Fetal Surgery

Fetal Surgery

Of the approximately 4 million babies born in the United States each year, about 120,000 (3 percent) have a complex birth defect. Maternal-fetal specialists have long known that some birth defects could be successfully treated after birth. But as technology, fetal imaging and prenatal testing have improved in the past few decades, so too has our knowledge of fetal development.

Expanded diagnostic tools have allowed us to identify more precisely when conditions worsen during fetal development. This knowledge has helped us develop new ways to help babies sooner while in utero. Today, fetal therapy is recognized as one of the most promising fields in pediatric medicine, and prenatal surgery is becoming an option for a growing number of babies with birth defects.

Fetal Surgery

Treating birth defects before birth

Fetal surgery allows us to intervene earlier. Using highly sophisticated surgical procedures, we are now able to treat certain disabling and life-threatening birth defects during fetal development instead of after birth, and to offer new hope to families.

Fetal surgery is a complex and challenging procedure, requiring the most expert, comprehensive care for both mother and unborn baby. Few medical teams have the skill and resources to perform such complex procedures, which can present significant risks for both mother and baby.

The Center for Fetal Diagnosis and Treatment at Children’s Hospital of Philadelphia has been providing this care to patients since 1995, experience that helps us to deliver the best outcomes while minimizing the risks to both you and your baby. Be sure to ask these questions before you allow a clinical program to perform fetal surgery.

 


Eyelod Aesthetics

Eyelod Aesthetics

Eyelid surgery (blepharoplasty) is a very popular and effective technique used to improve the appearance and function of your eyelids. Just like other areas of your body, your eyelid skin can lose elasticity as you grow older. This can cause sagging of the upper eyelids and bags under the eyes. Not only can this make you look older and tired, drooping eyelids can also interfere with your vision.

How Eyelid Surgery Works

At Palmetto Eye & Laser Center we perform eyelid surgery in Spartanburg, South Carolina, as an outpatient procedure.

  • Local anesthetic is administered
  • Incisions are made in the natural creases of the upper eyelids and/or the inside lower eyelid
  • Excess fat, skin and muscle is removed
  • The incisions are closed with small stitches that dissolve naturally

Because the incisions are made in the natural creases, scarring is usually minimal. To achieve the most natural-looking results, it is important to have eyelid surgery performed by a board certified eyelid surgery doctor that has extensive training and experience with this delicate procedure. Our eyelid surgeons have a strong track record of successful procedures and can share their experience and results with you.

Eyelod Aesthetics

Eyelid Surgery Recovery

It is common for the eye areas to have mild bruising and swelling for a week or two after surgery. Your eyes might also be sensitive to light and be prone to tearing. These are typically temporary side effects that can be minimized by following your doctor’s instructions for applying lubricating ointments, cold compresses, medications, etc.

Possible Complications of Eyelid Surgery

Your doctor should explain all of the potential complications that may occur with eyelid surgery, including:

  • Scarring
  • Infection
  • Bleeding
  • Dry eyes
  • Temporary lid lag
  • Blurry vision
  • Pain
  • Vision loss
  • Revision surgery

Eyelid surgery is a great method of facial rejuvenation and vision enhancement – if it is done correctly. If you are unhappy with the appearance or function of your eyes, contact us today to discuss your individual situation and find out if eyelid surgery might help you enhance your life.


Upper Eyelid

Upper Eyelid

The procedure of upper eyelid blepharoplasty has changed dramatically in both understanding and performance over the last 20 years. Upper eyelid overhang and the resultant tired facies have led patients to seek correction for the last century. Understanding the dynamic anatomy of the upper eyelid and the palpebral crease allows tailoring the fold and eradicating the tired look in most patients.

History of the Procedure

Upper eyelid skin resection and fat resection from the upper eyelid fat pockets have been performed for more than a century. In the last 20 years, skin and fat resection has decreased to avoid causing incomplete eyelid closure and dry eye symptomatology. A deeper understanding of the dynamic nature of the upper eyelid has led to invagination techniques, largely borrowed from the Asian double-eyelid procedure, to deliver a crisp upper eyelid fold at a height that is optimum for the patient.

Problem

Upper eyelid blepharoplasty is the surgical approach to addressing dermachalasis (also known as dermatochalasis) of the upper eyelid. Dermachalasis represents redundant, loose skin of the upper eyelid that occurs with aging.

 Clearly differentiate upper eyelid dermachalasis from the myriad other problems of the upper eyelid that often are a component of upper eyelid aging. True dermachalasis is common, but often, all upper eyelid problems are treated with upper eyelid skin blepharoplasty, which is useful only for treating dermachalasis. Even with this problem properly diagnosed and differentiated from other periorbital problems, a better treatment is often found with an anchor blepharoplasty compared to simple skin resection or skin and partial muscle and fat resection.

Brow ptosis is the most common cause of upper eyelid fullness. Carefully assess brow position prior to planned rejuvenation of the periorbita. Please see the Medscape Reference text on brow lift (Periorbital Rejuvenation Brow Lift) for a more detailed discussion of this topic. Aggressive treatment of the upper eyelid for the treatment of brow ptosis is inadequate and counterproductive and rarely leads to any marked improvement in the condition.

