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Epithelial lining: Pseudostratified ciliated/columnar squamous Importance: Squamous carcinoma may arises in the cyst muscle relaxant food safe 2 mg zanaflex. Branchial fistulas are those derived from 2nd branchial cleft and open externally in the lower third of neck muscle relaxant addiction cheap zanaflex online american express, near the anterior border of sternocleidomastoid spasms 1983 generic 2 mg zanaflex with visa. In 10% cases spasms between shoulder blades order genuine zanaflex line, it occurs an one side in which 95% are on left side and 5% on right side. Transnasal endoscopic: With the advent of endoscopic surgery for nose and sinuses, most of the leaks from the anterior cranial fossa and sphenoid sinus can be managed endoscopically with a success rate of 90% with first attempt. This herniation of orbital contents into the maxillary antrum is visualized radiologically as a convex opacity bulging into the antrum from above. The symptoms include enophthalmos, diplopia, restricted upward gaze and infraorbital anesthesia. Forced deduction test: Detects extraocular muscle entrapment in blowout fractures. Surgical repair can be done by the following: y Neurosurgical intracranial approach. A 40-year-old chronic cigratte smoker presents with reddish shiny plaques in the floor of mouth. Condylar fractures (35%) are most common followed by those of angle (20%), body (20%) and symphysis(15%) of mandible. A 14-years-old boy presents with fever, sore-throat ulcers and cervical lymph node enlargement. Taste buds are highest in circumvallate papillae > Foliate papillae > Fungiform papillae. Vestibule is seen in ear (in inner ear bony labyrinth), nose (skin lined portion of nose), larynx (part above ventricular bands) and oral cavity. Internet Search Toluidine blue is a metachromatic dye which can efficiently detect the mitotic figures in sections of paraffin embedded human tissue especially in oral cavity. Labial artery Abbe Estlander flap is used for reconstruction of upper or lower lip. Dhingra 6/e, p 228 Commando Operation: It consists of hemiglossectomy including a portion of the floor of mouth, segmental or hemimandibulectomy and block dissection of neck nodes. Bailey and Love 24/e, p 723; 25/e, p 755 80% of all salivary stones occur in the submanidbular glands because their secretions are highly viscous. Dhingra 6/e, p 183 Expl: Fracture of zygoma is called as tripod fracture as when the bone fractures, it is separated at its three processes viz zygomaticofrontal, zygomatico temporal and infraorbital. Blow out fracture Blow out fracture is isolated fracture of orbital floor, when a large blunt object strikes the globe. This leaves us with 2 options-Adenovirus and Ludwigs angina Harrison 17th/ed, p 210 says about Adenovirus pharyngitis: "Since pharyngeal exudate may be present on examination, this condition is difficult to differentiate from streptococcal pharyngitis. A 70-year-old male who has been chewing tobacco for the past 50 years present with a six months history of large, fungating, soft papillary lesions in the oral cavity. Two biopsies taken from the lesion proper show benign appearing papillomatosis with hyperkeratosis and acanthosis infiltrating the subjacent tissues. An 80-year-old patient present with a midline tumor of the lower jaw, involving the alveolar margin. An old man who is edentulous squamous cell carcinoma in buccal mucosa that has developed infiltrated to the alveolus. Radiotherapy Ramavati, a 40-year-old female, presented with a progressively increasing lump in the parotid region. After laparoscopic appendectomy, patient had fall from bed on her nose after which she had swelling in nose and slight difficulty in breathing. Dhingra 5/e, p 230, 6/e, p 218; Mohan Bansal p 381-2 Aphthous ulcers are recurrent and superficial ulcers, usually involving movable mucosa i. This is because sublingual gland is active throughout whereas parotid and submandibular gland secret saliva only in response to food. Devita 7/e, p 982; Bailey and Love 25/e, p 735 Lesions and conditions of the oral mucosa associated with an increased risk of malignancy. Devita 7/e, p 982; Bailey and Love 25/e, p 735; Mohan Bansal p 376-7 "Leukoplakia is the most common premalignant oral mucosal lesion.

