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It relays information between the areas of the subcortex to the cerebral cortex erectile dysfunction due to diabetic neuropathy purchase discount red viagra on-line, regulates consciousness erectile dysfunction 19 year old male purchase red viagra from india, regulates sleep erectile dysfunction medication cialis purchase online red viagra, and regulates alertness erectile dysfunction vacuum discount 200 mg red viagra fast delivery. It gets its blood supply from many branches of the posterior cerebral artery (paramedian erectile dysfunction pills side effects buy red viagra visa, inferolateral impotence what does it mean quality 200mg red viagra, posterior choroidal). There are three parts to the thalamus, they are bulb-shaped masses that are approximately 5. The neurohypophysis secretes two very important hormones: Oxytocin and Vasopressin. The basal ganglia are important in many functions, namely motor control and learning. The main components of the basal ganglia are the Striatum, Pallidum, Substantia Nigra, and the Subthalamic Nucleus. The substantia nigra contains large levels of melanin within dopaminergic neurons, these structures are dark and thus stand out from the rest of the surrounding structures. The pars compacta acts as an input to the basal ganglia circuit, supplying the striatum with dopamine. The pars reticulata serves as an output, which conveys signals from the basal ganglia to numerous other structures. The signals exiting the subthalamic nucleus are glutaminergic, which are excitatory. These signals travel to many different structures including the substantia nigra, lateral pallidum, and medial pallidum. The blood-brain barrier is formed by the Arachnoid, Intracerebral capillary endothelium, and Choroid Plexus endothelium. Ultimately, all of the dural venous sinuses will empty into the internal jugular vein. Injuries to the head can cause bleeding into the brain (hemorrhages, clots, hematomas). It is a highly conceptual topic, and full understanding of these concepts is essential to success on the Step 1 exam. Causes an increase in sodium reabsorption, increase in potassium secretion, and increase in hydrogen secretion. It is located strategically in a location that allows it to maximally regulate these functions (located between the vascular pole of the renal corpuscle and the distal convoluted tubule). Free Water Clearance Filtration Fraction the filtration fraction represents the proportion of fluid that reaches the kidney which passes to the renal tubules. Angiotensin 2 binds to receptors in the intraglomerular mesangial cells, stimulating the release of aldosterone from the zona glomerulosa of the adrenal cortex. Cl- and K+ are transported into the lumen, which is necessary for secretion of acid. H+ pumped out of the cell and into the lumen in exchange for K+ through a proton pump. The following illustration puts all of the above information into play, significantly simplifying your understanding of the whole process. Intracellular enzymes separate T3 and T4 from the protein Free T3 and T4 enter the circulation *T3 provides negative feedback to the anterior pituitary. Isovolumetric Contraction this is the point between the closure of the mitral valve and the opening of the aortic valve. Systolic Ejection the heart squeezes and blood is ejected through the aortic valve. This phase can be considered the phase between the time the aortic valve opens and closes. Isovolumetric Relaxation this is the period of time between the closure of the aortic valve and the opening of the mitral valve. Rapid filling phase After the opening of the mitral valve, blood pools rapidly into the left ventricle. This rate does not create a ventricular rate of 100 because the sympathetic and parasympathetic fibers have the ability to control how much gets through. This results in a slow conduction velocity that helps to prolong transmission from the atria to the ventricles. Acutely, cardiac output will increase due to stroke volume increases, whereas chronically cardiac output is a result of an increase in heart rate. Preload is increased when there is an increase in blood volume, sympathetic stimulation, and even exercise. Vasodilators will decrease the afterload, this includes most commonly drugs like hydralazine. This law explains that synchronization of cardiac output and venous return occurs without needing external factors to come into play. The classic presentation is the "sawtooth" pattern, which occurs as a result of identical