The auditory (eustachian or pharyngotympanic) tube is a mucosal-lined tube that provides a direct connection from the nasopharynx to the middle ear cavity hair loss in men who men buy 1mg finpecia fast delivery. A respiratory infection can travel from the upper respiratory tract to the oropharynx or nasopharynx and then on into the middle ear via the auditory tube hair loss facts cheap 1mg finpecia with amex. The choanae are paired openings from the nasal cavity into the nasopharynx and do not connect with the auditory tube or the middle ear hair loss remedies generic 1mg finpecia visa. The facial canal and the internal acoustic meatus are passages for facial and vestibulocochlear nerves hair loss evaluation order finpecia 1 mg without a prescription, respectively hair loss in men xy finpecia 1 mg low price. Neither of these is a likely site for the spread of infection from the upper respiratory tract to the middle ear hair loss in men glasses finpecia 1 mg cheap. The maxillary sinus drains via the middle meatus, specifically via the semilunar hiatus. The inferior meatus drains the lacrimal secretions carried by the nasolacrimal duct, whereas the superior meatus drains the posterior ethmoidal and sphenoid sinuses. The nasopharynx and sphenoethmoidal recess are not situated in close proximity to the maxillary sinus and are therefore not involved in its drainage. The sphenoidal sinus provides the most direct access to the pituitary gland, which is situated directly above this sinus. Neither the frontal sinus nor maxillary sinus has any direct communication with the interior of the cranial vault and would therefore not allow the surgeon a potential access point to the pituitary gland. The cribriform plates are also located too far anteriorly from the pituitary gland. The cavernous sinus is situated within the cranial vault and surrounds the pituitary gland; it is not a site for surgical entrance to the cranial cavity. These reflexes are mediated by the glossopharyngeal and vagus nerves, respectively. Together, the glossopharyngeal and vagus nerves are responsible for the contraction of the muscles of the pharynx involved in the gag reflex. In this case the glossopharyngeal nerve was injured when the tonsils were excised, resulting in the loss of the sensory side of the reflex. The mandibular and maxillary nerves are part of the trigeminal nerve and are thus largely associated with the sensory supply of the face, sinuses, and oral cavity. The facial nerve is involved with taste of the anterior two thirds of the tongue; however, it does not mediate the gag reflex. The recurrent laryngeal nerve is often at risk of being damaged during a thyroidectomy. Patients who have a transected or damaged recurrent laryngeal will often present with a characteristic hoarseness following surgery. The posterior cricoarytenoid is supplied by the recurrent laryngeal and would thus be impaired following damage to the nerve. The posterior cricoarytenoid is the only muscle responsible for abduction of the vocal cords, and paralysis of this muscle would result in a permanently adducted position of the involved vocal cord. The other muscles listed are all adductors of the vocal cords, and paralysis of these would not lead to closure of the airway. The pharyngeal tonsil is situated in a slitlike space, the pharyngeal recess, in the nasopharynx behind the opening of the auditory (eustachian) tube, and a pharyngeal tonsil in this location can lead to blockage of the drainage of the auditory tube. The lingual tonsil is located in the posterior aspect of the tongue, whereas the palatine tonsil is contained within the tonsillar fossa between the palatoglossal and palatopharyngeal arches. The superior pharyngeal constrictor would not be involved in occlusion of the auditory tube because it is located more posteriorly. The uvula is drawn upward during deglutition and prevents food from entering the nasopharynx; it does not block the auditory tube. Infection can spread from the nasopharynx to the middle ear by way of the auditory tube, which opens to both spaces. The first pharyngeal pouch is responsible for formation both of the auditory tube and middle ear cavity. The third pharyngeal pouch develops into the inferior parathyroid gland and thymus, whereas the fourth pharyngeal pouch forms the remainder of the parathyroid glands and the ultimobranchial body. The sixth pharyngeal pouch is not well defined and would therefore not contribute to the development of the auditory tube. The greater palatine nerve is responsible for innervation of the hard palate, or the hard part of the roof of the mouth. The lesser palatine nerve supplies the soft palate and palatine tonsil but is not involved in supply to the hard palate. The posterior superior alveolar nerve supplies multiple structures, including posterior portions of the gums, cheeks, and the upper posterior teeth. The inferior alveolar nerve has several branches, including the mental nerve, incisive branch, mylohyoid nerve, and inferior dental branch. The lingual nerve supplies taste and general sensation to the anterior two thirds of the tongue. Damage to the internal laryngeal nerve would result in a general loss of sensation to the larynx above the vocal cords, leaving the patient with an inability to detect food or foreign objects in the laryngeal vestibule. The external laryngeal nerve and recurrent laryngeal nerve are both at risk during thyroidectomy. Damage to the recurrent laryngeal nerve would result in paralysis of all the laryngeal muscles except the cricothyroid; it would render the patient hoarse, with a loss of sensation below the vocal cords. Loss of the external laryngeal nerve would lead to paralysis of the cricothyroid muscle and vocal weakness. Injury to the hypoglossal nerve would result in weakness or paralysis of muscle movement of the tongue. Ankyloglossia (tongue-tie) is characterized by a lingual frenulum that extends all the way to the tip of the tongue. This condition can cause problems with speech, feeding, and oral hygiene as a result of the low range of motion of the tongue. Of the answer choices listed, the left facial nerve of the patient is the most likely to be damaged during the mastoidectomy. The facial nerve exits the skull via the stylomastoid foramen, just anterior to the mastoid process. A lesion of the facial nerve is likely to cause the symptoms described as a result of paralysis of the facial muscles. Depending upon the site of injury, the patient could also lose the chorda tympani branch of the facial nerve, leading to loss of taste from the anterior two thirds of the tongue ipsilaterally as well as loss of functions of the submandibular and sublingual salivary glands. Normally the tonus of the buccinator muscle prevents the accumulation of saliva and foodstuffs in the oral vestibule. Although a lesion of the facial nerve would paralyze the other muscles listed, the buccinator is the most important muscle of the cheek. Compression of the optic chiasm can cause bitemporal hemianopia due to compression of nerve fibers coming from the nasal hemiretinas of both eyes. Compression of