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The practical importance of leukoplakia is the danger of its developing into carcinoma order malegra dxt online now erectile dysfunction pills cialis. Desquamation also appears simulta­ neously which leaves areas of smooth red and shiny tongue order on line malegra dxt erectile dysfunction statistics age. Appearance of ‘warty excrescences’ or small lump should arouse suspicion and these portions should be excised and examined histologically buy cheapest malegra dxt erectile dysfunction pills canada. It does improve the condition initially discount malegra dxt 130 mg with visa fda approved erectile dysfunction drugs, but it increases the chance of malignancy. Moreover, to add more problem such malignant lesions become resistant to further radiotherapy. Aphthous (dyspeptic) ulcer — is a small painful ulcer seen on the tip, undersurface and sides of the tongue in its anterior part. The ulcer is small, superficial with white floor, yellowish border and surrounded by a hyperaemic zone. Dental ulcer — is caused by mechanical irritation either by a jagged tooth or denture. These ulcers occur at the periphery or on the undersurface of the tongue at the sides. It often presents a slough at its base and surrounded by a zone of erythema and induration. The syphilitic conditions which are more often seen in the tongue are the gumma and chronic superficial glossitis. Such ulcers are shallow, often multiple and greyish yellow with slightly red undermining margin. It is usually seen at the upper part of frenum linguae and in the undersurface of the tip. It is usually single, but may be multiple if superimposed on chronic superficial glossitis. These are discrete, hard and mobile in the early stage but become fixed to the underlying structures in late stages. Gradually vesicles appear which later on burst to form multiple superficial ulcers which are extremely painful. In this case the aetiology is mainly smoking and hence this ulcer is called ‘smoker’s ulcer’. These are — (i) Papilloma; (ii) Haemangioma; (iii) Lipoma; (iv) Lymphangioma; (v) Neurofibroma; (Vi) Lingual thyroid; (vii) Salivary gland tumour; (viii) Osteoma. Sometimes a hard swelling may be seen in the posterior third of the tongue just beneath the foramen caecum. Lymphangioma and neurofibroma are discussed later under the heading of ‘Macroglossia’. Even if the ulcer is shallow, the base will be felt to extend much more deeply, as the growth is invasive. In the anterior 2/3rd epidermoid carcinomas with cell-nest formation is mostly seen. The reason is that the anterior 2/3rds of the tongue is covered by thick stratified, comified epithelium with numerous papillae. Differentiation is less in case of cancer tongue than in case of cancer of the lip, that is why prognosis of tongue cancer is worse than that of lip cancer. In the posterior 3rd of the tongue there is little or no comification, there are abundant racemose glands and numerous collection of lymphocytes near the basal layer of the cells. Very rarely one can come across adenocarcinoma or malignant melanoma in the tongue. Carcinoma of the anterior 2l3rds of the tongue usually starts on the lateral margin of the tongue and invades the floor of the mouth early but it remains limited to the side affected and does not extend to the other side across the midline. Carcinoma of the posterior 3rd of the tongue tends to spread to the corresponding tonsil, epiglottis and soft palate. Regional lymph nodes are affected by embolic spread and not by permeation, so that the intervening tissue is not involved. One set of lymphatics from the tip of the tongue also pass to the juguloomohyoid gland. The jugulodigastric group of the upper deep cervical nodes ultimately receives the efferent lymphatics from the submandibular and submental groups, so that in later stages the jugulodigastric group will be involved regardless of the original site of the tumour. It should be remembered that secondary infection of the growth also causes enlargement of the draining nodes. So enlargement of the draining lymph nodes do not always mean lymphatic metastasis. The reason is that the growth remains occult and when the patient presents it is in relatively late stage. Increase in female incidence may be attributed to increase in smoking habit among females. Decrease in male incidence is attributed to low incidence of syphilis, decreased use of the clay pipes, improved standard of