Upper eyelid ptosis also commonly is mistaken for upper eyelid dermachalasis and cannot be treated with simple upper eyelid blepharoplasty or anchor blepharoplasty. Repair the dehiscence or shortened levator muscle in individuals with good levator function but acquired or congenital ptosis. If ptosis requires correction, perform an anterior or posterior procedure (Fasanella-Servat or partial Mullerectomy to preserve conjunctival mucus-secreting glands).

Pathophysiology

In an Asian patient with an upper eyelid lacking a fold (congenital), often some degree of medial epicanthus also is present. The degree to which the medial epicanthus is hidden by the epicanthal fold determines whether correction is necessary. Medial epicanthoplasty is discussed in Treatment, but a small median epicanthus is also an ethnic trait, and complete removal in all instances can markedly change the appearance of the individual. Clearly discuss this preoperatively and plan the degree of correction if necessary.

Upper Eyelid

Indications

The primary indication for upper eyelid blepharoplasty is the patient’s desire to improve his or her appearance. In rare instances, upper eyelid skin occludes peripheral vision, and some insurance carriers are willing to contribute to operative costs to improve the condition after visual field examination and mapping are performed. Rarely, a component of brow ptosis is absent in these patients.

The indications for upper eyelid procedures in the Asian patient merit further discussion. The intent of the procedure is to create a more beautiful Asian eye, not to create a Caucasian-appearing eye. The author has had parents bring in 5-year-old children for the procedure, and, although he declined to perform the procedure, the author believes individual practitioners should decide whether they consider this a congenital defect or a cosmetic variance.

Contraindications

No contraindications exist to a properly conceived and performed upper eyelid blepharoplasty in the typical patient. Approach lagophthalmos with caution, since no skin should be resected, but other corrections can be performed with the procedure. Multiply operated upper lids can present a formidable challenge to those inexperienced with the changing anatomy from previous surgery. The patient’s attitude and expectations must be appropriate and reasonable. The patient’s general health is always a consideration, but the procedure is minimally invasive, and, when performed alone, it can be performed readily with local anesthetic unaugmented by sedatives.


Head And Neck Oncology

Head And Neck Oncology

What are cancers of the head and neck?

Cancers that are known collectively as head and neck cancers usually begin in the squamous cells that line the moist, mucosal surfaces inside the head and neck (for example, inside the mouth, the nose, and the throat). These squamous cell cancers are often referred to as squamous cell carcinomas of the head and neck. Head and neck cancers can also begin in the salivary glands, but salivary gland cancers are relatively uncommon. Salivary glands contain many different types of cells that can become cancerous, so there are many different types of salivary gland cancer.

Cancers of the head and neck are further categorized by the area of the head or neck in which they begin. These areas are described below and labeled in the image of head and neck cancer regions.

Oral cavity: Includes the lips, the front two-thirds of the tongue, the gums, the lining inside the cheeks and lips, the floor (bottom) of the mouth under the tongue, the hard palate (bony top of the mouth), and the small area of the gum behind the wisdom teeth.

Pharynx: The pharynx (throat) is a hollow tube about 5 inches long that starts behind the nose and leads to the esophagus. It has three parts: the nasopharynx (the upper part of the pharynx, behind the nose); the oropharynx (the middle part of the pharynx, including the soft palate [the back of the mouth], the base of the tongue, and the tonsils); the hypopharynx (the lower part of the pharynx).

Larynx: The larynx, also called the voicebox, is a short passageway formed by cartilage just below the pharynx in the neck. The larynx contains the vocal cords. It also has a small piece of tissue, called the epiglottis, which moves to cover the larynx to prevent food from entering the air passages.

Paranasal sinuses and nasal cavity: The paranasal sinuses are small hollow spaces in the bones of the head surrounding the nose. The nasal cavity is the hollow space inside the nose.

Salivary glands: The major salivary glands are in the floor of the mouth and near the jawbone. The salivary glands produce saliva.

Head and neck cancer regions. Illustrates location of paranasal sinuses, nasal cavity, oral cavity, tongue, salivary glands, larynx, and pharynx (including the nasopharynx, oropharynx, and hypopharynx).
What causes cancers of the head and neck?

Alcohol and tobacco use (including smokeless tobacco, sometimes called “chewing tobacco” or “snuff”) are the two most important risk factors for head and neck cancers, especially cancers of the oral cavity, oropharynx, hypopharynx, and larynx. At least 75% of head and neck cancers are caused by tobacco and alcohol use. People who use both tobacco and alcohol are at greater risk of developing these cancers than people who use either tobacco or alcohol alone. Tobacco and alcohol use are not risk factors for salivary gland cancers.

Infection with cancer-causing types of human papillomavirus (HPV), especially HPV type, is a risk factor for some types of head and neck cancers, particularly oropharyngeal cancers that involve the tonsils or the base of the tongue. In the United States, the incidence of oropharyngeal cancers caused by HPV infection is increasing, while the incidence of oropharyngeal cancers related to other causes is falling (9). More information is available in the HPV and Cancer fact sheet.

Head And Neck Oncology

Other risk factors for cancers of the head and neck include the following:

Paan (betel quid). Immigrants from Southeast Asia who use paan (betel quid) in the mouth should be aware that this habit has been strongly associated with an increased risk of oral cancer

Preserved or salted foods. Consumption of certain preserved or salted foods during childhood is a risk factor for nasopharyngeal cancer .