the oculomotor nerve would cause the eye to deviate "out and down" (paralysis of the four extraocular muscles innervated by this nerve), ptosis (paralysis of levator palpebrae), and mydriasis (paralysis of constrictor pupillae). Compression of the abducens nerve would cause paralysis of the lateral rectus muscle, leading to medial deviation (adduction) of the eye. As a result, patients with trochlear nerve lesions commonly have difficulty walking down stairs. The superior cerebellar artery branches from the basilar artery just before it bifurcates into the posterior cerebral arteries. The trochlear nerve emerges from the dorsal aspect of the midbrain and can easily be compressed by an aneurysm of the superior cerebellar artery as it wraps around the midbrain. Aneurysms of the other arteries mentioned are not likely to compress the trochlear nerve, and lesions of the nerves listed are not likely to cause problems walking down stairs. Frey syndrome, a rare malady resulting from parotidectomy, is characterized by excessive facial sweating in the presence of food or when thinking about it. The dilator pupillae, levator palpebrae superioris, and smooth muscle cells of blood vessels in the ciliary body all receive sympathetic innervation. The postsynaptic cell bodies of the sympathetic neurons that innervate these structures are located in the superior cervical ganglion. The intermediolateral cell column contains presynaptic sympathetic neurons, but it is located only at spinal cord levels T1 to L2. A fracture of the lamina papyracea of the ethmoid bone is likely to entrap the medial rectus muscle, causing an inability to gaze laterally. A fracture of the orbital plate of the frontal bone could perhaps entrap the superior oblique or superior rectus muscle, but this would be very unusual. A fracture of the orbital plate of the maxilla can entrap the inferior rectus or inferior oblique muscles, limiting upward gaze. A fracture of the greater wing of the sphenoid is not likely to entrap any extraocular muscles. A lesion of the oculomotor nerve will cause the eye to remain in a "down and out" position. This is due to the actions of the unopposed lateral rectus (supplied by the abducens nerve) and the superior oblique (supplied by the trochlear nerve). The tertiary function of the superior oblique is to cause intorsion (internal rotation) of the eyeball, a function that is not usually seen unless the oculomotor nerve is paralyzed. The patient is also likely to present with a full or partial ptosis due to paralysis of the levator palpebrae muscle. The pupil will remain dilated because of loss of stimulation by parasympathetic fibers that innervate the constrictor pupillae muscle. The axons of olfactory nerves run directly through the cribriform plate to synapse in the olfactory bulb. Damage to this plate can damage the nerve axons, causing anosmia (loss of the sense of smell). Frey syndrome occurs following damage to parasympathetic axons in the auriculotemporal nerve. When these postganglionic cholinergic axons grow peripherally after parotid surgery, they establish synapses upon the cholinergic sweat glands, which are innervated normally only by sympathetic fibers. As the peripheral nerves make new connections, aberrant connections can be formed between the auriculotemporal nerve and other glands (not usually innervated by the auriculotemporal nerve). This results in flushing and sweating in response to the thought, smell, or taste of food, instead of the previous, normal salivary secretion by the parotid gland. The posterior cricoarytenoid muscle is the only abductor of the larynx that opens the rima glottidis and rotates the arytenoid cartilages laterally. The palatine tonsils are highly vascular and are primarily supplied by the tonsillar branch of the facial artery; therefore, care is taken to preserve this artery while performing a tonsillectomy. The palatine tonsil also receives arterial supply from the ascending pharyngeal, the dorsal lingual, and the lesser palatine, but the supply from the facial artery is by far the most significant. The inner surface of the tympanic membrane is supplied by the glossopharyngeal nerve. The auricular branches of the facial and vagus nerves and the auriculotemporal branch of the trigeminal nerve innervate the external surface of the tympanic membrane. The great auricular nerve arises from C2 and C3 and supplies the posterior auricle and skin over the parotid gland. The lingual nerve does not have anything to do with sensory supply of the tympanic membrane. The infraorbital branch of the maxillary division of the trigeminal nerve exits the front of the skull below the orbit through the infraorbital foramen. A needle inserted into the infraorbital foramen and directed posteriorly will pass through the foramen rotundum to reach the trigeminal ganglion and the beginning of the maxillary division of the trigeminal nerve. The mandibular division of the trigeminal nerve exits the skull through the foramen ovale. The middle meningeal artery exits the infratemporal fossa through the foramen spinosum to enter the cranial cavity. The inferior alveolar branch of the mandibular division passes into the mandibular foramen to then descend in the jaw to supply the mandibular teeth. The foramen magnum is where the spinal cord exits the skull and where the spinal accessory nerve ascends into the skull after arising from the cervical spinal cord and brainstem. If there is an injury to the internal laryngeal nerve, there is a loss of sensation above the vocal cords. In this case, for internal laryngeal injury to occur, one must conclude that the operative field extended above the position of the thyroid gland to the level of the thyrohyoid membrane. The external laryngeal nerve can be injured during a thyroidectomy, but its injury would result in paralysis of the cricothyroid muscle and weakened voice/hoarseness. Injury of the glossopharyngeal nerve would result in more widespread symptoms, including loss of sensation from the pharynx, posterior tongue, and middle ear. Injury to the hypoglossal nerve would cause deficits in motor activity of the tongue. Damage to the recurrent laryngeal nerve would result in paralysis of most laryngeal muscles, with possible respiratory obstruction, hoarseness, and loss of sensation below the vocal cords. The loose areolar connective tissue layer is known as the "danger zone" because hematoma can spread easily from this layer into the skull by means of emissary veins that pass into and through the bones of the skull. The carotid sinus is a baroreceptor that can be targeted for carotid massage to decrease blood pressure. For this reason, sustained compression of the carotid sinuses can lead to unconsciousness or death as the heart rate is reflexively reduced. The carotid body is a chemoreceptor, responsive to the balance of oxygen and carbon dioxide. Neither the thyroid gland nor the parathyroid gland has anything to do with acute control of blood pressure due to mechanical stimuli. The inferior cervical ganglion fuses with the first thoracic ganglion to form the stellate ganglion. It gives rise to the inferior cervical cardiac nerve and provides postganglionic sympathetic supply to the upper limb.
