This helps com ments necessitated by focusing on different points within the eye blood pressure 14090 order cardura with american express. Dynamic On/Off switch pensate for patient or examiner refractive error blood pressure chart symptoms order cardura 2mg with visa, the position of the PanOptic Soft Grip Focusing Wheel and rheostat ophthalmoscope and the changes in viewing requirements necessitated Some coaxial models offer an additional crossed linear polarizing control by focusing on different points within the eye pulse pressure of 20 cardura 2mg discount. When used in conjunction with available apertures heart attack marlie grace generic 2mg cardura amex, the coaxial the patient side eyecup helps the practitioner establish and maintain the ophthalmoscope yields 15 possible apertures heart attack grill locations cheap 2 mg cardura fast delivery. It also serves as the pivoting point for leverage in panning around the the illuminated lens dial enables the practitioner to check the lens being retina blood pressure chart sheet buy cardura 4 mg on line. While in contact with the patient hypertension and renal failure discount cardura on line, the eyecup occludes ambient light blood pressure medication for sleep order cardura 2 mg without prescription, used for a particular examination even in a darkened examination room. In addition to examination of the fundus, the ophthalmoscope is a useful diagnostic aid in studying other ocular structures. The light beam can be used to illuminate the cornea and the iris for detecting foreign bodies the PanOptic Ophthalmoscope features a Cobalt Blue Filter and add-on in the cornea and irregularities of the pupil. Corneal Viewing Lens (model 11820 only), which together can be used along with fluorescein dye applied to the cornea to look for abrasions Refer to pages 10 and 11 to learn how to conduct an ophthalmic and foreign bodies on the cornea. To attach the Corneal Viewing Lens: When used correctly and regularly, the Welch Allyn ophthalmoscope is 1. Refer to pages 8 and 9 to learn how to conduct an ophthalmic exam with the PanOptic ophthalmoscope. Hold the instrument up to your right eye and look through your thumb until the optic disc is as clearly visible as possible. Now examine the disc for clarity of outline, color, elevation and condition of the vessels. When the PanOptic is 3 inches from contact, instruct the patient to look into the light To look for abrasions and foreign bodies while the patient is still facing straight ahead. Continue moving towards the on the cornea with the corneal viewing patient until the eyecup reaches the orbit of the patient. Begin the exam about 6 inches from the patient with the focus wheel in the neu 3. To examine the extreme periphery, instruct the patient to fixate straight tral position. Hold the PanOptic up to your eye and position the ophthalmo is important to compress the eyecup to maximize this technique. The trip from 6 inches away to making contact must be one that is slow, deliberate, and steady. To examine the extreme periphery, instruct the patient to: room should be either semidarkened or completely darkened. Take the ophthalmoscope in the right hand and hold it vertically in side and use your left eye. It is recom slightly to the right (25) of the patient and direct the light beam into Position the ophthalmoscope about 6 inches (15 cm) mended that the polarizing filter be used when corneal reflection is present. Examine the disc for clarity of outline, color, in front and 25 to the right side of the patient. The optic disc should come into view when you are about 1 to 2 inches (3-5 cm) from the patient. Simultaneously check the location of the pattern numbers) lenses for clear focus of the fundus; the myopic, or near on the fundus. In this procedure, the crossed linear polarizing filter is especially useful since it dramatically reduces 7. Now examine the disc for clarity of outline, color, elevation and reflections caused by the direct corneal light path. You may also have the patient look at the light of the ophthalmoscope, which will automatically By selecting the +15 lens in the scope and looking at the pupil as in place the macula in full view. Look for abnormalities in the macula a fundus examination [2 inches (5 cm) distance from the patient], area. One can also easily detect lens opacities by looking at the pupil through the +6 lens setting at a distance of 6 inches (15 cm) from the patient. In the same manner, vitreous opacities can be detected by having the patient look up and down, to the right and to the left. Any vitreous opacities will be seen moving across the pupillary area as the eye changes position or comes back to the primary position. As the only window into the middle ear, the appearance and behavior of the tympanic membrane offer valuable information about possible Cochlea disease within the middle ear. Epitympanic Recess Fortunately, the ear provides easy access for examining and diagnosing disorders of the complex and interrelated ear, nose and throat system. External Ear Canal Otoscopy is one of the primary methods a practitioner uses for diagnosing patient complaints for the entire ear-nose-throat complex. Use of a well-designed otoscope which provides illumi nation, magnification and air pressure capability for checking Tympanic Membrane tympanic membrane mobility is, therefore, essential, allowing the practitioner to view the ear canal and, in particular, the Eustachian tympanic membrane with clarity. Tube Tympanic Cavity the examination instructions that follow this section use the Welch Allyn otoscope, which incorporates many features that aid Stapes in achieving an accurate, thorough examination. Apply Adults 4 mm or 5 mm light transmission provides a 360 ring of light without visual positive and negative air pressure Traditional obstruction or specular reflection. This distal light results in and view tympanic membrane Children 3 mm or 4 mm Otoscope glare-free viewing and an easier examination. A focusing wheel, conveniently located on each side of the otoscope and the back eyepiece, is available to the the first type of speculum is reusable and made of lightweight, durable practitioner for adjusting the focal length. KleenSpec tips are made of nontoxic When examining tympanic membrane mobility, the plastic and are available in two sizes: 2. The third type of speculum, available for traditional Welch Allyn otoscopes, is SofSpec. SofSpec fits snugly into the the Welch Allyn MacroView otoscope features external ear canal. These specula are available in three sizes: 3 mm, 5 mm, a unique specula attachment and removal design, and 7 mm and may be cleaned or sterilized by conventional methods. The first way is to hold the otoscope like a hammer by gripping the top of the power handle between your thumb and forefinger, close to the light source. You can conveniently hold the bulb of the pneumatic attachment between the palm of the same hand and the power handle. This way, any sudden flinch by the patient will not cause the otoscope to be jammed into the ear canal. It is very important that the otoscope be held correctly, particularly when examining children. A sudden movement by the patient could cause the skin on the inside of the ear canal to be pierced by the end of the speculum. It may be necessary to adjust the line of sight and the position of the speculum to get a complete view of the entire ear canal and all areas of the tympanic membrane. If the tympanic membrane or desired area in view is not in focus, the practitioner has the option to adjust the focal length of the optics system of the MacroView otoscope. Gently palpate the pinna to either side of the focusing wheel or on the back eyepiece of the otoscope. To shorten the focal length or zoom in, rotate the focusing wheel towards the smaller dashes on the side of the otoscope. Inspect the entrance to the ear canal for debris or pus, which might interfere or zoom out, rotate the focusing wheel towards the longer dashes. Choose the largest speculum that can comfortably be inserted into the ear removed from the otoscope. TipGrip feature (MacroView only) by rotating the TipGrip counter For adults, this is accomplished by retracting the pinna upwards and backwards. For children, this is accomplished by retracting the pinna horizontally backwards. Gently squeezing the insufflator attachment produces small changes in the air pressure of the canal. By observing the relative movements of the tympanic membrane in response to the induced changes in pressure, the practitioner can obtain valuable diagnostic information about the mobility of the tympanic membrane. The pneumatic otoscope may the introduction of a speculum into the external auditory canal also be useful in distinguishing