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Clinical Director, University of Chicago Pritzker School of Medicine
The prognosis for patients with sinonasal malignancies has improved over the last three decades skin care 8 year old order 40mg decutan with visa, but remains poor overall skin care 777 decutan 40mg on line. Consequently skin care regimen for 30s buy 30mg decutan, quality of life issues are very important when considering treatment acne jeans shop discount decutan 20 mg otc, particularly for those with extensive disease. The ethmoid and maxillary sinuses are intimately related to the orbit, separated by paper-thin bone that is deficient in places where nerves and blood vessels pass through. These anatomical features favour relatively early spread of tumours from these sites to the orbit. The roof of the frontal sinus is similarly thin and that of the superior part of the nasal cavity has many perforations through which the olfactory nerves pass. This line separated tumours into two groups, those that developed above it from those that developed below it. He suggested that superiorly based cancers tended to be more aggressive and poorly differentiated, whereas tumours arising from below the line were more amenable to treatment and, as a consequence had a better prognosis. This may well be the case, but it should be remembered that this classification was developed before the concept of craniofacial resection had been considered, let alone described. There have also been huge advances in radiation oncology that make this concept largely of historical interest. Inhalation of these carcinogens is responsible for about 40 percent of reported sinonasal malignancies. Foremost among these occupational hazards is exposure to hard woods in the furniture industry. Workers exposed to hard wood have a 70 times increased incidence of sinonasal adenocarcinoma, particularly in the ethmoid sinuses. The type of wood is a significant factor, with African mahogany being the most dangerous. It is thought that biologically active compounds in wood dust impair mucociliary clearance and predispose to carcinogenesis. Interestingly, sinonasal adenocarcinoma that develops in wood-workers has a better prognosis than other nasal adenocarcinomas. This increases the risk of developing sinonasal squamous cell carcinoma 250 times. The interval between exposure to nickel and the development of the tumour can be very prolonged. Smoking is also thought to play a role in the development of these tumours, perhaps in a synergistic fashion with wood dust. The incidence of chronic sinusitis in patients with sinonasal malignancies is the same as that in the general population. Nevertheless, maxillary sinus tumours are the most common (55 percent) followed by the nasal cavity (35 percent), ethmoid sinuses (9 percent) and rarely frontal and sphenoid sinuses (1 percent). Local invasion In general, sinonasal carcinomas tend to fill the sinus cavity before eroding its bony walls. Periosteum, Chapter 186 Nasal cavity and paranasal sinus malignancy] 2419 perichondrium and dura seem to act as a temporary barrier and resist tumour expansion to some extent, a feature possibly explained by the fibroelastic connective tissue component of these tissues. Only 25 percent of maxillary sinus carcinomas are contained within the antrum at the time of presentation. Tumours that arise in the ethmoid sinus spread medially into the nasal cavity, laterally into the orbit, superiorly into the anterior cranial fossa and inferiorly into the maxillary sinus (Figure 186. Frontal sinus tumours extend through the posterior wall into the anterior cranial fossa and frontal lobes, as well as anteriorly into the skin of the forehead and inferiorly into the nasal cavity. Tumours arising in the sphenoid sinus tend to spread laterally into the cavernous sinus and anteriorly into the ethmoids and nasal cavity (Figure 186. The tumour has broken through the lateral wall and presents as a swelling in the cheek. It is said that differentiation has little bearing on the ultimate prognosis, but this probably reflects the poor overall outcome for these patients and the relative rarity of poorly differentiated forms. Macroscopically, some sinonasal squamous cell carcinomas have a polypoid appearance, while others are more obviously fungating, friable and keratinizing. Adenocarcinoma likely in patients with tumours that have developed near the midline. Adenocarcinomas are generally found in the upper nasal cavity and ethmoid sinuses. Several histological subtypes of sinonasal adenocarcinoma are recognized, namely papillary, sessile, mucoid, neuroendocrine, intestinal and undifferentiated. Papillary adenocarcinomas tend to be locally malignant only and are the least aggressive form. They develop in 18 percent of patients with adenocarcinomas, in contrast to just 10 percent of those with squamous cell carcinomas. The presence of distant metastases is obviously a grave sign and one that signifies a very poor prognosis. The occasional patient with metastatic adenoid cystic carcinoma in the lungs can survive for some time if the primary site remains controlled.
