By K. Altus. Irvine University College of Law.

Radio- logical examination of the mastoid in the coalescent stage shows clouding of the air cells with destruction of all cell partitions cheap metoprolol 100mg mastercard, thus there occurs loss of clarity and distinctiveness of the air cells safe metoprolol 12.5mg. Treatment Acute suppurative otitis media In the initial stages of the disease buy 100mg metoprolol otc, nasal decongestants, antihistaminics, analgesics and antibiotics like Fig. Myringotomy provides drainage to the pent- up secretions and relieves the pain without the tissue necrosis of the tympanic membrane. Besides the systemic antibiotics (preferably following a culture sensitivity test of the ear discharge), the external canal should be cleaned of the discharge by suction or dry mopping and local antibiotic drops instilled. Mastoid surgery is reserved for those who start to develop a subperiosteal abscess, any Fig. There Indications are two types of incisions—posterior myringo- tomy and anterior myringotomy incisions The common indications of this procedure are (Fig. Acute suppurative otitis media, parti- Posterior myringotomy A J-shaped incision is made in posteroinferior quadrant of the cularly during exudative stage when the tympanic membrane as this is most accessible drum is bulging or the patient has severe area, is relatively less vascular and there are pain. In cases where deafness persists even after In acute otitis media a small 3-4 mm incision apparent control of acute suppurative is generally all that is required. In secretory otitis media, for aeration of the Anterior myringotomy This is done for the inser- middle ear (grommet insertion) and tion of grommets and for facilitating aspira- removal of secretions. In Ménière’s disease, myringotomy some- times gives dramatic relief though the exact In cases of purulent discharge drainage is mechanism is not known. This includes mastoid exploration and If a grommet has been introduced the exenteration of the cell tracts leading to patient is warned against getting water into petrous apex. Masked Mastoiditis Complications Those cases of acute mastoiditis which do not present with the typical symptoms and signs These include incudostapedial joint disloca- are grouped under the term masked or latent tion, injury to the chorda tympani nerve, and mastoiditis. This is usually the result of injury to the jugular bulb which may be pro- inadequate treatment with antibiotics, which jecting into the middle ear due to a dehiscence slow the process but do not completely check in its floor. There is a Gradenigo’s Syndrome dull aching pain with some amount of deaf- This symptom complex occurs when the ness and low grade fever. On examination, the process of acute mastoiditis involves the cell tympanic membrane shows an inflammatory tracts leading to petrous apex and causing thickening and congestion of the tympanic petrositis. Some amount of postaural otorrhoea, trigeminal neuralgia (headache, periosteal thickening with mastoid tenderness retro-orbital pain) and sixth nerve palsy. Radiological examination reveals is probably due to oedema involving the sixth the coalescent process of the mastoid. Persistent mucosal disease: Infection reaches the middle ear either through the eustachian tube or through a perforated tympanic membrane. These hyperplastic mucosal proliferations trap the infection which is responsible for its chronicity. In some cases especially in sclerotic mastoids, mucosal proliferation leads to polyp formation (Figs 10. Cholesterol granuloma: The middle ear gets ventilated through the eustachian tube. When there is mucosal hypertrophy it may block the posterior portion of the tympanum, thus creating vacuum which Figs 10. This provokes a foreign body reaction resulting in the formation of cho- lesterol granuloma. There is also an extremely vascular granulation tissue containing numerous cholesterol crystals, blood pigments, and giant cells. Tubal type: In this variety the infection The Ascaris had crawled up from upper respi- ascendes through the eustachian tube and ratory tract (Fig. Clinical Features This type is usually seen in children from the low socioeconomic strata and often 1. Tympanic type: In this variety the infection On examination, the external auditory reaches the middle ear through a defect in canal is seen full of mucopurulent dis- the tympanic membrane, usually a large charge and there is usually an anterior central perforation (persistent perforation perforation of the tympanic membrane. This is usually seen in adults nasal examination, a deviated nasal and often involves one ear only. There is septum, features of sinusitis or adenoids usually profuse discharge which responds may be seen. Tympanic type: It is usually seen in adults mality of the nose, paranasal sinuses and who complain of deafness and repeated nasopharynx, and if found, it should be infection of the ear. Aural These patients