By P. Jared. Loyola College, Baltimore.

Spreader grafts can gery or many years later from skin and soft tissue contraction buy pamelor 25 mg with mastercard anxiety burning sensation. The aesthetic spreader grafts are used when nasal dorsal asymmetries are consequences include an inappropriate relationship between present pamelor 25mg mastercard anxiety 5 year old. The wider end of the graft is orientated cephalically to the nasal tip and dorsal projection purchase pamelor with visa anxiety symptoms one side of body. A classification system create a thicker width in this region and reproduce an adequate of saddle nose deformities and the various reconstructive nasal contour. The grafts will then be nasal vault is the placement of onlay cartilaginous grafts. Butterfly grafts, as described by Clark and Cook,15 are another type of onlay graft. These grafts are typi- cally placed on the nasal dorsum, on top of the existing middle external. Ideally,conchalcartilageisused,astheintrinsic for the grafts to be precisely sutured into position. Tempo- rally, the graft is attached to the dorsal septum with a 27-gauge needle. After the graft(s) are positioned, they are sutured to the nasal septum in a horizontal mattress fashion with a 5–0 long-acting monofilament absorbable suture. The spreader graft technique provides both aesthetic and functional improvement of the middle nasal vault. An anterior approach is used to raise a skin flap, obtaining a concave cartilage graft. The caudal portion of the graft is placed be harvested with cartilage only or the graft can contain bone. The general goal of these reconstructive techniques mize the natural tendency for rib cartilage to warp. Because of their high flexibil- ity and good long-term results, Daniel prefers grafts consisting 14. In comparison, cadaveric rib cartilage is 110 Management of the Nasal Dorsum can manifest shortly after surgery or may present many years 14. Frequently, rhinoplasty maneuvers designed to improve aes- To prevent postsurgical problems of the middle nasal vault, thetics can diminish nasal infrastructure and have untoward functional nasal anatomy must be understood and respected. This is especially true after reduction This enables the surgeon to diagnose preexisting conditions that rhinoplasty when components of the nasal infrastructure are may contribute to postoperative middle vault complications removed or weakened. Many prophylactic surgical techni- Surgical weakening of the nasal infrastructure produces vari- ques are used to prevent nasal vault complications after rhino- ous functional complications. Furthermore, weak- spreader grafts or onlay butterfly grafts) and suture techniques ening the nasal infrastructure can lead to aesthetic problems. These techniques allow reduction of the Aesthetic complications related to cartilaginous dorsal hump dorsal nasal projection while maintaining nasal width and struc- include inverted-V deformity, hourglass deformity, and saddle tural support. These aesthetic and functional complications and maintains or improves preoperative nasal function. This patient has a weak middle nasal third and is predisposed for internal nasal collapse. Facial Plast Surg Clin cedures may result in cosmetic and functional complications. Spreader graft: a method of reconstructing the roof of the middle Surg 2008; 24: 327–338 nasal vault following rhinoplasty. Bending of the upper lateral cartilages for 2009; 17: 91–113 nasal valve collapse. Plast Reconstr Surg 2008; 122: 1883–1891 113 Management of the Dorsum 15 anagem ent of Naso-septal L-strut Deform ities David W. Kim and Theresa Gurney reconstructing the nose as rhinectomy was a common form of 15. It wasn’t until the 19th century that surgical tech- Early in the training of every nasal surgeon, we are admonished niques to correct the septum were introduced and documented to have great respect for the nasal septum. Adams in 1875 recommended fractur- that “where the septum goes, so goes the nose” and the septum ing the septum, with subsequent splinting. The During this time, directed removal of deviated cartilage was value of this minimal width varies from surgeon to surgeon, no introduced. Ingals began with attempts to excise a small por- doubt born out of surgical training and perhaps modified by tion of anterior cartilage. A common value for this dimension is sive excisional approach as others utilized saws and chisels to 1. There is little involved excisions that sometimes extended to the vomer and in the literature revealing from where this value originates; perpendicular plate of the ethmoid and usually included the nonetheless, it remains a concept that likely every surgeon has overlying mucosa on one or both sides. One certainly can imagine the resultant cosmetic deformities This ingrained reverence for the L-strut, while helpful in pre- and functional complications of these often