oral hygiene and decrease in consumption of country liquor. Many patients ignore the condition at this stage, until and unless some more symptoms develop within a span of a few months. An old patient sitting in the outpatient department repeatedly spitting into his handkerchief is a good indication of carcinomaof the tongue. Offensive smell in the mouth occurs due to bacterial stomatitis as the patient is unable to swallow saliva. It becomes even worse when the floor of the mouth is involved and ultimately this causes difficulty in speech. When the lingual nerve is involved pain may be complained of and such pain may be referred to the ear through auriculotemporal nerve another branch of the 3rd division of the 5th cranial nerve (mandibular nerve). It must be remembered that growth situated on the posterior 3rd of the tongue often escapes notice of an intelligent patient and even the clinician if he does not examine the case carefully. Such patients often present with hoarseness of the voice, dysphagia, difficulty in speech or even lump in the neck. Its surface is irregular, the edge is indistinct and the consistency is hard (most important feature). It is important to examine thefloor of the mouth, gums, the jaw, tonsils andfauces. Palpation of the posterior part of the tongue and laryngoscopy examination are highly important if one does not want to miss growth in the posterior 3rd of the tongue. It is again stressed that enlargement of the draining lymph nodes does not necessarily mean lymphatic metastasis, but this may be caused by secondary infection of the growth. In these cases hemimandibulectomy may be required alongwith excision of the growth. Radium needles, Radon seeds or radioactive tan­ talum wires or192 Iridium wire are placed in the growth in one plane with a distance of 1 cm. When the growth is deeper and extends more than 1 cm into the tongue, it is difficult to treat these growths with interstitial radiother­ apy and teletherapy should be used. This therapy is particularly useful in the posterior l/3rd of the tongue, where interstitial radiotherapy is also difficult to employ. When the lesion is large than 2 cm in diameter it is usually irradiated by external beam irradiation. The submandibular nodes are also included in the field even if no nodes are palpable. Then 6-8 weeks later an excision is carried out in continuity (Commando operation). Sometimes block-dissection may be performed alongwith haemiglossectomy and this is called Commando operation. Role of radiotherapy is extremely poor so far as treatment of secondaries is concerned. When the primary recurs even after radiotherapy and surgery, cryosurgery may be tried. In case of extreme pain due to advanced growth, blocking of the trigeminal nerve with 5 % phenol may be considered. Patients with tongue cancer die from following conditions:— (i) Cancerous cachexia and starvation. In case of arteriovenous fistula ligation of both lingual arteries should precede partial excision. Veiy rarely onemay find mucosal neuroma of the tongue (it is often associated with medullary carcinoma of the tongue) (Fig. Treatment is partial excision, particularly the portion which protrudes out of the mouth. In such cases fissures are mainly transverse, though there may be a deep furrow in the middle of the tongue. Fissures may appear in the tongue due to hereditary or acquired syphilis, chronic superficial glossitis and even in carcinoma. In syphilis and in chronic superficial glossitis the fissures are usually longitudinal. In these cases there may be (a) accumulation of food debris between the filiform papillae of the tongue, (b) there may be overgrowth of normal bacterial flora of the mouth and (c) the desquamated cells are not normally removed by movement of the tongue. In normal individuals fuiring of the tongue is only noticed in case of excessive smokers. A reddish patch is found in the midline just in front of the circumvallate papillae due to inadequate covering of the tubercular impar. The importance of this condition is that it is often confused with (a) syphilitic wart or (b) carcinoma of the dorsum of the tongue. If these two pathologies can be excluded, no definite treatment is necessary for this condition. Hypertrophy of papillae becomes covered with such fungi and mass of bacteria and give dark colour to the tongue. Thus the dorsum of the tongue appears to have a patch of hairs and this condition is often called ‘black hairy tongue’.

