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To accurately identify a sphenoethmoidal (Onodi) cell generic alendronate 70mg amex womens health twitter, one must be able to recognize the transition from the poste- rior ethmoids to the sphenoid order alendronate online from canada menstrual cycle age 8. This follows the theme of being able to recognize the transition from frontal sinus to anterior Sphenoidotomy (Videos 23 to 27) ethmoids (frontal recess) discount alendronate 70 mg with amex leading women's health issues, to recognize the transition from an- terior to posterior ethmoids, and fnally to be able to recog- After dissection of the posterior ethmoids, the sphenoid nize the transition from posterior ethmoids to sphenoid sinus. Once the solid bony rim of the posterior atus by gently moving the superior turbinate laterally and choanae is identifed, the cell sitting directly above this solid visualizing the recess. If there is any horizontal ethmoidal recess, the sphenoid ostium should be visible in bony septation above this cell in this or subsequent more pos- most patients. The parasagit- the sphenoid ostium may be closed by scar tissue formation tal scan should always be checked as this can be very useful during healing and a sphenoidotomy should be performed in recognizing a sphenoethmoidal (Onodi) cell. The tip of the microdebrider blade is pushed when no middle meatal surgery is necessary such as a pa- against the mucosa just above the bony choanae on the an- tient with isolated sphenoid disease or for pituitary surgery. In the transethmoidal route the already identifed superior Two further indentations are made above this one thereby turbinate is used as the critical landmark for sphenoidot- measuring 12 mm from the bony rim of the posterior choana omy. Once the turbinate is removed fush with the face of the sphenoid directly above the third indentation. The anterior face of the sphenoid, the microdebrider is used to tip of the instrument is pushed through the bone and once palpate the face for the natural ostium of the sphenoid. It it has penetrated the sphenoid cavity it is twisted to enlarge is usually found at the junction of the lower one-third and the opening. A microdebrider or Kerrison punch is then used upper two-thirds but may be as high as the halfway point of to further open the sinus. The natural ostium is opened with the superior turbinate and is usually medial to the turbinate the punch or microdebrider initially inferiorly toward the on the anterior face of the sphenoid6 (Fig. However, There should be at least 8 to 10 mm of anterior face of the in patients with a sphenoethmoidal (Onodi) cell, the natu- sphenoid still above this lateral opening and this newly cre- ral ostium may be lower and more medial as the sphenoid is ated opening should therefore be well below the optic nerve. If the tip of the microdebrider does not fall into the natural ostium, medially and inferiorly as well (Fig. The noid is present then the following measurement technique anterior face of the sphenoid is removed up to the skull base should be followed to open the sphenoid. The bony rim of and laterally to the lamina papyracea and then fnally lowered Fig. The lower one-third of the superior tur- the posterior ethmoids have not as yet been opened. Note rior ethmoids have been sequentially opened the superior turbinate is how the anterior face of the sphenoid sinus is contributed by the sphe- divided into the thirds. The postnasal artery or vertical If the superior turbinate has been completely or partially branch of the postnasal artery is often cut during widening removed by previous surgery, the measurement technique of the sphenoid and requires bipolar cautery (Fig. In described previously is used to locate the position of the patients with signifcant new bone formation, an inferiorly natural ostium of the sphenoid sinus. Resection of part of the based mucosal fap can be elevated and the underlying bone superior turbinate may possibly remove some olfactory neu- drilled away before the fap is replaced. Studies done on olfaction after this technique have not been shown to adversely afect the sense of smell of the patient after surgery. Complications of Sphenoidotomy Epistaxis Bleeding is very common from the posterior nasal artery as it traverses the anterior face of the sphenoid on its way to the posterior septum. The posterior nasal artery is a branch of the sphenopalatine artery and travels horizontally just above the posterior choana (Fig. If this vertical branch is transected (and it often is as the sphenoid ostium is enlarged) a minor bleeder will be seen on the lower opening of the sphenoid. If the sphenoid os- tium is further enlarged inferiorly toward the foor of the sphenoid sinus, the main trunk of the posterior nasal ar- tery can be transected and result in a signifcant bleeder which usually spurts in a horizontal and medial direction.