back-to- back depolarizations. Calcium is released and binds to troponin C, which leads to the conformational change (moving tropomyosin out of the myosin-binding groove on actin filament) 3. Increases in efferent sympathetic activity and decreased efferent parasympathetic stimulation, leading to . There are different methods by which fluid is moved, it can either be pushed out of the capillary (capillary pressure), or it can be moved via osmotic pressure, where it is pulled. Determining whether fluid will move into or out of the capillary is based on the net filtration pressure. Perfusion limited is seen in healthy people, whereas diffusion limited occurs in those with emphysema, fibrosis, or when exercising. The question may come in the form of a definition, but it will most likely come in the form of a chart where you will have to calculate. If there is a mismatch, this indicates that there is a shunt and some degree of dead space in the same lung. A V/Q of 0 is indicative of a shunt (ie airway obstruction) A V/Q of is indicative of an obstruction of blood flow (ie physiological dead space). The metabolic pathways are very important; paying special attention to regulatory steps is crucial. While the details of biochemistry are not high-yield, the big picture as a whole is very high-yield material. The antibody or antigen that is added is linked to an enzyme, then a test solution is added to see if an intense color illuminates, indicating that there is a positive result. These proteins are then transferred to a membrane where they are probed using antibodies specific to the target protein. This technique allows for the detection of cellular control by determination of gene expression levels during differentiation and morphogenesis. The nucleotides belonging to the pyrimidine group are: Cytosine, Uracil, and Thymine. There are two types of chromatin, there is "heterochromatin", which is condensed and transcriptionally inactive, and there is euchromatin, which is looser and transcriptionally active. Double-Strand Damage: Three mechanisms exist to repair double-stranded damage, they are: 1. Those afflicted with this disease are extremely sensitive to sunlight and have a significantly high risk for skin cancer. Symptoms include: photosensitivity, brittle hair and nails, scaly skin, protruding ears, physical and mental retardation, and a receding chin. The patient suffers from sensitivity to sunlight, have short-stature, and age prematurely. The poly A tails are then bound by poly A binding proteins, which help to shift the processive mode of synthesis and this results in the addition of up to 250 nucleotides. Phenylalanine builds up causing a myriad of severe symptoms the increase in phenylalanine leads to an increase in phenylketones (phenylpyruvate, phenylacetate, and phenyllactate) in the urine. This is an autosomal recessive condition, where the patient cannot produce melanin from tyrosine (tyrosinase deficiency) or from a defect in the tyrosine transporters. There is an increase in the risk of skin cancer due to the lack of protective melanin in the skin. The cause is a defect in the ability to break down the branched chain amino acids Leucine, Isoleucine, and Valine. Homogentisic acid (alkapton) thus accumulates in the blood and is excreted in the urine in large amounts, leading to blackening of the urine upon standing. Excessive amounts of homogentisic acid cause damage the cartilage, leading to severe arthralgias. In this case, cysteine will be essential and should be increased in the diet, while simultaneously decreasing the amount of methionine in the diet. This results in an excess of cystine in the urine, which can predispose the patient to kidney stones. Glycogenolysis occurs in the liver and muscle, and is stimulated by epinephrine and/or glucagon in response to low blood glucose levels. This phase consumes energy that is used to convert glucose into two 3-C sugar phosphates (G3P). Regulation is by both alloesteric effectors and by covalent modifications (ie phosphorylation). It is inhibited by the presence of glucose-6-phosphate, which is the product of its activity. Hexokinase has a low affinity to glucose, thus it permits glycolysis initiation even if blood glucose levels are low. This complex consists of three enzymes that transform pyruvate (from glycolysis) into acetyl-CoA, through the process of pyruvate decarboxylation. There will be neurologic findings that can be managed by giving the patient amino acids that are purely ketogenic, such as Leucine and Lysine. In yeast, pyruvate is converted to ethanol in anaerobic conditions, in eukaryotes it is converted to lactate. There are four complexes that are embedded in the inner membrane, which are electrically connected by lipid-soluble electron carriers and water-soluble electron carriers.