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Nephroblastoma discount 130mg malegra dxt erectile dysfunction ultrasound protocol, which is exclusively a tumour of children generic malegra dxt 130 mg otc erectile dysfunction medications online, mostly occurs under 4 years of age discount malegra dxt 130 mg overnight delivery losartan causes erectile dysfunction, average 1 to 7 years generic malegra dxt 130 mg overnight delivery erectile dysfunction symptoms treatment. Between the ages of 7 years and 40 years malignant neoplasms of kidney are unusual. Von Grawitz considered this tumour to arise from ‘adrenal cortical rest’, which may sometimes be present in the cortex of the kidney. He came to this view as the microscopic appearance of the tumour closely resembles that of the zona glomerulosa of the adrenal cortex. Subsequently this view has been cancelled from the facts :— (i) That hypernephroma is never seen in other sites e. The aetiology of renal cell carcinoma is still uncertain, although a number of factors have been recognised which increase the risk of developing this carcinoma. These are — Shoe workers; Workers exposed to cadmium, particularly if they smoke; Leather tanners; Those who are exposed to contrast medium thorotrast; those exposed to petroleum products. Chronic administration of oestrogen to males in animal models have induced renal cell carcinoma. Renal cell carcinoma is not a typical familial disease, though it has been found to affect more than 1 member in the family. Autosomal dominant von Hippel-Lindau syndrome (cerebelloretinal haemangioblastomatosis) is considered to possess a high risk in developing this disease, which occurs at an earlier age than usual and is often bilateral. Most of the chromosomal abnormalities which have been described in spontaneous renal cell carcinoma involve deletions in the short arm of chromosome 3. As the tumour gradually grows in size, it compresses adjacent renal tissues and displaces calyces and the pelvis. This tumour is more common in the upper pole than lower pole, but are rarely found in other parts of the kidney. On cut surface the two chief characteristic features are its yellow colour and remarkable variegated appearance. The tumour cells may be (i) large with clear abundant cytoplasm with small eccentric nuclei, which are known as clear cells, (ii) small and compacl with cytoplasm containing basophilic granules, which are known as granu­ lar cells (dark cells), (iii) large and eosinophilic cells known as oncocytic cells and (iv) anaplastic cells. The clear cells are large and peculiarly clear owing to the presence of abundant lipids and glycogen. The majority are clear cell type, whereas the dark cell type is usually less common. The microscopic appear­ ance is very much similar to renal adenoma, from which many of these tumours arise. A particular type which is known as papillary cystadenocarcinoma is mainly composed of large eosinophilic cells (oncocytes), which are cystic with papillary arrangements. The anaplastic cells extremely vary in size and shape which may be polygonal or fusiform. This probably accounts for haemorrhages inside the tumour and great tendency of the tumour for blood spread. After the renal capsule has been penetrated, the surrounding perinephric fat is gradually invaded. When the tumour penetrates through the renal capsule and invades the perirenal fat, it then metastasises to the lymph nodes in relation to the hiluni of the kidney and from there to the paraaortic group of lymph nodes. Involvement of regional lymph nodes is reported in only 20% of cases undergoing radical surgery. Blood spread occurs in two ways — (i) by embolism, in which pieces of growth become detached and are swept into the venous circulation to become first arrested in the lungs. In the lungs the metastasis produces ‘cannon-ball’ deposits which are revealed in X-ray as round opaque metastases in the lungs and later on further small pieces may enter into arterial circulation and may be deposited in the bones. Thus the tumour may extend through the inferior vena cava into the right atrium keeping continuity with the parent tumour. Sometimes the solid columns of tumour tissue inside the renal vein may cause obstruc­ tion to the testicular vein particularly on the left side, in which side the testicular vein drains into the renal vein. Obstruction of drainage of the testicular vein may cause varicocele on the left side. So sudden left sided varicocele in an old man should arouse suspicion of adenocarcinoma affecting the left kidney. Through blood spread multiple metastases are common, though occasionally one may find solitary me­ tastasis only in the lung. In X-ray film the secondary deposits in the lung often present round appearance with a clean-cut circumscribed outline, to which the name cannon-ball