extensive, exci- venting saddle noses and ptotic tips, may contribute to a differ- sional approaches. The senior author recalls began to propose more conservative techniques in addressing performing a submucous resection of septal quadrangular carti- the septum while preserving its structure. He endeavored to maintain a “gener- the submucosal resection of cartilage and emphasized the ous” strut, which he did. The problem was that only a 1×2cm importance of maintaining the physiological mucosal covering. A scenario more structure we now call the L-strut in his emphasis to maintain common than this error of inexperience is the scenario in dorsal and caudal support. There continued to be modifications which the surgeon feels uncomfortable in modifying the sacro- of these procedures and by the 1950s Cottle, Goldman, Smith, sanct L-strut, even when doing so may be the only way to cor- and others formally disavowed radical resection techniques that rect the deformity in question. By avoiding the L-strut altogether, the surgeon is limited in the ability to treat significant deviations of the dorsal or caudal 15. Fortunately, these difficult problems may be treated safely and As the cornerstone of a building provides its stability, the quad- effectively. Todosorequiresathoroughknowledgeoftheanat- rangular cartilage and the osseous foundation upon which it omy and structural mechanics of the nose, careful analysis and rests provide structural support to the nasal framework. The localization of the deformity, excellent exposure and isolation of septum separates the two sides of the nose and stabilizes the the septal L-strut, and meticulous technique. If one tries to avoid the nerve, one may be unable to perpendicular plate of the ethmoid and the vomer. Theactiveearsur- plate and result in cerebrospinal fluid leakage and/or olfactory geon, who uses a systematic anatomic approach to find, isolate, nerve injury. At its cephalic border, the osseous septum and protect the nerve, is more likely to perform a safe and effec- attaches to the frontal bone and its posterior free edge forms tive operation. There is an active thought process involved, in the midline partition of the nasal choanae. Similarly, Anteriorly and caudally, the septum is cartilaginous, formally in nasal surgery, the surgeon must thoughtfully approach the sep- termed the “quadrangular cartilage. Dorsally, the paired, shieldlike upper lateral Ebers Papyrus describes initial attempts by Egyptians in cartilages are fused in the midline to the dorsal edge of the 114 Management of Naso-septal L-strut Deformities cartilaginous septum.

Although the hyperglycemia resolves more quickly than the metabolic acidosis cheap 25mg pamelor with mastercard anxiety panic attack symptoms, intravenous insulin therapy is continued until the anion gap has closed pamelor 25mg on-line anxiety symptoms for no reason. As the patient’s hyperglycemia and metabolic acidosis resolve order genuine pamelor line anxiety symptoms postpartum, intravenous insulin therapy can be discontinued and a transition to subcutaneous insulin can be initiated. Signs and symptoms of cerebral edema include severe headache, sudden deterioration of mental status, bradycardia, hypertension, and incontinence. Diabetes can be considered a secondary cause of immune deficiency (Case 40) and be heralded by oral or vaginal candidiasis. Her serum glucose level is 250 mg/dL, and her urinalysis is posi- tive for 2+ glucose but is otherwise negative. Stop intravenous insulin therapy and allow the patient to begin subcuta- neous insulin administration. This condition is far more common in overweight children, especially those with a family history of the condition. Although each of these conditions alone could be caused by other diagnoses, the constellation is concerning for diabetes mellitus. Up to 75% of newly diagnosed diabetics have a progressive decrease in the daily insulin requirement in the months after their diabetes diagnosis; a few patients temporarily require no insulin. This “honeymoon” period usually lasts a few months, and then an insulin requirement returns. A strict adher- ence to diabetic diet will not increase endogenous insulin production and the disease does not resolve with treatment. Although many patients have hyperkalemia on initial laboratory work due to their acidosis, they are often intracellularly depleted of potassium. Administering a potas- sium binder would further decrease her total-body potassium and could result in cardiac arrhythmias. The patient should not be converted to subcutane- ous insulin until her glucose has normalized, her bicarbonate level is greater than 18 mEq/L, and her serum pH is greater than 7. Because of the risk of causing hypoglycemia with continued insulin therapy, dextrose should be added to her fluids. Intravenous infusion of insulin should continue until acidosis resolves and the anion gap closes. Any