A routine H&E histologic section from an irregular white area within the anterior wall of the heart of a 71-year-old male who died secondary to ischemic heart disease reveals the myocytes to be replaced by diffuse red material youth erectile dysfunction treatment order generic red viagra online. It is secreted by fibroblasts and has a high content of glycine and hydroxyproline c erectile dysfunction overweight red viagra 200 mg fast delivery. It is secreted by hepatocytes and is mainly responsible for intravascular oncotic pressure d erectile dysfunction drug companies discount red viagra 200 mg with visa. It is secreted by monocytes and contains a core protein that is linked to mucopolysaccharides impotence age 45 order red viagra mastercard. It is secreted by plasma cells and is important in mediating humoral immunity General Pathology 49 44 erectile dysfunction treatment penile prosthesis surgery purchase 200mg red viagra mastercard. Examining her eyes reveals the lens of her left eye to be in the anterior chamber vyvanse erectile dysfunction treatment order red viagra with visa. Abnormal copper metabolism Decreased levels of vitamin D Decreased lysyl hydroxylation of collagen Defective synthesis of fibrillin Defective synthesis of type I collagen 45. Which one of the listed changes correctly describes the pathophysiology involved in the production of pulmonary edema in patients with congestive heart failure Decreased plasma oncotic pressure Endothelial damage Increased hydrostatic pressure Increased vascular permeability Lymphatic obstruction 46. Which one of the listed clinical scenarios best illustrates the concept of active hyperemia A 22-year-old second-year medical student who develops a red face after being asked a question during a lecture b. A 37-year-old male who develops massive swelling of the scrotum due to infection with Wucheria bancrofti c. A 69-year-old male who dies secondary to progressive heart failure and at autopsy is found to have a "nutmeg" liver d. A 6-year-old boy who develops the sudden onset of intense scrotal pain due to testicular torsion. A 71-year-old female who develops perifollicular hemorrhages due to a deficiency of vitamin C 50 Pathology 47. Grossly display features of recanalization Grossly have lines of Zahn Grossly have the appearance of "chicken fat" overlying "currant jelly" Microscopically appear attached to the wall of the blood vessel Microscopically have alternating layers of cells and platelets 50. Deep leg veins Lumen of left ventricle Lumen of right ventricle Mesenteric veins Superficial leg veins General Pathology 51 51. He is taken to the emergency room, where he is evaluated and immediately taken to surgery. There his left testis is found to be markedly hemorrhagic due to testicular torsion. Arterial occlusion Septic infarction the collateral blood supply of the testis the dual blood supply of the testis Venous occlusion 52. A young child who presents with megaloblastic anemia is found to have increased orotate in the urine due to a deficiency of orotate phosphoribosyl transferase. The combination of a primary defect, such as bilateral renal agenesis, along with its secondary structural change is best referred to by which one of the listed terms As a general rule, familial disorders that involve abnormalities of structural proteins (rather than deficiencies of enzymes) and present during adulthood (rather than childhood) have what type of inheritance pattern Autosomal dominant Autosomal recessive Mitochondrial X-linked dominant X-linked recessive 52 Pathology 55. Myotonic dystrophy Limb-girdle dystrophy Facioscapulohumeral dystrophy Duchenne muscular dystrophy Polymyositis 56. Assume that both parents are carriers for the abnormal gene that causes cystic fibrosis. The Hardy-Weinberg principle states that, given a frequency of a certain allele A of p and a frequency q of another allele a at the same locus on the same autosomal chromosome in a population with random mating (panmixia), then the number of heterozygous carriers is equal to a. A 6-year-old female is being evaluated for recurrent episodes of lightheadedness and sweating due to hypoglycemia. Physical examination reveals an enlarged liver and a single subcutaneous xanthoma. Laboratory examination