Perioral dermatitis Folliculitis Hidradenitis suppurativa Onset usually after age 30. Generic Name Retinoids Tretinoin* Adapalene* Retin-A, Avita, Refissa, Tretin-X Differin Cream, 0. Pregnancy category C May be helpful in patients who cannot tolerate benzoyl peroxide without hydrocortisone. Benzoyl peroxide may cause irritant or allergic contact dermatitis and it may bleach fabrics. Salicylic acid is a mildly keratolytic agent that is present in many nonprescription medications. Medication Tetracycline* Doxycycline* Minocycline* Formulations 250, 500 mg 50, 100 mg 50, 100 mg Dosing 500 mg once daily to twice daily 50-100 mg once daily to twice daily 50-100 mg once daily to twice daily Notes Needs to be taken on empty stomach. Potential adverse effects include skin discoloration, vertigo and other central nervous system symptoms, hepatitis, and lupus-like syndromes. Pregnancy category B Erythromycin* 125, 250, 333 mg 250-500 mg once to twice daily *Generic availability for some or all formulations. Topical combination acne medications typically contain a retinoid or benzoyl peroxide with an antibiotic or with each other. In general, they are much more expensive than their constituents used separately, but they are easier to use and have better patient acceptance and adherence. Tetracycline, doxycycline, and minocycline are the most commonly used antibiotics for acne because of their antibacterial and anti-inflammatory effects. These antibiotics should not be used by pregnant or nursing females or by children under age 8. Doxycycline and minocycline are generally recommended in the literature as the antibiotics of first choice. Amoxicillin is also occasionally used for patients who have gastrointestinal symptoms with other antibiotics. Isotretinoin is a teratogen with a very high risk for severe birth defects if taken during pregnancy in any amount, even for a short period of time. There are several other potential adverse effects (eg, cutaneous, neurological, skeletal, and lipid disorders) associated with isotretinoin. Evidence-based guidelines still recommend the use of isotretinoin in the appropriate patient. Several guidelines based on evidence-based medicine have been published for the treatment of acne. The following are treatment options for various types of acne based on these guidelines. Treatment Options for Acne3,5 Comedonal acne: Topical retinoids are the first-line treatment for comedonal acne. Papular/pustular acne: Mild disease: First-line therapies include a topical retinoid plus a topical antibiotic. If the patient does not respond or if the patient has severe disease oral antibiotics plus a topical retinoid plus benzoyl peroxide gel or wash are first-line therapies. Alternative therapies include switching to another type of topical retinoid plus another type of antibiotic plus benzoyl peroxide. However limiting milk intake and a low glycemic index diet may be of some benefit in acne. Adherence is generally improved by counseling and education on the cause of acne and proper use of medications, addressing cost issues and other pitfalls of treatment plans, and the use of medication reminders (eg, text messages from the clinic or medication reminder apps). Indications for Consultation Patients with acne who do not respond to therapy or who may be candidates for isotretinoin therapy should be referred to dermatology. Nodular acne: the first-line therapy for nodular acne includes an oral antibiotic plus a topical retinoid plus benzoyl peroxide gel or wash. Patients who do not respond to therapy could be switched to another oral antibiotic or another type of topical retinoid. If the patient still has persistent nodular acne, they may need a referral to dermatology for management that might include the use of oral isotretinoin therapy. Patients with severe nodular acne that is unresponsive to therapy could be left with permanent scars if they receive suboptimal treatment. Benzoyl peroxide gel or wash should be used with topical or oral antibiotics to reduce the risk of bacterial resistance to antibiotics.