The osteotomy cut is kept low hair loss cure protein buy 1mg finpecia with visa, as close to the face as possible hair loss in menopause cures finpecia 1 mg without prescription, to prevent any palpable step-off along the nasal wall and a "pinched-nose" appearance hair loss in men treatments purchase finpecia 1mg without prescription. Indeed hair loss in men zombie 1mg finpecia overnight delivery, the lateral osteotomy is mostly an osteotomy of the nasal (ascending) process of the maxilla rather than of the nasal bone hair loss youtube buy finpecia 1mg free shipping. At the cranial end of the nasal bone hair loss 18 year old male cheap finpecia 1 mg on-line, from the osteotomy line to the dorsum, the backfracture is usually performed digitally or occurs spontaneously with medial rotation and pressure of the osteotomy (see Figure 747). The back fracture is usually at the nasofrontal groove, the thin portion of the nasal bone. If the osteotomy enters the thicker bone of the nasofrontal angle, a rocker deformity may result. In this situation, the surgical dressing is applied immediately after osteotomies to minimize edema. If there is significant bleeding, small precut strips of Telfa packing (a smoothsurfaced, absorbent material) may be placed. A thin coat of benzoin is applied over the nose and precut Steri-strips are applied cautiously over the nose from the root to the supratip area with 12 mm of overlap. If tip work has been performed, a sling around the columella is placed lightly enough for support, yet sufficient for adequate venous drainage of the tip. If glasses must be worn, they may be worn over the cast during the first week, and then with supportive tape if they are heavy. In addition, patients should refrain from smoking and taking aspirin or ibuprofen for at least 2 weeks. Finally, nasal saline irrigation and half-strength hydrogen peroxide on a cotton applicator should be used to minimize crusting in the nasal passage and around the vestibule. The most common complication is a dissatisfied patient due to nasal irregularities or asymmetries, or new or persistent nasal obstruction. The risk of infection is minimal in the absence of hematoma because of the excellent blood supply to the nose. Other rare complications include septal hematoma, septal abscess, septal perforation, suture granuloma, anosmia, and anesthesia-related complications. Rhinoplasty is among the most challenging surgeries that the otolaryngologist will perform. Many years of experience are typically needed before a consistently excellent result is achieved. This challenge drives the rhinoplasty surgeon to constantly analyze his or her own technique and results, reaching for an illusive ideal that may eventually satisfy both surgeon and patient. Elaboration of an alternative, segmental, cartilage-sparing tip graft technique: experience in 405 cases. The optimal medial osteotomy: a study of nasal bone thickness and fracture patterns. After birth, no additional follicles arise, although the size of follicles and hair can change with age. A reduction of the total number of follicles occurs only with scarring or skin loss. Androgenetic alopecia, in fact, does not involve a loss of follicles, but an androgen-mediated alteration of their anatomy that causes hair loss. Matrix cells of the hair bulb are rapidly proliferating, producing the hair shaft and its cortex. Matrix cells proliferate and migrate upward into a shape determined by the inner root sheath. The dimensions and curvature of the inner root sheath determine the diameter and shape of the hair. The dermal papilla resides at the base of the follicle and controls the number of matrix cells. The dermal papilla and the follicular epithelium interact to induce the cyclic and repeating pattern of normal hair growth. Epithelium stem cells of the outer root sheath bulge migrate from the follicle to repopulate the epithelium after injury such as that which occurs in laser resurfacing. The outer root sheath also contains Langerhans and Merkel cells, respectively, serving important immunologic and neurosensory functions. Each follicle proceeds through three stages throughout the life of the follicle: (1) anagen (growth), (2) catagen (involution), and (3) telogen (resting). Follicles of different parts of the body have differing lengths of time spent in the anagen stage. The amount of time spent in the anagen stage is directly proportional to the length of hair. For example, scalp follicles typically are in the growth phase for 28 years and produce long hairs, whereas eyebrow follicles spend 23 months in the anagen stage and produce shorter hairs. Biologic functions include providing protection from potentially harmful environmental elements, such as wind and cold temperatures, and dispersing hair follicle products, such as pheromones in nonverbal human interaction. Whereas only 8% of nonbalding men state that losing hair would concern them, 50% of men with mild hair loss and 75% of men with moderate to severe hair loss express concern over the loss of hair. Men with hair loss feel older and less physically and sexually attractive than nonbalding men. With the advent of effective medical therapies and refined surgical techniques, a multibillion-dollar hair restoration treatment industry has emerged. The physician can provide the first step in the therapeutic treatment of the individual with hair loss. The physician may be the only person who can broach the topic of hair loss with the patient without appearing judgmental or grossly inappropriate. With a basic understanding of normal hair physiology and the most common causes of hair loss, the physician from any subspecialty can provide effective care for those with hair loss. More specifically, after recognizing the presence of hair loss in the patient and making the appropriate diagnosis (male pattern baldness or alopecia areata, etc. The impact of such help on the individual with hair loss can be profoundly positive. Androgens and various growth factors affect the length of time spent in the anagen stage. During the catagen stage, the follicle involutes with apoptosis of the follicular keratinocytes and melanocytes. The telogen phase of scalp hair lasts 24 months, after which the follicle reenters the anagen stage. If a higher percentage of hair follicles are in the telogen stage, more shedding of hair results. Androgens and certain drugs increase that percentage, thereby causing a further loss of scalp hair. Thirty percent of 30-year-old men and 50% of 50-year-old men suffer from male pattern baldness. White men are four times more likely than African-American men to suffer from this type of hair loss. Reversible causes of hair loss involve an interruption in the natural hair follicle growth cycle. The most common types of reversible alopecia include androgenetic alopecia (eg, male pattern baldness and female pattern hair loss), alopecia areata, and telogen and anagen effluvium. Although androgenetic alopecia is technically reversible because it