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A: It is a chelating agent cheap 0.2mg flomax free shipping, acts by binding pruritogens in intestine and increases excretion in stool purchase flomax without prescription. A: As follows: • If asymptomatic or if the patient presents with pruritus: Survive for more than 20 years discount 0.4mg flomax with mastercard. Risk factors for malignancy are older age cost of flomax, male sex, prior blood transfusion, signs of cirrhosis and portal hypertension. Presentation of a Case: • The abdomen is distended, fanks are full with everted umbilicus. However, liver is enlarged if cirrhosis is due to haemochromato- sis and primary biliary cirrhosis. Secondary: Causes are— • Haemolytic anaemia such as:b-Thalassaemia major, chronic haemolytic anaemia due to other cause, pyruvate kinase defciency. A: In haemochromatosis, absorption of iron is more and inappropriate to the body needs. Ultimately progressive and excessive accumulation of iron causes elevation of plasma iron, increase saturation of transferrin and high level of ferritin, which is deposited in different organs of the body. In general population, serum iron and transferrin saturation are the best and cheapest tests available. A: As follows: • Avoid foods rich in iron (such as red meat), alcohol, vitamin C, raw shellfsh, also iron therapy. Then, venesection is continued as required to keep the serum ferritin normal (usually 3 to 4 venesections/year is needed). Following venesection, most of the symptoms improve or disappear, except testicular atrophy, diabetes mellitus and chondrocalcinosis. It removes 10 to 20 mg of iron/day, mainly used if the patient cannot tolerate venesection, especially those with cardiac disease or severe anaemia. Oral chelators, deferasirox, 20 mg/kg once daily and deferiprone, 25 mg/kg three times daily, may be given. Even in cirrhotic patients, prognosis is good compared to other causes of cirrhosis. Once a mass is visible or palpable in the abdomen, ensure whether it is intra-abdominal or extra-abdominal, while the patient is in supine position. For this, ask the patient to keep the arms across the upper chest and raise the head upward up to halfway (rising test). Or, ask the patient to raise both the extended legs from the bed (leg lifting test). Intra- abdominal mass will either disappear or decrease in size and extra-abdominal mass will be more prominent. You must mention the possible common differential diagnosis according to the site of the mass and also the age of the patient (cause may be different in young middle aged or elderly). Another example of mass in the anterior abdominal wall (in or under skin) Instruction by the examiner: • Look at the abdomen, what are your fndings? Presentation of a Mass in Anterior Abdominal Wall: • There is a mass in the right upper abdomen, 4 3 5 cm, surface is smooth, margin is slightly irregular, frm in consistency, non-tender and fxed to the overlying skin. A: As follows (mention according to the fndings and also age of the patient): If the patient is young, causes are: • Lymphoma of stomach. If the patient is middle-aged or elderly, the causes are: • Mass in left lobe of liver: Hepatoma, secondaries and hydatid cyst. Other investigations according to the fndings in ultrasonography: • If gastric mass: Endoscopy and biopsy (to diagnose carcinoma of stomach and lymphoma). A: Tell the causes according to the age of the patient: If the patient is young or early-aged: • Appendicular lump (tender). A: Causes are (mention according to the age of the patient): If the patient is young (or also any age), the causes are: • Thick colon (in irritable bowel syndrome). Mass in left iliac fossa If the patient is elderly, the causes are: • Faecal mass. A: It is as follows: • In a jaundiced patient with palpable, non-tender gall bladder, the cause is unlikely to be gall stones, rather it is due to carcinoma of head of the