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Similarly alendronate 70mg line menstruation bright red blood, disruption of the crista terminalis may interfere with normal internodal conduction discount 35 mg alendronate with mastercard zinc menstrual cycle. In contrast purchase alendronate 35 mg amex women's health center vassar, it is located subendocardially, rather than subepicardially, within the triangle of Koch and adjacent to the right fibrous trigone (or central fibrous body). Centrally, the node is more compact and is characterized by an interlacing arrangement of P cells. A: The sinus node lies subepicardially in the terminal groove of the right atrium (right lateral view). C: The right bundle branch is a small cordlike structure that courses along the septal and moderator bands (opened right ventricle). D: In contrast, the left bundle branch represents a broad sheet of fibers that travels subendocardially along the left side of the ventricular septum. It thereby represents the only normal avenue for electrical conduction between the atrial and ventricular myocardium. Thus, during operative procedures involving these valves or a membranous ventricular septal defect, care must be taken to avoid injury to the His bundle. Both regions are characterized by numerous parallel bundles of Purkinje cells and working ventricular myocytes, separated by delicate fibrous tissue (28). During fetal and neonatal life, these conduction bundles are often dispersed or separated within the central fibrous body. The final destination of each bundle within the right or left ventricle is probably determined by its position proximally within the penetrating portion of the His bundle. These accessory pathways are apparently nonfunctional in most individuals, although they may produce ventricular preexcitation in some. Such bypass tracts can be single or multiple and may be identified by electrophysiologic mapping. In contrast, the left bundle branch represents a broad fenestrated sheet of subendocardial conduction fibers that spreads along the septal surface of the left ventricle. As it courses toward the ventricular apex and both mitral papillary muscles, the left bundle branch may separate into two or three indistinct fascicles. Left ventricular pseudotendons also may contain conduction tissue from the left bundle branch (29). Microscopically, the bundle branches consist of Purkinje cells and ventricular myocytes (28). Interestingly, following a right ventriculotomy for reconstruction of the right ventricular outflow tract, the electrocardiogram characteristically exhibits a pattern of right bundle branch block, even though the right bundle has not been disrupted. Cardiac Innervation Because the embryonic heart tube first forms in the future neck region, its autonomic innervation also originates from this level. From the cervical ganglia arise three pairs of cervical sympathetic cardiac nerves, which intertwine as they join the cardiac plexus between the great arteries and the tracheal bifurcation. Several thoracic sympathetic cardiac nerves arise from the upper thoracic ganglia and also join the cardiac plexus. From the parasympathetic vagus nerves emanate the superior and inferior cervical vagal cardiac nerves and the thoracic vagal cardiac nerves, which also enter the cardiac plexus. These nerves then descend from the cardiac plexus onto the heart and innervate the coronary arteries, conduction system, and myocardium. In addition, afferent nerves concerned with pain and various reflexes ascend from the heart toward the cardiac plexus. Transplanted hearts are completely denervated early after transplantation and can respond only to circulating substances, such as catecholamines, but usually not to autonomic impulses. Moreover, because afferent pathways are also lost, coronary obstruction owing to chronic transplant vasculopathy may be associated with undetected myocardial ischemia, because chest pain cannot develop. Examination of Cardiac Specimens General Features Evaluation of cardiopulmonary specimens from patients with congenital heart disease entails more than documentation of the underlying anomalies, although this is certainly important.

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No attempt is made if necessary to combine endoscopic resection with a craniot- to remove tumor from surrounding structures generic alendronate 35mg amex menstruation 6 weeks after giving birth. At the time of surgery cheap 35mg alendronate with mastercard breast cancer metastasis, complete macroscopic resection space to operate then a surgical plane is established between was achieved endoscopically and we felt that there would the tumor and the lamina papyracea or purchase alendronate with amex pregnancy risks after 35, if absent, the orbital be no additional beneft in performing a craniotomy. In the region of the skull base this plane is estab- tient underwent postoperative radiotherapy and to date is lished between the skull base or, if absent, the dura. In most patients crusting is not prob- Neck Clinic felt that he would not be suitable for craniofa- lematic in the long-term although some patients (who have cial resection and so he was ofered endoscopic resection had radiotherapy) can continue to have signifcant crust- and radiotherapy. The tumor was debulked and, after space ing if mucociliary drainage is not reestablished after some was created, a good surgical plane was able to be established months. The tumor was then able to of budesonide diluted in 240 mL of saline is used to wash be dissected of the dura and the orbital periosteum. An en- tive and if successful can be used for months or even years to doscopic medial maxillectomy was performed to improve keep the patient symptom free. Complete macroscopic tumor removal was achieved and the patient ofered postoperative radiotherapy. Douching of the nose with saline is started This chapter presents a detailed overview of this anatomy immediately postoperatively. Crusting will usually continue and the various endoscopic surgical techniques used to ad- for a few months and may worsen during and immediately dress this region. Endoscopic medial maxillectomy for inverted 601–617, x papillomas of the paranasal sinuses: value of the intraoperative 11. Arch Otolaryngol Head Neck Surg sinonasal inverted papilloma including endoscopic medial maxillec- 1996;122(2):122–129 tomy. Endoscopic removal of juvenile angiofbro- Otolaryngol Clin North Am 2006;39(3):619–637, x–xi mas. Otolaryngol Clin North Am 2006;39(3): Laryngoscope 1994;104(5 Pt 1):582–605 639–656, xi Endoscopic Resection of the 17 Eustachian Tube and Postnasal Space The most common tumor of the postnasal space is nasopha- be understood. In these cases be removed and the underlying medial pterygoid muscle recurrent tumor is best managed by external procedures such exposed (Figs. The lateral pterygoid excision if the tumor has not extensively infltrated the sur- muscle attaches to the lateral aspect of the lateral pterygoid rounding structures. If the tumor signifcantly infltrates the sur- the mandibular branch (V3) of the trigeminal nerve is seen rounding tissue, they are removed by traditional techniques (Fig. Directly posterior to V3, in the apex of the fossa with appropriate vascular control. However, there are a small of Rosenmüller, the internal carotid artery can be seen number of rare benign and malignant tumors that occur in the (Figs. Examples of these are the minor salivary gland tumors (benign and malignant), malignant melanomas, and Surgical Approach (Video 50) juvenile angiofbromas. These tumors usually have an identif- able plane and a pushing front which will allow identifcation The nose is prepared in the standard fashion. A pterygopal- of the surgical plane and can be excised endoscopically even if atine fossa block is placed through the mouth and greater there is limited extension into the parapharyngeal space. The frst doscopic resection is appealing as it allows a complete resec- step for this surgery is to remove the posterior half of the tion of the tumor with minimal morbidity in contrast to the inferior turbinate. A large middle meatal antrostomy is done external approaches that have signifcant associated morbid- with exposure of the posterior wall of the maxillary sinus ity. The use of both nostrils allows greater angu- Anatomy lation and, if signifcant bleeding occurs, clearance of blood, so that surgery can continue. This results in the removal of the posterior half of the septum and gives great access to both sides of the postnasal space for the two-surgeon approach.