Reduced contact quotients are usually found in cases of vocal fold palsy and paresis and in some cases of muscle tension dysphonia associated with weak and breathy voices acne 70 off generic 5mg decutan otc. The standard deviation of the contact quotient is generally increased in dysphonic patients acne gel prescription cheap 30mg decutan fast delivery,26 reflecting the increased difficulty in controlling the degree of contact in speech tasks acne xojane safe decutan 40 mg. In normal voice production when a sustained vowel sound is produced over a few seconds the vibratory conditions and vocal tract remain stable acne on neck buy decutan uk. This leads to a relatively stable harmonic structure which can be seen as a series of dark bands on the spectrogram. A fundamental law of digital signal processing (Nyquist sampling theorem) is that it is not possible to capture frequencies that are greater than one half of the sampling rate. This means that the higher the frequency sampling rates (narrow-band spectrogram) the more individual frequencies are seen. Conversely at lower frequency sampling rates (broad-band spectrogram), the harmonic structure is seen less clearly as individual frequency bands merge forming broad bands. They vary in position depending on the constrictions in the vocal tract which in turn are determined by the relative position and shaping of the tongue and lips. The first is aperiodic vibration of the vocal folds or some other structure within the vocal tract. Increasing vocal effort and moving from falsetto through modal to creaky (pulse) voice also increases the spectral noise. Unfortunately these measures do not distinguish between pathological changes as a result of turbulent noise and irregular glottal excitation. Although it is probably more reliable overall to pick out the formant frequencies by hand, these automated techniques provide a quick, useful alternative. They are not always reliable, particularly if the signal changes abruptly, the F0 is too high (above 350 Hz) and if there are significant antiresonances, i. Like other acoustic measures, the degree of effort used in producing the voice sample, day-to-day variability11 and algorithms for calculating the noise energy in the signal can all influence results69 so care must be taken when comparing studies. Visual assessment Visual inspection of the larynx is mandatory for diagnosis or exclusion of laryngeal disease. This can usually be performed in the clinic, but occasionally a diagnostic microlaryngoscopy needs to be performed either when the patient cannot tolerate an examination in the clinic or when the diagnosis is still uncertain. For more detailed descriptions of laryngostroboscopy and other imaging techniques, see Refs133, 134, 135, 136, 137, 138, 139. Aerodynamic measures Clinically, there are three main factors that can be measured which are of interest in voice production: air volume, airflow and air pressure. The process depends, however, on the assumption that the voice signal is truly periodic. In practice, it is difficult perceptually to distinguish between the sensations associated with: (1) frequency irregularity from cycle to cycle of vocal fold vibration, (2) amplitude irregularity from cycle to cycle and (3) the presence of random noise in the voice. The air volume used during phonation is a percentage of the total respiratory volume. In normal conversational speech, the speaker pauses for breath when the lung volume reaches the resting expiratory reserve volume and inhales to a lung volume typically above the tidal volume level. Body plethysmography should be used and remains the gold standard if measurements of air volume changes during speech or singing are required. Alternative approaches are to use magnetometers and inductance plethysmographs placed over the chest and abdominal walls, although the accuracy of these techniques has been questioned. As the /z/ sound is dependent on vocal fold vibration, abnormalities which interfere with this vibration150 or affect glottic closure would be expected to reduce the /z/ value but not have any significant effect on the /s/ time thus increasing the ratio. Although this simple test is used quite widely, in practice some of the original precepts have been challenged as it depends on eliciting a maximum performance in a speaker. Subsequent studies have shown that there is a wide range in normal values and its sensitivity and utility are therefore questionable. This is derived from the oral airflow signal measured using a special pneumotachograph placed in a circumferentially vented face mask. Inverse filtering aims at processing the airflow signal to eliminate the effects of the vocal tract resonances. Oral/nasal airflow ratios can be measured and calculated and are of most utility in relation to the assessment of velopharyngeal function and, for particular classes of speakers (see Baken and Orlikoff152 for a useful overview). The phonation threshold pressure is the minimum subglottal pressure required to induce oscillation. The most accurate method of measuring subglottic pressure is to place a pressuresensing device in the subglottis. This can be achieved by performing a percutaneous cricothyroid or tracheal puncture with a large bore hypodermic needle and attaching it to a pressure transducer. Subglottic pressure may also be estimated indirectly by using a body plethysmograph or a pressure transducer placed in the oesophagus. An estimate of the average subglottal pressure during vowel production can be obtained by measuring pressure at the midpoint of a line connecting two successive pressure peaks. Other studies have shown higher mean scores for patients with vocal cord palsy (total score = 75), but otherwise similar values for muscle tension dysphonia and cysts/polyps. This confers the dual advantages of privacy to the wearer and efficiency in post-acquisition processing. Modern digital processing and miniaturization are now advancing to the point where very comprehensive data accumulation will provide for not only greater analytic depth, but also for warning biofeedback to the wearer in the working environment. These four measures were extracted from 22 well-known acoustic measures of voice quality based on sustained vowels and determined by correlation analysis, mutual information analysis and principal component analysis. Although currently based on relatively small databases, some conclusions can be drawn from the data (see Table 166. Voice condition Nonpathological Spasmodic dysphonia Pretreatment muscle tension dysphonia (functional dysphonia) Reused with permission from Ref. Unfortunately, this multidimensional definition does not easily lend itself to objective measurement.