pancreas, cholangiocarcinoma, carcinoma of ampulla of Vater and extrinsic pressure in bile duct. Reverse of the law is: • Obstructive jaundice without palpable gallbladder is unlikely to be carcinoma head of pancreas and extrinsic pressure in common bile duct. Exception of the law is: • Double impaction: Stones, simultaneously occluding the cystic duct and distal common bile duct. A: Gall stone is associated with chronic cholecystitis and gall bladder is fbrosed, which is unable to enlarge. Causes of mass in central abdomen (according to the age and sex): If the patient is young or early-aged, the causes are: • Lymphoma. If the patient is elderly or middle-aged, the causes are: • Intra-abdominal malignancy. A: As follows (mention according to your fndings, considering the age and sex of the patient): • In female: Pregnancy in young, fbroid uterus, ovarian cyst or other ovarian mass (e. A: As follows: Causes of unilateral renal mass: • Renal cell carcinoma (in middle-aged or elderly), Wilm’s tumour (in children). Presentation of a Case: • There is a mass in epigastric region, 9 3 7 cm, irregular, non-tender, margin is ill-defned, frm in consistency and not freely movable. A: I want to palpate left supraclavicular gland (Virchow’s gland, called Troisier’s sign). In carcinoma of stomach, there may be metastasis to left supra-clavicular lymph node. Any patient above 40 years of age presenting with 3 A’s (Anaemia, Anorexia, Asthenia). Paraneoplastic syndrome (such as acanthosis nigricans, dermatomyositis, thrombophlebitis migrans). Adenocarcinoma (95%) is of 2 types: • Intestinal (type 1): arising from areas of intestinal metaplasia (more common, with better prognosis). Diet: • Preservatives in diet: nitrites and nitrates, convert to N-nitroso compounds, which are carcinogenic. Nitrate is converted by nitrite reducing bacteria, which colonize in achlorhydric stomach. This organism is responsible in 60 to 70% cases, mostly associated with achlorhydria. Chronic infammation with generation of reactive oxygen species and depletion of antioxidant ascorbic acid are also important. Others: pernicious anaemia, adenomatous gastric polyp, familial adenomatous polyposis, Ménétrier disease, blood group A and frst-degree relatives. A: It is defned as ‘when carcinoma is confned to mucosa or submucosa regardless of lymph node involvement’. It may be cured by endoscopic mucosal resection or endoscopic submucosal dissection. Stomach becomes like a rigid tube (other causes of linitis plastica are lymphoma, sarcoidosis and secondary syphilis). Lymphoid tissue is not found in the normal stomach but lymphoid aggregates develop in the presence of H. Patients with primary gastric lymphoma have stomach pain, ulcers or other localized symptoms, but systemic complaints such as fatigue or fever are rare. Treatment: • Primary type: Treatment with anti-helicobacter therapy may regress the tumour. If no response, other therapy for lymphoma should be given (radiotherapy or chemotherapy). Presentation of a Case: • There is a mass in epigastric region, 7 3 7 cm, irregular, nontender, margin is ill-defned, frm in consistency and not freely movable (the patient is also extremely emaciated). Q:What relevant do you like to see if it is carcinoma of the head of the pancreas? Also the patient is emaciated, may be pigmented also (all features are due to obstructive jaundice). A: Usually adenocarcinoma (90%), which arises from the epithelium of pancreatic duct. A: As follows: • Painless obstructive jaundice, with palpable gall bladder in case of carcinoma of head of pancreas. Courvoisier’s law: In a jaundiced patient with palpable gall bladder, the cause is unlikely to be gall stones, rather it is due to carcinoma head of pancreas and extrinsic pressure in bile duct. In this operation, pancreas, duodenum, draining lymph node and part of mesentery are removed). Tumours of the body and tail are resected as part of laparoscopic distal pancreatectomy.

