Co-Director, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine
The severity of the attacks often diminishes with time and in some patients the attacks cease in later years arrhythmia jaw pain cheap 100mg lopressor mastercard, particularly after the menopause in women hypertension and heart disease purchase lopressor american express. While common in the community arrhythmia treatment medications purchase lopressor 100 mg on line, careful diarysupported studies show that 10% of patients coming to see a primary care physician/general practitioner have tension-type headache blood pressure pills kidneys purchase 50mg lopressor fast delivery, while 92% have migraine. Tip E Less than 10% of patients presenting to general practitioners with disabling headache have tension-type headache. Psychogenic mechanisms are said to be relevant in some patients, but the evidence is poor. Some form of sensitization with second-order trigeminal neurons is likely to be involved. Predisposing factors Genetic factors First-degree relatives of probands with chronic tension-type headache have about three times the risk of chronic tension-type headache than the general population, suggesting the importance of genetic factors in chronic tension headache17,18. At school or at work, the patient should sit in a comfortable chair which is adjusted to the height appropriate for the desk (to ensure good posture) with light adjusted to the correct angle for comfort. Investigations and diagnosis Investigations are not necessary unless a secondary headache is suspected. Diagnosis is based on the history: episodic tension-type headache is featureless headache on 15 days a month; chronic tension-type headache is featureless headache on 15 days a month for 3 months. A course in relaxation training may be highly beneficial in a wellmotivated patient. They are now conducted by psychologists, physiotherapists, and many hospitals and community health centers. Various forms of biofeedback may assist relaxation but do not make a substantial impact. For patients in whom episodic tension-type headache or, less frequently, migraine becomes transformed into chronic tension-type headache, overuse of analgesic drugs frequently plays a role in aggravating the disorder, and discontinuation of daily drug intake often results in improvement. Pharmacologic19 Tricyclic antidepressants: amitriptyline, in particular, may be very helpful, commencing with one-half of a 25 mg tablet at night and gradually increasing to three tablets (75 mg) as a single nocturnal dose, provided there are no adverse effects such as drowsiness and confusion. Treatment should be continued for about 6 months and then gradually phased out to see whether it is still necessary or whether improvement can be maintained with relaxation alone. They should be used for short periods only, and under supervision, because of the risk of habituation, dependency, and drug-induced headache. Increases in neuropeptide markers of this system rapidly return to normal after treatment with sumatriptan. The mechanism by which nitroglycerine can induce an attack of cluster headache is at least partly due to activation of the trigeminovascular system. Headache 151 Tip E Most (90%) of patients with acute cluster headache are agitated and move about while less than 10% of migraineurs behave that way. Primary cough headache25 A bilateral headache of sudden onset, lasting less than 1 minute, and precipitated by coughing, in the absence of any intracranial disorder, such as a Chiari type I malformation. Should the pain become bilateral, a lumbar puncture may be indicated to exclude intracranial hypertension. Chronic Attacks occur for more than 1 year without remission, or with remission lasting less than 14 days. This is effective in about 80% of cases in whom it should be maintained for the duration of the bout before weaning off slowly. Prognosis the headaches usually recur once or twice a day, often at night, for a period of 4 weeks to 4 months. The clinical spectrum of familial hemiplegic migraine associated with mutations in a neuronal calcium channel. Current practice and future directions in the management of migraine: acute and preventive. Comparison of first degree relatives and spouses of people with chronic tension-type headache. Management of chronic tensiontype headache with (tricylic) antidepressant medication, stress-management therapy and their combination: a randomized controlled trial.