appearance has been applied. In the bone the tumour is remarkably destructive or osteolytic so that it may cause pathological fracture later on. A solitary metastasis in the bone occurs more frequently in this than in any other tumour. It is the third tumour surpassed only by lung and breast to involve brain by metastasis. Its maxi­ mum incidence, which constitutes about l/3rd of cases, is in the 6th decade. As mentioned, bleeding is painless unless accompanied by renal colic due to passage of blood clots. Such low grade pyrexia is often due to absorption of blood and necrotic material from the tumour itself. This type of pyrexia usually disappears after nephrectomy, but if it persists, it indicates presence of metastasis. Such symptoms are :— (a) In case of lung metastasis — persistent cough, haemoptysis, chest pain and dyspnoea. Oedema of the legs may be occasionally seen which is secondary to neoplastic involvement of the inferior vena cava. Physical examina­ tion of the chest may not reveal any definite sign, though metastasis is present. Liver is a common site of metastasis, in which case it becomes enlarged and nodular. Haematuria is the earliest symptom and all cases of haematuria should be investigated with utmost care to exclude malignant tumour in the urinary tract. If blood is seen coming through one ure­ teric orifice and clear urine through the other orifice, probably he is having an adenocarcinoma or a papil­ loma in that kidney. Excretory urography and other investigations as mentioned below should be per­ formed quickly to exclude adenocarcinoma of the kidney. Hypercalcaemia is sometimes seen as a few tumours are known to secrete parathor­ mone. Calyces may be bent, elongated or distorted or even amputated or absent due to the presence of the tumour. This con­ dition is also seen in polycystic kidney, but the differentiating features are that polycystic kidney is often a bilateral condition and the spider legs in this condition are smoother in outline in compari­ Fig. Note how the pelvis is compressed and the calyces are more irregular due to the irregular margin of the tumour. The unaffected calyces pass upwards or downwards according to the situation of the tumour. Some tumours are rela­ In the left scan an enlarged kidney is visible which on the right transverse tively avascular and diagnosis becomes scan shows abnormal echoes from tumour tissue. It must be remembered that skeletal me­ tastasis is only recognised in 50% of cases by X-ray. The place of adjuvant lymph node dissection remains controversial, as is the place of adjuvant radiotherapy com­ bined with nephrectomy. These cases are suitable for radical nephrectomy including removal of perirenal fat and regional lymph nodes. Levels of erythropoietin, renin and carcinoembryonic antigen will fall to normal level after such radical nephrectomy. Treatment of these cases is palliative X-ray therapy with or without chemotherapy. Most authorities feel that X-ray therapy or radiotherapy does not work appre­ ciably in adenocarcinoma of kidney and its metastasis, so its effectivity either pre- or post-operatively have been disagreed by majority of the urosurgeons. But in this group as operation is almost impossible, this is the only form of treatment available. The treatment of this group is radical nephrectomy with excision of the solitary metastasis, be it lobectomy or pneumonectomy for lung metastasis or amputation for a bone metastasis. In these cases partial nephrectomy should be considered with removal of adjacent perirenal fat and regional lymph nodes. After opening the abdomen the surgeon should carefully assess the resectability of the tumour. Once it is determined that the tumour is resectable, the tumour is not further handled and the surgeon puts all attention to the renal pedicle. Before manipulating the kidney it is advisable to deal with the renal pedicle to prevent further blood borne metastasis due to handling of the tumour. The inferior vena cava should be palpated carefully to detect any tumour thrombus within it. Al the time of dissecting the renal vein, if tumour thrombus is detected it should be opened and the tumour thrombus is removed. Now the renal artery is ligated and divided and the ureter is ligated and divided as low as possible. The perinephric fat and fascia are gradually separated from the surrounding tissues from outside inwards. While the dissection is proceeding inward, all the regional lymph nodes are included within the kidney mass. Ultimately the tumour with the whole kidney, perirenal fat and regional lymph nodes are removed. Many urosurgeons now recommend transcatheter renal arterial embolisation 1 to 7 days before nephrectomy which facilitates operation. By this technique tumour cell dissemination during the operation is also prevented to certain extent.