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The caudal upper lateral cartilages should be pulled structural support order flomax 0.4 mg on-line, bone poses a higher risk of palpable internal or caudally during the suture stabilization to straighten any external irregularity order flomax on line amex, and is more difficult to suture fixate purchase flomax 0.4mg on-line. The dorsal profile of the spreader grafts order flomax 0.2mg on-line, upper lat- eral cartilages, and septum should be coplanar and smooth. In Caudal Deviation: Mild to Moderate situ trimming of the grafts can ensure an even dorsal surface. The caudal septum may be deviated at the anterior septal angle, Spreader grafts serve two potential functions in the posterior septal angle, or anywhere in between. For small to moderate deviations in rela- exist to correct or camouflage these deformities. These include tively weak septal cartilage, thicker, stronger spreader grafts caudal septal repositioning, caudal extension grafting, caudal may be used to span the curved dorsal septal segment. The For more severe deviations with stronger, more resistant sep- tip may appear to be midline on frontal view if the caudal sep- tal cartilage, asymmetric or curved spreader grafts may be tum and associated medial and intermediate crura cant back placed to compensate for the asymmetry of the middle vault. In these cases, the caudal septum may be freed from the significantly, the dorsal line will appear straighter with proper ligamentous attachments to the nasal floor and shifted over the differential graft placement. Placement of unilateral spreader nasal spine to the opposite side and sutured into position. Management of posttraumatic nasal deformities: the crooked nose and the saddle nose. For instance, if the caudal extension graft reimplantation or causes buckling, a conservative trim of 1 to is longer posteriorly toward the nasal spine, the nasolabial 2mm of the posterior septal angle may be performed to create angle may be opened with a resultant appearance of increased room for repositioning. If the graft is longer anteriorly toward the tip, counter- will lead to loss of tip projection. These techniques rely on the stability side of the deviation may decrease the memory of the cartilage of the caudal extension graft and original caudal septum to sta- and aid in correction. Therefore, the native caudal septum must be Mild to moderate caudal deflections may be corrected with structurally intact and securely attached to the nasal spine and several different techniques. The caudal septum can be cross- maxillary crest to ensure durable stabilization. Cartilage grafts with an opposite curvature to the deviation can also be used to force such deviations into a straight orientation. Another versatile technique to treat the caudal septum is the caudal extension graft. In this technique, the caudal septum is effectively lengthened with a cartilage graft so that the medial crura can be sutured to it. The graft overlaps the existing caudal septum by at least 1cm and is stabilized with at least three hor- izontal mattress sutures. For the deviated caudal strut, a slight curve to the graft allows for compensation of the curvature of the existing caudal septum. The medial crura are then sutured onto the graft to stabilize the nasal base and tip into an appropriate midline position. Patients with a relative caudal septal deficiency may present with columellar retraction and an underprojected, overrotated tip. The extension graft can also be used overlapping margin of cartilage can be beveled to minimize to lengthen the foreshortened nose. Proper execution allows the sur- Severe dorsal and caudal septal deflections require more geon to correct severe caudal septal deviations as well as provide aggressive treatment. Simple camou- In cases in which the majority of the L-strut is deviated, the flaging or repositioning techniques are likely to result in incom- affected portion of the dorsal septum is removed en bloc with plete correction. Thus, with the exception of a remnant of removal of the deviated L-strut segments with replacement 19 dorsal-cephalic septum left attached at the osseocartilaginous with a straight autologous cartilaginous graft. At minimum, ment of intact, straight cartilage from the remainder of the sep- enough dorsal remnant should remain to allow for suture fixa- tum is utilized. Double-layered auricular cartilage may be used tion to the replacement graft—typically at least 1. Carved costal cartilage is replacement graft will have to be and the less complicated the another alternative. It is critical that the attachments of the because of the thickness of the graft, increased donor morbid- dorsal remnant to the septal bone are stable as this point will ity, and potential for warping. In cases After widely exposing the septum and isolating it from the in which the dorsal septum deviates immediately caudal to the upper and lower lateral cartilages, the site of septal L-strut bony-cartilaginous junction due to dislocation, the entire L- deformity must be determined. As emphasized earlier, at least a