reveals increased serum uric acid and cholesterol with decreased serum glucose levels. Following oral administration of fructose, there is no increase in blood glucose levels. A liver biopsy specimen reveals increased amounts of glycogen in hepatocytes, which also have decreased levels of glucose-6-phosphatase. In tissues affected by the predominant form of Niemann-Pick disease, which one of the following is found at abnormally high levels Physical examination reveals a child with short stature, coarse facial features (low, flat nose, thick lips, widely spaced teeth, facial fullness), a large tongue, and clear corneas. Laboratory examination reveals increased urinary levels of heparan sulfate and dermatan sulfate. Metachromatic granules (Reilly bodies) are found in leukocytes from a bone marrow biopsy. Hyperphenylalaninemia Tyrosinemia Tyrosinase-positive oculocutaneous albinism Alkaptonuria Maple syrup urine disease 62. Which one of the listed processes is the most likely cause of an aneuploid karyotype A reciprocal translocation between two acrocentric chromosomes Deletion of both ends of a chromosome with fusion of the damaged ends Division of the centromere along a transverse plane Failure of homologous chromosomes or paired chromatids to separate Two breaks within a single chromosome with reincorporating of the inverted segment 63. Gross examination at the time of autopsy reveals polydactyly, a cleft lip and palate, and a single, central eye ("cyclops"). Further examination reveals holoprosencephaly, consisting of fused frontal lobes with a single ventricle. Which of the listed chromosomal abnormalities is most consistent with these findings A 2-month-old girl presents with a soft, high-pitched, mewing cry and is found to have microcephaly, low-set ears and hypertelorism, and several congenital heart defects. A 6-year-old female with a fair complexion is being evaluated for severe mental retardation and seizures. A 19-year-old female of average intelligence and short stature is being evaluated for amenorrhea. Physical examination reveals that she has a shield-shaped chest and her elbows turn outward when her arms are at her sides. She has a "thick neck" and you notice the absence of secondary female characteristics. Which immunoglobulins are characteristically present on mature (virgin) B cells, which are B lymphocytes that have not yet been exposed to the appropriate antigen What type of antibody is produced first against a bacterial infection, is very effective at activating complement, and is too large to cross the placenta Which one of the following sequences correctly describes the usual temporal sequence of T-lymphocyte maturation within the cortex and medulla of the thymus Double negative double positive single positive Double negative single positive double positive Double positive double negative single positive Double positive single positive double negative Single positive double positive double negative 72. In antigen recognition by cytotoxic T lymphocytes, the T cell receptor recognizes antigens bound to a. Ten minutes after being stung by a wasp, a 30-year-old male develops multiple patches of red, irregular skin lesions over his entire body. This response is primarily the result of liberation of specific vasoactive substances by the action of a. Activated T lymphocytes on smooth muscle cells IgA on basophils and mast cells IgA on lymphocytes and eosinophils IgE on basophils and mast cells IgE on lymphocytes and eosinophils 76. After receiving incompatible blood, a patient develops a transfusion reaction in the form of back pain, fever, shortness of breath, and hematuria. Which one of the following histologic or immunofluorescent findings is most indicative of a delayed type hypersensitivity reaction A linear immunofluorescence pattern in the wall of the esophagus Caseating granulomas in hilar lymph nodes Councilman (apoptotic) bodies in the liver Fibrinoid necrosis around dermal blood vessels Numerous eosinophils in a nasal polyp 78. A human and an animal Two individuals of different species Two individuals of the same species Two individuals of the same inbred strain Identical twins General Pathology 59 79. Histologic examination of the kidney reveals neutrophils within arterioles, glomeruli, and peritubular capillaries. Donor cytotoxic T lymphocytes that are directed against host antigens Host cytotoxic T lymphocytes that are directed against donor antigens Donor natural killer cells that are directed against host antigens Preformed donor antibodies that are directed