complain of improved toilet is better performed under the hearing when the external auditory canal microscope and the ear examined in detail is full of pus, which deteriorates when the for any pathology that may otherwise be pus is mopped off. Culture sensitivity: Culture sensitivity of the that the transmission of sound waves is discharge is done to select proper antibio- better in the presence of pus. Both systemic as well as local anti- Patch test A cigarette paper or a piece of biotics are used. Local antibiotics are used gelfoam is placed on the tympanic membrane as ear drops and include neomycin, genta- perforation and the patient asked if he hears micin, quinolones and chloramphenicol better. Surgical Management (Tubotympanic Type) The aim of surgery is to provide a safe, dry Investigations and a hearing ear. Culture sensitivity test of the discharge where the predisposing factors are in the helps in selection of proper antibiotics. The aural polyp should be removed with utmost care as it Treatment of Tubotympanic Disease may be attached to the oval or round The aim of the treatment is to control the window or the facial nerve. Myringoplasty: When the ear has become ear dry and finally reconstruct the hearing dry, the tympanic membrane defect should mechanism. Treatment of underlying cause: Proper infection of the middle ear as well as to attention should be paid to any abnor- improve the hearing. Chronic Suppurative Otitis Media 67 Myringoplasty Tragal perichondrium and homograft tympanic membrane are also used by some.

On examination generic metoprolol 100mg online, the patient is polite and pleasant effective 12.5mg metoprolol, demonstrating the typical features of Williams syndrome effective metoprolol 25 mg. On cardiac examination, increase in the right ventricular impulse at the left lower sternal border is noted. No murmurs are audible in the chest or back, though the exam may be compromised by the patient’s body habitus. Bibasilar interstitial and patchy air space disease is present Chest X-ray: A chest radiograph is performed (Fig. Discussion This patient with William syndrome has severe diffuse peripheral arterial stenosis. The increase in right ventricular impulse and loud P2 suggest that the right ven- tricular pressure is elevated. The lack of a murmur suggests that the elevated right ventricular pressure is not secondary to pulmonary valvular, supravalvular, or branch stenosis; rather, the lack of a murmur suggests that the stenosis is in the peripheral pulmonary vasculature. Peripheral pulmonary artery stenosis is further supported by the areas of decreased pulmonary vascularity on chest radiograph. Referral to the cardiologist for evaluation results in an echocardiogram which demonstrates normal intracardiac anatomy without pulmonary valvular, supraval- vular, right or left branch pulmonary artery stenosis. The estimated right ventricular pressure is equal to the systemic blood pressure, strongly supporting the diagnosis of peripheral pulmonary artery stenosis. The severe stenosis of the peripheral pulmonary arteries is only demonstrated on cardiac catheterization through a pulmonary angiogram. Cardiac catheterization: In the cardiac catheterization laboratory, pressure mea- surement confirms pulmonary hypertension, with a right ventricular pressure equal to systemic systolic blood pressure. Multiple areas of peripheral pulmonary stenosis are noted (white arrows), along with abnormal arborization of the pulmonary vasculature 10 Pulmonary Stenosis 147 strates multiple areas of peripheral pulmonary stenosis, along with abnormal arborization of the pulmonary vasculature. Since the pulmonary hypertension is severe, the patient undergoes balloon dilation of multiple areas of stenosis in the peripheral pulmonary vasculature. McCarville Key Facts • The incidence of bicuspid aortic valve is common, however, only small per- centage of such individuals develop aortic stenosis during childhood years. Definition Congenital aortic stenosis results from abnormalities in the formation of the valve leaflets. These abnormalities include fusion of one or more valve leaflets, leading to bicuspid or unicuspid aortic valves, respectively, or malformation of the leaflets of a trileaflet aortic valve. While bicuspid aortic valve is common, comprising up to 2% of the general population, the vast majority of these valves are not obstructive during childhood. Current evidence points to a heritable aspect to the development of congenital bicuspid valves with an K. Holmes (*) Department of Pediatric Cardiology, John Hopkins Medical Institutes, 600 N. Of note, a bicuspid aortic valve may also have associated ascending aortic dilation that may be present, with or without evidence of valve pathology. Acquired valvular aortic stenosis results from acute rheumatic fever or age- related degeneration secondary to valve sclerosis and calcification. Age-related aortic stenosis is prevalent