between a thin atrophic intact may cause a reflex dilatation of the circumferential and manubrial tympanic membrane adherent to the medial wall of the middle blood vessels supplying the tympanic membrane. This procedure provides a simple method for Following a prolonged examination of the ear or in a crying child, determining tympanic membrane mobility and is of value in this vasodilatation may produce an appearance mimicking that of the recognition of many middle ear disorders. Exostoses in the ear canal are more often multiple than single and are usually bilateral. They are usually asymptomatic, extremely slow growing and seldom enlarge sufficiently to occlude the meatus. Multiple exostoses appear to result from the prolonged stimulation of the bony external canal with cold water and are consequently seen more commonly in persons who swim frequently. In this case, a large piece of sponge rubber was cream colored, thickish debris which may have a fluffy appear removed. In adults, a forgotten piece of cotton wool is frequently ance due to the presence of tiny mycelia. The foreign body or an unsuccessful attempt to remove caused by Aspergillus niger, it may be possible to identify the tiny it can both product secondary otitis externa or damage to the grayish-black conidiophores. In young children, it is sometimes is often inflamed and granular from invasion by fungal mycelia. In the early stages of acute otitis media, the tympanic the skin of the ear canal is painful, infected and swollen, and it membrane varies according to the stage of the disease. There is tympanic membrane is retracted and pink with dilatation of the often a considerable amount of keratin debris in the canal which manubrial and circumferential vessels. Gram negative gresses, the tympanic membrane bulges, becoming fiery red and anaerobic bacteria are the most common pathogens; however, in color and may eventually perforate, releasing pus into the a culture of material should be a clinical consideration. The handle Keratosis obturans is more frequently seen in patients with of the malleus is usually foreshortened, chalky-white in color, and bronchiectasis and chronic sinusitis. The presence of a thin, serous extremely difficult because of its consistency and its frequent effusion within the middle ear gives the tympanic membrane a adherence to the underlying canal skin; a general anesthetic yellowish or even bluish appearance, and in cases of incomplete may be required in some patients. Pseudomonas, Proteus, and Coliforms are in the tympanic membrane with its lumen patent and free of any the three most commonly isolated bacteria; however, fungal exudate or debris. They occur as a Perforations of the pars tensa of the tympanic membrane can result of a postinflammatory deposition of thickened hyalinized result from infection or trauma. In this case the large central collagen fibrils in the middle fibrous layer of the tympanic perforation resulted from repeated middle ear infections. This photograph shows tympanosclerotic deposits transparent pseudomembrane resembling an open perforation enveloping the incudostapedial joint. This thinned segment of a ossicular chain by tympanosclerosis is responsible for some healed tympanic membrane lacks the strength of a normal drum cases of acquired conductive hearing loss. In this case, a thin atrophic tympanic membrane washing is a proven method to remove cerumen, and is one of the most commonly is draped over the head of the stapes and the tip of the long performed procedures in the primary care office. It can sometimes be provides an effective device using suction and irrigation to remove cerumen from difficult to differentiate an atrophic, immobile, retracted tympanic patients of all ages. This easy-to-use system allows for cleaner and safer irrigation membrane from a large central perforation. Tympanometric results can indicate otitis media with effusion, perforated tympanic membrane, patent tympanostomy tube, ossicular disruption, tympanosclerosis, cholesteatoma, as well as other middle ear disorders. Audiometric measurement of auditory function can determine the degree of hearing loss, estimate the location of the lesion within the auditory system that is producing the problem, and help establish the cause of the hearing problem. Serious intracranial complications may result from the expansion and erosion of the Otoacoustic emissions is a response generated by structures (outer hair cells) in the cholesteatoma sac. The apparently fixating eye is then covered and the behav ior of the uncovered eye is noted. If there is no movement of the uncovered eye, that eye is then covered and the other eye observed. The findings vary depending on the diagnosis: In a person with normal vision, covering either eye will not produce any move ment of the other eye. On removing the occluder, there is no movement of the uncovered eye, which continues to look straight ahead. On uncovering, it will move in the opposite direction to rees tablish binocular fixation. On uncovering the formerly fixating eye, it will either move again to take up fixation or may continue to remain deviated de 486 17 Ophthalmic Instruments and Diagnostic Tests 487 pending on whether it is a unilateral or an alternate heterotropia. One can also make out the fixation pattern, that is, whether there is strong fixation prefer ence for one eye, free alternation (formerly deviated eye continues to maintain fixation indefinitely), weak alternation (formerly deviated eye maintains fixa tion for some time, such as until a blink), or eccentric fixation (on covering the fixating eye, the deviated eye makes no movement or an incomplete move ment) is present. Apply the following rule: the apex of the prism should point toward the deviation: Esodeviations: Place the prism base out. Alternate Cover Test In this test, the patient looks at the fixation target with both eyes open, and the oc cluder is alternately moved between the two eyes to produce maximal dissociation of the two eyes. The patient should not be allowed to regain fusion while the cover is being transferred. It can be used to diagnose a latent squint of even 2 de grees and small degrees of heterotropia. A red Maddox rod (which consists of many glass rods of red color set together in a metallic disk) is placed in front of one eye with the axis of the rod at a right angle to the axis of deviation. Thus the patient will see a point light with one eye and a red line with the other. Due to dissimilar images of the two eyes, fusion is broken and heterophoria becomes manifest. The number on the Maddox tangent scale where the red line falls will be the amount of heterophoria in degrees (Fig. Double Maddox Rod Test this test helps in detecting and measuring cyclodeviations. The axes of the Maddox rod(s) are rotated until the two lines seen by the patient are parallel. The degrees of cyclodeviation and direction are measured from the trial frame with excyclodeviation having out ward rotation and incyclodeviations having inward rotations. Maddox Wing Test the Maddox wing is an instrument by which the amount of heterophoria for near (at a distance of 33 cm) can be measured. The fields that are exposed to each eye are separated by a diaphragm in such a way that they glide tangentially into each other.
At rest hypertension interventions buy generic cardura canada, lesions located toward the upper lip or on the superior they outline a V-shaped space called the glottis (see phonatory surfaces heart attack vs heart failure purchase 4 mg cardura mastercard. The posterior end of web (< 3 mm below the lower lip) does not affect the each vocal cord (the thyroarytenoid muscle) inserts voice arteria occipital best purchase cardura. Obliteration of the Reinke space the vocal cords at rest is approximately 13 mm for retards or prevents the mucosal vibratory wave hypertension 16080 purchase 2 mg cardura with visa, result women and 16 mm for men blood pressure grapefruit cardura 2mg fast delivery. However blood pressure medication cough discount 4 mg cardura amex, if one approximate for phonation arrhythmia interpretation generic cardura 2mg, the entire glottis is closed vocal cord is stiff but straight (nonvibratory) and the in a male arrhythmia recognition course buy generic cardura 2mg on line, whereas a small posterior chink is often other vibrates and approximates well against the nonvi present in a female, giving the female voice quality a brating vocal cord, the voice may be remarkably good slightly softer and airy tone. Vocal Pathologies: Diagnosis, Treatment and phonation produced higher spectral levels and a less steep fall. They also determine the shape of the mucosal vibra speech, singing, or other forms of communication are tory wave, which in turn