against host antigens Preformed host antibodies that are directed against donor antigens 80. A 28-year-old female with arthritis and a bimalar photosensitive, erythematous rash on her face b. A 35-year-old female who presents with dry eyes, a dry mouth, and enlarged salivary glands. A 47-year-old female who presents with periorbital lilac discoloration and erythema on the dorsal portions of her hands 60 Pathology 82. Workup reveals decreased left ventricular filling due to decreased compliance of the left ventricle. When viewed under polarized light, this material displays an apple-green birefringence. It is then injected intraperitoneally by percutaneous, ultrasound-guided injection at 16, 17. Autosomal dominant Autosomal recessive Mitochondrial X-linked dominant X-linked recessive General Pathology 61 85. This mass is resected and histologic examination reveals a tumor composed of cells having elongated, spindle-shaped nuclei. The tumor does not connect to the overlying epithelium and is found only in the wall of the stomach. Adipocytes Endothelial cells Glandular epithelial cells Smooth muscle cells Squamous epithelial cells 87. The pathology report from a biopsy specimen indicates that this mass is an invasive adenocarcinoma. Which one of the listed descriptions best describes the most likely histologic appearance of this tumor A uniform proliferation of fibrous tissue A disorganized mass of proliferating fibroblasts and blood vessels A disorganized mass of cells forming keratin A uniform proliferation of glandular structures A disorganized mass of cells forming glandular structures 62 Pathology 88. A 35-year-old male presents with the new onset of a "bulge" in his left inguinal area. After performing a physical examination, you diagnose the bulge to be an inguinal hernia. You refer the patient to a surgeon, who repairs the hernia and sends the resected hernia sac to the pathology laboratory along with some adipose tissue, which he calls a "lipoma of the cord. Which one of the following features would have been present had the lesion been a lipoma rather than normal adipose tissue Anaplasia Fibrous capsule Numerous mitoses Prominent nucleoli Uniform population of cells 89. Which one of the listed numbered sequences best illustrates the postulated sequence of events that precedes the formation of an infiltrating squamous cell carcinoma of the cervix The lesion is removed surgically, and histologic sections reveal sheets of malignant cells with clear cytoplasm (clear cell carcinoma). Acute-transforming viruses Fungi and parasites Gram-negative bacteria Gram-positive bacteria Slow-transforming viruses 92. Point mutations of the oncogene c-ras can result in the inability of the product of this oncogene to bind with a. A 4-year-old African boy develops a rapidly enlarging mass that involves the right side of his face. Biopsies of this lesion reveal a prominent "starry sky" pattern produced by proliferating small, noncleaved malignant lymphocytes. A 76-year-old male farmer presents with a 2-cm mass on the left side of his forehead. A 17-year-old male presents with a lesion on his face that measures approximately 1. He has a history of numerous similar skin lesions that have occurred mainly in sun-exposed areas. Workup reveals that his anemia is the result of bleeding from a colon cancer located in the sigmoid colon. Which of the listed markers would be most useful for future follow-up of this patient for the evaluation of possible metastatic disease from his colon cancer A smear of material obtained from one of these vesicles reveals several multinucleated giant cells with intranuclear inclusions and groundglass nuclei. A 19-year-old man living in New Mexico presents to a local clinic after a 1-day history of fever, myalgia, chills, headache, and malaise. He complains of vomiting, diarrhea, abdominal pain, tachypnea, and a productive cough. He is treated with antibiotics, but the next day he develops acute respiratory failure with cardiopulmonary arrest and dies. Postmortem examination of the lungs reveals intraalveolar edema, rare hyaline membranes, and a few interstitial lymphoid aggregates. Ebola virus Dengue fever virus Hantavirus Yellow fever virus Alphavirus 66 Pathology 101. A 6-year-old boy develops a facial rash that has the appearance of a slap to the face.