Oral health. Poor oral hygiene and missing teeth may be weak risk factors for cancers of the oral cavity Use of mouthwash that has a high alcohol content is a possible, but not proven, risk factor for cancers of the oral cavity.

Occupational exposure. Occupational exposure to wood dust is a risk factor for nasopharyngeal cancer . Certain industrial exposures, including exposures to asbestos and synthetic fibers, have been associated with cancer of the larynx, but the increase in risk remains controversial . People working in certain jobs in the construction, metal, textile, ceramic, logging, and food industries may have an increased risk of cancer of the larynx. Industrial exposure to wood or nickel dust or formaldehyde is a risk factor for cancers of the paranasal sinuses and nasal cavity.

Radiation exposure. Radiation to the head and neck, for noncancerous conditions or cancer, is a risk factor for cancer of the salivary glands .

Epstein-Barr virus infection. Infection with the Epstein-Barr virus is a risk factor for nasopharyngeal cancer and cancer of the salivary glands.

Ancestry. Asian ancestry, particularly Chinese ancestry, is a risk factor for nasopharyngeal cancer.

What are the symptoms of head and neck cancers?

The symptoms of head and neck cancers may include a lump or a sore that does not heal, a sore throat that does not go away, difficulty in swallowing, and a change or hoarseness in the voice. These symptoms may also be caused by other, less serious conditions. It is important to check with a doctor or dentist about any of these symptoms. Symptoms that may affect specific areas of the head and neck include the following:

Oral cavity. A white or red patch on the gums, the tongue, or the lining of the mouth; a swelling of the jaw that causes dentures to fit poorly or become uncomfortable; and unusual bleeding or pain in the mouth.

Pharynx. Trouble breathing or speaking; pain when swallowing; pain in the neck or the throat that does not go away; frequent headaches, pain, or ringing in the ears; or trouble hearing.

Larynx. Pain when swallowing or ear pain.

Paranasal sinuses and nasal cavity. Sinuses that are blocked and do not clear; chronic sinus infections that do not respond to treatment with antibiotics; bleeding through the nose; frequent headaches, swelling or other trouble with the eyes; pain in the upper teeth; or problems with dentures.

Salivary glands. Swelling under the chin or around the jawbone, numbness or paralysis of the muscles in the face, or pain in the face, the chin, or the neck that does not go away.

How common are head and neck cancers?

Head and neck cancers account for approximately 4% of all cancers in the United States. These cancers are more than twice as common among men as they are among women. Head and neck cancers are also diagnosed more often among people over age 50 than they are among younger people.

Researchers estimated that more than 65,000 men and women in this country would be diagnosed with head and neck cancers in 2017.

How can I reduce my risk of developing head and neck cancers?

People who are at risk of head and neck cancers―particularly those who use tobacco―should talk with their doctor about ways that they may be able to reduce their risk. They should also discuss with their doctor how often to have checkups. In addition, ongoing clinical trials are testing the effectiveness of various medications in preventing head and neck cancers in people who have a high risk of developing these diseases. Descriptions of these clinical trials can be accessed by searching NCI’s list of cancer clinical trials. NCI’s list of cancer clinical trials includes all NCI-supported clinical trials that are taking place across the United States and Canada and around the world.  For information about other ways to search the list, see Help Finding NCI-Supported Clinical Trials.

Avoiding oral HPV infection may reduce the risk of HPV-associated head and neck cancers. However, it is not yet known whether the Food and Drug Administration-approved HPV vaccines Gardasil®, Gardasil 9®, and Cervarix® prevent HPV infection of the oral cavity, and none of these vaccines has yet been approved for the prevention of oropharyngeal cancer. More information about these vaccines is in the NCI fact sheet Human Papillomavirus (HPV) Vaccines.

How are head and neck cancers diagnosed?

To find the cause of the signs or symptoms of a problem in the head and neck area, a doctor evaluates a person’s medical history, performs a physical examination, and orders diagnostic tests. The exams and tests may vary depending on the symptoms. Examination of a sample of tissue under a microscope is always necessary to confirm a diagnosis of cancer.

If the diagnosis is cancer, the doctor will want to learn the stage (or extent) of disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Staging may involve an examination under anesthesia (in an operating room), x-rays and other imaging procedures, and laboratory tests. Knowing the stage of the disease helps the doctor plan treatment.

How are head and neck cancers treated?

The treatment plan for an individual patient depends on a number of factors, including the exact location of the tumor, the stage of the cancer, and the person’s age and general health. Treatment for head and neck cancer can include surgery, radiation therapy, chemotherapy, targeted therapy, or a combination of treatments.

People who are diagnosed with HPV-positive oropharyngeal cancer may be treated differently than people with oropharyngeal cancers that are HPV-negative. Recent research has shown that patients with HPV-positive oropharyngeal tumors have a better prognosis and may do just as well on less intense treatment. An ongoing clinical trial is investigating this question.