represents an interruption in the hair follicle growth cycle, no treatment exists that permanently reverses the process. The most common irreversible types of hair loss include those resulting from scars, trauma, surgery, and burns. Clinical Findings Androgenetic alopecia in men starts with bitemporal hairline recession followed by thinning of the vertex. Further thinning of the vertex results in a bald patch that may enlarge and combine with the progressively receding frontal hairline. This eventually results in a narrow rim of hair of the lower parietal and occipital regions. Such female hair loss shows a different pattern in which a diffuse thinning of the frontal or parietal scalp occurs. The resulting hair loss, though as common in women as in men, is less evident and can be camouflaged with effective hair styling. Affected women typically have normal menses, pregnancies, and general endocrine function. An extensive hormonal evaluation is indicated only in the case of irregular menses, a history of infertility, hirsutism, severe acne, or virilization. Differential Diagnosis Androgenetic alopecia has a distinct pattern in both men and women, rendering its diagnosis relatively easy. Other reversible causes of hair loss, such as alopecia areata and certain conditions that induce a telogen effluvium, should be ruled out. General Considerations Androgenetic alopecia is the most common cause of hair loss and occurs in genetically susceptible individuals. Hair loss in both affected men and women typically begins Complications Complications of alopecia center on the psychosocial impact on the individual as alluded to above. Medical and surgical treatments of hair loss are not mutually exclusive and, in fact, are often used in combination. Individuals undergoing hair restoration surgery will start medical therapy to maintain the existing hairs and therefore limit the amount of additional coverage needed through surgical techniques. Drug therapy is able to prevent further thinning of existing hair and can restore some of the coverage that has been lost. The therapeutic effect of both drugs requires the continued use of the medication. Surgical therapy ultimately achieves an overall scalp density less than that of normal hair. Given its limitations, the goal of surgical restoration is to achieve a well-groomed, presentable appearance with acceptable coverage of the bald scalp. This was based on three randomized double-blind placebocontrolled trials in which a total of 1879 men experienced increased hair counts at the vertex and frontal regions compared with the placebo group after 1 year. Adverse effects related to sexual dysfunction occur slightly more commonly than with placebo and are largely reversible; 1. Finasteride is contraindicated in women who may become pregnant or are pregnant because of the potential for 5-reductase inhibitors to inhibit the virilization of the genitalia of male fetuses. Both preparations have the effect of prolonging the anagen stage, thus enlarging miniaturized follicles. Approval was based on significantly increased hair counts in 2294 men with mild to moderate vertex thinning who participated in a 12-month controlled trial with placebo. Minoxidil was originally developed as an antihypertensive medication, a result of its potassium-mediated vasodilatory effects. Adverse effects of minoxidil center on irritation of the scalp and occur in 7% of patients using the 2% solution. The donor hairs that provide the source of hair to be distributed can be transferred in the form of hair flaps, or more commonly as free grafts. The most common surgical technique currently employed involves hair grafting because of its low morbidity, reliable results, and acceptable effect. He discussed a twice-delayed parieto-occipital flap of hair-bearing scalp that was rotated to restore the frontal hairline and midscalp region. Sheldon Kabaker introduced this technique to North America in 1978 after observing Juri perform the surgery in Argentina. Other surgical techniques have been described including scalp reduction procedures that remove non hair-bearing scalp with or without tissue expansion. Because of relatively higher rates of morbidity, as well as the limited potential for a natural-appearing result, all of these surgical procedures have been supplanted by mini-micro grafting and follicular-unit hair transplantation techniques. With regard to terminology, micrografts refer to 12 hair grafts and minigrafts represent 36 hair grafts. Follicular-unit grafts refer to naturally occurring entities that include 14 hairs. These groupings represent follicular units that contain single hairs or 24 hairs. Headington was the first to describe the follicular unit in 1954 as containing 14 terminal hairs, 1 vellum hair, sebaceous lobules, and other appendages. The majority of grafts become immediately viable, commonly enter a telogen stage of shedding, and ultimately show growth of transplanted hair in approximately 612 months. Whereas normal donor site hair has a density of approximately 100 follicular units per square centimeter, transplanted hair has a density of 1040 follicular units per square centimeter. The result, therefore, is not a high level of density but an adequate amount of coverage that provides a natural, albeit thinning, appearance. Grafting techniques for female androgenetic alopecia, in which the hair loss involves a diffuse thinning, is often less effective because of the limitations on resulting hair density. Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. The state of the art: donor site harvest, graft yield estimation, and recipient site preparation for follicularunit hair transplantation. The process is typically self-limited and commonly results in spontaneous remission. Prevention No preventive measures exist, although further progression of alopecia areata can be halted with medical therapy. Clinical Findings Alopecia areata typically manifests as patchy, round, smooth areas of balding scalp. Although most often the patient is otherwise healthy, atopy, vitiligo, Hashimoto thyroiditis, pernicious anemia, and Addison disease are occasionally associated. Serum thyroid-stimulating hormone levels should therefore be measured in affected children. Antineoplastic drugs and radiation therapy induce an anagen effluvium in which the rapidly proliferating bulb matrix cells are specifically affected.
