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journalofotolaryngology-blog · 3 years ago

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Expanded Endoscopic Endonasal Approach and Adjuvant Radiotherapy for the Treatment of Locally Advanced Sinonasal and Skull Base Adenoid Cystic Carcinoma: Case Report and Literature Review

Abstract

Introduction: Adenoid Cystic Carcinoma of the sinonasal and skull base region is a challenging tumor to treat due to its late onset of presentation and frequent compromise of vital neurovascular structures. Surgical treatment followed by conventional irradiation are the optimal treatment options, often requiring extensive open approaches and mutilating interventions due to its localization. Endoscopic endonasal approaches are relatively new procedures that combined with new adjuvant radiation techniques could achieve similar oncological outcomes with significant less morbidity.

Methods: We present the case of a patient with non-metastatic Adenoid Cystic Carcinoma (ACC) locally advanced of the sinonasal and skull base region diagnosed and treated at the Instituto Nacional de Cancerología of Bogotá D.C, Colombia between the years 2017 and 2020 who underwent endoscopic endonasal tumor resection and subsequent adjuvant management with Intensity modulated radiotherapy (IMRT).

Results: Endoscopic and imaging control was performed according to the protocol of the surgical group with nasal endoscopies every 3-4 months during the first 2 years and serial images every 6 months. Follow up for 35 months with adequate local control and minimal aesthetic or functional sequelae.

Conclusion: Multidisciplinary management with endoscopic endonasal resection and adjuvant radiotherapy appears to be an effective oncological alternative to open surgical procedures, with less morbid and minor functional sequelae, for patients with locally advanced ACC tumors of the sinonasal region.

Keywords: Adenoid cystic carcinoma; Sinonasal carcinoma; Paranasal sinuses; Head and neck cancers; Transnasal endoscopic surgery; Adjuvant radiation

Introduction

Adenoid cystic carcinoma (ACC) is a rare tumor that generally affects the salivary glands in the head and neck [1], the most common site are the minor salivary glands followed by the paranasal sinuses [2]. ACC can affect all age groups but is most common between 50 and 60 years [3]. Adenoid cystic carcinoma of the head and neck is difficult to control, due to its high propensity for recurrence and distant metastasis. These tumors show high propensity of dissemination to the skull base and cranial nerves, which is found in up to 50% of patients displaying changes such as bone lysis and perivascular or perineural spread through the skull foramens [3,4]. Unfortunately for these patients, this extensive compromise is often found when the first symptoms appear [5,6].

These tumors are usually diagnosed in a locally advanced stage, as the symptoms can be mistaken as chronic rhinosinusitis or inflammatory changes on CT scan images [7].

Historically, the main treatment for adenoid cystic carcinoma has been surgical oncological resection of the primary tumor followed by adjuvant radiation therapy (RT) [8]. However, in cases of locally advanced tumors with skull base involvement, radical resection with negative margins is often impossible to achieve, which increases the risk for recurrence of the disease. Different studies have shown that treatment with adjuvant RT with curative intention is a therapeutic option that reduces the probability of local recurrence [9], with an improvement in local control of 30 to 80%. This is indicated in patients with T3-T4 tumors, incomplete resection or with close margins (1-5mm), bone involvement, perineural invasion and histological factors for high degree of disease recurrence. The most modern irradiation techniques such as modulated intensity allows to achieve greater conformation of the dose providing optimal therapy with less toxicity. Other randomized studies have shown contradictory results, without a clear benefit of adjuvant therapy in this type of paranasal sinus tumors [5,8,10-12].

Despite the well stablished role for open oncological surgical resection in sinonasal malignant tumors, these techniques are associated with high morbidity and mortality, since the location within the sinuses and skull base requires extensive and mutilating procedures, which limits the complete resection (R0) of this tumor and increases the facial deformity or complications such as CSF (cerebrospinal fluid) leak. The endoscopic transnasal surgery recently appears as a safe and effective approach in selected patients, that reduces the morbidity of open procedures with similar oncological results with the additional advantage of achieving better aesthetic and functional results [13].