More information about treatment for specific types of head and neck cancers is in the following PDQ® cancer treatment summaries, which are available in patient and health professional versions, as well as in Spanish (the links below go to the patient versions in English):

  • Hypopharyngeal Cancer
  • Laryngeal Cancer
  • Lip and Oral Cavity Cancer
  • Metastatic Squamous Neck Cancer with Occult Primary
  • Nasopharyngeal Cancer
  • Oropharyngeal Cancer
  • Paranasal Sinus and Nasal Cavity Cancer
  • Salivary Gland Cancer

The patient and the doctor should consider treatment options carefully. They should discuss each type of treatment and how it might change the way the patient looks, talks, eats, or breathes.

What are the side effects of treatment?

Surgery for head and neck cancers often changes the patient’s ability to chew, swallow, or talk. The patient may look different after surgery, and the face and neck may be swollen. The swelling usually goes away within a few weeks. However, if lymph nodes are removed, the flow of lymph in the area where they were removed may be slower and lymph could collect in the tissues, causing additional swelling; this swelling may last for a long time.

After a laryngectomy (surgery to remove the larynx) or other surgery in the neck, parts of the neck and throat may feel numb because nerves have been cut. If lymph nodes in the neck were removed, the shoulder and neck may become weak and stiff.

Patients who receive radiation to the head and neck may experience redness, irritation, and sores in the mouth; a dry mouth or thickened saliva; difficulty in swallowing; changes in taste; or nausea. Other problems that may occur during treatment are loss of taste, which may decrease appetite and affect nutrition, and earaches (caused by the hardening of ear wax). Patients may also notice some swelling or drooping of the skin under the chin and changes in the texture of the skin. The jaw may feel stiff, and patients may not be able to open their mouth as wide as before treatment.

Patients should report any side effects to their doctor or nurse, and discuss how to deal with them.

Where can I find more information about clinical trials for patients with head and neck cancers?

Clinical trials are research studies conducted with people who volunteer to take part. Participation in clinical trials is an option for many patients with head and neck cancer. Ongoing clinical trials are testing the effectiveness of treatments for head and neck cancers. Descriptions of these clinical trials can be accessed by searching NCI’s list of cancer clinical trials, which includes all NCI-supported clinical trials that are taking place across the United States and Canada and around the world. For information about other ways to search the list, see Help Finding NCI-Supported Clinical Trials.
People interested in taking part in a clinical trial should talk with their doctor. Information about clinical trials is available in the NCI publication Taking Part in Cancer Treatment Research Studies. This resource describes how research studies are carried out and explains their possible benefits and risks.

What rehabilitation or support options are available for patients with head and neck cancers?

The goal of treatment for head and neck cancers is to control the disease, but doctors are also concerned about preserving the function of the affected areas as much as they can and helping the patient return to normal activities as soon as possible after treatment. Rehabilitation is a very important part of this process. The goals of rehabilitation depend on the extent of the disease and the treatment that a patient has received.

Depending on the location of the cancer and the type of treatment, rehabilitation may include physical therapy, dietary counseling, speech therapy, and/or learning how to care for a stoma. A stoma is an opening into the windpipe through which a patient breathes after a laryngectomy, which is surgery to remove the larynx. The National Library of Medicine has more information about laryngectomy in MedlinePlus.

Sometimes, especially with cancer of the oral cavity, a patient may need reconstructive and plastic surgery to rebuild bones or tissues. However, reconstructive surgery may not always be possible because of damage to the remaining tissue from the original surgery or from radiation therapy. If reconstructive surgery is not possible, a prosthodontist may be able to make a prosthesis (an artificial dental and/or facial part) to restore satisfactory swallowing, speech, and appearance. Patients will receive special training on how to use the device.

Patients who have trouble speaking after treatment may need speech therapy. Often, a speech-language pathologist will visit the patient in the hospital to plan therapy and teach speech exercises or alternative methods of speaking. Speech therapy usually continues after the patient returns home.

Eating may be difficult after treatment for head and neck cancer. Some patients receive nutrients directly into a vein after surgery or need a feeding tube until they can eat on their own. A feeding tube is a flexible plastic tube that is passed into the stomach through the nose or an incision in the abdomen. A nurse or speech-language pathologist can help patients learn how to swallow again after surgery. The NCI booklet Eating Hints: Before, During, and After Cancer Treatment contains many useful suggestions and recipes.

Is follow-up care necessary? What does it involve?

Regular follow-up care is very important after treatment for head and neck cancer to make sure that the cancer has not returned, or that a second primary (new) cancer has not developed. Depending on the type of cancer, medical checkups could include exams of the stoma, if one has been created, and of the mouth, neck, and throat. Regular dental exams may also be necessary.

From time to time, the doctor may perform a complete physical exam, blood tests, x-rays, and computed tomography (CT), positron emission tomography (PET), or magnetic resonance imaging (MRI) scans. The doctor may monitor thyroid and pituitary gland function, especially if the head or neck was treated with radiation. Also, the doctor is likely to counsel patients to stop smoking. Research has shown that continued smoking by a patient with head and neck cancer may reduce the effectiveness of treatment and increase the chance of a second primary cancer.

Additional information can be found at NCI’s Follow-Up Medical Care page.

How can people who have had head and neck cancers reduce their risk of developing a second primary (new) cancer?