determines the pitch, loudness, formed. Opera singers form unique vocal tract the duration and shape of the mucosal vibratory shapes to allow noninjurious and efficient singing, and wave cycle form specific opening and closing phases they show a unique clustering of powerful spectral that determine specific vibratory modes or vocal quali peaks (the so-called singing formants) at about 3 kHz. This clustering results in an acoustic boost that helps a the time interval between cycles is called the funda singer to compete with the sound of an orchestra. It is interesting to note that tremor-like vocal To generate sound, P must reach at least 5 cm Hs 2O, oscillations having similar rate may be present in decep but P can exceed 50 cm Hs 2O in loud or overly pres tion. Current evidence for the existence of laryn tance cannot be measured directly, but is estimated to geal macrotremor and microtremor. Acta Otolaryngol 10442747] (The study describes acoustic differences in voice Scand. Any voice con vocal fatigue, voice breaks, cough, globus syndrome, and, dition, but specifically when hoarseness is present and the occasionally, dysphagia. Common Speech Disorders in Otolaryn in medical complications (including potential legal conse gologic Practice. Rochester, Minnesota: American Academy of quences), as well as delays in treatment and a potential loss Otolaryngology Press, 1979. San many patients with dysphonia, especially patients who use Diego: Plural Publishing, 2007. Western Sec ing because no visible pathology was noted at the initial tion: Triological Society. Symptoms, laryngeal findings, and cord lesions that affect the mucosal vibratory wave, result 24-hour pH monitoring in patients with suspected gastroesoph ing in air loss, noise, vocal cord stiffness, and pitch restric ageal-pharyngeal reflux. The psychoacoustic and psy unintentional injury to the recurrent laryngeal nerve), (b) chometric analyses require a trained ear and longstanding the planned treatment (eg, an overinjection of polytef [ie, expertise, not unlike what is needed to assess auscultatory Teflon] during attempts to correct breathy paralytic dys noises. However, the problems with these analyses result phonia or irradiation), or (c) a change to the underlying from the potential for loose terminology and a non-uni nature of the primary dysphonia as a function of treatment form interpretation. A subjective description of one type of (eg, denervation of the vocal cord to combat vocal spastic dysphonia used over 350 different clinical terms. There ity, Botox, and vagal stimulation); (10) functional dyspho fore, using numerical perceptual rating scales is preferred nia (eg, persistent prepubertal voice in a postpubertal male, when subjectively assessing voice problems. Attempts to elective aphonia, ventricular dysphonia, and inhalational use acoustic objective analysis to detect voice quality corre dysphonia); (11) gender euphoria; (12) emotional causes; lations with underlying pathology continue, but solutions and (13) environmental-occupational causes. Speech Evaluation in A harsh, rough, and stiff voice quality with a Medicine and Psychiatry, Vol. A limited upper pitch range with soft breathy phonation, no mucosal lesions, and rotation of Common Assessment Findings the posterior larynx can indicate superior laryn Below is a review of terms used to clinically describe the geal nerve involvement. Hoarseness is frequently used dysphonia, or functional (psychosomatic) dys as a wastebasket term and leads to a wrong impression phonia oscillations my be random. It is especially used in error when one is Odynophonia describes a sensation rather than attempting to define a rough or harsh voice quality, voice quality and is associated with pain or dis since this is typically associated with vocal cord stiffness comfort when speaking or vocalizing. Total aphonia, or lack of voice in the absence of a Breathy or soft voice is used to describe a voice that phonatory cough, can indicate severe separation is generated by incomplete glottic closure (eg, in of the glottis either caused by organic and func unilateral vocal cord paralysis, vocal cord bowing, tional origins or following total laryngectomy. Asthma A diplophonic or multiphonic voice is present like wheezing happens only on exhalation when when the vibratory pattern between the vocal the vocal cords are open. This inhale asthma medications, vocal cord mucosa can condition can be caused by a myriad of benign be affected and severe dysphonia can occur. Typ and malignant mucosal lesions, neurologic com ically, stopping medication is enough to reverse plications, laryngeal fractures, or psychosomatic the condition. A wet, gargling voice, also referred to as hydro No matter how the voice sounds, the sound of the phonia, describes phonation that is produced by pathologic voice may evoke negative emotions that are excessive mucus within the glottic space. This incongruence can be very frustrating and tion that is mixed with a ventricular vibration. An under standing of these factors by the examining clinician goes a long way toward enhancing bedside manners. The purpose is to map out phonatory characteristics, demonstrate phonatory deficits, and correlate findings with visual (ie, physiologic) data. Bar ring minor technical problems, either dedicated instru mentation or a computerized approach can be used for a fast, reliable, and reproducible acoustic analysis. Intonation pattern of a sentence spoken static and dynamic pitch changes of the voice during by a male speaker showing pitch (lower tracing) and in speech. Current evidence for the existence of laryngeal distance from D1 to A6 on a piano. This distinction icap Index and laboratory measurements and shows that these two methods give independent information and essentially is of import when examining patients with gender reas correlate poorly. However, in objective When assessing patients who sing professionally, acoustic terms, pitch refers to the fundamental frequency their vocal registration should be included in the evalu of the voice or the speaking fundamental frequency, both ation. Using a musical scale notation is a preferred of which are recorded in vocal cycles per second or hertz method of communicating clinical findings to these (Hz). San Diego: that is obtained by subtracting the duration of the pitch College Hill Press, 1997. Fundamental frequency is age and gender depen Loudness represents acoustic intensity that is measured in dent. The average level of fundamental frequency for a decibels and is dependent on both the subglottic air pres child is approximately 250 Hz; it is 200 Hz for an adult sure and the airflow exiting the glottis. Obtaining the abso female, and for an adult male, it is approximately 120 lute phonatory intensity is difficult; therefore, it is typically Hz. The maximum fundamental frequency range for reported in relative rather than in absolute decibels. Wide mid-frequency ranges and lowest at both the low and high filter spectrography shows vocal tract resonation, repre levels of fundamental frequency. Values below or above this tuations; (7) the richness of harmonics; (8) the relative measure are considered pathologic. These features are critical when analyzing vocal cord stiffness, vibratory irregularity due to lesions that are To make a more orderly representation of pitch and benign, mucosal, iatrogenic (eg, with the use of Teflon or loudness, a profile of the fundamental frequency, mea thyroplasty), or that cause adynamic vibration. These fea sured in decibels and referred to as a phonetogram, has tures are also significant when evaluating patients who use been developed. The phonetogram, which is a voice their voices professionally, have neurologic or functional range profile, represents the minimums and the maxi dysphonias, have carcinoma, or experience stridor, noise, mums of vocal loudness at selected levels of fundamen wheezing, or obstructive airway problems (eg, snoring). Clinically, a phonetogram is a Long-Time Average Spectrum reflection of the vocal capacities rather than the mea surement of the glottic function. Vocal intensity pro the long-time average spectrum technique is used to files are used to assess vocal cord paralysis, vocal cord plot compressed speech spectrum levels over time. This bowing, presbyphonia, odynophonia, functional disor technique relates the acoustic parameters to perceptual ders, and patients who use their voices professionally. Overpressure and breathiness in spastic dysphonia: an Spectrography acoustic and perceptual study. Correlation with perceptual as sessment of weak and strangled voice was shown to be valid. The use of the multidimensional voice profile is advantageous in comparing pretreatment and post-treat