strut may be removed and suture stabilization may be per- 1. At the posterior septal angle, the caudal septum the posterior septal angle is midline, a remnant of cartilage may must be dissected free from the tough attachments to the nasal be left there for suture fixation as well. The deviated portion of the L-strut is teum of the nasal spine may be used for stabilization. The extent of resection is determined by the amount of the L- The cartilage should be relatively straight with a minimum strut deformity. Positioning is determined by the relationship torted, most of the dorsal strut can be left intact. If most of the to the dorsal cartilaginous remnant, the bony dorsum, the caudal and dorsal segment is deviated, subtotal septal resection desired anterior septal angle and tip position, the nasal spine, and reconstruction may be indicated. Once the opti- resection should be midline; therefore the L-strut should be mal position is determined, the dorsal aspect of the graft is divided just cephalad to the point at which it begins to deviate overlapped to the dorsal cartilaginous remnant by at least from the midline. The new posterior septal angle is then sutured to the a flat rectangular-shaped graft is used to replace the caudal nasal spine periosteum or mattressed to the cartilaginous rem- strut. The shape and orientation of this graft should be directed nant in this region. The graft should extend beyond Once positioned and stabilized, the L-shaped strut becomes its native preoperative position to overlap the medial crura as the fixation point for the upper lateral and lower lateral carti- would a caudal extension graft. This should result in restoring symmetry to the middle tion of the nasal tip structures onto the new caudal strut in the vault, tip, and nasal base. The graft should overlap with the dorsal septal rem- lized to the dorsal margin of the septal replacement graft with nant by at least 1cm. Spreader grafts may be interposed nylon mattress sutures are then placed between the dorsal rem- between the upper lateral cartilages and graft to set optimal nant and the graft, restoring the L-shaped septal strut. The medial must be positioned based on neighboring landmarks: its dorsal crura are then sutured to the caudal strut to stabilize the nasal margin should be colinear with the remainder of the remnant base. To prevent a palpable or visible midline columellar prom- septum, the posterior septal angle should abut the nasal spine, inence, the caudal aspect of the graft should not protrude the anterior septal angle should be just behind the domal carti- beyond the medial crura. Similarly, the domes should project lages, and the free caudal margin should overlap the medial anterior to the level of the new anterior septal angle. The graft is then sutured to the periosteum of the nasal achieved through a combination of proper positioning of the spine with at least two horizontal mattress sutures. After the medial crura on the caudal strut as well as dome binding new L-shaped strut is stabilized, the medial crura are sutured to sutures. As with caudal septal replacement, these maneuvers the caudal aspect of the graft with horizontal mattress sutures. A may be adjusted to effect subtle changes tip rotation and pro- running mattress suture of 4–0 plain catgut on a straight needle jection. Tip rotation, projection, the midline and the dorsal support and tip support of the nasolabial angle, and columellar show may be modulated by nose restored. Other techniques such as shield grafts or graft length, position, and medial crural suture stabilization rela- crushed cartilage onlay grafts may then be performed to tive to the graft. In executing this technique, the surgeon must provide additional camouflage or refinements to the recon- anticipate the three-dimensional relationship of this graft to the struction (▶ Fig. Management of posttraumatic nasal deformities: the crooked nose and the saddle nose. The bony dorsal position and tip position General Considerations should serve as landmarks to determine where ideal middor- sal projection should lie. Preinjury photographs are helpful in The collapsed nose deformity represents one of the most making this assessment. Often the etiology is an evaluate for the presence of septal perforation and to assess untreated septal hematoma secondarily becoming infected, the status of the internal valve area. The amount and condi- forming an abscess, and leading to septal cartilage resorption. The residual Early diagnosis and evacuation of the hematoma can prevent septum integrity and support can be gauged by gentle palpation this deformity. Gross deficiency of dorsal sep- downward digital pressure indicates a significant compromise in tal cartilage results in an illusion of excessive width on frontal support and should alert the surgeon that simple onlay grafting view and an obvious scooped appearance on lateral view—from alone will not be adequate treatment. Gradual contracture of the skin and mucosa may take septum, a loss of tip support may ensue, resulting in significant place onto the receding nasal skeletal framework over time.