child diagnosed with ketoacido- sis who also exhibits signs of neurologic dysfunction should be evaluated for cerebral edema so that treatment can be initiated quickly. She reports that he has added about 15 lb, but she has not noticed a major growth spurt. Further questions reveals that he often snores while sleeping and that he sometimes seems to gasp for air at night. At school, he is hyperactive and is having trouble keeping up his grades, often falling asleep in class. On physical examination, his weight is in the 95th percentile for his age (up from the 75th percentile on his last visit), and his body mass index has increased from 25 to 35. His physical examination is normal other than his oropharynx dem- onstrating bilateral tonsillar hypertrophy. Appropriate weight management is appropriate for all obese children which will further reduce symptoms and a variety of health-related risks. The prevalence has been reported to range between 1% and 5% with the peak preva- lence occurring between the ages of 2 to 8 years and without gender differences. Risk factors for this condition include obesity, anatomical factors (adenotonsillar hypertrophy, retro/micrognathia, tongue size), and increased upper airway collaps- ibility (altered neurological upper airway reflexes, hypotonia, upper airway inflam- mation). Primary snoring happens in individuals who do not have any associated ventilatory problems or sleep disturbances. Nighttime symp- toms include snoring, excessive sweating, restless sleep, mouth breathing, apneas, gasping, labored or paradoxical breathing, and hyperextension of neck during sleep. Daytime symptoms include difficulty concentrating, behavioral and mood prob- lems, morning headaches, excessive daytime sleepiness, and failure to thrive. The physical examination should include evaluation of growth parameters (obesity or failure to thrive), head and neck structures (enlarged tonsils/adenoids, excessive pharyngeal tissues, narrowed oropharynx, septal deviation, hypertrophic nasal tur- binate, abnormal facial structures), and the cardiopulmonary system (hyperten- sion, pulmonary hypertension, cor pulmonale, and right-sided heart failure). Additional risk factors are based on underlying illnesses such as craniofacial anomalies, Down syndrome, and neuromuscular disease. However, compliance is a major problem and, therefore, is not the recommended first-line treatment. Nighttime symptoms are more easily recognizable, but daytime symptoms include morning headaches, difficulty concentrating, behavior and mood problems, excessive daytime sleepiness, and failure to thrive. For preschool-age children, the predomi- nant remedial problem is adenotonsillar hypertrophy. His- tory and physical examination alone have poor positive predictive values and can sometimes be misleading. He was a full-term infant, has experienced no significant medical problems, and is developmentally appropriate. His upper and lower body segment measurements demonstrate normal body proportions. His father is 6 ft 4 in (193 cm) tall; he began pubertal development at 13 years of age. His mother is 5 ft 11 in (180 cm) tall; she had her first menstrual cycle at the age of 14 years. Considerations This patient has essentially stopped growing (or is growing at a rate less than expected). Left wrist radiographs on children older than 2 years (or the knee in those younger) are compared to published “normals” to determine how old the bones appear compared to chronologic age, thus providing an estimate of the remaining growth potential of the bones. Many conditions can result in short stature; a growth and social his- tory (to identify psychosocial growth failure), physical examination, and selected screening tests usually help to identify the problem’s etiology. The growth velocity of a child is assessed by obtaining height and weight mea- surements over time and plotting them on standardized growth charts. Deviations from the normal on a growth chart are often the first clue a problem with growth exists. In the first year of life, children grow at a rate of approximately 23 to 28 cm per year. At puberty, growth increases to 8 to 9 cm per year for girls and to 10 to 11 cm per year for boys. By approximately 24 months of age, most children settle into a percentile growth channel, remaining there for the remainder of their childhood. Significant devia- tions from these expectations alert the clinician to potential growth problems (ie, “fall off their curve”). Their family history is positive, however, for one or more parents with pubertal develop- ment delays (“late bloomers”) who developed normal adult height. A short child in a family with a classic history of “late bloomers” often requires no laboratory or radiographic evaluation. Sometimes a bone age is helpful to reassure the patient and family that much bone growth remains and normal height will be achieved.