ment results. It also provides an overall description of dysphonia, because single acoustic parameters alone are insufficient in delineating the complexity of phonatory pathologies. The multidimensional voice profile can compare individual clinical data with a built-in database adjusted to age and gender. Fundamental frequency values can be derived from the position of the tenth harmonic. The fuzzy dark por tions of the spectrograph represent the noise present in voiceless consonants. Pathologic vocal rates are between 5 Hz and 6 Hz, a rate similar to the vibrato rate. San Diego: Sin A normal voice is produced when the glottic approxi gular Publishing Group, 1995. Current evidence for the existence of laryn centage of vocal cord contact area loss can be derived geal macrotremor and microtremor. Therefore, substantial difficulties in maintaining vowels on target are encountered when singers must sing loudly. Therefore, vowel production should be examined when studying patients who sing professionally. Maximum Phonation Time the maximum phonation time corresponds to the time an individual can phonate per each inhalation. Phonoscopic transoral rigid procedure mum phonation time values are between 17 and 35 sec onds for adult males and between 12 and 26 seconds for showing the on-line visualization of the vibratory process adult females. The glottographic signal and longing this time is characteristic for an overapproximated pitch and intensity values are displayed for analysis. Although the maximum phonation time lacks diag nostic capabilities, it is useful in the preoperative and post operative assessments of unilateral vocal cord paralysis and over many vibratory cycles while newly introduced high bowing, in monitoring medialization (eg, thyroplasty or speed stroboscopy shows consective cycles and not aver various intracordal injections), and in lateralization proce ages it can only show short sign duration. San Diego: for either immediate or subsequent viewing and analy College Hill Press, 1997. New York: Springer Phonoscopy provides the clinician with a wealth of Verlag, 1981. Baltimore: Williams on the principle of illuminating a vibrating object with & Wilkins, 1996. Vocal Pathologies: Diagnosis, Treatment and it vibrates, therefore making the vibrating object appear Case Studies. High-speed imaging: ap Laryngovideostroboscopy or digital stroboscopy pro plications and development. New York: Springer-Ver expired during the first second (the forced expiratory lag, 1981. The individual values can be fitted against expected age and gender val Electroglottography is another method of evaluating ues, with critical values for a normal population ranging vocal cord vibration. The interpretation of aerody of electrical impedance across tissue and open space. Other forms of glottographic technology include Granqvist S, Hertegard S, Larsson H, Sundberg J. A new tech analysis of vocal fold vibration and transglottal airflow: ex ploring a new experimental setup. The article points that relationships be however, its clinical value remains questionable at this tween these two entities is complex specifically with respect to time. These dis vibrations: high-speed imaging, kymography, and acoustic analysis: a preliminary report. Electroglottographic measurements of glot tal function in vocal fold paralysis in women. Electrodes in laryngeal electromyography: cord paralysis, stenosis, webs, or patients who use their reliability comparison. They are also useful when the volume of gas ment of vocal cord mobility problems in children. These tests are useful when determining the differential diagnoses of psychogenic dysphonias. The voice load test: an objective acoustic test to assess left cricothyroid muscle, the right cricothyroid muscle, voice quality as a factor of voice usage over time. In Proceed ings of the 2nd World Voice Congress and 5th International and the right thyroarytenoid muscle. An upper esophageal insufflation test is used ficacy and usefulness of electromyography, with a specific to test failures in acquiring voice after tracheal punc focus on the pediatric patient as well as in determining the ture procedures. Because sudden change in aerodynam differential diagnosis of vocal cord paralysis versus vocal cord fixation. Intrinsic laryngeal gases of other density than air (eg, helium), such tests muscle activity in a spastic dysphonia patient. Similarly, the head-position Prognostic value of laryngeal electromyography in vocal ing test, which can cause changes in vocal cord approxi fold paralysis. A neck pressure test can also be used to test fail covery from acute neurogenic injuries [ie, paralysis] of the ures in acquiring voice after esophageal injection (eg, vocal cords. Laryngeal electromyography is a cost-effective clinically An array of nerve blocks, as well as the so-called oral useful tool in the evaluation of vocal fold function. In addition, a uating various vocal cord dysfunctions in the absence of visi recurrent laryngeal nerve block is often crucial in test ble organic mucosal lesions. A temporary block of the superior laryngeal tromyography and their clinical applications. The challenge of determin nonfunctional phonatory segment after total laryngec ing work-related voice and speech disabilities in California. It also appears that neuroradiographic studies that Hague, Netherlands: Kugler Publishers, 2001. With spasmodic dysphonia, vocal tremor and ventricular dysphonia additional testing, this technique may prove to be excellent by auditory and phonoscopic observations. The Hague, cord paralysis or due to mechanical problems (eg, arytenoid Netherlands: Elsevier, 1997. Most patients with cross-linkages between the epithelium and the superior benign laryngeal disorders present with dysphonia. These layer of the lamina propria (ie, Reinke space) allow oscilla disorders are particularly prevalent in individuals who use tion of the mucosal wave during phonation, as the epithe their voices professionally. Once it air passes between the adducted vocal folds, the Ber is established that there is no evidence of malignancy, noulli effect causes vibration of the mucosa of the vocal patients can be treated appropriately, ideally within a folds, producing sound. A properly equipped voice clinic must have adduction of the vocal folds or directly interfering in access to video-laryngeo-stroboscopy and be conducted vibration of the mucosa produce dysphonia. Most benign laryngeal lesions are treatable with a combination of surgery and speech therapy, but mea sures to prevent the recurrence of disease by instigating and maintaining lifestyle changes are also necessary. Any preceding upper res the larynx consists of a cartilaginous framework com piratory tract infections, direct or vocal trauma, or prising the single thyroid, cricoid, and epiglottic carti endotracheal intubation should be noted. Persistent, lages and the paired arytenoid, corniculate, and cunei progressive dysphonia in a smoker must always raise the form cartilages. The larynx is suspended from the hyoid possibility of malignant disease, particularly if associ bone by the thyrohyoid membrane. Adults have to the vocal process of the arytenoid cartilages posteri a greater incidence of malignant disease, whereas in orly. Alteration in the position and length of the vocal children who are hoarse the chief differential diagnosis folds is primarily the result of movement of the synovial is between vocal cord nodules and juvenile papilloma cricoarytenoid joints, with a contribution from move tosis. An occupational history is of particular relevance, ment of the cricothyroid joints. Above the vocal folds because the voice disorder may be secondary to the pat run the false cords, formed by the medial border of the tern of voice use or working conditions. These are separated from the vocal previous surgery is essential, as is documenting any pre folds by horizontal sinus known as the laryngeal ventri vious laryngeal treatment or speech therapy. It is also useful in the diagnosis of lesions such the patient examination should include a full ear, nose, as intracordal cysts and in differentiating these lesions and throat exam, including a conventional inspection from vocal cord nodules.