Functional obstruction usually occurs as a result of either the failure of the normal muscular mechanism of eustachian tube opening hair loss cure vitamin generic finpecia 1mg mastercard, as seen in cleft palate hair loss 3 months after baby 1 mg finpecia, or insufficient stiffness of the cartilaginous portion of the eustachian tube hair loss in men solutions buy 1 mg finpecia with amex, often seen in infants and young children hair loss baby generic finpecia 1mg on-line. The more acute angle of the eustachian tube seen in children hair loss treatment youtube discount 1 mg finpecia with amex, compared with adults hair loss cure yeast buy finpecia 1 mg, may also result in the impaired function of the eustachian tube opening. If the eustachian tube is abnormally patent or short, its normal protective function against the reflux of nasopharyngeal contents is lost. The protective mechanism of breast-feeding has not been clearly demonstrated, but is likely to be related to antibacterial and immunologic benefits conferred by breast milk. Passive smoking results in inflammation of the mucosa of the middle ear cleft as well as impaired mucociliary clearance, which lead to an increased susceptibility to infection. These genetic variations may be related to anatomic and physiologic variations in the eustachian tube. Because the tensor veli palatini muscle lacks its normal insertion into the soft palate, it is unable to open the eustachian tube properly on swallowing. Inflammation of the middle ear mucosa results in an effusion, which cannot be cleared via the obstructed eustachian tube. This effusion provides a favorable medium for proliferation of bacterial pathogens, which reach the middle ear via the eustachian tube, resulting in suppuration. Less frequently identified pathogens include group A streptococci, Staphylococcus aureus, and gram-negative organisms such as Pseudomonas aeruginosa. This finding may occur for a variety of reasons, including (1) antibiotic therapy before tympanocentesis; (2) nonbacterial pathogens (eg, viruses, chlamydia, and mycoplasma); and (3) pathogens that do not proliferate in classic culture conditions (eg, mycobacteria and anaerobic bacteria). Adenoidectomy also has a demonstrable effect, though more modest than that seen with tympanostomy tubes. Otitis externa also presents with otalgia and otorrhea and may be the primary diagnosis, or it may be secondary to the infected discharge from the middle ear. If otalgia is the primary complaint, then referred pain should be considered, particularly when otoscopy reveals a normal tympanic membrane. The common sites of origin of referred otalgia are the teeth and temporomandibular joints. In adults, malignant neoplasms of the pharynx and larynx may present with otalgia as the only symptom. In neonates and infants with a high fever and systemic upset, the possibility of meningitis should be considered. The use of antibiotics is probably beneficial, but there is a trade-off between benefits and side effects. There is no difference demonstrated in recurrence rates or the development of complications among different antibiotics. Older children usually complain of earache, whereas infants become irritable and pull at the affected ear. A high fever is often present and may be associated with systemic symptoms of infection, such as anorexia, vomiting, and diarrhea. Otoscopy classically shows a thickened hyperemic tympanic membrane, which is immobile on pneumatic otoscopy. Further progression of the infective process may lead to the spontaneous rupture of the tympanic membrane, resulting in otorrhea. At this stage, it is often not possible to visualize the tympanic membrane because of the discharge in the ear canal. If symptoms are severe, a blood count often reveals a leukocytosis, and blood cultures may detect bacteremia during episodes of high fever. A culture of the ear discharge is helpful in guiding antibiotic therapy in patients in whom the first-line treatment is unsuccessful. As a consequence, factors resulting in an overproduction of mucus, an impaired clearance of mucus, or both can result in the formation of a middle ear effusion. Both viral and bacterial infection can lead to the increased production and viscosity of secretions from the middle ear mucosa. Infection also leads to inflammatory edema of the mucosa, which may obstruct the eustachian tube. Temporary paralysis of cilia by bacterial exotoxins further impedes the clearance of an effusion. Experimental studies have confirmed that the failure of eustachian tube opening can result in a middle ear effusion. Because gas is constantly being absorbed into the microcirculation of the middle ear mucosa, a negative pressure develops in the middle ear cleft if the eustachian tube is blocked. This negative pressure results in the transudation of fluid into the middle ear cleft. The fact that a middle ear effusion can develop as a result of barotrauma (eg, scuba diving) supports this theory for the pathogenesis of middle ear effusions. There is an optimum viscosity of mucus at which effective mucociliary transport occurs. If the mucus formed in a middle ear effusion is either too serous or too mucoid, then the cilia will be unable to clear it efficiently. Recently, the concept of biofilms in the pathogenesis of otitis media has been raised, but the evidence is not conclusive. Biofilms are the structured community of bacterial cells adherent to the mucosa and have antibacterial resistance property. Decongestants and antihistamines for acute otitis media in children (Cochrane Review). General Considerations Otitis media with effusion is defined as the persistence of a serous or mucoid middle ear effusion for 3 months or more. Various terms, such as chronic secretory otitis media, chronic serous otitis media, and "glue ear," have been used to describe the same condition. It is the most common cause of hearing loss in children in the developed world and has peaks in incidence at 2 and 5 years of age. Tympanogram Type A Middle Ear Pressure 99 daPa to +200 daPa Typical Appearance of Trace 659 B No compliance peak C 400 daPa to 100 daPa daPa = deca Pascal. In younger children, the only symptom may be delayed speech development or behavioral problems. Another common symptom is a "blocked" feeling in the ear, which may cause infants and young children to pull at their ears. Otoscopy classically reveals a dull gray- or yellowcolored tympanic membrane that has reduced mobility on pneumatic otoscopy. If the tympanic membrane is translucent, an air-fluid level or small air bubbles within the middle ear effusion may be seen. In adults presenting with a unilateral middle ear effusion, the possibility of a nasopharyngeal carcinoma should be considered. It is easy to use, provides reproducible results, is inexpensive, and is widely tolerated by patients-even young children. By measuring the compliance of the middle ear transformer mechanism, it provides an objective assessment of the status of the middle ear. Tympanometry produces a peak (ie, maximal compliance) when the pressure in the external ear canal equals that of the middle ear. By varying the pressure in the external ear, the tympanometer is able to provide information on the status of the middle ear (Table 493). If there is an effusion in the middle ear, then compliance does not vary with changes in canal pressure, and a flat (Type B) tympanogram is produced. If the air in the middle ear is at or near atmospheric pressure, then a normal (Type A) tympanogram is produced. Negative middle ear pressure results in a Type C tympanogram, with the compliance peak being at less than 99 daPa (deca Pascal). Audiometry provides an assessment of the severity of hearing loss and is Treatment A. A period of watchful waiting of 3 months from the onset (if known) or from the diagnosis (if onset unknown) before