Plan B One-Step reduces the odds of pregnancy by 89% and Next Choice One Dose prevented 84% of expected pregnancies purchase cheap pamelor on line anxiety 7 reasons, which is better than it may seem discount pamelor 25 mg with mastercard anxiety 9 code. In the absence of these two medications buy 25 mg pamelor amex anxiety symptoms 3 days, the pregnancy rate from a single act of unprotected intercourse is about 8% (i. Plan B One-Step and Next Choice One Dose work primarily by delaying or stopping ovulation. The major side effects of Plan B One-Step are heavier menstrual bleeding, nausea, abdominal pain, headache, and dizziness. Importantly, if pregnancy does occur, having used levonorgestrel will not increase the risk for major congenital malformations, pregnancy complications, or any other adverse pregnancy outcomes. These drugs will not terminate an existing pregnancy and will not harm a fetus if present. Because Plan B One-Step and Next Choice One Dose act before fertilization and implantation, they cannot be considered abortifacients. For women aged 15 years and older, Plan B One-Step and Next Choice One Dose are now available over the counter. For women who are not yet 15 years old, Plan B One-Step is still available, but a prescription is required. Prescriptions can be obtained from private physicians, clinics run by Planned Parenthood, and student health departments at colleges and universities. According to the package insert, women should take 1 tablet within 72 hours of intercourse and a second tablet 12 hours later. Like Plan B One-Step, Next Choice can be obtained without a prescription (by women 15 years and older) or with a prescription (by women younger than 15 years). Ulipristal Acetate Emergency Contraception Pill Ulipristal acetate [ella] is a drug that acts as an agonist-antagonist at receptors for progestin. Like levonorgestrel, ulipristal acetate prevents conception primarily by suppressing ovulation. Despite this similarity, ulipristal acetate and levonorgestrel differ in two important ways. First, ulipristal acetate remains highly effective when taken up to 5 days (120 hours) after intercourse, whereas levonorgestrel is most effective when taken within 3 days (72 hours) of intercourse. Second, whereas levonorgestrel [Plan B One-Step, Next Choice, Next Choice One Dose] is available without a prescription for women 15 years and older, ulipristal acetate [ella] requires a prescription for all women, regardless of age. The dosage for ulipristal acetate is 1 tablet (30 mg), taken up to 5 days after unprotected intercourse. Estrogen/Progestin Emergency Contraception Pills (Yuzpe Regimen) The Yuzpe regimen, first described in 1974 by Professor A. The first dose should be taken within 72 hours of unprotected intercourse and the second dose 12 hours later. Pregnancy is prevented by interfering with ovulation, fertilization, and implantation. However, if mifepristone is taken after this time, it may terminate pregnancy that has already begun and thus can be considered an abortifacient. In the United States the drug has one approved indication: termination of early intrauterine pregnancy; cotreatment with misoprostol is usually required. Investigational uses include breast cancer, ovarian cancer, meningiomas, Cushing syndrome, uterine fibroids, and endometriosis. In addition, mifepristone is the most effective drug known for emergency contraception, although it is not used routinely for this purpose. Mifepristone, followed by misoprostol, is a safe and effective alternative to surgery for termination of early pregnancy. Principal adverse effects are abdominal pain and vaginal bleeding, which are unavoidable aspects of abortion. In contrast to surgical abortion, which is generally unavailable before 8 weeks of gestation, abortion with mifepristone is performed early—within 7 weeks of conception. Although mifepristone also blocks receptors for glucocorticoids, this action does not contribute to abortion. First, blockade of progesterone receptors leads to decidual breakdown and detachment of the conceptus. Third, mifepristone increases uterine production of prostaglandins and renders the myometrium more responsive to the contractile effects of these prostaglandins. If mifepristone alone fails to induce abortion, the patient is given 400 mcg of oral misoprostol, a synthetic prostaglandin that reinforces uterine contractions induced by mifepristone. Clinical Trials In a study conducted in France, the abortion success rate with mifepristone/misoprostol was nearly 99%. Success was defined as termination of pregnancy with complete expulsion of the conceptus. All women in the study had amenorrhea for less than 50 days before receiving mifepristone. Dosing was done as follows: each patient received a 600-mg oral dose of mifepristone and, if abortion had not occurred within 48 hours, each was given a 400-mcg dose of oral misoprostol; a second dose of misoprostol (200 mcg) was offered if abortion had not occurred by 4 hours after the first dose. In the majority of patients (69%), abortion occurred within 4 hours of the first misoprostol dose. In the United States success with mifepristone/misoprostol has also been good —although not quite as good as in France. In 1999 American researchers reported that the abortion rate with mifepristone/misoprostol declined with increasing duration of gestation. Success was greatest (92%) when gestation was 49 days or less, falling to 83% during days 50 to 56 of gestation and to 77% during days 57 to 63. There is good evidence that intravaginal misoprostol is more effective and better tolerated than oral misoprostol. After intravaginal misoprostol, 95% of conceptuses were expelled without the need for surgery, compared with only 87% after oral misoprostol. With intravaginal dosing, abortion occurred within 4 hours in 93% of patients, compared with 78% of patients receiving oral misoprostol. The incidence of nausea and vomiting with intravaginal dosing was significantly lower than with oral dosing. Intravaginal misoprostol—but not oral misoprostol—has been associated with very rare cases of severe sepsis, one heart attack, and one death (from hemorrhage) after a ruptured ectopic pregnancy. However, a causal relationship between these events and mifepristone/misoprostol has not been established. Adverse Effects The most common side effects are bleeding, cramping, nausea, vomiting, diarrhea, and headache. About 80% of patients experience transient cramping, beginning 1 hour after taking misoprostol; most women require an opioid analgesic for relief.