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Q 222 Self Assessment & Review: Gynecology Sarcomatous Change a fibroid undergoes malignancy muscle relaxant drug names order genuine zanaflex on line, the most common malignancy which is seen is leiomyosarcoma muscle relaxant cyclobenzaprine high 2 mg zanaflex amex. Subserous fibroids do not affect fertility rates but removing them increases fertility muscle relaxant 771 discount zanaflex online american express. Intramural fibroid slightly decreases fertility but removal does not increase fertility muscle relaxant used during surgery buy zanaflex 2mg. Note According to the latest concept - Asymptomatic fibroids of any size can be managed expectantly. Hence, main role of medical management is preoperative and in women nearing menopausal age to avoid surgery. It is performed by an interventional radiologists and involves catheterization of the femoral artery to gain access to the hypogastric arteries. Under fluoroscopic guidance the uterine arteries are occluded using gel foam, polyvinyl alcohol, in patients not suited for or not desirous of surgical therapy. A pregnant woman with fibroid uterus develops acute pain in abdomen with low-grade fever and mild leukocytosis at 28 week. Sucheta, a 29-year-old nulliparous women complains of severe menorrhagia and lower abdominal pain since 3 months. All of the following are the indications for myomectomy in a case of fibroid uterus except: a. Novaks Gynae 15/e p445) the fibroid shown is the figure is suberseal with 50% intramural component. Dutta Gyane 6/e p635 It is a myoma screw: Uses: To fix the myoma after the capsule is cut open to give traction while the myoma is enucleated of its bed (myomectomy) To give traction in a big uterus (multiple fibroids are requiring hysterectomy while the clamps are placed. Simultaneous, bilateral clamping of the infundibulopelvic ligaments by rubber guarded sponge holding forceps may be employed. The instrument is placed at the level of internal os with the concavity fitting with the convexity of the symphysis pubis.

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Shaw 15th/ed p 380 Chapter 14C Gynecological Oncology: Ovarian Tumors Marker: Granulosa cell tumour secrete inhibin which is a useful marker for it muscle relaxant chlorzoxazone side effects buy 4 mg zanaflex with visa. Metastasis: It is peculiar in case of granulosa cell tumour infantile spasms 2 year old buy 2 mg zanaflex otc, it first involves opposite ovary followed by metastasis in lumbar region spasms in legs buy 2mg zanaflex with amex. Williams Gynae 1st/ed p 214; Merck manual online medical library on Internet; Jeffcoate 7th/ed p 531 18 muscle relaxant with least side effects trusted zanaflex 2 mg. M/C, route of spread is via lymphatics(Novaks 15/e,p1396) but hematogenous and direct spread are also seen. Devita 7th/ed p 1391; Williams Gynae 1st/ed p 741 Though Dysgerminoma is most radiosensitive tumour known, treatment of choice is oophorectomy of involved side followed by cisplatin based chemotherapy to preserve fertility, as dysgerminoma is seen in young women with average age incidence being 20 years. Shaw 15th/ed p 376-7; Williams Gynae 1st/ed p 214-5 Dermoid cyst: Dermoid cyst is a benign teratoma. Textbook of Gynaecology Sheila Balakrishnan 1st/ed p 183 Chapter 14C Gynecological Oncology: Ovarian Tumors 24. Histologically tumour has signet ring cells in the background of myxomatous stroma. Ovarian malignancies generally present with vague symptoms like abdominal pain, dyspepsia, and patient may also experience irregular menses and if pelvic mass compresses the bladder or rectum she may have urinary frequency or constipation. In advanced stages patients have symptoms related to presence of ascites, omental metastasis or bowel metastasis like abdominal distension, dyspnea, bloating, nausea, anorexia or early satiety. In the patient given in the question all these symptoms are present (which could be seen in other cancers as well) plus her Ca 125 levels are raised, which favors the diagnosis of ovarian cancer in her. Lasts Anatomy 10th/ed p 302 Ovarian pain is referred along the medial side of thigh the obturator nerve during its course, when runs in front of the internal iliac vessels is separated from the normally situated ovary by only the parietal peritoneum lining the pelvic wall, thus pain from the ovary may be referred along the nerve to the skin on the medial side of thigh. Hydrothorax develops secondary to flow of ascitic fluid into the pleural space via lymphatics of the diaphragm. Novak 14th/ed p 510 "A benign cystic teratoma is the most common neoplasm to undergo torsion, and it to the M/C benign tumor diagnosed during pregnancy. Novak 14th/ed p 1462-3 Pseudomyxoma peritonei is a condition in which the neoplastic epithelium secretes large amounts of gelatinous mucinous material. Novak 14th/ed p 1477 "Whenever malignancy is suspected, a staging laparotomy should be carried out. Malignant epithelial ovarian tumor "Malignant ovarian tumour are often bilateral solid and present with ascites. Physical examination Mobility Consistency Laterality Cul-de-sac Radiography Size Septations Calcification Omental caking Ascites Intra operative Benign tumour Mobile Cystic Unilateral Smooth on P/V examination Usually < 10 cm size < 2 mm thickness Seen in teratoma Absent Absent Unilateral cyst with no adhesion Capsule intact Malignant tumour Fixed, large and multiloculated Solid or firm Bilateral Nodular on P/V examination Any size Multiple septations > 3 mm in size Usually absent Seen Present Solid areas with adhesion, rupture may occur. Other options: Dysgerminoma of ovary is seen in 1st or 2nd decade with mean age of 20 years; therefore is unlikely in women of 45 years. In Q 42-Presence of papillary vegetation is suggestive of malignancy and hence is an indication for laparotomy. Shaw 15th/ed p 380; Williams Gynae 1st/ed p 391 "Specifically women with an abrupt onset, typically within several months or sudden worsening of virilising signs should prompt concern for a hormone producing ovarian or adrenal tumor. Williams Gynae 1st/ed p 391 Rapidly developing hirsutism with amenorrhoea and change in voice is suggestive of masculinizing tumour like Arrhenoblastoma or androblastoma which are invariably associated with raised testosterone (T > 200 ng/dl). All masculinizing tumour have similar presentation characterized by defeminization such as breast atrophy and amenorrhoea, hirsutism, ache hoarseness of voice, muscular development, clitoromegaly and receding hair line. Removal of tumour restores the secondary sexual character but hoarseness of voice is permanent. Sutton 2nd/ed p 1085 An ovarian mass with radio opaque shadow on X-ray points towards dermoid cyst as the diagnosis.