considering intervention is therefore advisable. Ideally, early treatment should be initiated in patients in whom spontaneous resolution is unlikely. A multicenter randomized controlled trial identified both the season of attendance (ie, July to December) and a bilateral hearing impairment of > 30 dB as factors that make spontaneous resolution less likely. Autoinflation with purpose-built nasal balloon has been shown to be beneficial, although compliance is generally poor. Medical treatments include antibiotics, steroids, decongestants, and antihistamines. The small chance of benefit from antibiotic therapy needs to be considered along with the fact that a number of patients treated with antibiotics develop significant side effects, such as gastroenteritis and atopic reaction. Myringotomy and aspiration of middle ear effusion without ventilation tube insertion has a short-lived benefit and is not recommended. Insertion of tympanostomy tubes-The aim of tympanostomy tube insertion is to allow ventilation of the middle ear space-hence to improve hearing thresholds. The prolonged ventilation of the middle ear may also allow resolution of chronic inflammation of the middle ear mucosa. Complications include myringosclerosis, purulent otorrhea, and residual perforation after extrusion. There are two main types of tympanostomy tubes: short-term tubes (eg, grommets), which remain in the tympanic membrane for an average of 12 months, and long-term tubes (eg, T-tubes), which can remain for several years. The high incidence of residual perforation following the use of long-term ventilation tubes indicates that they should not be used in uncomplicated cases. The rationale for adenoidectomy is that it relieves nasal obstruction, improves eustachian tube function, and eliminates a potential reservoir of bacteria. General Considerations Chronic suppurative otitis media is defined as a persistent or intermittent infected discharge through a nonintact tympanic membrane (ie, perforation or tympanostomy tube). Chronic suppurative otitis media is particularly prevalent in developing countries and is more common in lower socioeconomic groups in the developed world. Pathogenesis There are a number of mechanisms by which a persistent tympanic membrane perforation may develop. This weakness of the tympanic membrane both predisposes to perforation and reduces the likelihood of spontaneous healing. Although most tympanic membranes heal spontaneously after the extrusion of ventilation tubes, a small percentage do not. There are two main mechanisms by which a chronic perforation can lead to continuous or repeated middle ear infections: (1) Bacteria can contaminate the middle ear cleft directly from the external ear because the protective physical barrier of the tympanic membrane is lost. The loss of this protective mechanism results in the increased exposure of the middle ear to pathogenic bacteria from the nasopharynx. Differential Diagnosis the primary differential diagnosis is the presence of a cholesteatoma. Both pathologies present with a very similar clinical course, and the presence of severe inflammation or granulation tissue can cause difficulty with the diagnosis. Reexamination after a course of medical treatment usually provides an accurate diagnosis. If granulations are severe and unresponsive to antimicrobial therapy, then chronic granulomatous conditions such as Wegener granulomatosis, mycobacterial infection, histiocytosis X, and sarcoidosis should be considered. The discharge is usually mucopurulent, although chronic infection of the middle ear may lead to polyp or granulation tissue formation, which can result in bloodstained otorrhea. To properly visualize the tympanic membrane, it is necessary to suction the discharge from the external auditory canal with an operating microscope. The middle ear mucosa, seen through the perforation, is edematous, sometimes to the point of polyp formation. If the perforation is of sufficient size, it may be possible to identify the presence of ossicular discontinuity due to necrosis of the long process of the incus. Both medical and surgical interventions play a role in achieving these aims (Table 494). Clearing the discharge from the external auditory canal allows the topical agent to reach the middle ear in an adequate concentration. Ototoxicity has been demonstrated in animal models, and the use of gentamicin for vestibular ablation in Meniere disease is well documented. This circumstance is probably due to a combination of the relatively low concentration of aminoglycoside reaching the middle ear and edema of the middle ear mucosa, which prevents the direct absorption of the drug through the round window. The recent availability of topical ofloxacin preparations may prove to be as effective as topical aminoglycosides without the ototoxic potential. An audiologic evaluation is necessary, because the majority of patients have an associated conductive hearing loss. Systemic antibiotics-Systemic antibiotics tend to have a poor penetration of the middle ear and are therefore less effective than topical antibiotics. Unfortunately, these quinolone antibiotics are not recommended in children owing to the possibility of causing arthropathies. This circumstance limits the choice of systemic antibiotics in children to broad-spectrum penicillins, such as piperacillin and cephalosporins, which must be administered parenterally. However, if otorrhea recurs or persists despite medical treatment or if the patient feels handicapped by a residual conductive hearing loss, surgical therapy should be considered. Tympanoplasty-Ideally, surgery should be carried out when the infection has been adequately treated and the middle ear mucosa is healthy, since the chance of a successful outcome is increased. In this situation, a tympanoplasty, with repair of the tympanic membrane and ossicular chain (if required), is recommended. Tympanomastoid surgery-In cases that are refractory to medical treatment, it is necessary to perform tympanomastoid surgery (tympanoplasty combined with a cortical mastoidectomy). The aims of this procedure are to aerate the middle ear and mastoid, remove chronically inflamed tissue, repair the tympanic defect, and reconstruct the ossicular chain. Sequelae Tympanosclerosis Tympanosclerosis is characterized by hyalinization and the deposition of calcium in the tympanic membrane, middle ear, or both. If the process is limited to the tympanic membrane (ie, myringosclerosis), then hearing is usually unaffected. However, if the middle ear is involved, then the ossicular chain can become immobilized, resulting in a conductive hearing loss.