Anteriorly acne in pregnancy cheap decutan 30mg on-line, there is a thickening of the membrane tretinoin 025 acne proven decutan 10mg, the cricothyroid ligament acne and diet generic 30mg decutan overnight delivery, which connects the cricoid and the thyroid cartilages in the midline acne reddit decutan 10 mg on-line. The glottis the glottis lies between the false and true vocal cords which cover the vestibular and vocal ligaments, respectively (Figures 162. Laterally, a horizontal slit opens into an elongated recess, the laryngeal ventricle. From the anterior part of the ventricle, the saccule of the larynx ascends between the vestibular ligament and the inner surface of the thyroid cartilage as high in some people as the upper border of the thyroid cartilage. The vestibular folds are two thick folds of mucous membrane each enclosing a narrow band of fibrous tissue, the vestibular ligament, which is the lower border of the upper quadrilateral membrane. It is fixed in front at the angle of the thyroid cartilage just below the attachment of the epiglottic cartilages and behind the anterolateral surface of the arytenoid cartilage just above the vocal process (Figure 162. The vocal folds extend from the middle of the angle of the thyroid cartilage to the vocal process of the arytenoid cartilages and underlying them is the upper border of the conus elasticus. Each fold is a layered structure consisting Hyoid bone Thyoid cartilage False vocal fold True vocal cord Quadrangular membrane Thyroepiglottic m. The intermediate layer contains elastic fibres and the deep layer collagen fibres. The vocalis muscle, which forms the main body of the vocal fold, lies lateral and deep. At the anterior end of the vocal fold there is a mass of collagen fibres which are connected to the inner perichondrium of the thyroid cartilage and to the deep layer of the lamina propria posteriorly. Adjacent to this mass of collagen fibres just posteriorly, there is another mass of elastic fibres continuous with the intermediate layer of the lamina propria called the anterior macula flava. A similar structure is seen at the posterior end of the membranous part of the vocal fold. These structures appear to serve as cushions to protect the ends of the vocal folds from mechanical damage caused by vocal fold vibration. The anterior three-fifths of the vocal cord is between the vocal folds and is called the intermembranous part of the cord. The remaining two-fifths posteriorly are between the vocal processes of the arytenoid and are Table 162. The lower part of the muscle is thicker and forms a distinct bundle called the vocalis muscle. Cricothyroid this is the only intrinsic muscle that lies outside the cartilaginous framework of the larynx Superior border of lateral part of the arch of the cricoid Posterior surface of the muscular process and outer edge of the arytenoid Posterior aspect of the muscular process (superficial to the transverse arytenoid) Back of the thyroid prominence and cricothyroid ligament Muscular process of arytenoid Crosses over and attaches to the same point on the other arytenoid Apex of the other arytenoid Opens the glottis. Upper horizontal fibres rotate the arytenoids and move the muscular processes towards each other separating the vocal processes and abducting the cords. Lateral vertical fibres draw the arytenoids down the sloping shoulders of the cricoid separating the arytenoids Adducts and lowers the tip of the vocal process by rotating the arytenoids medially Adducts the vocal fold and controls the position of the vocal fold Abducts and elevates the tip of the vocal process the vocal fold becomes elongated and thin. The free edge of the vocal fold is rounded and passively stiffened Vocal fold adducted, lowered, elongated and thinned. The edge of