All of these deformities can be corrected (or prevented) ular mucosa or lateral crural strut grafts to get them to flatten generic pamelor 25 mg line anxiety symptoms 24 7. This chapter will describe techniques used to create a refined discount 25 mg pamelor overnight delivery anxiety symptoms everyday, aesthetically pleasing nasal tip cheap pamelor uk anxiety symptoms lasting all day. Structural grafting provides the opportunity for Before work begins on the nasal tip, the dorsal height and width consistently reproducible results and the integrity needed to should be established. This is in contrast sions weaken the tip support and require suture reconstitution. After the septum is released from its mucoperichon- tions can be formulated and executed according to individual drium, it can be fixed between the crural footplates using 5–0 needs. The tip can be projected into any point using either caudal extension or columellar strut grafts. A long strut graft can be harvested from the septum rupts several major and minor tip support mechanisms. A fractured strut graft can be repaired cause the tip to drop during the first 2 years after surgery. In these situa- settling will corrupt many of the favorable changes achieved tions, it is better to find an alternative source. Recurrent ptosis lengthens the nasal lage can be used but often lacks sufficient strength. The supratip choice but is accompanied by additional surgical time and break is diminished. A strong base will support the dome and 15mm) or a septal extension graft can be placed to support counteract postoperative forces that cause tip settling. Hemi- and full-transfixion incisions release the crura from The columellar strut graft should be placed in a precise the membranous septum in preparation for tip repositioning. A graft resting on the nasal Assessment of the relationship of the medial crura to the caudal spine will inevitably migrate to the right or left of the spine and septum is the key determinant for base stabilization. Grafts contacting the nasal spine can also cause Short crura with footplates that do not extend to the nasal an audible clicking sound to the patient. Medial crura can be sutured The strut graft should be trimmed 1 to 2mm below the to a long caudal septum to increase their integrity and resil- domes. Grafts projecting into the soft tissue envelope risk exter- ience to gravitational forces. Resection of the caudal septum along with adequate amounts of vestibular mucosa will decrease the After the tip lobule is rotated, projected, and fixed to a stable amount of visible columella. Patients seeking primary rhinoplasty are frequently Historically, too much emphasis was placed on resection concerned with a bulbous tip. Prominent, cephalically oriented without reconstitution or suture contouring of the lateral crura convex alae make the nose look wide and round and lacking in to achieve the desired form. A conservative cephalic trim should preserve at least risks external valve collapse, buckling, bossa, and other deform- 8 to 10mm (laterally) and 5 to 7mm (medially) of alar carti- ities. Although weak, flimsy alae are not always iatrogenic, they lage) If the alae remain convex and difficult to contour, they are typically encountered in revision rhinoplasty. The auricular cymba concha is the pri- significantly more malleable, allowing easy repositioning. The natural curvature of important to preserve the cartilage-mucosal attachments later- the cymba closely resembles the three-dimensional contours of ally along to the pyriform aperture to increase stability. Typically, a single cymba concha can be used alae require excision and 180-degree rotation to turn the con- to reconstruct both alae. Alar replacement grafts Following, or in conjunction with a cephalic trim, the domal must be long enough to span the distance between the dome angle and tip-defining points are created. Grafts that are too short do not pro- defined as the angle between the long axis of the medial and vide the requisite support to the lateral limb of the tripod and intermediate crura and the long axis of the lateral crura. Costal cartilage can be dynamics of the nasal tip modifications can be conceptualized obtained to provide adequate grafting material when the ears with the tripod theory. External nasal Thus, tip position can be altered with combinations of length- valve collapse frequently results in complaints of nasal obstruc- ening or shortening tripod limbs. A strut graft can be harvested from the Domal incisions are designed to lower the cephalic septum or rib. Typically, a cephalically based triangle of the ala, and is placed between the vestibular mucosa and ven- cartilage is excised from the dome (▶ Fig. If the cephalic margin is placed higher than the caudal margin, the supratip break will be located Many surgeons rely on cephalic recontouring of the ala com- higher on the dorsum, creating the illusion of an