Clinical features: the pain is dull blood pressure chart age 35 order exforge paypal, situated in the back and in front without any radiation blood pressure medication when pregnant generic exforge 80mg with visa. At times, the lesion is revealed by laparoscopy, hysteroscopy or laparotomy Treatment: the treatment aims at the cause rather than the symptom. During premenstrual period, due to pelvic congestion or increased blood flow, there may be marked engorgement in the vein pressure on ureter stasis infection pyelonephritis pain. The pain is usually located on one side and does not change from side to side according to which ovary is ovulating. It may be associated with slight vaginal bleeding or excessive mucoid vaginal discharge. The probable factors are: (i) Increased tension of the Graafian follicle just prior to rupture, (ii) Peritoneal irritation by the follicular fluid following ovulation and (iii) Contraction of the tubes and uterus. In obstinate cases, the cure is absolute by making the cycle anovular with contraceptive pills. The patient has a congestive type of dysmenorrhea without any demonstrable pelvic pathology. Laparoscopic diagnosis is difficult, as with intraperitoneal pressure and Trendelenberg position, these vessels may be compressed but will reappear as the pressure is reduced. The patient complains of vague disorders with backache and pelvic pain with long standing position, ovarian dysmenorrhea bicornuate uterus unilateral location of pelvic endometriosis small fibroid polyp near one cornu right ovarian vein syndrome colonic or cecal spasm 182 TexTbook of GynecoloGy there is altered estrogen: progesterone ratio or diminished progesterone level. Symptoms must be severe enough to disturb the life style of the woman or she requires medical help. Pathophysiology: the exact cause is not known but the following hypotheses are postulated: (a) Alteration in the level of estrogen and progesterone starting from the midluteal phase. A single oral dose of 20 mg was found to improve the psychiatric and behavioral symptoms significantly. The drugs are usually prescribed at least two days prior to the onset of symptoms and to be continued till menstruation starts. Suppression of ovarian cycle: Suppression of the endogenous ovarian cycle can be achieved by: Danazol 200 mg daily is to be adjusted so as to produce amenorrhea. Primary dysmenorrhea is almost always confined to ovulatory cycle and relieved following pregnancy and vaginal delivery. While primary dysmenorrhea occurs before the age of 20, secondary dysmenorrhea may occur at any age. In ovarian dysmenorrhea, the pain is referred to the area innervated by T10 to L1 segments. Right ovarian vein syndrome is due to engorgement of right ovarian vein premenstrually so as to compress the right ureter with resultant pyelonephritis and pain. Hysterectomy with bilateral salpingo-oophorectomy in patients approaching menopause may be an option. Causes: Menorrhagia is a symptom of some underlying pathology-organic or functional. Emotional upset Functional Due to disturbed hypothalamo-pituitary-ovarianendometrial axis. Definition Polymenorrhea is defined as cyclic bleeding where the cycle is reduced to an arbitrary limit of less than 21 days and remains constant at that frequency. If the frequent cycle is associated with excessive and or prolonged bleeding, it is called epimenorrhagia. Hyperstimulation of the ovary by the pituitary hormones may be the responsible factor. While metrorrhagia strictly concerns uterine bleeding but in clinical practice, the bleeding from any part of the genital tract is included under the heading. Causes the causes may be local (uterine synechiae or endometrial tuberculosis), endocrinal (use of oral contraceptives, thyroid dysfunction, and premenopausal period), or systemic (malnutrition). Incidence the prevalence varies widely but an incidence of 10 percent amongst new patients attending the outpatient seems logical. The bleeding may be abnormal in frequency, amount, or duration or combination of any three. Pathophysiology the physiological mechanism of hemostasis in normal menstruation are: (1) Platelet adhesion formation. The endometrial abnormalities may be primary or secondary to incoordination in the hypothalamopituitary-ovarian axis. It is thus more prevalent in extremes of reproductive period-adolescence and premenopause or following childbirth and abortion. Emotional influences, worries, anxieties, or sexual problems sometimes are enough to disturb the normal hormonal balance. The follicular development is speeded up with resulting shortening of the follicular phase. Rarely, the luteal phase may be shortened due to premature lysis of the corpus luteum. Endometrial study prior to or within few hours of menstruation reveals secretory changes. There is undue prolongation of the proliferative phase with normal secretory phase. Irregular shedding of the endometrium the abnormality is usually met in extremes of reproductive period. In irregular shedding, desquamation is continued for a variable period with simultaneous failure of regeneration of the endometrium. Endometrial sampling performed after 5th or 6th day of the onset of menstruation reveals a mixture of secretory and proliferative endometrium. Irregular ripening of the endometrium There is poor formation and inadequate function of the corpus luteum. Secretion of both estrogen and progesterone is inadequate to support the endometrial growth. The endocrine profile in the luteal phase shows persistent low level of urinary pregnanediol level of less than 3 mg or plasma progesterone level less than 5 ng/mL. Endometrial study prior to or soon after spotting reveals patchy area of secretory changes amidst proliferative endometrium. In the absence of growth limiting progesterone due to anovulation, the endometrial growth is under the influence of estrogen throughout the cycle. As there is no ovulation, the endometrium is under the influence of estrogen without being opposed by growth limiting progesterone for a prolonged period. After a variable period, however, the estrogen level falls resulting in endometrial shedding with heavy bleeding. Bleeding also occurs when the endometrial growth have outgrown their blood supply. Due to increased endometrial thickness, tissue breakdown continues for a long time. Bleeding is prolonged until the endometrium and blood vessels regenerate to control it. On naked eye examination, the endometrium looks thick, congested and often polypoidal (multiple polyposis). Microscopically (a) There is marked hyperplasia of all the endometrial components. There is however, intense cystic glandular hypertrophy rather than hyperplasia with marked disparity in sizes. In about 30 percent, the endometrium is hyperplastic and in the remaining, there are evidences of irregular shedding, irregular ripening, or atrophic pattern. Investigations the investigation aims at: To confirm the menstrual abnormality as stated by the patient.