The initial step in permanent waving and relaxing calls for reduction of the disulphide bonds to facilitate slippage and longitudinal displacement of the protein strands to reshape the hair filament hair loss in men velvet cheap 1mg finpecia with visa. This is followed by 229 Forensic Examination of Hair re-oxidation to reform disulphide linkages in order to set the hair in its new configuration hair loss cure earache cheap 1 mg finpecia otc. This can be accomplished by slow oxidation in air or by the use of mild oxidizing agents hair loss juicing recipes buy generic finpecia 1mg line. The cystine disulphide bond is irreversibly cleared hair loss in men quilters finpecia 1mg with amex, giving rise to two sulphonic acid groups in the form of cysteic acid residues hair loss 5 years after chemo cheap finpecia 1 mg mastercard. Generally the following scheme should speak to each characteristic: · · · temporary dyes/surface coatings/acidic dyes semi-permanent/limited penetration/disperse dyes permanent/deeper penetration/oxidative (reactive) dyes hair loss birth control order 1 mg finpecia. Temporary hair dyes or rinses are designed to be removed with one subsequent washing. Semipermanent colourants are expected to persist through several washings, and permanent dyes should retain their colour indefinitely (McLaughlin, 1963). With the permanent dyes, re-dying the hair is only necessary to dye the proximal portion as the hair grows out. Since the rinses must be readily removable, the temporary dyes are essentially water-soluble surface coatings which rinse off with an aqueous washing. The relatively large molecular size of the acidic dyes make them well suited for this purpose since they are effectively prevented from penetrating the hair fibre. The common acidic dye preparations are aqueous solutions of species bearing an azo group (-N=N-) and a solubilizing group. The weak surface binding of these molecules produces no permanent chemical or structural change in the hair fibre. The product may also contain a variety of other ingredients such as surfactants, thickeners and an acidic buffer. A range of hair colouring ingredients used in modern hair colour rinses are shown in Figure 6. Temporary hair colour rinses will usually contain from two to five colour ingredients in order to reach the desired shade. Tints for grey hairs may have only two dyes, while red, brown and black colouration will usually have four or five dyes (Robbins, 1994). These colourants are made of pre-formed dye molecules that diffuse into and bind within the hair fibre to a limited degree without the need for subsequent interaction with hydrogen peroxide (Anstead, 1963; Bell and Whewell, 1963). Primarily consisting of neutral aromatic amines, nitro aromatic amines and anthraquinones (Robbins, 1994), these polar substances diffuse slowly into the shaft where weak polar and van der Waals binding occurs between the dye molecule and the hair. According to Robbins (1994), as many as twelve dyes may be required to achieve a desired colour. The product may also include water and glycols, surfactants, fragrance, amide and acid or alkali to achieve the desired pH. In light of the solubility of these dyestuffs their application to the hair relies on the following equilibrium (McLaughlin, 1963): Dyestuff (solid)-Dyestuff (in sol. The limited water solubility of these chromophores is essential for the colourant deposition, since this is a diffusion-controlled mechanism (Wong, 1972). Apart from the presence of the weakly bound dye molecules, there is no significant alteration of the hair fibre with the use of these non-reactive dyes. The larger size of these molecules once formed effectively prevents their diffusion out of the hair. The common oxidative dye precursors are difunctional derivatives of benzene such as ortho- and paraaminophenols and para-phenylenediamines (Tucker, 1971)-see Figure 6. The precursor molecules are oxidized (usually by hydrogen peroxide) to active intermediates which are capable of condensing with unoxidized precursors (self-coupling) or coupling agents included in the formulation. The new dinuclear, trinuclear or polynuclear indo dye can undergo further reaction with dye precursor or coupler to polynuclear species which infrequently undergo intramolecular cyclization to phenoxazines or phenazines (Corbett, 1972; Robbins, 1994). The utility of the couplers lies in the subtlety of shades produced through their addition. The common couplers (resorcinols, maminophenols and m-phenylenediamines-see Figure 6. Hydrogen peroxide is the preferred oxidizer since the oxidation reaction of the precursors is slow relative to the condensation with the couplers, therefore the latter reaction is preferred. Further, the only residual species following oxidation with hydrogen peroxide is water. Corbett (1972) reports the active intermediate of these reactions to be the diiminium or quinoniminium ions of the precursor as appropriate. In addition to the presence of the dye molecules in the hair shaft, the oxidative process of these hair products can cause changes in the keratins. The reader interested in a fuller treatment of oxidation dyes or permanent hair dyes is referred to the comprehensive coverage in Robbins (1994). Almost exclusively, the only metallic dye in use currently is composed of 1 to 2 per cent solutions of lead acetate and surface active agents. This process involves reaction of the metallic salt with sulphur groups in the surface of the hair to produce insoluble lead sulphide and lead oxide (McLaughlin, 1963). This type of dye is marketed primarily as a colour restorer for men with grey hair. The hair tends to appear dull with this treatment since the hair shaft can become coated with the reaction products. The effect sought is lightening of the hair through destruction of the chromophore of the pigment. Human hair colour is manifest through a combination of factors such as pigment granule content and density, cuticle transparency and reflectivity as well as the presence or absence of air in the medulla. Pigment granules contain melanins, protein-bound polymers of indole quinone units (Henderson et al. Commercial products marketed for lightening hair have been formulated to dissolve and disintegrate the melanin granules. The common bleaching products are alkaline (pH 911) solutions of hydrogen peroxide, salts of persulphate and stabilizers. The action of the oxidizers, however, is 233 Forensic Examination of Hair Figure 6. A decrease in the cystine content of human head hair following moderate bleaching has been found. Extensive application of bleaching products may additionally produce a small decrease in the methionine, threonine, lysine, histidine and tyrosine content (Robbins, 1994). The shift in cystine content is a result of irreversible oxidative cleavage of the disulphide bonds which Robbins (1994) reports occurs primarily through S-S fission, producing two cysteic acid residues per disulphide bond oxidized. Intermediates of the oxidative cleavage of cystine to cysteic acid such as monoxides and dioxides have been detected during wool oxidation. These species have been demonstrated only in very low concentrations in human hair oxidation (Robbins, 1994). Although the end product sought with 234 Forensic Examination of Hairs for Cosmetic Treatment Figure 6. The softening process is designed to free cross-linking in adjacent polypeptide chains so that they may be shifted longitudinally relative to each other. Only the protein chains are free to slide past each other unencumbered, allowing the hair to be manipulated into the