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Therefore generic 35mg alendronate otc breast cancer fundraising, the ovary becomes a major source of androgens and adipose tissue for estrogen proven alendronate 35 mg breast cancer 88 year old woman. Endometrial estrogenization buy alendronate 70 mg low price pregnancy, timely ovulation, and progesterone withdrawal are the prerequisites for normal menstruation. Patients with oligomenorrhea with clinical estrogen sufficiency (Tanner breast stages 4–5) should be subjected to progesterone challenge (medroxyprogesterone acetate 10 mg/day for 5–7 days) after ruling out pregnancy. If progesterone withdrawal results in bleed- ing, it suggests that the endometrium is adequately primed with estrogen, and the cause of oligomenorrhea is anovulation. Absence of bleeding after with- drawal of progesterone suggests inadequate endometrial priming with estrogen. Patients with abnormalities in the hypothalamo–pituitary–ovarian axis like hypogonadotropic hypogonadism and hyperprolactinemia do not respond to progesterone withdrawal as they are estrogen deficient. Despite estrogen suf- ficiency, some women may not bleed with progesterone challenge and require further evaluation. In what situation a patient with secondary amenorrhea with estrogen defi- ciency may bleed on progesterone challenge test? In addition, patients on progesterone therapy may have progesterone breakthrough bleed despite estrogen insufficiency. Predictors of ovulation help in timing the ovulation and in deciding the fertility period. The markers of ovulation are regularity in menstrual cycles, increased basal body temperature (0. Treatment options depend on the need of patient and are listed in the table given below. Additive/ Primary concern Must First-line second line Hirsutism Lifestyle modification Oral contraceptive pills Antiandrogens Menstrual irregularities Lifestyle modification Oral contraceptive pills Metformin Metabolic abnormalities Lifestyle modification Metformin – (prediabetes/diabetes) Ovulation induction Lifestyle modification Clomiphene citrate Metformin 42. Patients with hirsutism and/or menstrual irregularities should be treated with oral contraceptives. In addition, some progestins have inhibitory effect on 5α-reductase activity and interfere with androgen action. Lone use of antiandrogens is con- traindicated as it may lead to menstrual irregularities (mid-cycle bleed due to deficient progesterone production/action) and can cause under-virilization in the male fetus, if conceived. Spironolactone is the preferred antiandrogen, as its safety and efficacy are well established in clinical practice. It inhibits cytochrome P450-dependent enzymes in the androgen biosynthetic pathway and blocks the androgen receptor. The initial dose is 100 mg per day which can be increased slowly up to 200 mg per day in divided doses and is given for at least 12–18 months. Other antiandrogens like cyproterone acetate, flutamide, and finaste- ride are mildly effective and fraught with adverse effects, hence are less preferred. The patient needs to be reassured that prolonged treatment is required to have an appreciable effect on hair growth, as hair cycle lasts 3–6 months. The effi- cacy of treatment is assessed by thinning of hair, decrease in hirsute score, resolution of acne, decrease in frequency of cosmetic treatment, and objective measurement of hair diameter. What are the possibilities when an adolescent girl with hirsutism who is on oral contraceptives shows suboptimal response or worsening of hirsutism with treatment? This results in a decrease in ovarian hyperandrogenism, thereby provides a conducive milieu for follicular growth and development and regularizes menstrual cycles. It was advised to continue metformin till the end of first tri- mester as it was thought to prevent fetal wastage (by facilitating timely oocyte maturation and improvement in luteal function), and possibly dysglycemia.

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