elongated bined with interdomal suturing to refine the nasal tip. They can be used to camouflage subtle amoreacuteangleandasharpermarginthanasimple irregularities, asymmetries, and misshapen dome cartilages. If the mattress suture is overtightened, the tension The graft is harvested from the septum such that the leading can displace the ala medially. A simple suture is placed at edge of the tip graft is created from the septal cartilage that the cephalic margin to prevent pinching of the ala. A mattress suture placed at the caudal border (point A) narrows the dome angle marked in yellow. Plumping grafts augment a retracted columella, enhanc- external auditory meatus is the thickest portion of the concha ing the lobule-to-columella ratio. The skin is elevated from the perichondrium, enhancing tip definition in thick nasal skin. An skin is unlikely to accentuate the contours of refined dome car- intact perichondrium contributes to the cartilage’s strength. They con- grafts push into the thick soft tissue envelope and enhance defi- tribute to the structural integrity of the nasal tip but are not nition. Judicious resection of the soft tissue envelope will allow sufficient to prevent recidivistic ptosis in the absence of other the skin to conform to a contoured nasal skeleton. The leading edge of the graft scissors, the fibroadipose tissue can be excised, revealing the should project 1 to 2 mm above the nasal dome. Even with broad dissection, This establishes the tip-defining point and contributes to the external scarring, pincushioning, and other sequelae are rarely presence of a supratip break. Shield Extremely thin nasal skin is a more challenging variable in grafts projecting>3 mm above the dome should be supported rhinoplasty. Thin skin makes cartilage structure appear more by a vertically positioned buttress graft placed between the prominent, and subtle asymmetries are accentuated. Many sur- shield-medial crura complex to reinforce and prevent bending geons are reluctant to place tip grafts under thin nasal skin to back of the tip graft. The dimensions of the tip graft may vary avoid risking postoperative visualization of the graft. However, with individual patient needs; however, most grafts are approx- patients with thin nasal skin are still good candidates for tip imately 10 to 15mm×8 to 12 mm×1 to 3mm. External visualization and “gravestone” deformities can The medial crura can be prepared to augment or decrease tip be avoided with proper precautions. Conservative resection of the caudal margin at the In thin-skinned patients, grafts are initially made 15 to 20% base of the medial crura will decrease the amount of graft rota- larger than will ultimately be required. Any irregularities of the cartilage surface and lateral and Plumping grafts are small pieces of cartilage stacked into a superior borders should also be feathered and smoothed using pocket created at the base of the columella, above the nasal a 15-blade scalpel.

An estimate of a child’s ultimate height potential is calculated using the parents’ heights discount pamelor 25 mg on line anxiety symptoms to get xanax. A girl’s final height can be predicted as follows: (Mother’s height in cm + [Father’s height in cm + 13])/2 order discount pamelor line anxiety jealousy. These children demonstrate a growth rate that is slow buy 25mg pamelor overnight delivery anxiety jelly legs, usually falling away from the normal growth curve (in contrast to constitutional delay where growth parallels the third to fifth percentile curves). On examination these children often appear younger than their stated age and frequently appear chubby (weight age > height age). Clues that growth failure may be caused by an underlying condition not already mentioned include poor appetite, weight loss, abdominal pain or diarrhea, unex- plained fevers, headaches or vomiting, weight gain out of proportion to height, or dysmorphic features. Children with growth failure who do not fall into another, more appropriate category are classi- fied as having idiopathic short stature. He has no significant past medical his- tory and his physical examination is normal. He has a normal past medical history, and although always a bit small for age, he has really noticed that he has fallen behind his peers in the last 2 years. His father began puberty at the age of 16 and completed his growth at the age of 19; he is now 6 ft 2 in (188 cm) tall. His mother began her pubertal development at the age of 10 and had her first menstrual period at the age of 13; her height is 5 ft 4 in (163 cm). Her father is 5 ft 10 in (178 cm) tall, and her mother is 5 ft 5 in (165 cm) tall. Over the past 3 years she has dropped from the 25th percentile for height to the 5thpercentile. Additional imaging or laboratory evaluations would not be necessary in this case because this child has no other symptoms aside from short stature. He eventually will enter puberty, but the psychosocial