People who have been treated for head and neck cancers have an increased chance of developing a new cancer, usually in the head, neck, esophagus, or lungs. The chance of a second primary cancer varies depending on the site of the original cancer, but it is higher for people who use tobacco and drink alcohol.


Perioperative Regional Anesthesia

Perioperative Regional Anesthesia

Healthcare providers have become increasingly focused on pro- viding effective management of acute perioperative pain in all patients, but especially older adults, as the size of this patient population has steadily increased in recent years. Advances in anesthetic and surgical techniques, an improved understanding of the pathophysiology of pain, the development of new opioid and nonopioid analgesic drugs, the incorporation of regional techniques that reduce or eliminate reliance on traditional opi- oid analgesics, and novel methods of drug delivery have all led to greater numbers of older patients undergoing major sur- gery.

An increased prevalence of chronic medical conditions among older individuals may also lead to higher degrees of acute and chronic pain (including acute-on-chronic pain). For instance, acute exacerbations of arthritis, osteoporotic fractures of the spine, cancer pain, and pain from acute medical condi- tions (eg, ischemic heart disease, herpes zoster, peripheral vas- cular disease) must be properly addressed in order to maximize multimodal perioperative pain management. In addition, older individuals are adopting more active lifestyles that can predispose them to trauma and orthopedic injuries that require surgery.

The term elderly encompasses both chronologic and physi- ologic factors. Chronologic age is the actual number of years an individual has lived, whereas physiologic age refers to func- tional capacity or reserve within organ systems defined in pathophysiologic parameters. The chronologic component can be divided into two separate groups: the “young old” (65 to 80 years of age) and the “older old” (greater than 80 years of age).5 Physiologic reserve describes the functional capacity of organ systems to compensate for acute stress and traumatic derange- ments. When present, comorbid disease states such as diabetes mellitus, arthritis, renal insufficiency, ischemic heart disease, and chronic obstructive pulmonary disease (COPD) can all decrease a patient’s physiologic reserve making it difficult for him or her to recover from traumatic or surgical injury.

There are a host of additional factors that may compromise the ability to provide optimal and effective acute pain manage- ment to older patients. A consequence of the comorbid diseases that afflict this patient population with increased frequency is the medications used in treatments for such diseased condi- tions, along with a subsequent increased risk of drug-to-drug and disease-to-drug interactions. An improved understanding of age-related changes in physiology, pharmacodynamics, and pharmacokinetics must be incorporated into any acute pain medicine care plan for older individuals. Altered responses to pain among the elderly population along with difficulties in pain assessment for certain individuals with cognitive dysfunc- tion are potential problems that must also be considered.

Several theories have been advocated to describe the multi- dimensional aspects and consequences of aging that underscore the complexities and difficulties encountered in developing optimal regional anesthetic and analgesic choices for elderly patients. Therefore, the focus of this chapter is to outline the physiologic and pharmacologic implications of aging on surgi- cal anesthesia and acute pain management, as well as the poten- tial risks and benefits of neuraxial blockade along with peripheral nerve/nerve plexus blockade in geriatric patients.

PHYSIOLOGIC CHANGES ASSOCIATED WITH AGING AND CONSIDERATIONS FOR REGIONAL ANESTHESIA/ANALGESIA

Aging is characterized by progressive reductions in the homeo- static reserves of nearly every organ system. Declining organ function, often referred to as homeostenosis, may be gradual or progressive and becomes evident by the third decade of life. The compromised function of each organ system generally occurs independent of changes to other organ systems and may be influenced by a host of factors, including diet, environment, habits, and genetic predisposition. Optimal anesthetic manage- ment using regional techniques in elderly patients depends upon a knowledge and understanding of normal age-related changes in anatomy, physiology, and response to pharmacologic agents. It is also important to distinguish normal physiologic alterations of the central
nervous system (CNS), cardiovascular, pulmonary, and hepatorenal systems from disease-related pathophysiologic changes.

Nervous System Function

Aging results in anatomical and biochemical changes of the brain, spinal cord, and peripheral nervous system (PNS) that result in qualitative and quantitative alterations in function. In addition, advanced age can be associated with decreased brain volume, a manifestation of the loss of neurons, as well as a reduction in cerebral white matter nerve fibers. Specifically, the number of cholinergic and dopaminergic neu- rons declines, and morphologic changes in neuronal fibers occur that result in fewer synaptic contacts and neuroreceptors.

Perioperative Regional Anesthesia

Cardiovascular Function

There are a variety of morphological and functional changes in the cardiovascular system associated with aging, including a reduction in left ventricular compliance, generalized hypertro- phy of the left ventricular wall, fibrotic changes of the heart, and decreased myocardial compliance. These changes can result in increased stroke volume and elevated diastolic and systolic blood pressure. Many elderly patients present with cardiac pathology, including moderate to severe coronary artery disease, valvular heart disease, and conduction defects that increase the risk of postsurgical morbidity and death. The effects of aging on cardiac output in the absence of coexisting disease may have minimal influence on the resting individual, but functional changes can become evident with stress and effort-dependent stress. Anesthetics and anesthesia technique may also interact with the patient’s preexisting cardiovascular disease in a manner that may be unfavorable. For example, patients with a fixed cardiac output (as in aortic stenosis) may not tolerate a decrease in systemic vascular resistance associated with neuraxial anesthesia well. Acute/extreme hemodynamic variability in the setting of regional anesthesia, however, can be overcome with careful titration of neuraxial anesthesia with an epidural or spinal catheter and skillful use of vasopressors.