Tumors > 10 cm3 blood pressure 3020 generic lopressor 50 mg line, peritumoral edema blood pressure kits at walgreens order lopressor 25mg visa, and meningiomas in the anterior skull base were reported to be at higher risk of posttreatment complications hypertension numbers generic lopressor 25 mg mastercard. A subjective improvement in existing tumor-related symptoms was noted in 60% of patients blood pressure sounds buy lopressor online pills. In a series of 199 meningiomas, predominantly of the skull base, the 5-year local actuarial control rate was 93. Clinical symptoms (ocular movement, visual function, exophthalmos, and pain) 243 Clinical Sites Radiosurgery is an important treatment modality for the management of skull base tumors, including meningiomas, pituitary adenomas, glomus tumors, and chordomas. Emerging applications of radiosurgery in the treatment of other skull base malignancies include nasopharyngeal cancer and those who have failed previous conventional external beam radiotherapy. Meningiomas Meningiomas, which arise from arachnoid cap cells, are benign, slow-growing, well-circumscribed solid tumors. Symptoms at presentation vary widely as they largely reflect tumor location, with common locations including cerebral convexities, falx cerebri, tentorium cerebelli, cerebellopontine angle, sphenoid ridge, and spine. These tumors may undergo malignant transformation, can be locally destructive, and cause adjacent bony erosion or hyperostosis. Asymptomatic, small, benign lesions 244 Rhinology and Endoscopic Skull Base Surgery Figure 35. Singledose stereotactic radiosurgery would place the cranial nerves in the cavernous sinus at risk for transient or permanent injury. Fractionating the treatment would enable local control of tumor with an improved toxicity profile. Treatment planning was performed using fusion of a dedicated computed tomography and high-resolution T1-weighted magnetic resonance imaging. Treatment of tumors close to the optic nerve and/or optic chiasm can be challenging. Stanford University reported on the use of CyberKnife radiosurgery in the treatment of perioptic tumors in 49 patients (27 with meningioma, 19 with pituitary adenoma, 2 with craniopharyngioma, and 1 with mixed germ cell tumor). Patients with optic chiasm involvement (19 out of 49 patients) were treated with five fractions at 5 Gy per fraction. Over a median follow-up of 45 months, radiographic control was reported in 94% of patients and visual fields remained stable or improved in 94% of patient. Furthermore, Stanford University reported on the safety and efficacy of CyberKnife for large (> 15 cm3) cranial base meningiomas with good treatment efficacy without increased cranial nerve toxicity when treated with five fractions at 5 Gy per fraction. Radiation may be indicated as an adjuvant treatment to surgery depending on surgical pathologic findings. With complete surgical resection, meningioma recurrence rates are 7 to 12% at 5 years and 20 to 25% at 10 years. Surgical or chemical debulking was necessary before radiosurgery for large tumors with extrasellar extension. Nonfunctioning adenomas had higher control rates than functioning adenomas, despite receiving a lower dose. The rate of hormone normalization was also high in Cushing disease but lower in prolactinoma and lowest in acromegaly. Highdose treatment was necessary for functioning adenomas to control tumor growth and oversecretion of hormones. This study demonstrated that careful consideration of radiation dose and volume needed to be tailored according to the type of pituitary adenoma, size, and the secreting functional component present. The 5-year cumulative risk of new onset hypogonadism, hypothyroidism, or hypoadrenalism was 3. Longer follow-up data for radiotherapy and functional outcomes have been reported in a study conducted at the University of Florida; 141 patients with pituitary 245 Pituitary Tumors Pituitary adenomas are identified in nearly 20% of pituitary glands in autopsy studies and represent 10 to 20% of primary adult brain tumors. Functional adenomas usually present with endocrine dysfunction depending on the hormone. Approximately 75% of adenomas are functional adenomas, whereas 25% are nonfunctional. Prolactinomas are the most common functional adenomas (30%), followed by somatotropic (25%), and less commonly corticotropic and thyrotrophic. They often present with symptoms related to invasion or compression of adjacent structures. Symptoms include headache, cranial nerve deficits secondary to cavernous sinus invasion, and hormonal disturbances. Superior temporal deficits, homonymous hemianopsia, and central scotoma may also result. Goals of therapeutic management include control of tumor mass and its effect on normal function, and correcting any endocrine deficiencies. This allows dose fall off from the tumor and keep the dose of the optic chiasm below 8 Gy in a single fraction. If this cannot be achieved, consideration of fractionated 246 Rhinology and Endoscopic Skull Base Surgery Figure 35. Pathology demonstrated a pituitary adenoma with strong staining for synaptophysin, significant staining for adrenocorticotropic hormone, and rare staining for prolactin. Postoperatively, the patient underwent CyberKnife stereotactic radiotherapy targeting the right cavernous sinus residual tumor. She was treated with a hypofractionated regimen to a total dose of 25 Gy delivered in five fractions. Organs at risk include the optic chiasm (pink) and the right optic nerve (yellow). During each treatment, the patient was temporarily immobilized with a frameless thermoplastic head and neck mask on the robotic couch. Proper alignment was confirmed daily using real-time (intrafractional) kilovolt imaging and skull tracking.