Case Report

60-year-old woman who presented in January 2017 with decreased visual acuity associated with right diplopia. The MRI study of the paranasal sinuses showed an expansive bony appearance tumor with involvement of the sphenoid sinus, skull base, clival region and extending to the suprasellar prepontine cistern measuring 49x 44x42 mm (Figure 1). Surgical resection was taken in place in March 2017 with an extended endonasal endoscopic procedure (trans pterygoid and trans clival approach), finding a rubbery tumor that involved the posterior and middle wall of the right maxillary sinus, right pterygomaxillary fossa and the medial portion of the infratemporal fossa, sphenoid sinus with extension to the posterior cranial fossa eroding the middle and superior clivus. There was also tumor infiltration in bilateral peri carotid tissue. A wide resection of the medial wall of the cavernous sinuses was achieved, maintaining its integrity.

Partial involvement of the dura was also observed in the medial region and right paramedian region, requiring a fascia late graft for reconstruction. A median and superior clivectomy was performed and partial resection of the inferior clivus until a macroscopically healthy bone tissue was obtained achieving a macroscopically complete resection at this level (verified with Brainlab® neuronavigation system). The Histopathology report indicated adenoid cystic carcinoma, with cribriform pattern, tubular and solid. Histological grade 2, with perineural involvement, immunochemistry reported CD117 (+); P40 (+); EMA (+); CK5 / 6 (+); CK7(+); GATA3(+); PHH3: up to 4 mitoses/10 high power fields; ki67: 25% which is in relation with the characteristics reported in literature (Figure 2). The patient received adjuvant IMRT technique External Radiotherapy with curative intent, doses from 2 Gy to 66 Gy in the surgical bed between June 6, 2017 and July 19, 2017 with adequate tolerance (Figure 3).

During the follow-up period, endoscopic and imaging control was performed according to the protocol of the surgical group with nasal endoscopies every 3-4 months during the first 2 years and images every 6 months. The latest follow-up images in January 2020 (35 months after treatment) showed postoperative changes in the endonasal approach with the presence of scarring tissue in the residual portion of the clivus, without evidence of lesions suggesting tumor residue or recurrence. The endoscopic findings were free of recurrent disease. The patient presented mild complications associated to radiotherapy: actinic fibrosis, grade II xerostomia without trismus and remained with vision loss in the right eye and hearing loss that she presented in the preoperatively. (Figure 4).

Discussion

The ACC tumor of the paranasal sinuses and skull base is a tumor that presents an indolent clinical pattern with a tendency towards perineural invasion. It represents 3 to 5% of all head and neck cancers [9] and about 6 to 10% of malignant tumors of the salivary glands [9]. With a low incidence of lymph node and distant metastases, between 3 and 5.5% [7]. Sayan M et al., Estimate that the annual global incidence rate is 0.4 to 13.5 cases per 100,000 habitants [8]. Advanced T stage reflects a poor prognosis for patients, and 10-year survival is very low [3,6,9]. It has been found that the histological subtype (tubular, cribriform, solid, or mixed) and the subsite of origin in the paranasal sinuses influences the prognosis, classifying the solid subtype as the most malignant and those originated in the ethmoid and sphenoid sinus as those with the lowest disease-specific survival in 5 years, reported in 25% [4,6,14].

The presence of lymph nodes in the neck does not have a significant impact on survival, but it does increase the risk of developing distant metastases since this can occur even in the absence of locoregional recurrence [15]. Some recent studies have shown that the expression of c-Kit mutations is associated with a significantly worse prognosis, whereas the expression of EGFR provides better survival at 3 years [10]. Historically, the main treatment for ACC has been surgical resection of the primary tumor followed by adjuvant radiation therapy (RT) [6]. This has been established as an optimal therapy for this type of tumors [5,11,12]. However, in cases in which the tumor is locally advanced with proximity to vital neurovascular structures, treatment represents a real challenge for the treating team.

According to the study by Sayan et al., Adjuvant RT can improve local and regional disease control [8]. However, Ellington et al. reported that RT does not provide any benefit on overall survival (OS) [16]. Also, we found in a prospective french study adjuvant RT was indicated in 57% of cases for locoregional control, mainly in cases where the surgery is micro or macroscopically incomplete and in high-grade tumors (> 30% solid component) making the adjuvant RT a good therapy for these patients [6]. Nevertheless, the benefit of adjuvant radiotherapy on overall survival (OS) has not been demonstrated with randomized studies, and therefore it is difficult to establish a treatment protocol that is widely accepted [10,12]. There is evidence of a slight increase in disease-specific survival at 5 years to 73.5% with adjuvant RT following surgical resection, taking into consideration that the newest radiation techniques as IMRT, allows reduction in the dose directed towards organs at risk, compared to conventional bilateral opposing field techniques [17].