ramifications of remaining shorter and appearing more immature than his peers may warrant treatment. Monthly testosterone injections “jump start” the pubertal process without altering final growth potential; a pediatric endocrinologist might be required to assist. If a child’s growth chart is unavailable, questions about a child’s clothing or shoe size changes may pro- vide valuable information. Obtaining history about parental growth pattern and their onset of puberty also provides important diagnostic clues to the child’s etiology of short stature. Growth hor- mone deficiency is not an emergent condition but the earlier the diagnosis is made the sooner appropriate treatment can be initiated. Obtaining a growth hormone level would not be diagnostically helpful because its secretion is pulsatile. Referral to a pediatric endocrinologist would be warranted if initial screening tests confirm the suspected growth hormone deficiency. Describe laboratory and radiologic tests that are helpful in determining the etiology of precocious puberty. Establish the treatment and follow-up necessary for a child with precocious puberty. Considerations This 5-year-old girl has precocious puberty signs (breast and pubic hair develop- ment and tall stature). She may have true (central) precocious puberty or preco- cious (noncentral) pseudopuberty. Of note, timing of puberty events approximates a normal distribution with a strong genetic component. For example African American children start puberty earlier on average than Caucasian children. A trend toward earlier start of puberty among today’s chil- dren, as compared to previous generations, has been noted. May be caused by gonadal failure, chromosomal abnor- malities (Turner syndrome, Klinefelter syndrome), hypopituitarism, chronic dis- ease, or malnutrition. Hypothalamic-pituitary-gonadal activation leading to secondary sex characteristics. Hormones usually are either exogenous (birth control pills, estrogen, testosterone cream) or from adrenal/ovarian tumors. Girls with precocious pseudopuberty have an independent source of estrogens causing their pubertal changes. An exogenous source of estrogen (birth control pills, hormone replacement) or an estrogen-producing tumor of the ovary or adrenal gland must be considered. Three main patterns of precocious pubertal progression can be identified, particularly in girls. Most girls who are younger than 6 years at onset have rapidly progress- ing sexual precocity, characterized by early physical and osseous maturation with a loss of ultimate height potential. Girls older than 6 years typically have a slowly progressing variant with parallel advancement of osseous maturation and linear growth and preserved height potential. In a small percentage of girls, a spontaneous regression or unsustained central precocious puberty at a young age is seen, with normal pubertal development at an expected age. A neurologic history may identify past hydrocephalus, head trauma, meningo- encephalitis, or the presence of headaches, visual problems, or behavioral changes. The type, sequence, and age at which pubertal changes were first noticed (breast and pubic/axillary hair development, external genitalia maturation, menarche) give valuable information regarding the etiology of the problem. Important questions include the following š Has the child been rapidly outgrowing shoes and clothes (evidence of linear growth acceleration)? Serial height mea- surements are critical for determining the child’s growth velocity. The skin should be examined for café-au-lait spots (neurofibromatosis, tuberous sclerosis), oiliness, and acne. The presence of axillary hair and body odor, the amount of breast tissue, whether the nipples and areolae are enlarging and thinning, and the amount, loca- tion, and character of pubic hair are documented (Tanner staging, Figures 45–1 and 45–2). If the testes are different in size and consistency, a unilateral mass is considered. Testicular transillumination may be helpful in differentiating a mass which is solid versus cystic (hydroceles usually transilluminate). In girls, the clitoris, labia, and vaginal orifice are examined to identify vaginal secretions, maturation of the labia minora, and vaginal mucosa estrogenization (dull, gray-pink, and ruggated rather than shiny, smooth, and red). In precocious puberty, serum sex hormone concentrations usually are appropri- ate for the observed stage of puberty, but inappropriate for the child’s chronologic age. Serum estradiol concentration is elevated in girls, and serum testosterone level is elevated in boys with precocious puberty. Pelvic ultrasonography is indicated if gonadotropin- independent causes of precocious puberty (ovarian tumors/cysts, adrenal tumors) are suspected based on examination. The goal of treating precocious puberty is to prevent premature closure of the epiphyses, allowing the child to reach full adult growth potential.