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In acute bleeding 20 units in 20 ml of 5% dextrose should be given intravenously over 20 minutes 130 mg malegra dxt with amex erectile dysfunction clinic raleigh. Presently Octreotide proven malegra dxt 130 mg erectile dysfunction doctor specialty, the long-acting somatostatin analogue is being used equally effectively malegra dxt 130 mg fast delivery erectile dysfunction drugs compared. The side effects of pitressin are due to generalised smooth muscle contraction buy 130 mg malegra dxt with visa erectile dysfunction treatment saudi arabia, (a) Cramping abdominal pain, which may be associated with bowel evacuation, is distressing to the patient, (b) Coronary artery vasoconstriction may lead to myocardial ischaemia. Recently propranolol is being used to prevent recurrent bleeding by reducing cardiac output. In acute bleeding intravariceal injection is preferred, but to stop recurrence of bleeding para-variceal injection is preferred. Complications of this method are primarily (a) retrosternal chest pain due to phlebitis, (b) Local microperforation, though major perforation is rare, (c) Pulmonary complications such as effusion which may be accompanied by fever. This step may be even omitted in case of good risk patients where one can think of urgent shunt operation after preliminary trial of pitressin and sclerotherapy. The gastric balloon is then fully inflated with 300 ml air and appropriate traction must be applied. The oesophageal balloon should be inflated to 45 mm Hg only if the gastric balloon does not control the bleeding. Complications are (a) aspiration is common, (b) Ulceration of the gastric and oesophageal mucosa from sustained pressure can produce more bleeding, (c) Oesophageal rupture from this technique is quite rare, but if occurs, is fatal. At the onset percutaneous transhepatic portal vein puncture is made under local anaesthesia. It is better to sclerose the varices with 100% alcohol initially, followed by occluding agents into the feeding vessel. Initial control rate of bleeding from oesophageal varices has been claimed to be 45% to 90%, though there has been a high rebleeding rate of about 25% to 75% in almost all series within a few days to months. It must be remembered that the use of transhepatic embolisation is a temporary step in poor risk patients who continue to bleed following Pitressin therapy, sclerotherapy and tamponade. Those variceal haemorrhage which did not respond to either drug treatment or endoscopic therapy, this technique seems to be the best. Under local anaesthesia and analgesia with sedation, the shunts are introduced under fluoroscopic and ultrasonographic guidance. A guidewire is inserted into the hepatic vein and ultimately into a branch of the portal vein through internal jugular vein and superior vena cava. By this time a drop in portal venous pressure with reasonable control of variceal haemorrhage can be detected. The main complication is perforation of the liver capsule, which may result in fatal intraperitoneal bleeding. There is also a chance of post-shunt encephalopathy in about 40% of patients, an almost similar incidence found after surgical shunts. The main longterm complication is stenosis of the shunt which may result in further variceal haemorrhage. Shunt operation is usually done as an elective operation after one bout of haemorrhage. There is no place of prophylactic shunt operation, as being far from beneficial, it is sometimes deleterious. This operation is contraindicated in cases of (i) elderly patients, (ii) with severe encephalopathy, (iii) with marked liver failure i. The patients who remain in the contraindication group of the shunt operation should be treated by one of the emergency operations. But these do not decrease the portal vein pressure or prevent subsequent haemorrhages. The periosteum of the rib is elevated from its outer as well as the inner surface. The whole rib is then resected and an incision is made on the periosteum as well as the parietal pleura. The parietal pleura lying over the oesophagus is incised very carefully to expose the lower end of the oesophagus. The oesophagus is now transected transversely and resutured with continuous catgut so that all the bleeding vessels are held and occluded by the catgut suture. Nowadays circular stapling device is being used which can be quickly applied and the result is also similar to this operation. This operation gradually lost its popularity as the oesophagus is not a good gut to anastomose because of its low vascularity. For this reason Boerema-Crile and Milnes-Walker introduced the operation where the oesophageal musculature was incised longitudinally so that the anasto­ motic leakage did not follow. Similarly