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These include inflammatory arteria iliaca comun buy exforge 80mg low cost, infectious prehypertension nhs buy generic exforge pills, neoplastic, and photodermatoses (see Table 32-1). The distribution of skin lesions is often helpful in diagnosing skin diseases located on the arms. Viral and bacterial cultures can be performed if primary or secondary infection is suspected. Skin biopsies can be done if the clinical presentation is atypical or otherwise equivocal. Rarely, mildly pruritic Allergic contact dermatitis Common F>M Age: any age Pruritic and painful fissures. M = F Onset at any age but peaks in 20s and 50s Uncommon F>M Age: 30-60 years Common F>M Age >20 years. More common in atopic patients Common M>F Age: bimodal; peaks in young adults and the elderly Common M:F unknown Age: all. More common in hot humid areas, farms, and crowded living conditions Asymptomatic or mildly pruritic. Chronic Associated with arthritis Family history of psoriasis Pruritic or symptomatic Lasts months to years May be drug-induced or associated with hepatitis C Paroxysmal episodes of pruritus disproportionate to external stimuli (eg, changing clothes). Emotional stress may exacerbate Pruritic Chronic waxing and waning course Associated with dry skin Lichen planus Lichen simplex chronicus Nummular eczema Infectious Tinea corporis Mild pruritus History of contact with infected people or animals. Lin Noah Goldfarb Evaluation / 274 Hands have structures with many unique structural and functional features. Hands are often the first body part to come in to contact with objects and substances in our environment. As a result, they are frequently the site of exposure to allergens, irritants, and infectious agents. This concept is central to the transmission of pathogens and development of certain dermatologic conditions such as contact dermatitis. Given their distal location, the neurovascular supply of hands (particularly the digits) can also predispose the hands to neuropathies, ischemic insults, and vasculitides. Hands tend to get more sun exposure than centrally located anatomical structures thereby subjecting them to photodermatoses and actinic damage. Sunlightinduced dermatoses and connective tissue disorders present on the dorsal hands with pink papules and plaques. Widespread actinic keratoses on the hands are also included in this chapter because they are sometimes misdiagnosed as a "rash. Tinea manuum may be clinically indistinguishable from inflammatory dermatoses such as dermatitis and psoriasis. Patch testing should be done if allergic contact dermatitis is a likely diagnosis. Viral and bacterial cultures can be done if primary or secondary infections are suspected. A thorough history with review of systems and physical exam are very important for cutaneous manifestations of internal disease and connective tissue disorders. Suspicion for these diseases may prompt further evaluation with appropriate diagnostic studies. May be only manifestation of disease Uncommon F>M Onset: 50-60 years of age Uncommon F>M Age: 30-60 years Pruritic and sometimes painful Chronic course with exacerbations Triggers: frequent hand washing or wet work Usually worse in winter Family history of atopy Very pruritic Chronic and recurrent, episodes last 2-3 weeks. Exacerbated by sweat and stress Painful fissures or pruritic Chronic indolent course May have arthritis and family history of psoriasis Pruritus, burning, pain Lasts years Waxing and waning course Asymptomatic or pruritic Lasts months to years May be drug-induced or associated with hepatitis C infection Asymptomatic or painful. On dorsum presents with annular red patch/plaque with peripheral scale at leading edge. Nails may be affected Grouped and confluent vesicles on red edematous base on a distal digit (continued) Psoriasis vulgaris Palmoplantar pustulosis Lichen planus Infectious Warts Common M>F More common in children and young adults Uncommon M>F Tinea manuum Asymptomatic or pruritic. Disease Neoplastic Actinic keratoses Common M>F Age: >40 years Asymptomatic or tender Duration: months to years Risk factors: advancing age, cumulative sun exposure, outdoor occupation, and fair skin type Pruritus or burning Duration: weeks to months Maybe related to sun exposure. In many people it is a site of minimal sunlight exposure as it is usually covered by clothing. Dermatoses within this distribution may be