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Choanal atresia: embryologic analysis and evolution of treatment blood pressure headache safe lopressor 12.5 mg, a 30-year experience arteria esfenopalatina buy generic lopressor line. Wise An understanding of the embryological material discussed in Chapter 1 will serve as a solid foundation for understanding the complex relationships between the nasal cavity and paranasal sinuses heart attack kidney damage generic 25mg lopressor otc. Knowledge of these relationships is necessary for evaluating nasal and paranasal sinus pathology and subsequently completing safe and effective endoscopic and open procedures heart attack 38 years old order 25mg lopressor with amex. This chapter explores basic considerations of skull base anatomy, while other chapters emphasize on specific areas and procedures. Primarily, the nasal cavity and the paranasal sinuses are protected by components of the maxilla and the ethmoid, sphenoid, and frontal bones. The vomer, the lacrimal, and the zygomatic bones also contribute to the overall structure of the nasal and sinus cavities. Given the number of bones involved and the contiguous and vital structures that these bones protect, thorough attention must be paid to all aspects of the nasal cavity and the paranasal sinuses. Nasal Cavity the right and left nasal cavities are often considered mirror images of each other; however, precise symmetry between these sides is typically an exception and almost never the rule. The anterior border of the nasal cavity is the nasal vestibule, which contains the transition zone from the external squamous epithelium of skin to the respiratory mucosa that lines the nasal cavity and paranasal sinuses. Medially, the nasal cavity is bordered by the nasal septum, which contains contributions from the maxillary crest and vomer inferiorly, the quadrangular cartilage anteriorly, and the perpendicular plate of the ethmoid bone superiorly. Anterolaterally, the nasal bones, the upper and lower lateral cartilages, and the soft tissue gives shape to the external nasal pyramid. The choana serves as a posterior limit to the nasal cavity and transition into the nasopharynx. The lateral portion of the nasal cavity contains the most complex anatomy and will be covered in depth in subsequent sections within this chapter. Maxillary Sinus the maxillary sinus is bordered by the alveolar portion of the maxillary bone anteriorly, the orbital floor superiorly, the zygoma laterally, the pterygopalatine and infratemporal fossae posteriorly, and the lateral nasal wall medially1. Entry into the maxillary sinus is usually through the solitary natural ostium identified within the posterior 8 Surgical Endoscopic Anatomy of the Nose, Paranasal Sinuses, and Skull Base sinus decreases in volume, the orbital contents tend to fill a larger volume of the midface. Small maxillary sinus volumes and relatively large orbital volumes are seen in young children before full aeration of the maxillary sinuses, cystic fibrosis, and silent sinus syndrome of the maxillary sinus. Infraorbital ethmoid (Haller) cells must also be considered during endoscopic intervention as they tend to narrow the outflow tract of the maxillary sinus. Although they overwhelmingly originate from the anterior ethmoid sinus, they can emanate from the posterior ethmoid cells in roughly 12% of patients. The uncinate process has been partially resected, and the maxillary ostium has been widened (arrow). However, in up to 23% of patients, accessory ostia may form through the anterior or posterior fontanelles. Two anatomical variants of maxillary sinus are important for an endoscopic surgeon. Usually 15 cm3 in volume, the maxillary sinus can have variable pneumatization, potentially resulting in a hypoplastic sinus. As the maxillary the ethmoid sinus is not one sinus, but a complex of ethmoid sinus cells with contributions from the middle and superior turbinates. The ethmoid sinus is the only sinus that is not a self-contained singular cell with one clear ostium. Because of the complexity of the ethmoid sinus, stepwise discussion of its key components will help highlight several important relationships. Uncinate Process the hook-shaped uncinate