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Managing asymptomatic 28E Can J Cardiol Vol 20 Suppl E October 2004 Surgical management of valvular heart disease patients with chronic aortic regurgitation. Chronic aortic regurgitation: medial changes associated with bicuspid aortic valve: Myth or the effect of aortic valve replacement on left ventricular volume, reality Chronic aortic abnormalities of the ascending aorta and pulmonary trunk in patient regurgitation: Prognostic value of left ventricular end-systolic with bicuspid aortic valve disease: Clinical relevance to the Ross dimension and end-diastolic radius/thickness ratio. Ann Thorac Surg ventricular systolic function on long-term survival in mitral and 2001;72:1502-8. Improved late Marfan syndrome: Long-term survival and complications after aortic survival in patients with chronic aortic regurgitation by earlier aneurysm repair. Ann Thorac Surg left function and reversal of ventricular dilatation after valve 2002;73:438-43. Management of the patient with aortic root disease and aortic Circulation 1980;61:484-92. Evaluation Operative management of Marfan syndrome: the Johns Hopkins of the results of aortic valve replacement in symptomatic patients. Circulation surgery in patients with marfan syndrome: Long-term survival, 1996;94:2472-8. Circulation treatment of Marfan patients with aneurysms and dissection of the 1980;61:493-5. Therapeutic management of insufficiency: Factors associated with progression to aortic valve patients with Marfan syndrome: Focus on cardiovascular replacement. Thoracic aortic aneurysm:natural history replacement versus aortic valve replacement: A case-match study. Aortic root surgery in Marfan syndrome: patients with aortic incompetence and aneurysm of the ascending Current practice and evolving techniques. Late results of valve-preserving operation in with mechanical and biologic prostheses in middle-aged patients. Ann Thorac Surg Modified conduit preparation creates a pseudosinus in an aortic 1996;62:1301-12. Mechanical and bioprosthetic aortic valve the porcine bioprosthetic valve: Interrelationship of valve survival replacement. Ann comparison of tissue and mechanical valves using a patient-oriented Thorac Surg 2001;71(Suppl 5):S269-72. Logeais Y, Langanay T, Corbineau H, Roussin R, Rioux C, deterioration with the Carpentier-Edwards porcine bioprostheses. Aortic valve replacement in the elderly: Bioprosthesis Can J Cardiol 1999;15:973-8. Long-term outcome after selection of porcine bioprostheses for cardiac valve replacement: biologic versus mechanical aortic valve replacement in 841 patients. Primary aortic standard porcine bioprosthesis: Primary tissue failure (structural valve valve replacement with allografts over twenty-five years: Valve deterioration) by age groups. J Thorac events after valve replacement with the St Jude Medical prosthesis in Cardiovasc Surg 1995;110:186-94. CarboMedics with allograft/autograft: Subcoronary versus intraluminal cylinder or mechanical prosthesis: Performance at eight years. Long-term follow-up of Cardiopulmonary response to maximal exercise in young athletes morbidity and mortality after aortic valve replacement with a following the Ross procedure. Exercise hemodynamic performance of the pulmonary aortic St Jude valve at 18 years: Performance profile and autograft following the Ross procedure. Aortic root replacement experience with the Medtronic-hall valve prosthesis: A follow-up with a pulmonary autograft in young adults: Medium-term results in study of 1104 consecutive patients. Ann mechanical prostheses for aortic valve replacement in patients Thorac Surg 1995;60:S297-302. Can J Surg procedure for aortic valve disease: Long-term results of the pioneer 1999;42:27-36. Pulmonary autograft for aortic Valve replacement in patients on chronic renal dialysis: Implications valve replacement in rheumatic disease. Cardiac valve replacement in patients with aortic valve replacement with pulmonary autograft. Ann Thorac Surg with mechanical and biological prostheses in chronic renal dialysis 1998;66(Suppl 6):S162-5. Bileaflet mechanical valve Hemodynamic performance during maximum exercise in adult (St Jude Medical valve) replacement in long-term dialysis patients. J Thorac Cardiovasc Surg aortic valve replacement in patients with congestive heart failure: 1997;113:667-74. Aortic valve aortic valve disease and pulmonary autograft root dilatation after the replacement with cryopreserved aortic allograft: Ten-year experience. Reoperation on Aortic valve replacement: Comparison of late survival between stentless aortic xenografts. Medium-term determinants of left experience with the freestyle bioprosthesis: midterm results at the ventricular mass index after stentless aortic valve replacement. Clinical and hemodynamic valve substitute on changes in left ventricular function and results at 6 years. Comparison of three different A comparison between stentless and stented valves with regard to types of stentless valves: Full root or subcoronary. Ann Thorac Surg the changes in left ventricular mass and function after aortic valve 2001;71(Suppl 5):S293-6. Comparison of late outcome after stentless versus size on change in left ventricular mass following aortic valve stented xenograft aortic valve replacement. Stentless porcine aortic root: and size on functional outcome and ventricular mass in patients Valve of choice for the elderly patient with small aortic root Prosthesis Patient-prosthesis mismatch is negligible with modern small-size patient mismatch affects survival after aortic valve replacement. Dossche K, Vanermen H, Wellens F, De Geest R, Degrieck I, J Heart Valve Dis 1998;7:207-10. A comparative tolerance after aortic valve replacement by small-size prosthesis: hemodynamic study. Comparative rest and Left ventricular hypertrophy and mortality after aortic valve exercise hemodynamics of 23-mm stentless versus 23-mm stented replacement for aortic stenosis: A high risk subgroup identified by aortic bioprostheses. Comparative rest and symptomatic status, morbidity and mortality after aortic valve exercise hemodynamics of allograft and prosthetic valves in the replacement with a bioprosthetic heart valve. Haemodynamics Hemodynamic and physical performance during maximal exercise and left ventricular mass regression: A comparison of the stentless, in patients with an aortic bioprosthetic valve: Comparison of stented and mechanical aortic valve replacement. The effect of Randomized controlled trial of stented and stentless aortic prosthesis-patient mismatch on aortic bioprosthetic valve bioprotheses: Hemodynamic performance at 3 years. Effects of exercise Prosthesis-patient mismatch: Hemodynamic comparison of stented on Doppler-derived pressure difference, valve resistance, and and stentless aortic valves. Semin Thorac Cardiovasc Surg effective orifice area in different aortic valve prostheses of similar 1999;11(4 Suppl 1):98-102. Regression of left ventricular mass one year after aortic comparison of second and third-generation stented bioprostheses in valve replacement for pure severe aortic stenosis. Left ventricular mass and left ventricular function on performance of the St Jude disc regression early after aortic valve replacement. Aortic valve affecting left ventricular mass regression after aortic valve replacement for octogenarians: Are small valves bad Time course of left Patient-prosthesis mismatch can be predicted at the time of ventricular remodeling after stentless aortic valve replacement. The five-year reop eration rate is approximately 5% and the five-year complica tion-free survival rate is 80% to 90%. The underlying mitral valve morphology is the most hood is injury sustained from prior rheumatic fever. The pathological the morphological appearance of the mitral valve apparatus is process causes leaflet/chordal thickening and calcification, assessed by two-dimensional echocardiography, including commissural fusion or shortening, chordal fusion or a combi leaflet thickness and mobility, commissural calcification and nation of these processes. Heavy echogenicity at the commissures due to transmitral flow (eg, exercise, emotional stress, infection, preg calcification is a predictor of poor outcome and is not ade nancy) or a decreased diastolic filling period (eg, uncontrolled quately covered by the Wilkins score (11-14). The intermediate results of percutaneous mitral valvotomy are similar to open mitral valvuloplasty (15-17). The significant complications are severe mitral regur minimally symptomatic patient is greater than 80%. The the mitral valve morphology is the factor of greatest impor survival drops to less than three years when severe pulmonary tance in determining outcome. The risk of early mortality related to myxomatous degeneration, calcific disease of the eld is 5% in young patients and may be as high as 10% to 20% erly and functional disorders. The functional Natural history causes are ischemia, dilated cardiomyopathy, infiltrative or Long term survival from mitral regurgitation is poorly delineated restrictive cardiomyopathy, and hypertrophic cardiomyopathy. Severe mitral regurgitation due to flail leaflets has been reported to have a Pathophysiology mortality of 6. The 10-year incidence of atrial fib Acute severe