In this case the patient received Radiotherapy technique IMRT, to provide doses from 2Gy to 66Gy in the surgical field, two months after the total resection of the tumor via trans nasal approach. Resulting in a low morbidity radiation technique with low risk for associated complications. Follow-up MRI and periodic endoscopic evaluations were performed for 2.5 years after definitive treatment, since it is the best modality to identify recurrent lesions, evaluate the skull base, perineural spread and intracranial extension [7]. During the follow-up period, no recurrent lesions were found. The outcomes of our case are like the findings of Sayan et al, Ali S et al and Meyers et al, who reported that surgery followed by adjuvant RT can improve local and regional control of the disease [8,17,18], considering this combination, the best approach to the treatment of non-metastatic ACC [5,11,12]. Further research with prospective randomized analytical studies will present type I and II evidence on the treatment of adenoid cystic carcinoma of the sinonasal and skull base region that is necessary to establish widely accepted treatment protocols [10,12].

Conclusion

This clinical case illustrates the multidisciplinary approach that these patients with complex sinonasal malignancies require to achieve adequate control of their disease. Management by an extended endoscopic endonasal procedure with adjuvant radiation therapy (IMRT), appears to be an effective oncological alternative to well-selected cases of patients with locally advanced ACC tumors of the sinonasal tract.

Acknowledgement

Mario Melo MD, Pathologist, Instituto Nacional de Cancerología, Bogotá D.C. For providing the histopathology report and photos.

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laserpiles · 3 years ago

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What is The Cost of Fistula Laser Treatment in Hyderabad?

What is Fistula?

A fistula occurs as a result of an abnormal connection between two body parts, usually an organ or vessel and another structure. They are usually caused by an injury or surgery. Sometimes, infection or inflammation also can result in a fistula.

Theoretically, while Fistula can happen in many different places of the human body, the most common locations however are:

An artery and vein

The cervix and vagina

The neck and throat

The space inside the skull and paranasal sinus

The bowel and vagina

The colon and surface of the body, causing faeces to exit through a gap aside from the anus

The stomach and surface of the skin

The uterus and greater peritoneal sac (the space between the walls of the abdomen and internal organs)

An artery and vein within the lungs (results in blood not learning enough oxygen within the lungs)

The navel and gut

Symptoms of Fistula

The symptoms will vary depending on the location:

Between different parts of the large and small intestines: diarrhoea

Between the intestines and the bladder: urinary tract infection

Between the intestines and vagina: stool or gas may passed through the vagina

The most common fistulas tend to occur in and around the anus, so the symptoms to be watchful for are inflammation, swelling, or pain around the rectal area. You may also notice a lump initially at the location of the opening of the fistula; these lumps can open and start oozing foul-smelling fluids like pus, blood, or stool. Some other symptoms for a few other types of fistula are:

Burning smell while urinating; the urine may contain blood

Pain with bowel movements

Bleeding

Occasionally fever coupled with feeling tired

Causes – Anal Fistula

The leading causes are

Clogged anal glands and anal abscesses.

Regional enteritis (a disease of the intestine) and

Radiation (due to treatment for cancer)

Diagnosis of Fistula

A digital rectal examination is sufficient to diagnose an anal fistula but some patients require more tests to screen for:

1. Sexual infections

2. Inflammatory bowel diseases

3. Rectal cancer

4. Diverticular diseases

Doctors suggest tests like ultrasound, a CT scan, or an MRI to be conducted.

THE SOLUTION

While prevention is the best treatment helped by maintaining a good nutritional habit coupled with abstaining from smoking which is critical for fistula healing, treatment at times involves surgery to cut the connection between the organs.

Anal fistula can be treated but they do not heal quickly as fibre tissues develop on the inner walls of the fistula.