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Supplementary medica- The nasal packing is usually left in the nasal cavity for the first 2 tion may be administered during this phase discount flomax generic, most commonly to 8 hours postoperatively discount flomax online, unless there is bleeding indication 39 Rhinoplasty Assessment or history purchase flomax online now. There are various types of nasal packs a surgeon can administered within 60minutes before surgical incision buy 0.4 mg flomax amex, and use (e. Weber et al in two extended studies suggest erative use and amoxicillin with davulanic acid postoperatively conventional resorbable materials with smooth surface for opti- when the history of the patient and the type of the procedure mal results. Most of the surgeons, however, use nasal otics are administered in patients with combined endoscopic packs only when it is necessary. It is dearly documented that that patients with nasal packing are more “protected” from besides a relative prolonged postoperative swelling, concurrent septal dislocations and intranasal synechiae. In addition, there are studies suggesting the avoidance of use of petroleum-based 5. This is a rare side effect recorded in patients treated with cient perioperatively most of the time. Alternatively, ibuprofen topical petroleum-based antibiotic ointment applied on the nasal packing and along the incisions. Some com- mon decongestant agents found in nasal sprays, oral medicines, Use of steroids as a routine adjunctive therapy in rhinoplasty is and other forms are oxymetazoline, xylometazoline, phenyl- highly popular among facial plastic surgeons. In addition, it is ephrine, pseudoephedrine, phenylpropanolamine, and napha- reported by some surgeons that postoperative discomfort and zoline. Our usual method is to spray each nostril twice with pain is considerably decreased, although there is no controlled 0. We advise the patient to use the same spray no more roids are simultaneously questioned. Further literature research than 4 days postoperatively to relieve nasal stuffiness. The most reveals their actual efficacy in reduction of postoperative peri- common decongestants are over-the-counter, but a few of them nasal and periorbital swelling and ecchymosis. Controlled dosage of the drug is 10mg dexamethasone is commonly used by the authors half an implemented to avoid drug abuse leading to rebound conges- hour prior to anesthesia induction and near termination of the tion and other adverse reactions. We do not use sys- adverse reactions have been reported from the antimicrobial temic postoperative corticosteroids in the vast majority of our agent benzalkonium chloride (a quaternary ammonium procedures. In case of excessive and persistent swelling of the included in some nasal solutions to prevent the growth of bac- supratip area, it is recommended to initiate treatment with top- teria)31 such as allergic sensitization, reduced mucociliary ical injections of triamcinolone from the first week postopera- transport, rhinitis medicamentosa, and neutrophil dysfunction. There are studies revealing The magic plants, or “Zauberpflanzen” as the Germans call that there is no statistically significant difference in the postop- them, have been well known for centuries and highly popular erative infection rate between the patient receiving antibiotic during recent years. Arnica sibility of a toxic shock syndrome that has been randomly montana or wound herb is a perennial flower and made avail- described in case reports in the literature, usually associated able in gel, cream, and ointment. Several homeopathic rem- (yet not scientifically proved) with complicated cases with pro- edies can be found as well. The enzymes are a collection of ● The majority of the rhinoplasty side effects, such as sore proteolytic enzymes found in pineapple juice and in the stems throat and nasal and periocular edemas and bruising, will dis- of pineapple plants. Minor residual edemas remain enzymes that constitute one of the most popular herb products for several months up to a year. Their aid in reducing postopera- ● Patients are encouraged to report all nasal injuries to the sur- tive edema and ecchymosis after a rhinoplasty procedure is geon, no matter how minor they appear to be. In some cases, it is recommended for 3 weeks, 8 times daily starting 1 week after surgery, although there is 5. It is more accurately termed sinus massage, for it is the sinuses Formula rather than the nose that is massaged. It is believed but Several methods have been introduced to relieve the patient’s notproved that through friction, heat is generated, postoperative discomfort and help fast wound healing. Prior to helping drainage from the sinuses, promoting nasal a patient’s discharge, we give to the patient a printed form with congestion relief. There are numerous instructions and rules facilitating the patient’s recovery period: 5. Typically, It is normal to