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The approach to parathyroidectomy may be endoscopic erectile dysfunction juice recipe generic red viagra 200 mg line, or an "open" standard (traditional) approach may be employed thyroid erectile dysfunction treatment discount 200mg red viagra free shipping. An additional adjunct to parathyroid surgery is the intraoperative assay of parathyroid hormone (level may drop as much as 50% from the preoperative level following excision of the affected gland[s]) impotence male cheap red viagra 200mg. Employing local anesthesia with conscious sedation (or additional cervical plexus block or general anesthesia) erectile dysfunction doctor dallas order red viagra 200 mg line, a 1-inch incision is made above the suprasternal notch; a more exact location can be deter- 778 Chapter 26 Neck Surgery mined by placing the (plastic-protected) radioactivity detection probe erectile dysfunction pills review red viagra 200 mg on line, the Neoprobe erectile dysfunction doctors in arizona red viagra 200 mg generic, over the neck. The endoscope and the Neoprobe (protected by a sterile plastic sleeve) are inserted through the incision. The audible signal leads to the location of the enlarged gland; it is carefully dissected from surrounding structures. Its artery and vein are clipped, being certain that no nervous structure is jeopardized, and the lesion is removed. The excised specimen is then scanned, and if the radioactive signal is commensurate with the preoperative level, no further excision or exploration is indicated. If otherwise parathyroid hormone assay is done and is still inconclusive regarding whether pathological glandular tissue remains, the other glands must be explored (with an open procedure, as necessary). Care is taken, as in thyroidectomy, to identify and protect the recurrent and superior laryngeal nerves. Once parathyroid glands are identified, they are isolated and excised, as indicated according to the pathology. As stated above, when all four glands are uniform, a portion of one may remain in situ. For Preparation of the Patient, Skin Preparation, Draping, Equipment, Instrumentation, and Supplies, see Thyroidectomy, pp. The forearm site is covered with a towel until the surgeon is ready to transplant the resected portion of the parathyroid gland. Reminder: the scrub person should remain sterile and the back table kept sterile until the patient is extu- Chapter 26 Neck Surgery 779 bated, breathing satisfactorily on his/her own, and taken from the room. A tracheostomy tray is brought into the room; it is opened if the patient shows signs of airway obstruction. Thyroglossal Duct Cystectomy Definition Excision of thyroglossal duct cyst and duct in continuity with the mid-portion of the hyoid bone to the foramen cecum. Discussion the thyroglossal duct is an embryological remnant that extends from the foramen cecum at the base of the tongue, through the hyoid bone to the thyroid gland. When a ductal sinus or cyst is present, it is usually found inferior to the hyoid bone. Although most patients with thyroglossal duct cyst are children, patients with thyroglossal duct cyst can even be elderly. Rarely, ectopic thyroid tissue (including papillary carcinoma) may be encountered along the tract; squamous cell carcinoma, likewise, is a rare finding. An incision is made between the hyoid bone and thyroid cartilage, along natural skin lines. A central portion of the hyoid bone is removed to prevent recurrence, and the cephalad portion of the duct is ligated or preferably dissected 780 Chapter 26 Neck Surgery to the foramen cecum. The specimen is excised (with a 5- to 10-mm core of muscle at the base of the tongue, when applicable). Preparation of the Patient For children, see the special considerations in Pediatric General Information, p. Arms may be extended on padded armboards (adult), or padded restraints may be used on extremities (for the pediatric patient). Instrumentation Thyroidectomy tray (adult) Minor orthopedic procedures tray, available Tracheostomy tray (available) Basic pediatric procedures tray (child) Right-angle clamps with fine points (2) Supplies Antiembolitic hose (adult), optional Indelible marking pen, optional Basin set Blades, adults (2) #10, (1) #15; children (2) #15 Suction tubing Needle magnet or counter Magnetic instrument pad Electrosurgical pencil, needle tip, cord, holder, and scraper Medicine cup and labels Control syringe, methylene blue dye, and needle, optional Skin closure. Administering preoperative medication (if any), administration of anesthesia, preparing the room, monitoring body temperature to retain body heat, maintenance of accurate fluid balance, methods used to restrain the patient, etc. To plan and consider all the