Pharmacokinetic and Pharmacodynamic Changes in the Elderly

Aging affects the pharmacokinetics and pharmacodynamics of medications (eg, sedative/hypnotics, opiates, nonopioid analge- sics, local anesthetics), the physiologic functions of the body, and the composition/characteristics of organs and tissues within the body to variable degrees. The physiologic changes and effects on pharmacokinetics and pharmacodynamics in older patients, as well as some alterations that may be required for drug regimens in older patients. Information in these tables addresses a number of issues related to local anesthetics and opioid analge- sics in view of their widespread use and importance in periop- erative pain management for older patients. The altered response to drugs associated with aging can be highly variable and somewhat unpredictable among individuals and are gener- ally attributable to aging alone, but such responses may be compounded by a higher incidence of degenerative and other coexisting diseases in this patient population.

Multimodal Drug Therapy and the Elderly

A perioperative plan of care that includes a regional technique in an elderly patient must consider the inherent risk of sedation/ hypnosis, multimodal drug regimens, and local anesthetic medi- cations. Safety principles of treatment with analgesic and sedative medications for pain management in older patients, specific to regional and regional peripheral nerve blockade. Sedative drugs (eg,midazolam, propofol) used during block placement should be easy to administer, short-acting, have a high safety margin, and limited adverse effects. Epinephrine can prolong peripheral nerve blockade duration, but caution must be exercised as epinephrine may cause an ischemic neurotoxicity in peripheral nerves with preexisting neuropathy (eg, in patients with diabetes).

Physiology and the Perception of Pain in the Elderly and Clinical Implications

Several review articles have summarized the many age-related changes that occur in pain perception and the neurophysiology of nociception in elderly surgical patients. There are extensive alterations in the structure, neurochemistry, and function of both the PNS and CNS of older patients. Included among these changes is the neurochemical deterioration of opioid and serotonergic systems. Therefore, there may be changes in nociceptive processing, including impairment of the pain inhibitory system, and pain intensity after surgery may be greater or less than otherwise expected from the severity of surgical trauma induced. In one study, older patients matched for surgical procedure reported less pain in the postoperative period, and pain intensity decreased by 10% to 20% for each decade after 60 years of age.


Weak And Strong Opioids

Weak And Strong Opioids

WEAK OPIOIDS

A collection of medications that include codeine, hydrocodone, and tramadol is recommended as the second tier of the WHO analgesic ladder. These are the weak opioids, and they are used for mild to moderate pain, often in combination with step 1 analgesics. Variation in the metabolism of weak opioids is considerable among individuals, which leads to a somewhat unpredictable analgesic effect. One way to minimize toxicity is to combine lower doses of agents from different classes of drugs to obtain additive or even synergistic effects while staying within the tolerability limits of each agent. Hydrocodone and codeine are, for example, often compounded with APAP to take advantage of each agent’s different mechanism of action.

Codeine itself has only a very weak direct analgesic effect, but it is metabolized in the liver to morphine. Codeine analgesic effects are thought to be due to the binding of morphine and subsequent active morphine metabolites to opioid receptors. Codeine also acts centrally to suppress cough. Some patients poorly metabolize codeine to morphine because of a genetic variation, and in these patients, codeine likely has little analgesic effect.

Tramadol is thought to have effect on a wide variety of pain-modulating pathways. It is most notably a weak opioid receptor agonist and an SNRI. The tramadol active metabolite, O-desmethyltramadol, is a stronger opioid receptor agonist than tramadol itself. Patients who are poor metabolizers of tramadol need relatively higher doses to achieve an analgesic effect because of decreased formation of the active metabolite.

Tramadol should be used cautiously or not at all in patients taking other serotonin reuptake inhibitors because of a concern for serotonin syndrome.
Hydrocodone is a semisynthetic analogue of codeine that acts at various opioid receptors. In the United States, all commercially available hydrocodone formulations also include either APAP or ibuprofen. Hydrocodone has limited utility in very severe pain, because the dosing of hydrocodone is limited by the APAP or ibuprofen with which it is compounded.

Weak And Strong Opioids

STRONG OPIOIDS

Strong opioids make up step 3 of the WHO analgesic ladder. They are indicated for moderate to severe cancer pain or pain not adequately controlled by medications in the first two steps. Oxycodone, morphine, fentanyl, hydromorphone, buprenorphine, and methadone are examples of strong opioids. Patients with severe cancer pain should be initially treated with these medications rather than starting with weak opioids. The variability in opioid dose requirement is marked between different individuals and within individuals over time, which necessitates careful and ongoing dose adjustment.

Constipation, nausea, and vomiting are well-known adverse effects of opioid medications. Preventive therapy, such as with antiemetics and laxatives, should be available to patients taking opioid analgesics. If any particular opioid is not well tolerated by a given patient, administration of an equal analgesic dose of a different opioid may provide better pain control with fewer adverse effects. Physical dependence and tolerance are expected consequences of prolonged opioid use. Dependence is a physical state in which the body goes through withdrawal symptoms if a drug is stopped abruptly. If a medication is to be discontinued in a patient with physical dependence, it is important to slowly titrate off of the medication to avoid withdrawal. Tolerance refers to the loss of efficacy over time of a dose of medication that was previously effective. Dependence and tolerance should not be confused with addiction, which is a compulsive use of drugs for nonmedical reasons.