mitral regurgitation: the sudden volume over rillation was 30% and of congestive heart failure was 63%. At load results in pulmonary congestion because both the unpre 10 years, 90% of patients had died or undergone surgery. For pared left atrium and left ventricle cannot accommodate the patients who did not have surgery, the mortality was 34% per regurgitant volume. The mortality varied considerably for Chronic severe mitral regurgitation: Chronic mitral regurgita ejection fraction less than 60% versus greater than 60%. Adopted and modified from American College of Cardiology and American Heart Association Guidelines (9) to accommodate increasing regurgitant volume (45-52). The duration of the compensated phase of mitral regurgitation may last for many years. The Mitral regurgitation relates to deficiency in leaflet free edge ejection fraction may be maintained at a low normal range of apposition and effective coaptation (59,60). Mitral regurgitation severity can be reparability of a leaky valve, while various Doppler based assessed semiquantitatively through planimetry of the colour parameters are available for semiquantification of mitral regur flow Doppler mitral regurgitation jet in the left atrium, inter gitation severity. A newer approach is to measure the vena con chamber dimensions, ventricular function, structure of the tracta width (narrowest diameter of the mitral regurgitation jet mitral valve, Doppler measurements, as well as temporal by colour flow Doppler as it emerges from the mitral regurgi changes in these parameters. The classification of the amplitude and shape of the continuous wave Doppler mitral regurgitation severity is outlined in Table 38. Trace or flow reversal is also useful in distinguishing moderately severe mild mitral regurgitation with a structurally normal mitral versus severe degrees of mitral regurgitation. Interrogation of valve may represent normal variants in subjects without valvu the entire coaptation line from medial to lateral is necessary to lar dysfunction. The assessment must evaluate with moderate and severe mitral regurgitation warrant consid location of origin of jet(s) at the coaptation line and then jet eration of surgical therapy. Patients with ejection fraction of 60% and gitation can be defined as 60 mL/beat for regurgitant volume, minimal symptoms have better survival rates than patients 50% for regurgitant fraction and 0. Each variable is scored on a four-point scale from zero and long term survival (94-102). Long term residual regurgi to three, the individual scores are added and the average is cal tation may be related to progressive pathological changes culated. The outlook for the patient with chronic mitral regurgitation are ejection fraction less than ischemic mitral regurgitation is worse than with other forms of 60%, end-systolic volume index greater than 60 mL/m2, and mitral regurgitation. Ischemic mitral regurgitation is usually end-systolic diameter greater than 45 mm or 26 mm/m2 (70-72). The one exception is rup fraction less than 60% have greater likelihood of developing a tured papillary muscle, an acute catastrophic event. Ejection fraction less than 60% is indicative of forms: structural and functional. Mitral valve repair or replacement with Structural: Structural causes are papillary rupture (complete preservation of the subvalvular apparatus diminishes the mag or partial) and papillary elongation. Of all patients with severe nitude of postoperative reduction in ejection fraction (73-81). One-third of umes, dimensions and ejection fraction are essential for deci patients with rupture have complete disruption (leading to sion-making (82). Patients with severe mitral regurgitation and tion with normal valvular apparatus (141-146). Adopted and modified from American College of Cardiology and American Heart Association Guidelines (9). Posterior and lateral displacement dictated by preoperative coronary angiography (147). Functional mitral Total papillary muscle rupture can rarely be amenable to regurgitation is always due to loss of coaptation. There is usually replace the ruptured portion of the subvalvar apparatus have echocardiographical indentified anatomic substrate for com been described and should be used. Partial papillary muscle rupture may be addressed by repar ative techniques accompanied by remodelling ring annuloplasty. In both cases, the timing of structural and functional ischemic mitral regurgitation is much evaluation is controversial. The recommendations that follow are therefore the Transthoracic echocardiogram is preferable in an awake result of the experience of the primary panel members. Leaflet clo Structural: Acute mitral regurgitation is an uncommon com sure should be qualitatively assessed. The measurements plication of acute myocardial infarction and the incidence has should include effective regurgitant orifice area, because a regurgitant orifice area of 20 mm2 or greater and regurgitant probably been significantly reduced with the widespread use of thrombolytic therapy. In the case of complete rupture of the volume of 30 cc or greater correlates with mortality. Functional mitral 25% of patients are expected to survive if treated nonsurgically. It may be necessary to unmask month survival of 50% when treated medically and these significant mitral regurgitation by exercise such as stress patients develop chronic, severe mitral regurgitation. Medical treatment: the medical management of acute severe Patients who demonstrate no, or mild, mitral regurgitation mitral regurgitation complicating acute myocardial infarction while ischemia-free are likely to benefit from revascularization should be aimed at hemodynamic stabilization in preparation alone (148). The residual anatomy but can be misleading because of the nonphysiologi mitral regurgitation after annuloplasty can be due to the man cal conditions. The two proce biplane ventriculography, echocardiography, magnetic reso dures for grade three and four functional regurgitation pro nance imaging or radionucleotide imaging. If the degree of mitral regurgitation in the acute setting Chronic, functional ischemic mitral regurgitation (grade 3+ varies significantly with episodes of ischemia and if good tar or 4+) should be addressed by coronary artery bypass surgery get vessels are identified on the coronary angiography, it is and elimination of the mitral regurgitation. The use of repair likely that these patients will benefit from coronary artery techniques (tight remodelling annuloplasty) versus replace bypass surgery alone. If the mitral regurgitation is grade two with a large area of Ventricular restoration surgery to treat functional mitral reversible ischemia and nondilated remodelled ventricles, then regurgitation with dilated remodelled ventricles has had limited revascularization alone may be appropriate therapy. The surgical therapy should address all components remodelled ventricles without evidence of reversible ischemia, of the mitral apparatus and ventricle including revasculariza then corrective mitral surgery with reduction annuloplasty and tion of viable myocardium, reduction of ventricular volume revascularization may be warranted (143,150,166). These geometric abnormalities gery has been identified to be a strong predictor of poor sur result in mitral annular enlargement, papillary muscle dis vival (164). Chronic postmyocardial regional remodel leaflet with a tight rigid or semirigid annuloplaty ring. Posterior infarction Restrictive remodelling annuloplasty may be ineffective produces functional mitral regurgitation more often than ante because of ventricular dilation which displaces the papillary rior infarction. Anterior infarction does not enlarge or distort muscles and impairs leaflet coaptation with incomplete mitral the mitral annulus.