Tanner introduced subcardiac gastric transection due to high vascularity of the stomach and anastomosis in this organ is not followed by leakage. The patient is laid in the right lateral position and a nasogastric tube is pushed into the stomach. The steps of this operation are more or less similar to those of the previous one till the exposure of the lower end of the oesophagus. The muscles of the oesophagus are incised longitudinally and the edges are held apart by stay sutures. The columns of varices, usually 3 in number, are under-run with continuous catgut sutures. Recently sophisticated staplers are being used for oesophageal transection and reanastomosis. The technique is as follows : For transection of the oesophagus, the peritoneal cavity is entered and the oesophagogastric junction is exposed. The lower 3 cm of the oesophagus is mobilised and particular care is taken to avoid vagus nerve injury. The mucous and the submucous coats of the oesophagus are taken out off the musculature as a single tube and completely divided across. This operation may be performed when the bleeding varices are mostly in the stomach, otherwise this operation does not prove to be useful. In this technique portal hyperten­ sion is maintained which ensures portal venous perfusion and maintenance of liver function, but stops bleeding from varices and Fig. Note that the injec­ tion is made by the side of the varices, so that surrounding sclerosis causes constriction of varices. Injection is made inside the varices, so that intravariceal thrombosis occurs leading to cure of the condition. Left thoracotomy is performed for oesophageal transection and paraoesophageal devascularisation. Laparotomy is then performed for splenectomy, gastric devascularisation, selective vagotomy and pyloroplasty. But at the hands of other surgeons applying the same technique the mortality rate was higher (20% to 40%) and 5 years survival was 40% to 70% and rebleeding rate was 20% to 50%. Predominantly poor risk cirrhotics who are not even fit for emergency operations, may be given the advantage of this method. The benefits of sclerotherapy lie in the preservation of portal perfusion (portal blood flow is maintained) and maintenance of hepatic function. The poor risk patients who will not tolerate major surgery will mostly be benefited. Moreover morbidity and mortality of these operations in the acute man­ agement of variceal haemorrhage is quite high. However surgical shunts are quite effective in preventing rebleeding from oesophageal and gastric varices as they reduce the pressure in the portal circulation by diverting the blood into low-pressure systemic circulation. Surgical shunts may be divided into 2 groups — (i) selective — which includes splenorenal as it preserves blood flow to the liver while decompressing the left side of the portal circulation which is responsible for giving rise to the oesophageal and gastric varices. Similarly the selective shunts are asso­ ciated with a lower incidence of postsurgical encephalopathy. There are principally three types of shunt operations : (i) Portacaval, (ii) Lieno-renal and (iii) Mesenterico-caval. The duodenum and the head of the pancreas are mobilised to the left by Kocher’s manoeuvre to expose the inferior vena cava. Now the portal vein is exposed in the posterior part of the free border of the lesser omentum and is mobilised as far as possible. The spleen is removed as usual leaving behind as great length of the vein as possible. The vein is now separated from the body of the pancreas by ligating and dividing its tributaries. The left renal vein is dissected out and the peritoneum over it is carefully incised. A special clamp is applied to renal vein to partially occlude it and the splenic vein is anastomosed to the renal vein in an end-to-side fashion (Fig. The lower cut end is ligated and the proximal cut end is joined to the side of the superior mesenteric vein at the root of mesentery. Sometimes a dacron graft may be used to connect the superior mesenteric vein and the inferior vena cava. Occlusion of anastomosis by thrombosis, which makes the shunt operation a failure. Nor­ mally the toxic products of protein break down, mainly ammonia, enter the liver where they are detoxicated. After shunt operation these toxic products get direct access into the systemic circulation and reach the central nervous system particularly the brain causing encephalopathy. The clinical features are disorientation, rigidity of the limbs, flapping tremor of the outstretched hand and deep coma. In electroencephalogram there is marked slowing of the frequency upto the delta range. Treatment is restriction of protein diet, removal of blood from bowel with enemas or purgation with magnesium sulphate.