caused by an allergic contact dermatitis due to chemicals in clothing, soaps, dryer sheets, and other allergens. Since the trunk is generally covered by clothing, this occlusion often creates a warm, humid environment ideal for the development of diseases such as folliculitis, acne, and tinea versicolor. A high density of sebaceous glands in the presternal area may provide an ideal location for pityrosporum ovale yeast proliferation, making this a common location for seborrheic dermatitis. Skin folds, such as the abdominal skin folds and inframammary creases are prone to intertrigo and/or maceration, increasing the risk of developing cutaneous candida infections among other dermatoses. Interestingly some conditions including psoriasis and scabies often favor this site. The trunk is the area of the body that is most involved in diseases such as morbilliform drug rashes, guttate psoriasis, tinea versicolor, and pityriasis rosea. Skin biopsies can be done if the clinical presentation is equivocal or if Grovers disease or folliculitis due to pityrosporum is suspected. Typical locations: axillae, waistline, and umbilicus Red papules and plaques with silvery, thick, adherent scale typically on lower back, umbilicus, buttocks, and gluteal cleft. Chronic May have history of arthritis and family history of psoriasis Seborrheic dermatitis Common M>F Age: bimodal; peaks in infancy and adulthood Common F>M Age: any, most common in children and young adults Seen in fall or spring Asymptomatic or mildly pruritic. Intermittent with seasonal variation Pityriasis rosea Variable pruritus, sometimes preceding nonspecific "flu-like" symptoms Spontaneous remission in 6-12 weeks Begins with a herald patch, an oval, slightly elevated, salmon pink 2-5 cm plaque with trailing collarette scale. Spread by direct contact with infected humans, animals, soil, or autoinoculation from a dermatophyte infection present on other locations Variable pruritus. Disease Infectious Infectious exanthems Common Age: <20 years Viral pathogen most common, can be bacterial, mycoplasmal, rickettsial, or other Uncommon M>F Age: 15-40 Risk factors: men who have sex with men Common M:F unknown Age: any age, but usually >50 years Common Teens: M > F Adults: F > M Age: adolescents and young adults Common F>M Age: any, most common in hospitalized patients Prodromal symptoms including fever, malaise, coryza, sore throat, nausea, vomiting, diarrhea, abdominal pain, and headache Usually precedes cutaneous eruption by up to 3 weeks History of asymptomatic, genital ulcer several weeks to months prior to onset of rash. May be present or shortly precede onset of eruption Severe pain, paresthesias, or pruritus precedes eruption. History of recent changes or adjustments to medications Risk factors: elderly, concomitant viral infection Morphology and distribution extremely variable, virtually every cutaneous reaction may be seen. Lin Evaluation / 280 the legs are predisposed to dermatoses that are gravity dependent, including stasis dermatitis and vascular conditions such as leukocytoclastic vasculitis, the pigmented purpuric dermatoses, and livedo reticularis. Legs are also the site of frequent trauma and thus are susceptible to conditions that may be induced by trauma including superficial thrombophlebitis, pyoderma gangrenosum, necrobiosis lipoidica, chronic ulcers, and cellulitis. In patients with preexisting vascular conditions affecting the lower extremities, including diabetes mellitus, venous insufficiency, and peripheral vascular disease, traumatic wounds may take longer to heal and may have an increased risk of infection. Differentiating between these conditions can usually be done based on an appropriate history and physical examination. Occasionally, dermatitis on the lower extremities may be difficult to distinguish from a cellulitis. Cellulitis of the lower extremities tends be unilaterally, as compared to dermatitis, which usually is bilateral. The diagnosis of erythema nodosum and necrobiosis lipoidica can be made from the history and physical exam alone, but many clinicians obtain a skin biopsy to confirm the clinical diagnosis. Skin biopsies for routine histology and direct immunofluorescence should be done in all patients with suspected leukocytoclastic vasculitis to confirm the diagnosis and evaluate for IgA deposition. Basic laboratory tests should also be done to evaluate for renal or liver involvement. A skin biopsy