Carefully examine the contour of slides should be prepared from all tissue the kidney and the tumor heart attack restaurant purchase cardura 4mg visa, and identify poten blocks to expedite the mailing of slides to tial sites of capsular penetration heart attack 4sh cardura 4 mg free shipping. Submit shave sections of the vascular and ure from the periphery of the lesion prehypertension and exercise purchase 2 mg cardura overnight delivery, showing teral margins blood pressure 200120 cardura 2 mg mastercard. Areas of the tumor that appear different from the kidney and therefore deserves careful hypertension 16070 effective 2mg cardura. The renal sinus is the concave portion of dicate the exact site from which each sec the kidney that contains much of the pelvicalyceal tion is taken blood pressure symptoms purchase cardura online. This is most easily done by system and the principal arteries blood pressure vertigo cheap 4 mg cardura overnight delivery, veins hypertension yoga exercises generic cardura 2mg without prescription, lymphat taking Polaroid or digital photographs ics, and nerves that pass through this sinus. Carefully section and inspect the normal kid by the fact that the renal cortex lining the sinus ney, particularly adjacent to the tumor. A thick capsule surrounds the areas may show microscopic foci of persis pelvicalyceal structures and continues to cover tent embryonal tissue known as nephrogenic the medullary pyramids. Failure to submit re the renal sinus and protrude with a smoothly gional lymph nodes may render patients ineli encapsulated surface without invading the soft gible for some low-stage protocols. Such tumors do not meet the criteria for upstaging, unless they show Using the above guidelines for submission renal capsular penetration. The most Renal sinus vessels not inltrated common diagnoses in children are Wilms Renal vein contains no tumor (intrarenal vessels may be tumor, clear cell sarcoma of kidney, rhabdoid involved) tumor, congenital mesoblastic nephroma, and Lymph nodes contain no tumor No distant metastases renal cell carcinoma. If unfa spillage Tumor inltrates renal sinus vessels vorable histology (also called anaplasia) is pres Tumor in renal vein, removed without cutting across ent, comment on its extent (focal or diffuse). Record the number of metastases and Tumor removed in more than one part the total number of lymph nodes examined. Submit sections to demonstrate relationship of tumor to the renal capsule, renal hilum, and adjacent normal kidney. Examine and photograph the specimen, and then ink the surface (do not strip the capsule). Submit sections of the tumor that demonstrate its relationship to the adjacent renal parenchyma, the renal capsule, and the renal sinus. Sample the for additional lesions and the sinus for lymph blood vessels and any nodes. Following xation for 45 to 60 seconds, the preparation is stained and In some respects, pathologic evaluation of speci coverslipped. Do not use all of the tissue by freezing the should begin with cognizance of the clinical and entire specimen. These can be minute, yet error is vastly increased when these specimens major therapeutic decisions often depend on the are studied in a vacuum devoid of clinical or results of the pathology studies. As a consequence, much of the established by the smear, a frozen section may specimen may be lost unless it is recovered from not be necessary. The fragments tional tissue, it is generally wise to freeze only may be difcult to interpret histologically but one or two cores at the time of initial examination, can be invaluable. As is true for biopsies from other body sites, small specimens can be Cytologic preparations are essential in the frozen colored with eosin to facilitate identication at section and permanent section evaluation of all the time of embedding and sectioning. As illustrated, the preferred proce Frozen Sections/Permanent dure is as follows: A minute portion of the fresh Sections specimen is placed on a glass slide and, with con siderable pressure, smeared between an oppos Freezing must be accomplished as rapidly as pos ing slide. The slides are separated and immersed sible to minimize the formation of ice crystals. The recommended procedure is to estab of the mass adjacent to the brain should be sec lish a base of semifrozen mounting medium on tioned, if identied, particularly if portions of the a cold chuck. At least one section pletely frozen, because solidly frozen medium through the base of the tumor on the dura should will slowly freeze the tissue and encourage the also be taken. Decalcied sections of bone are formation of ice crystals by gradually drawing appropriate to evaluate skull invasion. Therefore, place Gliomas are an exceedingly heterogeneous the specimen on the partially frozen base, and group in terms of their macroscopic and micro immediately immerse it in liquid nitrogen. Generally, margins are not freezing, the specimen can then be covered with an issue and do not, unless specically stated by additional mounting medium and refrozen. Fragments of ependymomas, oligodendroglio In the case of gliomas, especially the well mas, and astrocytomas, in which little normal differentiated variety. Prior freezing produces en bloc specimens of gliomas, however, a series nuclear angulation and hyperchromatism, which of marked and recorded sections passing from can make it difcult to distinguish between glio the tumor into the macroscopically normal brain mas and to distinguish reactive or normal brain is appropriate. Unless you are as with central necrosis, the most diagnostic tissue sured of more tissue by the surgeon, use only a is usually found in the cellular rim immediately portion of the specimen for a frozen section. In this setting, multiple hold some tissue in reserve in glutaraldehyde tissue sections should be submitted so as not to (embedding later if necessary) for neoplasms for miss potential foci of active recurrent tumor. The molecular ded from encephalitic lesions if viruses are sus laboratory can be consulted in regard to specic pected, because no immunohistochemical agents tissue preparation. In this setting, tissue can be reserved frozen for special marker studies Specic Entities (see Chapter 41), although most of the relevant markers for the simple purpose of establishing a Meningiomas are frequently submitted with a clinical diagnosis can be performed on parafn dural attachment and arrive as either a complete embedded sections. Prognostically signicant information lymphomas in this setting may be little more than 40. Brain and Spinal Cord 221 a mass of macrophages and few if any residual as any other routine specimen, although some neoplastic cells. Generally, frozen sections are not recom the transsphenoidal route, and the specimens are mended on tissues from demented patients. Care must be taken not to freeze all of Specimens taken to control seizures are usually thespecimens,astheresultantartifactcomplicates from the temporal lobe. Pathology Report on Brain Basically, the tissues are xed in a standard for and Spinal Cord Biopsies malin solution for at least 48 hours. Immu be used later for Giemsa stains, oil red O stains, nophenotypic and genetic studies are often re acid phosphatase stains, chloracetate esterase quired for the diagnosis and classication of a stains, and immunouorescence for nuclear hematopoietic neoplasm. Two additional imprints timely and appropriate technical handling of im m ediatelyxedin95%alcoholshouldbe lymph nodes are, therefore, even more important prepared for possible hematoxylin and eosin than with other specimens. When lymph nodes are placed in an empty Next, tissue should be submitted for light mi specimen container or in dry gauze, the edges of croscopy and, if sufcient tissue is available, for the specimen dry out, producing a prominent immunohistochemical and genetic studies. Severe tions for light microscopy should include not edge artifacts can be introduced into a lymph onlythesubstanceofthenode,butalsothecapsule node even before the specimen reaches the surgi and perinodal soft tissues. Surgeons should there section for xation in neutral buffered formalin fore be instructed to place resected lymph nodes and at least one section in B-5 or an equivalent immediately into a balanced physiologic solution xative. If a section is submitted in a lymph nodes immediately to the surgical pathol mercury-based xative, remember to notify your ogy laboratory. Remember that lymph nodes can tissue processing laboratory personnel because also dry out on the cutting table, so proceed these sections require special processing. Avoid areas that appear necrotic its size, weight, and shape, and then slice it into or sclerotic as these areas may not contain a uniformly thin 2 to 3-mm sections. The best cut surfaces of the node, and ask the following techniques for submitting fresh tissue for im questions: Is the nodal architecture preserved If munophenotyping will depend on your individ the architecture is ablated, is the node grossly ual laboratory, but in general a representative nodular, or is the process diffuse What is the mal controlled temperature embedding medium appearance of the perinodal tissues Again, the rapid handling of tissue should be prepared, especially in cases of sus for these studies is crucial, because delays can 224 225 226 Surgical Pathology Dissection result in diffusion artifacts during immuno Important Issues to Address in staining. If tissue will be sent off-site for these Your Surgical Pathology Report analyses, it should not be frozen, but instead it should be kept cool on ice and rapidly trans on Lymph Nodes ported. Finally, if an infection is suspected or granu lomas are