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Comparative spinal distribution and clearance kinetics of intrathecally administered morphine muscle relaxant home remedy zanaflex 4 mg mastercard, fentanyl muscle relaxant pictures cheap 4mg zanaflex, alfentanil spasms below rib cage buy zanaflex visa, and sufentanil muscle relaxant 5658 purchase zanaflex 2 mg online. The csf and plasma pharmacokinetics of sufentanil after intrathecal administration. Glucuronidation of amines and other xenobiotics catalyzed by expressed human udp-glucuronosyltransferase 1a3. Morphine glucuronidation and elimination in intensive care patients: a comparison with healthy volunteers. Altered morphine glucuronide and bile acid disposition in patients with nonalcoholic steatohepatitis. The metabolism and bioavailability of morphine in patients with severe liver cirrhosis. Hydromorphone metabolites: isolation and identification from pooled urine samples of a cancer patient. Hydromorphone-3-glucuronide: a more potent neuro-excitant than its structural analogue, morphine-3-glucuronide. Fentanyl metabolism by human hepatic and intestinal cytochrome p450 3a4: implications for interindividual variability in disposition, efficacy, and drug interactions. Offset of pharmacodynamic effects and safety of remifentanil in intensive care unit patients with various degrees of renal impairment. Pharmacokinetics and pharmacodynamics of remifentanil in persons with renal failure compared with healthy volunteers. Identification of cytochrome p-450 isoforms responsible for cis-tramadol metabolism in human liver microsomes. Investigations into the drug-drug interaction potential of tapentadol in human liver microsomes and fresh human hepatocytes. A comparison of remifentanil and alfentanil in patients undergoing major abdominal surgery. A multicenter evaluation of total intravenous anesthesia with remifentanil and propofol for elective inpatient surgery. Effects of alfentanil on the pressor and catecholamine responses to tracheal intubation. High-dose remifentanil suppresses sinoatrial conduction and sinus node automaticity in pediatric patients under propofol-based anesthesia. Fentanyl added to propofol anesthesia elongates sinus node recovery time in pediatric patients with paroxysmal supraventricular tachycardia. Role of central and peripheral opiate receptors in the effects of fentanyl on analgesia, ventilation and arterial blood-gas chemistry in conscious rats. Diminished ventilatory response to hypoxia and hypercapnia after morphine in normal man. Anesthetic potency and influence of morphine and sevoflurane on respiration in mu-opioid receptor knockout mice. Presynaptic delta opioid receptors differentially modulate rhythm and pattern generation in the ventral respiratory group of the rat. Differential roles of opioid receptors in respiration, respiratory disease, and opiate-induced respiratory depression. Dose-dependent attenuation by fentanyl on cough during emergence from general anesthesia. Opioids with different affinity for subreceptors induce different effects on early and late sensory evoked potentials (sep) in man. Altered frequency distribution in the electroencephalogram is correlated to the analgesic effect of remifentanil. Influence of high-dose opioid anesthesia on posterior tibial nerve somatosensory cortical evoked potentials: effects of fentanyl, sufentanil, and alfentanil. Impact of anesthesia on transcranial electric motor evoked potential monitoring during spine surgery: a review of the literature. Effect of intrathecal opioids on somatosensory-evoked potentials during spinal fusion in children. Profiles of opioid analgesia in humans after intravenous bolus administration: Alfentanil, fentanyl and morphine compared on experimental pain. The influence of drug polarity on the absorption of opioid drugs into csf and subsequent cephalad migration following lumbar epidural administration: application to morphine and pethidine. The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine. Epidural morphine for analgesia after caesarean section: a report of 4880 patients. Risk factors for serious prescription opioid-related toxicity or overdose among veterans health administration patients. Predictors of delayed postoperative respiratory depression assessed from naloxone administration. Life-threatening critical respiratory events: a retrospective study of postoperative patients found unresponsive during analgesic therapy. Unidirectional cross-activation of grpr by mor1d uncouples itch and analgesia induced by opioids. What epidural opioid results in the best analgesia outcomes and fewest side effects after surgery A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Non-analgesic effects of opioids: opioid-induced nausea and vomiting: mechanisms and strategies for their limitation. Activation of mu opioid receptors in the ventrolateral periaqueductal gray inhibits reflex micturition in anesthetized rats.