Another challenge, particularly for patients with progressive head and neck cancer, relates to oral intake restrictions, such that medication elixir formulations and nasogastric/ gastric tube utilization are often needed. IV, subcutaneous, transdermal, buccal, sublingual, rectal, epidural, intrathecal, and intraventricular routes are alternatives for analgesic administration.

Considerable controversy exists as to whether long-term opioid therapy is appropriate for patients with chronic noncancer pain. In addition to concerns of addiction or diversion, there are significant side effects with long-term opioid use that include hormone deficiency (leading to hypogonadism, osteoporosis, and other problems), decreased immune function, tolerance, dependence, and opioid-induced hyperalgesia.

Furthermore, one study that looked specifically at facial pain found that 75% of patients failed to respond to opioid therapy, and many who took chronic opioids had functional decline. Because of the adverse effects of opioid therapy over months to years, other treatment modalities may be preferable, such as anticonvulsants, antidepressants, NSAIDs, or interventional therapies.
Several guidelines have been proposed for the use of opioids in chronic noncancer pain.

Source: Cummings Otolaryngology, 6E (2015)


Migraine

Migraine
A migraine is usually a moderate or severe headache felt as a throbbing pain on one side of the head.

Many people also have symptoms such as nausea, vomiting and increased sensitivity to light or sound.

Migraine is a common health condition, affecting around one in every five women and around one in every 15 men. They usually begin in early adulthood.

There are several types of migraine, including:

  • migraine with aura – where there are specific warning signs just before the migraine begins, such as seeing flashing lights
  • migraine without aura – the most common type, where the migraine occurs without the specific warning signs
  • migraine aura without headache, also known as silent migraine – where an aura or other migraine symptoms are experienced, but a headache doesn’t develop

Some people have migraines frequently, up to several times a week. Other people only have a migraine occasionally. It’s possible for years to pass between migraine attacks.

When to seek medical advice

You should see your GP if you have frequent or severe migraine symptoms.

Simple painkillers such as paracetamol or ibuprofen can be effective for migraine. However, be careful not to take too many painkillers as this could make it harder to treat headaches over time.

You should also make an appointment to see your GP if you have frequent migraines (on more than five days a month), even if they can be controlled with medication, as you may benefit from preventative treatment.

You should call 999 for an ambulance immediately if you or someone you’re with experiences:

  • paralysis or weakness in one or both arms and/or one side of the face
  • slurred or garbled speech
  • a sudden agonising headache resulting in a blinding pain unlike anything experienced before
  • headache along with a high temperature (fever), stiff neck, mental confusion, seizures, double vision and a rash

These symptoms may be a sign of a more serious condition, such as a stroke or meningitis, and should be assessed by a doctor as soon as possible.

Causes of migraines

The exact cause of migraines is unknown, although they’re thought to be the result of temporary changes in the chemicals, nerves and blood vessels in the brain.

Around half of all people who experience migraines also have a close relative with the condition, suggesting that genes may play a role.

Some people find migraine attacks are associated with certain triggers, which can include:

  • starting their period
  • stress
  • tiredness
  • certain foods or drinks

Migraine

Treating migraines

There’s no cure for migraines, but a number of treatments are available to help reduce the symptoms.

These include:

  • painkillers – including over-the-counter medicationssuch as paracetamol and ibuprofen
  • triptans – medications that can help reverse the changes in the brain that may cause migraines
  • anti-emetics – medications often used to reduce nausea and vomiting

During an attack, many people find that sleeping or lying in a darkened room can also help.

Preventing migraines

If you suspect a specific trigger is causing your migraines, such as stress or a certain type of food, avoiding this trigger may help reduce your risk of experiencing migraines.

It may also help to maintain a generally healthy lifestyle, including regular exercise, sleep and meals, as well as ensuring you stay well hydrated and limiting your intake of caffeine and alcohol.

If your migraines are severe or you’ve tried avoiding possible triggers and are still experiencing symptoms, your GP may prescribe medication to help prevent further attacks.

Medications used to prevent migraines include the anti-seizure medication topiramate and a medication called propranolol that’s usually used to treat high blood pressure. It may take several weeks before your migraine symptoms begin to improve.

Outlook

Migraines can severely affect your quality of life and stop you carrying out your normal daily activities. Some people find they need to stay in bed for days at a time.

However, a number of effective treatments are available to reduce the symptoms and prevent further attacks.

Migraine attacks can sometimes get worse over time, but they tend to gradually improve over many years for most people.


Chemical nature of hormones

Chemical nature of hormones

Characteristics of Hormones

Chemical Nature of Hormones

Chemically, hormones may be classified as either proteins or steroids. All of the hormones in the human body, except the sex hormones and those from the adrenal cortex, are proteins or protein derivatives.