special measures that must be taken for the pediatric patient, refer to Pediatric General Information, p. Document all information obtained, nursing interventions employed (with respect to the information obtained), and patient outcomes in the Perioperative Record (p. Reminder: the scrub person should remain sterile and the back table should be kept sterile until the patient is extubated, breathing satisfactorily on his/her own, and taken from the room. A variety of diverticula are seen in the hypopharynx and proximal esophagus; they are classified according to anatomical zone, pulsion versus traction, and, rarely, congenital. Its location is usually protruding through the fibers of the inferior pharyngeal constrictor muscle (posteriorly) just superior to the cricopharyngeus muscle. A less oftenencountered Killian-Jamieson diverticulum presents more inferiorly and laterally, adjacent to the recurrent laryngeal nerve. Symptoms of these diverticula may include the inability to swallow easily and, in neglected cases, malnutrition, dehydration, and pulmonary problems due to aspiration, necessitating surgical treatment. Smaller lesions or, in high-risk patients, cricopharyngeal myotomy (with or without division of the septum between the esophagus and the diverticulum), while not excising the diverticulum, is performed. This decreases the pressure about the orifice of the diverticulum, permitting the protrusion aspect to be minimized, with relief of symptoms. Myotomy can also be combined with excision by open surgery or by endoscopic excision (Dohlman procedure). An oblique incision is made paralleling the anterior border of the left sternomastoid muscle. The sternomastoid and carotid sheath are retracted laterally, and the thyroid gland and trachea medially (protecting the recurrent laryngeal nerve). The esophagus and diverticulum are identified and the latter dissected free from the surrounding structures (sometimes associated with dense adhesions if an Chapter 26 Neck Surgery 783 inflammatory reaction had been present). The diverticulum is excised, and the esophagus sutured closed in layers (or, alternatively, a transverse stapler may be used). A double-bladed rigid endoscope is positioned with one blade in the esophagus and the other in the diverticulum. A roticulating endoscopic linear stapler is employed, resulting in an opening of the pouch and a division of the cricopharyngeus muscle. Preparation of the Patient Anesthesia may be general or local with conscious sedation. The patient is placed in supine position, with the head on a padded or gel donut headrest turned to the side; the dependent ear is padded to prevent pressure injury. The table may be positioned in reverse Trendelenburg; a padded footboard is secured to the table. A shoulder roll or small sandbag is placed between the scapulae, extending the neck, to optimize exposure. A sequential compression device with leg wraps to prevent deep vein thrombosis may be applied when ordered. Otitis media results when the fluid (effusion or exudate) collects and becomes infected. When the infection persists, medical treatment may include antibiotics, steroids, antihistamines, decongestants, and/or analgesics. Myringotomy is indicated in both acute and chronic otitis media following unsuccessful medical treatment. Longterm ventilation of the inner ear is necessary for the mucous membranes to "dry". Incision of the tympanic membrane relieves the pain and restores hearing immediately. Some surgeons prefer a laser-made myringotomy incision, believing the technique permits better visualization than those made with a "cold" myringotomy knife. An aural speculum is inserted in the ear canal, and cerumen, if present, is removed by wire curette. For acute and some chronic infections, the inferior posterior portion of the tympanic membrane is incised with a (disposable) myringotomy knife. The incision of the tympanic membrane immediately relieves the pressure, and the serous fluid and/or pus exudate is suctioned. For chronic otitis media, the incision may be made in additional positions on the tympanic membrane. The aperture remains patent longer when made by laser, about 4 to 6 weeks, as opposed to only a few days when made by myringotomy knife. Special measures must be taken for the safe care of the pediatric patient in surgery. Myringotomy is performed employing general anesthesia for children and some adults, or the adult patient may receive a local anesthetic topically. The patient is supine, positioned at the top edge of the table with the