Fistula Laser Treatment Cost in Hyderabad

At Vitality’s Laser Piles Clinic, we believe in giving you the individual attention that you deserve. We are a specialty clinic in Hyderabad that’s dedicated to the Laser treatment of Piles, Fistula, and other related challenges. Our dedicated team of doctors, advanced laser surgery equipment, and economic costs make us the foremost sought out clinic for colon-related medical conditions in Hyderabad.

The fistula laser treatment cost will depend on the complexity of the individual cases. While fistulectomy is the most common surgical procedure used in a majority of fistula cases. The other methods may be using a bio prosthetic plug using a skin graft, coring out fistulous track using a dissection. While Laser ablation and using fibrin glue are two non-invasive options, on the other hand for complex cases Seton Techniques or Advancement Flap Procedures are used as seen fit by our doctors at our Laser Piles Clinics. We also have lady doctors for lady patients.

FINALLY

Having a fistula like any other disease is undoubtedly going to be an unpleasant experience, more so if you have ignored it for a while and discovered it late. The good news is that with 7 branches of our Vitality’s Laser Piles Clinics in and around Hyderabad, we have specialised and experienced doctors with excellent advanced laser treatment you do end up getting diagnosed with a fistula, at an affordable cost! So keep an eye on the symptoms and if you do notice any of them listed above, feel free to contact our specialists at your nearest Laser Piles Clinic’s branch. We are just a call away and what’s more the first consultation is absolutely free!

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falgunikurian · 4 years ago

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7 Powerful Tips for Treating Chronic Sinus Infection

Sinuses are the air-filled cavities on either side of the nose that are present in the bones of the face that form the top part of the respiratory tract. The main cause of chronic sinus infection is when the tissues present in the sinuses swell up. It can be clogged due to cold, allergies, or bacterial infections. That leads to the development of mucus. The by-product of this medical condition can result in headaches, snoring, or difficulty in breathing. In serious conditions like Sinusitis Diagnosis, the health can be deteriorated and could lead to Nasal and Paranasal Sinus Cancer. There are four types of sinus infection:

Acute sinus infection lasts for 4 weeks or less.

Subacute Infection (lasts 4 to 8 weeks)

Chronic sinus Infection (lasts 8 weeks or longer)

There are recurrent inflammation symptoms that are followed by several attacks within a year.

Symptoms

Common Cold

Fever

Nasal Congestion

Bad breath or unpleasant taste in the mouth

Mucus dripping down the throat from the nose

Tenderness under the eyes or on the bridge of the nose

Headaches

Cough

Problems in Breathing and smelling.

Diagnosis

People with evident symptoms such as the ones listed should get an appointment with a Sinusitis Doctor or ENT and get it checked out.

The temperature is higher than 38°C.

Symptoms that have lasted for more than 10 days.

Symptoms that are getting worse and affecting your health.

History of sinus infection over the past year.

Symptoms that aren’t eased by antibiotic medication.

The doctor will examine your nose by looking into it. Further, he or she will dive into some methods to diagnose chronic sinus infection and get the results quickly.

Detecting the problematic areas with an obstruction

There is a thin, flexible tube with a piece of fiber-optic light equipment that is used by doctors to examine your sinus. They are inserted through your nose allowing them to see inside of your sinuses. Some images can be taken using CT or MRI and can show details of your sinuses in the nasal area. This will be able to detect deep inflammation areas that are hard to find out by the endoscope. You may have to undergo Endoscopic Sinus Surgery specialists Coimbatore.

Finding out the underlying causes

The acute sinusitis or the further developed chronic sinus infection can be triggered by allergies. If you had a history of acute sinusitis as a precautionary, he or she might ask you for an allergy skin test. It is a safe and quick test that can ease out half of your pain in the future. If your condition is not improving and worsening, for further diagnostics the doctor will get samples from your nasal and sinus discharge. To find out the other cause like bacteria or fungi.

Treatment

Treatment options vary from case to case. Always follow what your ENT recommends. There are various treatments that can be done via your ENT such as the following:

Injected corticosteroids:

These medications are used to relieve inflammation from severe sinusitis, in addition to nasal polyps. It has side effects if it is used for a long term.

Antibiotics:

It is necessary for the treatment of sinusitis if you have a bacterial infection. Sometimes, the doctor might combine antibiotics with some other medicines.