the vocal fold becomes sharp and is passively stiffened No significant effect on the mechanical properties of the vocal fold Vocal process of arytenoid and anterolateral surface of the body of the arytenoid Lateral surface of the anterior arch of the cricoid. Fibres fan out and pass backwards in two groups Lower oblique fibres pass backwards and laterally to the anterior border of the inferior cornu of the thyroid cartilage. Anterior straight fibres ascend to the posterior part of the lower border of the thyroid lamina Lowers, shortens and thickens the vocal folds causing the edge of the fold to be rounded. The body of the fold is actively stiffened but the transition layers are passively slackened. Many fibres are prolonged into the aryepiglottic fold some continuing to the margin of the epiglottis as the thyroepiglottic muscle which tends to widen the inlet of the larynx pulling the aryepiglottic folds slightly apart Rotates the cricoid cartilage about the horizontal axis passing through the cricothyroid joint. It lengthens the vocal folds by increasing the distance between the angle of the thyroid cartilage and arytenoids. On contraction, the vocal folds are brought into a line between the anterior commissure and the posterior cricoarytenoid ligament, the level of the vocal folds is lowered and the entire fold elongated and thinned. The edge of the vocal fold becomes sharp and all the layers are stiffened Weak sphincter of the laryngeal inlet Widens the inlet of the larynx pulling the aryepiglottic folds slightly apart Alter the shape of laryngeal inlet Aryepiglotticus A continuation of the oblique arytenoid Thyroepiglotticus A continuation of the thyroarytenoid Posterior aspect of the muscular process of the arytenoid Back of the thyroid prominence and cricothyroid ligament Fibres pass around the apex of the opposite arytenoid and insert into the aryepiglottic fold Fibres pass upwards into the aryepiglottic fold All the intrinsic muscles of the larynx are supplied by the recurrent laryngeal nerve except the cricothyroid, which is supplied by the external branch of the superior laryngeal nerve. The unpaired transverse arytenoid and paired oblique arytenoid make up the interarytenoid muscle. Chapter 162 Anatomy of the larynx and tracheobronchial tree] 2137 Arytenoid cartilage Cricoid cartilage Posterior cricoarytenoid muscle Lateral cricoarytenoid muscle Transverse and oblique arytenoid muscles Cricothyroid muscles Thyroarytenoid muscle Vocal ligament Muscular process Vocal process Thyroid cartlilage Figure 162. Superior laryngeal nerve Internal branch External branch Superior laryngeal artery Inferior pharyngeal constrictor muscle Thyroid branches Cricothyroid muscle Cricopharyngeus muscle (part of inferior pharyngeal constrictor) Recurrent laryngeal nerve Inferior thyroid artery Oblique and transverse arytenoid muscles Posterior cricoarytenoid muscle Vertical part Oblique part Cricothyroid muscle Foramen for superior laryngeal vessels and internal branch of superior laryngeal nerve Figure 162. The height of the vocal folds diminishes towards the anterior commissure mainly because the inferior edge of the vocal fold slopes upwards. At the anterior commissure the lower edges of the vocal folds form the apex of the triangular fixed part of the epiglottis, so tumour involving the anterior commissure usually involves the subglottis. Mucous membranes of the larynx the mucous membrane lining of the larynx is closely attached over the posterior surface of the epiglottis, the corniculate and cuneiform cartilages and over the vocal ligament. The upper half of the posterior surface of the epiglottis, the upper part of the aryepiglottic fold, the posterior glottis and the vocal folds are covered with nonkeratinizing stratified squamous epithelium.