head on a padded, foam, or gel headrest, turned to the side, with the dependent ear well padded to avoid pressure injury. The arms are padded and may be restrained using softly padded restraints secured to the table, or one arm is restrained using a softly padded restraint and the contralateral arm is extended on a padded armboard and secured. A pillow may be placed under the knees to avoid straining back muscles, or the table may be flexed for comfort (adult). Check with the surgeon regarding the prep; most surgeons do not require the skin prep. Following surgery on the first side, the skin on the contralateral side is prepped and the patient may be draped again (infrequently). Lap sponges, placed at the sides of the neck, prevent the prep solution from pooling under the patient. Prep solutions are not permitted to pool on the drapes, as they excoriate the skin. Care is taken to avoid getting prep solution in the eyes; antibiotic ointment may be placed in the conjunctival sacs to protect the eyes. Three folded towels may be placed around the ear, and a drape (U or split) sheet may be used to cover the body. A microscope drape is not necessary; sterile handles may be used with the microscope. To plan and consider the special measures for the pediatric patient, refer to Pediatric General Information, p. Adjustments to be set include balance, focus, correct bend in the arm, and oculars. An adjustable focal length permits the surgeon to change the distance from 200 to 400 mm (f) without changing lenses. Safety precautions are observed to prevent injury to the patient and staff, as well as to prevent fire. In some facilities, insertion of prosthesis (or prostheses) is also documented in a hospital log. Tympanoplasty Definition Repair of the tympanic membrane with reestablishment of the ossicular continuity. Discussion A variety of inner ear reconstructive procedures, including procedures on the tympanic membrane and the ossicles (middle-ear structures) may be performed. A perforated tympanic membrane (eardrum) is usually due to trauma and will heal spontaneously on its own. Tympanoplasty may be performed to reconstruct or replace the perforated tympanic membrane when it does not heal spontaneously. Replacement is made by graft; an autograft of postauricular fascia is the most commonly used grafting material. Allografts from cadavers, once abandoned due to fear regarding transmission of viral infection, are again being used as well. Materials used for synthetic prostheses include stainless steel, platinum, tantalum, polyethylene, Plastipore, Fluoroplastic, and hydroxlapatite. Tympanoplasty is performed to repair ossicular discontinuity, for the treatment of chronic otitis media, adhesive otitis, and tympanosclerosis, and to excise cholesteatoma (in conjunction with mastoidectomy, p. Cholesteatoma is a benign cyst-like tumor of keratinized epithelium that erodes bone as it grows. Often a flap of atrophic epithelium (from the cholesteatoma) has retracted into the middle ear; it must be excised, along with any infected or questionably infected tissue. Approach to tympanoplasty, without mastoidectomy, may be endaural or postauricular. When both ears are involved, only one ear is operated upon; the ear with the worst hearing is selected for the first repair procedure. This leaves the patient with the better-hearing ear uninjured, should the procedure be unsuccessful. Infection, a rare complication of tympanoplasty, must be treated immediately to prevent sensorineural hearing loss and meningitis. An additional complication, a delayed reaction (6 weeks postoperative), is the formation of a granuloma over the oval window. Procedure When tympanoplasty involves repair of the ossicles, it is usually performed using general anesthesia, but local anesthetic with conscious sedation may also be employed. When using either type of anesthesia, local anesthetic injection is employed as well. The canal skin is elevated or removed; canalplasty may be necessary to provide better exposure. When repair is required, the edges of the perforation are separated and later prepared for a graft. To harvest the autograft, a duckbill elevator is used and lidocaine is injected under the fascia to separate it from the temporalis muscle. The graft is trimmed and laid flat or molded, or pressed (with a House Gelfoam press) and set aside to dry. A micro dissector, such as a Rosen needle, may be used to assess the pathology within with regard to the mobility of the ossicles.

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