desired style. Reshaping is followed by reformation of the cross-linking bonds between the proteins to give the new shape permanence. To achieve the degree of freedom between the polypeptide chains necessary, the softener must be capable of breaking several types of attachment. The forces responsible for the helical configuration of the protein chains are van der Waals attractions, hydrogen bonding, salt linkages (cross-links between acidic and basic amino acids) and disulphide bonds (Gershon et al. Hydrogen bonds will be extended and therefore inactivated by providing an aqueous environment. The disulphide bonds between the polypeptide chains are of major concern, in both relaxers and permanent waves. Commercial permanent wave products primarily utilize one of two reducing agents: mercaptans or sulphites. Preparations for home permanents usually employ the cold wave process in which thioglycolic acid (a mercaptan) in alkaline medium (pH 9) or sodium sulphite in a slightly acid solution (pH 6) serves as the reducing agent. Relaxers are formulated either to exploit the mercaptans and sulphites for reduction or to use an alkaline medium to accomplish this step. Hardening or reformation of the disulphide bonds may be accomplished through the application of acidic hydrogen peroxide (or similar mild oxidizer), mild alkaline (for sulphite reduction), or water rinsing followed by drying and air oxidation (relaxers using alkaline reduction). It has been suggested (Robbins, 1994) that reduction of the sulphide bond with thiol proceeds in two nucleophilic displacement reactions producing cysteine residues, while sulphites react by double decomposition producing a mercaptan and a bunte salt (organic thiosulphate) per reacted bond (Gershon et al. However, amino acid analysis of whole hair samples treated with relaxers and permanents reveals minor alterations in amino acid residue levels in relation to untreated hair. The most significant changes detected were decreased cystine and proline residues as well as an increase in arginine content for both treatments. Proline levels decreased in permed hair and increased in relaxed hair relative to virgin samples (Chao et al. Robbins (1985, 1994) further reports the possible formation of lanthionyl residues, disulphide, mixed disulphide, carboxymethyl thiocystine, and thioacetylated lysine. Among the effects on hair from chemical treatment are fibre swelling, tensile and torsional strength decrease, and fibre friction increase (Robbins, 1985). The interaction of these treatments with hairs and their effect on hairs is core to any consideration of hair cosmetics. However, in the context of forensic endeavour the ubiquitous nature of their use makes them, arguably, of less interest. This is partly because, after rinsing, hair will often show little detectable trace of the product used. Current fashion has seen increased use of polymer-based treatments including styling gels, and such treatment may be detectable by microscopic examination. This is done through the sorption or binding of lubricating and conditioning ingredients to the surface of hairs. According to Robbins (1994), hair conditioners are usually composed of the following types of ingredient: · · 236 oily or waxy substances including mineral oil, long-chain alcohols or triglycerides or other esters, including true oils and waxes, and silicones or fatty acids cationic substances consisting of monofunctional quaternary ammonium compounds or amines or polymeric quaternary ammonium compounds or amines Forensic Examination of Hairs for Cosmetic Treatment Table 6. As previously stated, shampoos and conditioners can be expected to interact mainly at the surface of the hair fibre. However, as the cuticle at the surface may be damaged, the possibility exists for these substances to interact with the cortex. Notwithstanding the earlier observation that most residues would be expected to be removed by rinsing, some residues may remain. This is the basis on which detection of these residues may be worth pursuing in the forensic context. Polymers have been used in cosmetic products for a number of decades; however, the introduction of 2-in-1 shampoos in the past decade has seen increased use of polymers. Polymers are found not only in shampoos and conditioners but also in styling products (lotions and gels), mousses and hair sprays (Robbins, 1994). Robbins (1994) considers polymers in hair products in terms of: · · · · · binding interactions chemical nature in situ polymerization reaction mechanisms rheological or flow properties film formation and adhesive properties. Much of this treatment relates to product performance and is not strictly relevant in a forensic context, although it may impact on the way in which the product is deposited or retained on the hair and hence the likelihood that it will be detected in a forensic protocol. Robbins (1994) reports that limited penetration into the hair of lower molecular weight polymers (10 kDa) can take place. With higher molecular weight polymers (up to 500 kDa) there may still be some limited diffusion into the cuticle of relatively undamaged hair, and intracellular diffusion is possible in damaged hair. The chemical composition of polymers includes a very wide range of compounds formulated in neutral, anionic and cationic products. A recent trend in hair products, especially popular with teenagers, has been the use of styling gels. These are aqueous or alcohol/water-based and are applied to wet hair before styling. Through a careful light microscopic examination, dying or bleaching is usually detectable visually. If the hair follicle was in the anagen stage (undergoing cell proliferation) when treated, natural hair colour will be observable between the root and the portion of the hair above the scalp line at the time of treatment. When this is the case, additional associative information may be gleaned from a comparison of the length of untreated hair in the questioned and known samples. However, this can only have meaning if the comparison is conducted on two hairs that were in the anagen growth stage from treatment through shedding. The importance of an adequate representative known sample cannot be overemphasized. The potential exists for comparing the colourant used on dyed hairs that appear similar microscopically. Several effective solvents have been reported (Macrae and Smalldon, 1979; Roe et al. No single system will be adequate for every circumstance; therefore, when faced with a sample that has been dyed, the appropriate chromatographic conditions should be explored on the known sample prior to extraction of the questioned hair. This method of dye comparison is relatively inexpensive and simple, but the extraction is somewhat destructive. Some workers have experienced difficulties with streaking of the spots after development. This procedure is a destructive one and, as such, consideration should be given to the priority of other non-destructive analysis. In the earlier approach by Tanada and co-workers (1991), some 50 mg of hair was required.
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