Immunotherapy:

They are basically allergy shots if allergies are contributing to your sinusitis symptoms.

Endoscopic sinus surgery

Surgery, even the word can make our heart sink. But, if no other option is working endoscopic sinus surgery might be an option. Depending on the source of obstruction, the doctor might use various instruments to remove tissue or shave away a polyp that’s causing the nasal blockage. Enlarging a narrow sinus opening also may be an option to open drainage.

Tips to Help from a chronic sinus infection:

You just got your diagnosis and you are worried about your health, we have some good news for you. You can make some lifestyle changes to manage acute and chronic sinusitis.

1. Sit back and Rest

It’s the first in line for any treatment process. You need to give your body some time to fight the inflammation and wait for a speedy recovery. As it’s important to give our health time to regain its strength. It’s the best treatment without any money involved.

2. Steam your sinus away

The typical science phenomenon is that heating the solid will change its molecular state and is not new to us. So, similarly inhaling steam, will help the mucus to get drained out. It will ease out the conditions of the nasal passage. The same procedure can be done with the help of a hot warm shower.

3. Saline Irrigation

There are some specially designed squeeze bottles, saline canisters, or neti pots. That helps directly rinse nasal passages. This home remedy is called nasal lavage. And can get your sinuses clear and this treatment has proven to be very effective. It might seem difficult at first, but it’s very easy to learn and without any pain.

4. Drink Up

Drinking water, tea, or juices without sugar are good ways to keep your system hydrated. Moreover, these fluids help in thinning out the mucus and get relief to the irritated sinuses. Secondly consuming good water intake will keep you away from other infections and improves your health.

5. Go back to the basics

Let’s learn from our ancestors. They used to rely on home remedies for any disease that has infected them. There are many anti-inflammatories, antibacterial properties, and immunity booster spices that are easily available in our country. Ginger, turmeric, cayenne pepper, and other spices have treated various medical conditions for a long time. There are many ways to try: ginger can be consumed with brewed hot tea, or with honey. This will help loosen the mucus and open the clogged areas, relaxing the sinus pressure. Another one is freshly grated horseradish root that can be held in the mouth for a few minutes. Once the taste has evaporated, it can be swallowed.

6. Apple Cider Vinegar- The wonder liquid

We all are familiar with the health benefits of Apple Cider Vinegar. It can be consumed with a cup of hot water. You can also add lemon and honey as per your taste. For better results, horseradish can also be mixed in it. It will help to thin out the mucus, drain the pressure, and relieve the pain.

7. Things to avoid

This acute bunch of chronic medical infections can be kept away by avoiding certain things. If you have a history with clogged nasal, then you should avoid alcohol, caffeine, and smoking, which lead to dehydration. There are some foods that can trigger sinus symptoms like fried and starchy foods, rice, meat, and strong spices. Cheese, Yoghurt, cold drinks, and Ice Cream should also be on the ‘Things to avoid’ list. They will prevent mucus from flowing through the nasal passage. Chocolate, yeast, and sugar amplify the mucus production in the sinuses. Food rich in vitamin A builds a strong immune system and it can be considered a good treatment before getting any disease. So line up your healthy groceries in your refrigerator.

Prevention Tips

Living a hygienic and healthy lifestyle. Wash your hands at regular intervals, if you have been to a crowded place or a public transportation system.

If you have lower immunity keep up with your ENT and some recommended immunizations. And get some regular health checkups.

Use a clean humidifier to keep the air moist in your surroundings.

As soon as you feel the symptoms are showing up, take an ample amount of rest to reduce the further complications.

#Sinus Treatments Sinuses Infection Tips for Treating Chronic Sinus Infection Best Treatments For Sinus

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webbingindia · 7 years ago

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How many types of cancer are there ?

Cancer is a stage where cells grow and reproduce in an uncontrolled way. Cancerous cells can occupy and destroy surrounding healthy tissues, including body parts. Generally, cancer begins in one part of the body and it spreads to other areas. This spread of cancer to other areas is known as metastatis.

Treatment depends on the type of cancer and its stage, if the cancer spreads body. Treatment is to kill cancerous cells without damaging normal cells. Advance technology makes it possible.