for routine histology and tissue culture for bacterial, deep fungal, and atypical mycobacterium infections should be performed in patients with suspected pyoderma gangrenosum. While the skin biopsy is nonspecific, a biopsy is required to exclude other diagnoses, since pyoderma gangrenosum is a diagnosis of exclusion. Skin biopsy on the lower extremity should be done with caution because wounds in this area heal more slowly and become infected more often. This is especially pertinent in patients with preexisting vascular conditions affecting the lower extremities, including diabetes mellitus, venous insufficiency, or peripheral vascular disease. Disease Inflammatory Asteatotic dermatitis Common M>F Age: typically >60 years Common F>M Age: middle-aged and elderly adults Common M>F Age: Adults Common M = F. May be associated with arthritis Family history of psoriasis Tender lesions Variable course May be associated with fevers and arthralgias Painful. Disease Systemic Diabetic dermopathy Uncommon M:F unknown Age: usually >50 years Uncommon F>M Age: young adults Asymptomatic Appears in crops. Slowly resolves with scarring Usually asymptomatic, but may ulcerate and become painful. The combination of abundant keratin and sweat creates an ideal environment for fungal infections.

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The inferior exuberant keloid scar shows the site of tracheostomy required to support the airway blood pressure medication that starts with c buy exforge 80mg. This involves the insertion of tracheostomy tubes of decreasing diameter until the patient can breathe with the tube occluded pulse pressure for dengue exforge 80 mg without a prescription. Tracheal stenosis may be the end result of scarring caused by inflatable cuffs or incorrect tracheal incisions. Adequate humidification, tracheal suction as required and physiotherapy will keep the chest free of secretions and prevent complications due to crusting. Most complications of tracheostomy are due to improper surgical technique, inflated cuffs or incorrectly shaped or sited tracheostomy tubes. The primary feature may be pain, but its severity may lead to dysphagia for solids, liquids and occasionally saliva. Candidal infection can give rise to a painful throat and is not uncommon in the immunocompromised. Treatment may be either local antifungal agents or parenteral administration if the patient also has systemic infection. Sore throats in adults Acute inflammatory lesions of the pharynx are very common and settle down rapidly as the immune system, with or without antibiotics, overcomes the causative organism. Miscellaneous conditions Blood disorders may present with lesions causing sore throats. Streptococcus is occasionally the primary causative organism rather than a secondary invader following a virus. Associated cardinal symptoms, such as weight loss, dysphagia, hoarseness, and a history of smoking and excessive alcohol intake, make such a diagnosis more likely. Management involves conservative measures to reduce or abolish the effect of irritating agents and tonsillectomy in selected cases. Peritonsillar abscess A peritonsillar abscess is a condition in which pus forms between the tonsil capsule and the superior constrictor muscle. If an abscess is suspected, management involves incision and drainage of the abscess and parenteral antibiotics. Complications of tonsillitis are infrequent, but spread of infection may lead to abscess formation in the peritonsillar, retropharyngeal or parapharyngeal spaces. Alcohol Chronic non-infective laryngitis Infectious mononucleosis Infectious mononucleosis (glandular fever) is commonly seen in teenagers and presents as an acute sore throat. These children do not require antibiotic therapy, but are managed conservatively by ensuring sufficient fluid intake, simple analgesics and bed rest so that spontaneous resolution may occur. Throat swabs are generally unhelpful in management as the most common organism isolated is Streptococcus. Treatment of acute tonsillitis is with bed rest and administration of antibiotics such as penicillin, with maybe the first dose parenterally. Maintenance of fluid intake is important, and paracetamol provides suitable analgesia and acts as an antipyretic in lowering the temperature. Think of infectious mononucleosis in teenagers, particularly if the tonsils are covered with a membranous exudate. The child is systemically unwell, there