The involved area is best excised and repaired with either a rotation flap or free flap acne on cheeks discount decutan 10 mg free shipping. Most now advocate radical surgery for even early disease with the objective of obtaining an en-bloc clearance of the tumour acne 70 buy decutan 20 mg amex. Approximately six weeks after the completion of radiotherapy acne jaw line buy decutan no prescription, the patient should have a planned craniofacial resection to encompass completely any residual tumour acne 7061 buy 20 mg decutan otc. High quality prosthetic rehabilitation is essential and requires the help of a maxillofacial laboratory. With a palatal resection, the defect must be sealed with either an obturator fitted with teeth to restore both speech and normal deglutition or by a free composite flap using microvascular techniques. Orbital resections leave an obvious cosmetic deformity and the Branemark system of titanium implants has revolutionized the fitting of facial prostheses. The choice is determined by the extent of the tumour and amount of bone that needs to be removed. Medial maxillectomy involves the clearance of the lateral wall of the nose including the ethmoid sinuses. Palatal resection along with the adjacent alveolus is used for tumours of the oral cavity that involve the hard palate. This is technically incorrect as palatal fenestration was originally described for placing radium implants into the cavity of the antrum containing tumour. Most fenestrations nowadays are closed with free flaps, but for some patients there is still some advantage with the older, less sophisticated procedure as it allows good visualization of the cavity after treatment with potential early detection of any recurrence. It gives excellent exposure to the nasal cavities, postnasal space, antra and pterygopalatine fossae. In selected cases, good exposure of the ethmoids is obtained, but for ethmoid malignancy the lateral rhinotomy incision gives better exposure. When combined with either a Le Fort 1 osteotomy or maxillotomy, it gives a very wide approach to the clivus and skull base and is of immense value for those extensive tumours which involve this region (Figure 186. The selection of the operation depends on the preoperative assessment, but generally if the palate or zygoma is involved a total maxillectomy is indicated. In most other tumours a lateral rhinotomy or midfacial degloving approach will this entails the total removal of the upper jaw, preferably as a bony box containing the tumour. Surgical approaches To facilitate the various bone resections it is necessary to use an appropriate soft tissue approach. This approach is usually attributed to Moure,24 but in fact was originally described by Michaux25 some 50 years earlier in 1854 and gives excellent exposure of both the nasal cavities and medial maxilla with a cosmetically acceptable incision in the lateral nasal crease (Figure 186. This approach is incorrectly attributed to both Fergusson and Weber, although it was originally described by Gensoul in 1833 (Figure 186. In most cases, splitting the lip is not necessary, but additional lateral exposure can be gained in this way. Some feel that an oral endotracheal tube gets in the way when fabricating the prosthesis and so prefer a nasal tube placed in the contralateral nostril. If the anterior fossa is opened, the patient should be loaded with phenytoin at the time of induction and maintained on this prophylactically for three months. The maxilla is freed from the skull by osteotomies through the frontal process of the maxilla. The body of the zygoma, the midline of the palate and the pterygoid plates need to be freed posteriorly. The palatal osteotomy is placed in the floor of the nasal cavity and may be made either with an oscillating or gigli saw. The pterygoid plates are best separated from the maxilla with a curved osteotome and subsequently dissected free from the muscles. The remaining bony attachments are the posterior ethmoid cells and posterior antral roof, and these break readily on mobilizing the maxilla. The remaining soft tissue attachments are freed with Mayo scissors and the maxilla removed. Bleeding from the internal maxillary artery is controlled initially by packing and then by application of a Ligaclip. The transverse limb should be placed close to the lid margin to prevent postoperative oedema of the lower lid. In the medial canthal region where the potential for skin loss as a result of radiotherapy is greatest, it is helpful to curve the incision forward over the nasal bones for additional support postoperatively. An incision along the crest of the philtrum and stepped on the lip is more acceptable than a midline incision. The mucosal incision along the midline of the hard palate turns laterally at the junction with the soft palate passing behind the maxillary tuberosity and then round the alveolus anteriorly. The facial skin flap is raised and all the soft tissue incisions are gently dissected free of the bone to allow the subsequent osteotomies (Figure 186. Following removal of the maxilla, further tissue must be resected to ensure complete tumour clearance and promote drainage from the remaining sinuses. The ethmoid cells should be exenterated completely and both the sphenoid and frontal sinuses opened widely. If there is obvious involvement of the orbital periosteum, orbital exenteration is generally indicated. The support of the globe is complex and virtually all the medial and inferior orbital walls can be removed without the eye sinking. Orbital exenteration is achieved by an extraperiosteal dissection and transection of the muscle cone at the apex with Mayo scissors. Bleeding from the ophthalmic artery can be stopped by applying local pressure or bipolar coagulation. Following orbital exenteration, the eyelids are preserved but the lid margins and tarsal plates are excised to give a smooth skin-lined cavity to which an onlay prosthesis can be fitted.