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This vali- Iontophoresis dated scale can aid in selecting patients appropriate for therapy and 25 Oral medications for assessing efectiveness of treatment buy discount malegra dxt 130 mg on-line impotence kit. Additionally generic 130 mg malegra dxt with mastercard how to get erectile dysfunction pills, the generalized reduction in sweat production Glycopyrrolate topical preparations Apply daily to afected areas can be dangerous in individuals who engage in exercise order malegra dxt online erectile dysfunction icd, sports malegra dxt 130 mg for sale young and have erectile dysfunction, or compounded as cream, lotion or work in hot environments. Te mechanism of action day every 1–2 weeks until therapeutic is unknown but may change the ability of the pores to secrete sweat, success or development of side efects or physically block the release of sweat via ions that enter the ducts. Anticholinergic mg/day every 1–2 weeks until therapeutic agents can also be added to the tap water. Not for Local surgical excision and liposuction or curettage techniques can continuous use. Prescription strength prod- sympathetic chain is interrupted at the T2, T3, and sometimes the ucts containing higher concentrations of metal salts most commonly T4 ganglion. It delivers microwave energy to the subcutaneous tis- clinical trial of any anticholinergic was with oxybutynin. In this ran- sues which preferentially destroy eccrine glands (and to a lesser domized placebo-controlled trial 50 patients received an initial dose extent apocrine glands and hair follicles) due to the physical prop- of 2. Approximately erty of preferential absorption of the energy by tissues with high 70% of the patients reported improvement in their axillary and water content. Similar results were published in a large phase 3 double-blind rotation generating heat and cellular thermolysis. A 3-year open label extension study revealed contin- be easily managed by postprocedure cooling with ice, nonsteroidal ued efectiveness and with similar duration of results. Numbness in the upper arm or axilla, blistering or ment in the quality of life of subjects. Te median tion is localized, reversible, and long-lasting although the therapeu- duration of efect for responders ranged from 134 to 152 days. One study documented results were similar to the previously reported outcomes for adults. This achieves excellent results, high to be treated should be identifed using a colorimetric test such as patient satisfaction, and helps to keep costs down. Although this basic technique can be used to treat many areas ment sides and results were maintained for 6 months. An average Terapy was well-tolerated and 98% of subjects said they would rec- of 10–15 injections per axilla is required, but will depend on the size ommend the therapy to others. No large- and if these ectopic areas of eccrine glands are missed, the results of scale studies have been published but multiple small-scale studies treatment may be suboptimal. Te start- ing pressure is typically around 130 psi (with a range of 1–350 psi) depending on the epidermal thickness. Nerve blocks are efective and can be performed in the ofce69,79–81; however, with the much simpler technique of ice and pressure described below, nerve blocks are not ofen used. All can be anesthetized at the level of the wrist using 1% or 2% lidocaine (Figure 9. Risks of a nerve block include infltration of the nerve with subsequent nerve injury and vascular puncture. In addition, temporary hand weakness afer the nerve blocks may limit the patients’ activities and ability to have both hands treated at one session. If the anesthesia is not complete, cholinergic nerve endings or a diferential recovery rate of the nerves other techniques may also be used (Table 9. Topical anesthetic containing lidocaine and cold packs tend not to provide adequate pain control. More intensive cold exposure can be helpful: the use of dichlorotetrafuoroethane or liquid nitrogen, sub- mersion of the hand in an ice bath, direct exposure of an ice cube Table 9. Just as the ice is removed, the vibrator is applied and the injection Ice and pressurea performed simultaneously. This is the authors’ preferred method of pain control a Authors’ preferences for most cases. Less is known about the dos- is injected intravenously following the application of a tourniquet ing, duration, and adverse events associated with pediatric use. Exsanguination of the extremity is performed Coutinho dos Santos published a series of nine children aged 6. This requires an assistant and there is some is no consensus on the optimal dose, the duration is variable, and movement of the patient’s hand, which can make injections chal- the injections are painful. All patients had an applied distal to the site of pain provided better analgesia than vibra- improvement in symptoms and a “signifcant decrease of Minor’s tion applied proximal to the site of pain. An ice cube is pressed frmly to the planned injection site for area, which can extend up the sides and onto the dorsum of the foot. Injections of frmly to the area for 7–10 seconds and then the vibrator is frmly the plantar surface can be technically more challenging due to the applied immediately adjacent to the injection site simultaneous to thickness of the stratum corneum in some areas, especially if cal- the injection (no more than 2–3 seconds). Te physician