Mechanism of Hormone

Action Hormones are carried by the blood throughout the entire body, yet they affect only certain cells. The specific cells that respond to a given hormone have receptor sites for that hormone. This is sort of a lock-and-key mechanism. If the key fits the lock, then the door will open. If a hormone fits the receptor site, then there will be an effect. If a hormone and a receptor site do not match, then there is no reaction. All the cells that have receptor sites for a given hormone make up the target tissue for that hormone. In some cases, the target tissue is localized in a single gland or organ. In other cases, the target tissue is diffuse and scattered throughout the body so that many areas are affected. Hormones bring about their characteristic effects on target cells by modifying cellular activity.

Chemical nature of hormones

Protein hormones react with receptors on the surface of the cell, and the sequence of events that results in hormone action is relatively rapid. Steroid hormones typically react with receptor sites inside a cell. Because this method of action actually involves synthesis of proteins, it is relatively slow.

Control of Hormone Action

Hormones are very potent substances, which means that very small amounts of a hormone may have profound effects on metabolic processes. Because of their potency, hormone secretion must be regulated within very narrow limits in order to maintain homeostasis in the body.

Many hormones are controlled by some form of a negative feedback mechanism. In this type of system, a gland is sensitive to the concentration of a substance that it regulates. A negative feedback system causes a reversal of increases and decreases in body conditions in order to maintain a state of stability or homeostasis. Some endocrine glands secrete hormones in response to other hormones. The hormones that cause secretion of other hormones are called tropic hormones. A hormone from gland A causes gland B to secrete its hormone. A third method of regulating hormone secretion is by direct nervous stimulation. A nerve stimulus causes gland A to secrete its hormone.


Liver Functions

Liver Functions

Functional unit of liver consists of lobules. Each hepatic lobule has cells radiating centrifugally from a central vein. The periphery of the lobule shows branches of hepatic artery, portal vein and bile duct. These three structures form the portal triad. There are large sinusoids present between the cells, which contain blood from portal vein and hepatic artery. The sinusoids drain blood into the hepatic vein. The endothelial cells lining the sinusoids have Kupffer’s cells and tissue macrophages. Biliary canaliculi are present between adjacent layers of cells. They collect bile and drain into the bile duct.
Each lobe of liver is drained by one hepatic duct. The right and left hepatic ducts join together to form the common hepatic duct. It joins with the cystic duct from gallbladder and forms the common bile duct. This opens at the second part of duodenum, together with the pancreatic duct (ampulla of Vater). The opening at the second part of duodenum is guarded by the sphincter of Oddi.

Liver has many functions which include metabolic, synthetic, storage, excretory, and detoxification. Carbohydrate metabolism Liver helps in glucose homeostasis. It shows glycogenesis, gluconeogenesis and glycogenolysis. It is the site for the conversion of galactose to glucose and fructose to glucose.

Protein metabolism The formation of urea from ammonia, deamination and transamination reactions take place in the liver. Fat metabolism Lipogenesis, lipolysis, β oxidation of fatty acids, synthesis of lipoproteins, synthesis and esterification of cholesterol, formation of bile acids from cholesterol, ketogenesis, take place in the liver.

Liver Functions
Formation of blood coagulation factors,
prothrombin synthesis in the presence of vit K,
synthesis of plasma proteins, formation of bile
salts takes place in the liver. Liver excretes bile pigments, drugs, metals and
dyes (BSP). Liver stores glycogen, vit A, D, B12 and iron. Inactivation of hormones, drugs, toxic substances
occurs in the liver. The Kupffer cells and macrophages in the liver
destroy blood cells.In the early foetal stage, liver is the site of
hemopoiesis.

It is the yellow colouration of skin and mucous membrane, due to increased bile pigments level in plasma. This condition occurs, when bilirubin level in the plasma exceeds 2 mg%. Depending on the cause, three types of jaundice can occur. They are hemolytic (prehepatic) and hepatic
Obstructive (posthepatic)
The hemolytic jaundice is caused by increased destruction of red cells, arising from intrinsic and extrinsic defects in RBCs. Hepatic jaundice occurs, due to hepatitis caused by virus. There are several forms of this type, i.e. Hepatitis A, B, C, etc. Obstructive type is caused by gallstones in the bile ducts and tumors of biliary tree.

Source: P. McKee, J. Calonje – McKee’s Pathology of the Skin (Elsevier)


Deglutition

Deglutition

It refers to the act of swallowing. It consists of oral, pharyngeal and oesophageal stages. The first stage is voluntary, second and third stages are involuntary.

Swallowing, or deglutition, is divided into three phases:

  • The buccal phase occurs voluntarily in the mouth when the tongue forces the bolus of food toward the pharynx.
  • The pharyngeal phase occurs involuntarily when food enters the pharynx, as follows:
    1. The soft palate and uvula fold upward and cover the nasopharynx to prevent the passage of food up and into the nasal cavity.
    2. The epiglottis, a flexible cartilaginous flap at the top of the larynx, folds down as the larynx rises. As a result, the opening to the trachea is covered, and food can pass only into the esophagus.

Deglutition

  • The esophageal phase occurs involuntarily in the esophagus. The esophageal sphincter, normally closed, opens to allow food to pass when the larynx rises during swallowing. When food reaches the lower end of the esophagus, the lower esophageal sphincter opens to allow the food to enter the stomach.