and has been recognized in up to 2% of adults over 65 population. Incidence Occurring in approximately 10% of cases of congenital heart disease, aortic stenosis refers to obstruction to outflow from the left ventricle due to narrowing at above, below, or at the level of the aortic valve. Narrowing at the aortic valve (valvular aortic stenosis) accounts for 71% of cases of aortic stenosis, 23% of aortic stenosis are due to narrowing below the valve (subvalvular aortic stenosis), and 6% due to narrowing above the level of the valve (supravalvular aortic stenosis). This chapter focuses on valvular aortic stenosis, which may be either congenital or acquired (Fig. The aortic valve orifice is small; this may be a result of thickening of valve cusps, adhesion of cusp edges rendering separation between cusps during systole limited and/or due to small valve annulus 11 Aortic Stenosis 151 Pathology Pathology of aortic stenosis varies with etiology of the disease; however, obstruction develops as a result of reduced effective valve orifice. In a bicuspid or unicuspid aortic valve, the fusion of individual valve cusps changes and reduces the normal motion of the valve. Unicuspid valves are more likely to result in stenosis in infancy and young childhood as the effective valve orifice is markedly reduced. Some valves become not only stenotic but also regurgitant as reduced coaptation of these thickened, abnormal coaptation of the valve leaflets in diastole leads to valve incompetence. In cases of critical aortic stenosis presenting in the newborn period, the valve is usually markedly abnormal and thickened, often with reduced diameter of the aortic annulus. Congenital aortic stenosis is frequently associated with other congenital heart defects. Most typically associated are other left-sided obstructive lesions including, hypoplastic left heart syndrome, coarctation of the aorta, subvalvular aortic stenosis, supravalvular aortic stenosis, and mitral stenosis. Bicuspid aortic valves, including normally functioning, nonstenotic valves, are frequently associated with aneurysm of the ascending aorta , leading to increased risk of aortic dissection. Pathophysiology Regardless of the precipitating cause of aortic valve obstruction, clinical manifestations of aortic stenosis are usually progressive over time. The left ventricle gradually hypertrophies in order to accommodate the increased force necessary for aortic valve opening. As hypertrophy eventually gives way to left ventricular failure, the left ventricle and left atrium dilate and changes related to increased left ventricular end-diastolic pressure and left atrial hypertension occur. Clinical Manifestations Patients usually remain asymptomatic until there is a mean gradient across the valve of more than 40 mmHg by echocardiography or peak-to-peak gradient by catheterization. Newborn children with critical aortic stenosis present in shock-like state within the first hours to 1 month of life as ductal closure leads to reduced antegrade flow blood flow across the aortic valve.

These devices do not permit knee rotation and are subject to failure (loosening) in pa- Bone In-growth and Porous Coating tients whose activity level is high cheap metoprolol 50 mg otc. Porous coating buy 25mg metoprolol visa, while significantly adding to the cost of Patellofemoral: Either as part of a total knee replacement 50mg metoprolol for sale, joint replacement, may significantly improve implant when a polyethylene “button” is cemented into the articu- longevity. Beads of a similar alloy are sintered onto the lar surface of the patella, or as a specific patellofemoral metallic components, permitting bony in-growth to occur joint replacement when the major knee compartments are without the need for intervening cement. Clearly, this requires stability to allow in-growth to occur, with implications for the postoperative period. Normal Appearances Anticipated normal plain-film appearances include re- sorption of medial femoral cortex at the calcar femoris Hip Replacements (98%), reduced bone density where it is unloaded, the ab- sence of a thin lucent rim around the implant, although The following features on plain film suggest an ideal po- such a lucency with a sclerotic margin is common (79%) sition for a total hip replacement. It is also normal to see endosteal sclerosis at the Acetabular anteversion should measure 0–30° on a true tip of a prosthesis (36%), localized periosteal new bone lateral view. The femoral component should be coaxial and cortical thickening, representing altered stress loading with the femoral shaft. Acetabular screws, if used, should (12%) and a degree of prosthetic subsidence (7%). The lucent line has Complications of Joint Replacement a sclerotic margin and develops during the first 2 years after insertion. A metal- joints, including pain and other symptoms, for which no bone lucency may be present immediately after surgery cause may