must adjust for the variation in depth to accu- assistant and coordinated timing to optimize pain control. Weakness of the hand or fngers is possible but is usually minor level of the ankle. Te incidence varies in published series, but and if the dorsum of the foot must be injected, the superfcial pero- ranges from 0% to 77%. Approximately 2 cc of 1% or 2% index fnger pinch, whereas gross strength or grip strength of the lidocaine is injected around each of the nerves. Twenty minutes or more may be nec- the dermal layer, especially superfcial over the thenar eminence to essary for the full efect to develop. If the anesthesia is not complete limit the chance that the drug will come in contact with the muscle another technique may also be used. Te duration of beneft lasted 3–6 months; adequately counseled on the risks of weakness, which is usually mild however, 20% of patients reported the treatment had no efect on and transient. Likewise, Almeida uses an adapter In the published literature, one patient reported weakness of plantar to shorten her 7 mm 30 G needle to measure 2. Gustatory sweating (Frey’s syndrome) is a relatively common complication afer surgery or injury in the region of the parotid gland and will be discussed later in the chapter. Five of 10 patients had partial disabil- ity in frowning of the forehead, but this was limited to a maximum of 8 weeks. Tere was no ptosis noted and satisfaction was good or excellent in 90% of the subjects. Similarly, Tan and Solish report that injections, particularly on the forehead or over any facial muscles, should be placed as superfcially as possible in order to attempt to minimize difusion into under- symptoms return on average of 4–12 months afer treatment of the 15 ling muscles. Böger treated 12 men sufering from bilateral craniofacial (Courtesy of Albert Ganss, International Hyperhidrosis Society. Decreased sweating was seen within 1–7 days afer injection and lasted a minimum of 3 months, but one patient experienced anhidrosis for 27 months. Side efects were limited to temporary weakness of the frontalis muscle (100%) and brow asymmetry that lasted 1–12 months in 17% of subjects. It is the observation of the authors that patients typically present with forehead sweating that may be combined with scalp sweating in a difuse pattern or in an ophiasis pattern. Te forehead can be treated more inferiorly if the response is not sufcient and if the patient is willing to accept the possibility of brow ptosis. Identifying the surface areas that need injection by the iodine-starch test can be technically challenging due to the body location, but is valuable. Using technique much the same for axillary injections, the treatment area is identifed with the starch-iodine technique and range from 60 to 100 U per side depending on the extent of the injections of 2. Te injections were well-toler- 5–72 U) and no recurrence of sweating was observed during the fol- ated, but the authors noted incomplete resolution of the sweating low-up period of 6 months. A marked long-lasting beneft of 11–36 due to insufcient dosing, and the duration lasted only 4 months. In clinical practice, the Minor’s iodine-starch test should be per- Chromhidrosis formed before injection to visualize the afected area that needs to be Chromhidrosis is a rare disorder characterized by the excretion of injected. Afer the iodine and starch have been applied to the area, the colored or pigmented sweat. It is most commonly confned to the face patient should chew on a piece of candy or food to stimulate the facial or axilla but has been noted elsewhere on the body. This patient had a dermatomal band of hyperhidrosis as identifed here with starch-iodine testing. Neurologic evaluation failed to detect a cause and he was successfully treated with botulinum toxin afer which he was lost to follow-up. Multiple neuropathies of the autonomic nervous sys- a band of sweating which clearly extended beyond the segmental tem or a failure in the synthesis or release of neurotransmitters have level of injury. Tere Residual Limb Hyperhidrosis Following Amputation is no therapy for the segmental progressive anhidrosis. Te dilution and injection technique and dos- a patient sufering from Ross syndrome with a defned area of anhi- ing is similar to that for other anatomic areas. Afer identifying the drosis in the right hand, the right axilla, and the right side of the face. Arch Dermatol were equally efective in blocking axillary sweating when studying 19 2002; 138: 539–41. A comprehensive starting 1 week afer injection, lasting 5 weeks, as well as accommo- approach to the recognition, diagnosis, and severity-based treat- dation difculties and conjunctival irritation that lasted 3 weeks. Dermatol Surg 2007; achieved excellent reduction in sweating, but the incidence of side 33: 908–23. Treatment Adverse events were common: dry mouth or throat (90%), indiges- of granulosis rubra nasi with botulinum toxin type A. Dermatol tion (60%), excessively dry hands (60%), muscle weakness (60%), and Surg 2009; 35: 1298–9. An epidermiological study Lower dosing may be the key to reducing the high incidence of side of hyperhidrosis. Efect of botulinum toxin type other secretory disorders and signifcantly improved the quality of A on quality of life measures in patients with excessive axillary life for the many patients who have been treated with it.

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