is dysphagia, halitosis, pyrexia, together with cervical lymphadenopathy. Tonsillectomy for peritonsillar abscess (quinsy) is only recommended if there is a past history of recurrent tonsillitis. The tonsils are usually symmetrical so that tonsillectomy for unilateral enlargement is necessary if a diagnosis of neoplasia is being entertained. More recently it has become apparent that the tonsils, usually in association with the adenoids in children and the uvulopalatal area in adults, may be a cause of snoring and the more sinister obstructive sleep apnoea. Procedure the tonsillectomy is performed under general anaesthesia by dissecting the tonsil from its bed. In children the blood pressure may be well maintained owing to a rise in the pulse rate until the cardiovascular system suddenly decompensates. It invariably resolves with antibiotics, only rarely requiring formal vessel ligation or transfusion. Snoring and Tonsillectomy and adenoidal conditions Nasal obstruction discharge 75 Secretory otitis media, acute otitis media Hyponasal speech Snoring and sleep apnoea. The child speaks as if he or she has a constant cold, with a low-pitched, lifeless tone. In children a paediatric flexible nasal endoscope is the most reliable way to assess the state of the adenoids. Increasingly, adenoidectomy is performed, under vision, using a postnasal space mirror and suction diathermy ablation. Tonsillectomy and adenoidal conditions Asymmetry in size of tonsils may be an indication for tonsillectomy. Secretory otitis media is frequently caused by Eustachian tube dysfunction secondary to adenoidal hypertrophy. Hypernasality is a severe handicap and may result if adenoidectomy is performed in children with a short or cleft palate. Adenoidectomy the indications and contraindications to adenoidectomy are summarized in Table 3. It is important to establish the precise symptoms, as a feeling of a lump in the throat is not as sinister a complaint as an actual sticking of food. Regurgitation of food and/or drink Weight loss Feeling of something in throat + dysphagia Otalgia Clinical features Pharyngo-oesophageal lesions may give rise to a feeling of something in the throat, prior to the development of true dysphagia. Patients with persistence of such a sensation, particularly if associated with certain cardinal features, require full investigation. Referred otalgia is not infrequent in inflammatory and neoplastic lesions causing dysphagia. Investigations the principal investigation is a barium swallow, which outlines the hypopharynx, oesophagus and stomach. In persistent dysphagia, even with normal radiological tests, a pharyngooesophagoscopy is mandatory. Chronic dysphagia Patients with chronic dysphagia require an in-depth history and examination as already discussed. Motor neurone disease results in a similar risk to the airway because of severe incoordination of the swallowing mechanism. Division of the cricopharyngeus (cricopharyngeal myotomy) may relieve dysphagia of neurological origin, as there is a failure of this segment of the lower pharynx to relax. Other causes include swallowed foreign bodies or the ingestion of caustic liquids. This very rare cause of dysphagia is due to an aberrant right subclavian artery coursing posterior to the oesophagus, causing a spiral filling defect. Treatment comprises aggressive medical therapy to counteract the acid reflux, and possible dilatation of the stricture. Regurgitation of undigested food particles is common and overspill may result in a chronic cough and pneumonitis. The pouch may increase in size to such an extent that it compresses the oesophagus to cause dysphagia. Achalasia of the oesophagus Achalasia of the oesophagus is caused by a failure of relaxation of the cardia and abnormal oesophageal muscular tone during swallowing. This results in a stricture at the defective site, with gross proximal dilatation of the oesophagus. The patient usually volunteers that the symptoms are noted particularly during periods of anxiety. It is now felt that in many cases of globus pharyngeus, acid reflux produces a reflex cricopharyngeal spasm leading to the symptom complex. It is therefore reasonable to give a trial of antireflux treatment, which may include simple antacids and proton pump inhibitors. All cases of chronic dysphagia require endoscopy, even in the presence of a normal barium swallow.


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