be found. In addition, not all abnormal joint replace- quential radiographs for cemented devices whereas slight ments are associated with symptoms. Overall, complica- subsidence is acceptable, and part of the design in unce- tions occur in 1-5% of total hip replacements annually. The major complications are described in the follow- ing: Knee Replacements Loosening With or Without Coexisting Infection Alignment: Obtain standing views to check alignment and compare with earlier radiographs. The infection rate is approximately 1% of total hip replacements, 2% of Total knee: The tibial articular surface should be par- total knee replacements and 3% of revision joints per an- allel to the floor in a weight-bearing position. Obviously, figures vary but at 10 years after inser- femoral component should lie in 5-7° of valgus. The tion as many as 50% of hips may appear radiographical- patellar button should be central and well embedded in ly loose, 30% requiring revision [5]. The progressive similarly to 3-phase bone scan but less well than conven- widening of an interface, especially if associated with bone tional radiographs [8]. The presence of a joint effusion (shown on plain X-ray or ultrasound) implies a Arthrography joint that is abnormal, although a small joint effusion is usual in total knee replacements. Additional signs include The major objective of arthrography is to obtain fluid for excessive component migration or subsidence of unce- culture and sensitivity and to document intra-articular mented components, subsidence of cemented components, needle position. It is important to remember to aspirate cement or fatigue fractures of metallic components, dis- material for both aerobic and anaerobic cultures. A periosteal reaction should always be re- riostatic, aspiration prior to local anesthetic or saline in- garded as suspicious of infection, as opposed to local cor- jection is preferred. If the joint appears ‘dry’, or only a tical thickening, which represents a stress response. False-positive and false-nega- ing may be extremely difficult but features that suggest tive cultures occur, and thus synovial biopsy is preferred infection include excessive bone destruction, the radiolu- by some authors. As empha- as a therapeutic trial (does this ablate the pain of which sized, periosteal new bone formation is highly suggestive the patient complains? However, in- The sensitivity of arthrography is increased when con- fection is often low grade and associated with a non-vir- trast medium is injected under pressure (with local anes- ulent organism, and may be difficult to detect. Further Investigations Features shown on arthrography include loosening, component failure and extra-articular collections and Scintigraphy [5] tracks. Specific signs at the acetabulum of loosening in- clude the leakage of contrast at the cement-bone/metal- Bone-seeking 99mTc compounds demonstrate abnormal up- cement interface in 90% of loose replacements and ex- take for 9-12 months post-operatively. Abnormal activi- Femoral loosening is confirmed in about 98% by contrast ty in the blood pool or perfusion phase should suggest in- medium tracking into the cement-bone interface below fection, particularly if the abnormality is diffuse. In the late the intertrochanteric line, or in the bone-metal interface phase, the classical 3-point scan suggests varus tilt and below the intertrochanteric line. Again, a diffuse increase in activity suggests in- stemmed devices, contrast medium below the level of fection; however, the ability to separate infection from asep- mid-component is abnormal. A normal bone scan has a hip include communication with greater trochanteric bur- strong negative predictive value. However, for reasons that sae (50%), supra-acetabular collections (33%) and filling have yet to be explained, bone scans are often abnormal in of the iliopsoas bursa (17%). Lymphatic filling remains a otherwise uncomplicated total knee replacements and thus controversial finding and is probably not significant, al- have a poorer positive predictive value. It had a high neg- At the knee, contrast under the tibial tray, or the cement ative predictive value but a poor positive predictive val- interface is abnormal. The finding of a 111Indium labeled white blood cells afford increased Baker’s cyst may explain a patient’s symptoms and signs, sensitivity and specificity when used in combination with but in most cases is not relevant. Aspiration was shown to 99mTc bone scans but also carry a significant false-nega- be 100% sensitive and specific for infection in the knee in tive rate. The overall sensitivity is 86% with a ment of total hip and total knee replacements because of specificity of 78% [7]. Generally, the artefacts produced by a prosthesis re- alignment pre-operatively especially, in patients with flect the orientation of the prosthesis relative to the main fixed flexion deformities and in prosthesis planning.