process is a curved bony extension from the lateral nasal wall that is often one of the first structures encountered on endoscopic intervention. Image demonstrates hypoplastic maxillary sinuses bilaterally, with relatively larger orbital volumes compared with the maxillary sinus volumes. Although they may not be present if the cells are not pneumatized, the region rests anterior and inferior to the frontal sinus and the frontal recess. It lies superior to the lateral connection of uncinate process and is positioned between the nasal bones, the lacrimal bones, and the maxilla. The position of the agger nasi region is very important in a thorough dissection of the frontal recess and frontal sinus. Any remnant or residual sinus tissue or septations left behind in the agger nasi region may result in obstruction of the frontal sinus outflow. Note that the uncinate process has both vertical and horizontal portions (arrows). Also note that the uncinate process partially covers the maxillary sinus ostium and the ethmoid bulla (*). It begins in the parasagittal plane anteriorly but then changes orientation to the semicoronal and then to the semiaxial planes as it travels posteriorly. The change in orientation is key to understanding the ethmoid sinuses as the middle turbinate serves as both the posterior and the medial boundary to the anterior ethmoid complex. The free edge of the middle turbinate is in the parasagittal orientation; as we follow the turbinate posteriorly past the ethmoid bulla, the vertical portion of the basal lamella can be the uncinate process attaches superiorly to the maxilla near the lacrimal bone and then sweeps inferiorly and posteriorly to a free edge without bony attachment5. This sweeping curve gives the uncinate process both vertical and horizontal portions. The superior attachment of the vertical portion of the uncinate process is variable and thus affects the drainage pattern of the frontal sinus. In this arrangement, drainage of the frontal sinus courses into the middle meatus, medial to the uncinate process. However, if the uncinate process attaches superiorly to the middle turbinate itself or directly to the skull base, frontal sinus drainage will occur lateral to the uncinate process and into the ethmoid infundibulum.
An endoscopic drill is needed to reduce the bone of the planum sphenoidale because of its thickness untreated prehypertension purchase lopressor 50mg with visa. Lesions involving the sella and suprasella are approached in a similar fashion; however pulmonary hypertension xray purchase lopressor us, dissection in the ethmoid cavity can be limited blood pressure medication nifedipine buy generic lopressor 25 mg. In cases with limited access hypertension classification discount lopressor 100mg with mastercard, resection of the superior turbinates can be performed and bilateral posterior ethmoidectomies can be done especially in cases with an Onodi cell. Patients should have adequate nasal decongestion with oxymetazoline followed by injection with lidocaine 1% with 1:100,000 epinephrine at the middle turbinate insertion to the lateral nasal wall. We are now using topical epinephrine pledgets (1:1000) in place of oxymetazoline because of the improved vasoconstriction. Topical vasconstrictive agents are used during the approach and exposure of the defect, however, they are not applied directly to the extradural or intradural skull base. The patient should be prepped for possible harvest of the appropriate tissue grafts. In cases where a pericranial 226 Rhinology and Endoscopic Skull Base Surgery the sphenoid sinus above the posterior septal artery pedicle are made and carried onto the septum. A Freer elevator can be used to reflect this mucoperiosteum inferiorly moving the pedicle away from potential harm. A 2-cm posterior septectomy and lowering of the bony face of the sphenoid can then be performed without violating the pedicle to the nasoseptal flap if needed. In addition, if a hybrid endoscopic/ microscopic approach is performed, reflection of the pedicle inferiorly protects it from injury with speculum placement during the microscopic portion. Lateral lesions of the middle cranial fossa skull base will require a wide opening of the