encountered on a preliminary frozen section evaluation, fresh sterile tissue should Extranodal Specimens be submitted for microbiologic studies. If a solid tumor is in the differential diagnosis, then con sider placing a small piece of tissue into glutaral the lymphatic system is not limited to lymph dehyde for electron microscopy. Lymphomas can arise anywhere in submitted fresh tissue for special studies are this rather extensive lymphatic system. Table 41-1 summarizes the type of tis over, they can arise in extranodal sites that are sues to be submitted for specic staining meth not part of the lymphatic system. Lymph Nodes 227 lymph nodes, it is important to recognize that a then be routinely processed in an organ-specic lymphoma can be encountered in almost any manner. Similar to dealing If the nature of a tumor is unknown at the with some epithelial neoplasm, remember to time of specimen processing, a touch prep or document the dimensions of the tumor, deter frozen section of the tumor is a fast, simple way mine the degree of involvement of adjacent struc to determine if you are dealing with lymphoid tures, assess the status of the surgical margins, proliferation. The un have as you begin the dissection because extra involved tissues should also be sampled, and nodal lymphoid proliferations, like their nodal any additional pathologic processes. Once tissue has been ob thyroiditis in thyroid resections) should be in tained for special studies, the specimens can cluded in the nal pathology report. If nodules are spleen removed for trauma is very different from present, count the number of discrete nodules. If the dissection of a spleen removed for a hemato the spleen was removed for trauma and if no poietic malignancy. This step is particularly im Before preparing these imprints, remove excess portant in cases of trauma. In particular, docu blood by blotting the surface of the spleen with ment whether the capsule is intact or lacerated, a towel. If any are found, Next, submit fresh tissue for immunopheno they should be removed and a representative typing. Expansion of the white pulp gives tissue should also be sent for genetic studies thecutsurface theappearanceofwhite noduleson such as gene rearrangements and karyotyping; a red background, while expansion of the red and if clinically indicated, fresh sterile tissue pulp gives the cut surface of the spleen a diffuse should be submitted for microbiologic studies. Spleen 229 Next, tissue should be submitted for light mi Important Issues to Address in croscopy. Submit thin sections so that they can x Your Surgical Pathology Report well, and submit at least one section representing each type of lesion seen and one section that in on Splenectomies cludes the splenic capsule. If the prominent than usual, or obscured (as by a spleen is enlarged but no lesions are noted, three to diffuse red pulp inltrate) This page intentionally left blank T ym s 4 the thymus, along with the lower pair of parathy demonstrate the relationship of the tumor to adja roid glands, is derived from the third and fourth cent structures, to the inked margins, and to any pharyngeal pouches. Because invasion into adjacent the gland fuse to form a pyramid-shaped organ organs is a critical feature used to identify malig enclosed by a thin brous capsule. The thymus nant thymomas, sampling should be directed to has a vital location adjacent to the important areas suspicious for capsular invasion. The gland usually sits because thymomas can be histologically hetero in the anterosuperior portion of the mediastinum, geneous, it has been suggested by Moran and 21 with the base of the thymus sitting on the pericar Suster that a minimum of ve sections should be dium and the upper poles of each lobe extending submitted from all thymomas. Is the organ well encapsulated, or is there evidence of a tumor with invasion into adjacent structures Are pieces of lung, pericar Important Issues to Address in dium, or blood vessels present Next, weigh the speci Your Surgical Pathology Report men, measure it in all three dimensions, and ink on Thymectomies the surfaces of the gland. Alternatively, one drop of cludes both a trephine core biopsy and uid aspi the aspirate can be placed at one end of a glass ration. The details of the preparation of these slide and then gently smeared using a pusher specimens are beyond the scope of this manual; coverslip, as illustrated. Because of processing, which might include iron staining, their small size, they generally do not have to be the preparation of additional smears, and possi sectioned for further processing. Generally, additional ing the size of the biopsy, while it is still fresh aspirates should be obtained for ancillary studies prepare imprints from the biopsy by gently such as cytogenetics and ow cytometry. Although of myeloid and erythroid elements, and their parafn embedding is certainly easier, plastic em degree of maturation. The marrow biopsy can bedding has the advantage of minimizing arti be used to assess quantitative aspects of matu facts produced by inadequate decalcication. To make smears on a coverslip, place a plasma cells (include the pattern of inltration drop on the edge of one coverslip, cover it with and their cytology) In cases for which only a biopsy is avail very brief description can sufce for features that able, sometimes only a descriptive diagnosis is are normal. This practice varies from institution to the biopsy, aspirate, and other ancillary studies institution. X d d s an d n d s C om m on U n com licated S ecim en s 4 the dissection of tonsils, adenoids, hernia sacs, a longitudinal cleft and stellate crypt openings. First, deep longitudinal clefts that extend into the un because these specimens are so frequently en derlying lymphoid tissue. By getting it right the rst time, in the size, shape, and consistency of the ton you can avoid developing bad habits that are sils can be appreciated by comparing the two perpetuated with subsequent dissections. For example, enlargement that is due mundane specimens are particularly suscepti to an inltrative process may best be appre ble to cursory and inattentive examinations. As ciated when the enlarged tonsil is compared is true for novel and complex specimens, the pro to the normal tonsil from the opposite side. Look for exophytic masses, ulcerations, bulky enlargement, and any other gross abnor malities. Bivalve the tonsils and adenoids along the long axis of each, and carefully inspect the Tonsils and Adenoids cut surface for masses, abscess formation, or other lesions. The term tonsils usually refers to the palatine ton Tonsils and adenoids do not always need to sils. These are located laterally on each side of be submitted for histologic evaluation. The deci the oral cavity as it communicates with the oro sion to sample these specimens depends on the pharynx. These are located along the roof of From our own experience, we have found that the nasal cavity as it communicates with the naso these specimens should be sampled for histologic pharynx. Even when these two structures are re evaluation if they meet any of the criteria listed ceived together in the same specimen container, below: they can easily be distinguished by their gross appearance. The tonsils or adenoids are grossly ab surface is covered by a thick brous capsule with normal. There is a size disparity between the two and is somewhat cerebriform, which is due to tonsils. Nonetheless, all grossly abnormal hernia sacs, all hernia sacs excised from adults, and all hernia If any one of the above criteria is met, the tonsils sacs from patients whose clinical history indicates and adenoids should be appropriately sampled a possible histology-based diagnosis should be for histologic evaluation. Most hernia tative sections of the tonsils and adenoids are sacs can be entirely submitted in a single tissue generally sufcient, but certain conditions may cassette for histologic evaluation. For larger speci require special processing or more extensive sec mens, a single cassette with sections representing tioning. For example, diffusely enlarged tonsils all components of the specimen is generally suf or adenoids with architectural effacement may cient. In this situation, the tonsils should be serially sectioned and submit Intervertebral disks typically consist of multiple ted in their entirety for histologic evaluation. If irregular fragments of brous tissue, cartilage, the tonsils or adenoids do not meet any of the and bone in variable proportions. These frag above criteria, they do not need to be sampled ments are small and generally do not require for histologic evaluation. This can Hernia sacs are pouches of peritoneum enclosing be done most efciently by measuring the aggre a hernia.