have blood-stained mucus discharge and crust- the authors’ postoperative follow-ups are for 3 years after sur- ing from the nose for the first 2 weeks. As is well It is useful to prepare cold compresses, ice packs, or even known, rhinoplasty takes a long time to reap fully the benefits, frozen veggies for application on the peritrau-matic area usually from 6 months to 1 year after surgery. It is advised not to apply the compress is strongly recommended to avoid revision rhinoplasties prior directly to the nose or on the skin and to use a towel or gar- to 1 year postoperatively. According to our experi- sion rhinoplasty to be performed much earlier than a year post- ence, the application of the cold compress should be operatively, and these are based mainly on non-aesthetic rea- 20minutes on the swollen area and not on the nose and then sons (see the box Indications for Early Revision Rhinoplasty 40minutes off. The patient should avoid sports, weight lifting, bend- Indications for Early Revision Rhinoplasty ing, or other strenuous activities for 3 to 4 weeks postopera- ● Graft malposition, rejection, and infection tively. Flushing the nasal cavity with The perioperative settings in the rhinoplasty procedure are the isotonic or hypertonic saline solution is believed to promote essential parameters that constitute the procedure itself. Intranasal splints and their effects on intra- nasal adhesions and septal stability. Plast Reconstr Surg 1989; 84: 41–44, discussion 45–46 [26] Weber R, Hochapfel F, Draf W. Comparison of ibuprofen and acetaminophen with codeine fol- lowing cosmetic facial surgery. Is the use of benzalkonium chloride as a preservative for nasal formulations a safety concern? The acute antibiotics in plastic surgery: trends of use over 25 years of an evolving spe- effect of smoking on cutaneous microcirculation blood flow in habitual cialty. Alcohol con- septoplasty: a survey of practice habits of the membership of the American sumption and blood pressure. Dietary Reference Intakes: group: American Academyof Orthopaedic Surgeons, American Association of Crit- Vitamin C, Vitamin E, Selenium, and Carotenoids. Perioperative risks and benefits of herbal supplements in American Society of Anesthesiologists, American Society of Colon and Rectal Sur- aesthetic surgery. Perioperative considerations for the patient on nesthesia Nurses, Ascension Health, Association of Perioperative Registered herbal medicines. Middle East J Anaesthesiol 2001; 16: 287–314 Nurses, Association for Professionals in Infection Control and Epidemiology, Infec- [6] Ulbricht C, Chao W, Costa D, Rusie-Seamon E, Weissner W, Woods J. Clinical tious Diseases Society of America, Medical Letter, Premier, Society for Healthcare evidence of herb-drug interactions: a systematic review by the natural stand- Epidemiology of America, Society of Thoracic Surgeons, Surgical Infection Society. Curr Drug Metab 2008; 9: 1063–1120 Antimicrobial prophylaxis for surgery: an advisory statement from the National [7] Anderson M, Comrie R. Current trends in local gery and cosmetic rhinoplasty: rationale, risks, rewards and reality. Laryngo- anesthesia in cosmetic plastic surgery of the head and neck: results of a Ger- scope 2009;119:778791 man national survey and observations on the use of ropivacaine. Use of the laryngeal mask airway as an alternative [37] Bandhauer F, Buhl D, Grossenbacher R. Antibiotic prophylaxis in rhinosur- to the tracheal tube during ambulatory anesthesia. Postrhinoplasty nasal cysts and the use of petroleum- Use of the laryngeal mask airway in the ambulatory setting. Effect of steroids rithms for prevention and treatment based on current evidence] Anasthesiol on edema, ecchymosis, and intra-operative bleeding in rhinoplasty. A randomized, controlled comparison between arnica topical preparation of the nose. Clin Otolaryngol 2007; 32: 505 and steroids in the management of postrhinoplasty ecchymosis and edema. Minimizing post-operative edema and ecchymoses by the use of Allied Sci 2004; 29: 582–587 an oral enzyme preparation (bromelain). Bromelain, the enzyme complex of pineapple (Ananas como- intransal surgery—is it necessary? J Ethnopharmacol 1988; 22: 191–203 42 6 Surgery of the Nasal Septum 44 Part 2 7 Septal Surgery in Rhinoplasty 49 Management of the Septum 8 The Importance of the Nasal Septum in the Deviated Nose 61 9 Evolution of the Septal Crossbar Graft Technique 68 10 Twenty-five Years of Experience with Extracorporeal Septoplasty 77 11 The Severely Deviated Septum: The Way I Solve the Problem 85 12 Reconstructive Septal Surgery 94 13 Treatment of Septal Hematomas and Abscesses in Children 99 2 Management of the Septum 6 Surgery of the Nasal Septum Gunter Mlynski As early as 1882, Zuckerkandl9 in his anatomical studies real- 6. He introduced the term “physiological septal of the airway that has more tasks than just allowing air to pass deviation.

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