maxillary sinus in addition to clearance of the ethmoid and sphenoid sinuses. Once this is done, the posterior wall of the maxillary sinus is removed to expose the pterygopalatine fossa. Identification of the internal maxillary artery and its terminal branch, the sphenopalatine artery, is performed. The vessels can be reflected inferiorly before the removal of bone at the skull base if an ipsilateral nasoseptal flap is needed. If the pedicle is violated or the lesion involves the pedicle and must be sacrificed as with a juvenile nasopharyngeal angiofibroma, a contralateral nasoseptal flap can be elevated. This is critical for stability and adequate acceptance of the graft at the recipient site. Anterior Cranial Fossa In defects involving the anterior cranial fossa, an underlay and overlay technique is often utilized. In some low-flow leaks involving the cribriform plate, an underlay technique is not always feasible because of an inadequate medial bony ledge and repairs may require an overlay graft of free mucosa. In high-flow leaks of the anterior cranial fossa, an underlay technique is often utilized when there are sufficient bony ledges around the perimeter of the defect. The graft material, usually avascular fascia can be placed either deep to the dura or between the dura and the overlying bone. If there is a dural defect with adequate edges, a fascial synthetic (DuraGen) or AlloDerm graft can be sutured in place as the initial step in repair. Originally devised for cardiovascular anastomoses, the technique was modified by Gardner et al for securing tissue grafts to the surrounding native dura. In addition, if sufficient dural edges are not available, this initial layer of closure will not be feasible. Preparation of the inlay site, involves adequately separating the adherent brain and dura from the overlying bone to allow acceptance of the graft material. Of note, any remaining mucosal tissue must be removed from the repair site to prevent delayed mucocele formation. The choice of graft as mentioned is usually autologous fascia or an allograft such as DuraGen or AlloDerm. The authors use Gelfoam to "tuck" and stabilize the underlay component of the graft. After placement of the underlay graft, in high-flow leaks a vascularized flap is placed as an overlay graft. A nasoseptal flap is the vascularized graft of choice because of the ease of harvest, graft durability, and the ability to cover any size skull base defect. One exception is sphenoid sinuses with increased postsellar aeration where a portion of the flap length is lost as it covers the sphenoid sinus before extending anteriorly onto the anterior cranial fossa skull base. The rostrum of the sphenoid sinus can be reduced to the clivus to alleviate some of this loss of length. It is recommended that for large Posterior Cranial Fossa Lesions involving the posterior central skull base, more specifically the clivus, are approached similar to an approach to the sella. The sphenoid sinuses are opened widely and if needed nasoseptal flaps are elevated. For defects in the area, the anterior incision for the nasoseptal flap does not need to be brought to the columella. In general, an anterior vertical incision at the anterior head of the middle turbinate provides sufficient length. The flap is reflected into the nasopharynx and the rostrum or face of the sphenoid sinus is reduced and brought flush with the mucoperiosteum overlying the clivus. Once this bone has been thinned, a Kerrison rongeur is used to remove the underlying bone. In cases where there is a bony ledge to place an underlay graft, the options consist of fascia, AlloDerm (LifeCell, Bridgewater, New Jersey), DuraGen (Integra LifeSciences, Plainsboro, New Jersey), or a fat plug technique. After this layer is placed either a free mucosal graft in case of low-flow leaks or a vascularized flap in case of a highflow leak is placed in an overlay fashion and secured with tissue glue and bolstered in place with Gelfoam (Pfizer, New York, New York) soaked in gentamicin and then nonabsorbable packing. An overlay graft requires preparation of the recipient site by the removal of mucosa from the edges of the bony Endoscopic Skull Base Defect Repair 227 A B C D E Figure 33.