Three main types of cancer treatments are:

· Surgery: removal of the tumor

· Chemotherapy: using drugs to kill cancer cells

· Radiation therapy: using ionizing radiation to kill cancer cells

Anti cancer drugs are also available in market.

There are more than 200 different types of cancer.

Types of cancer:

Adenoid Cystic Carcinoma

Adrenal Gland Tumor

Amyloidosis

Anal Cancer

Appendix Cancer

Astrocytoma - Childhood

Ataxia-Telangiectasia

Beckwith-Wiedemann Syndrome

Bile Duct Cancer (Cholangiocarcinoma)

Birt-Hogg-Dubé Syndrome

Bladder Cancer

Bone Cancer

Brain Stem Glioma - Childhood

Brain Tumor

Breast Cancer

Breast Cancer - Inflammatory

Breast Cancer - Metastatic

Breast Cancer in Men

Carcinoid Tumor

Carney Complex

Central Nervous System Tumors - Childhood

Cervical Cancer

Childhood Cancer

Colorectal Cancer

Cowden Syndrome

Craniopharyngioma - Childhood

Desmoplastic Infantile Ganglioglioma, Childhood Tumor

Endocrine Tumor

Ependymoma - Childhood

Esophageal Cancer

Ewing Sarcoma - Childhood and Adolescence

Eye Cancer

Eyelid Cancer

Familial Adenomatous Polyposis

Familial GIST

Familial Malignant Melanoma

Familial Non-VHL Clear Cell Renal Cell Carcinoma

Familial Pancreatic Cancer

Gallbladder Cancer

Gastrointestinal Stromal Tumor - GIST

Germ Cell Tumor - Childhood

Gestational Trophoblastic Disease

Head and Neck Cancer

Hereditary Breast and Ovarian Cancer

Hereditary Diffuse Gastric Cancer

Hereditary Leiomyomatosis and Renal Cell Cancer

Hereditary Mixed Polyposis Syndrome

Hereditary Pancreatitis

Hereditary Papillary Renal Carcinoma

HIV/AIDS-Related Cancer

Islet Cell Tumor

Juvenile Polyposis Syndrome

Kidney Cancer

Lacrimal Gland Tumor

Laryngeal and Hypopharyngeal Cancer

Leukemia - Acute Lymphoblastic - ALL - Childhood

Leukemia - Acute Lymphocytic - ALL

Leukemia - Acute Myeloid - AML

Leukemia - Acute Myeloid - AML - Childhood

Leukemia - B-cell Prolymphocytic Leukemia and Hairy Cell Leukemia

Leukemia - Chronic Lymphocytic - CLL

Leukemia - Chronic Myeloid - CML

Leukemia - Chronic T-Cell Lymphocytic

Leukemia - Eosinophilic

Li-Fraumeni Syndrome

Liver Cancer

Lung Cancer - Non-Small Cell

Lung Cancer - Small Cell

Lymphoma - Hodgkin

Lymphoma - Hodgkin - Childhood

Lymphoma - Non-Hodgkin

Lymphoma - Non-Hodgkin - Childhood

Lynch Syndrome

Mastocytosis

Medulloblastoma - Childhood

Melanoma

Meningioma

Mesothelioma

Muir-Torre Syndrome

Multiple Endocrine Neoplasia Type 1

Multiple Endocrine Neoplasia Type 2

Multiple Myeloma

Myelodysplastic Syndromes - MDS

MYH-Associated Polyposis

Nasal Cavity and Paranasal Sinus Cancer

Nasopharyngeal Cancer

Neuroblastoma - Childhood

Neuroendocrine Tumor

Neurofibromatosis Type 1

Neurofibromatosis Type 2

Nevoid Basal Cell Carcinoma Syndrome

Oral and Oropharyngeal Cancer

Osteosarcoma - Childhood and Adolescence

Ovarian, Fallopian Tube, and Peritoneal Cancer

Pancreatic Cancer

Parathyroid Cancer

Penile Cancer

Peutz-Jeghers Syndrome

Pituitary Gland Tumor

Pleuropulmonary Blastoma - Childhood

Prostate Cancer

Retinoblastoma - Childhood

Rhabdomyosarcoma - Childhood

Salivary Gland Cancer

Sarcoma - Kaposi

Sarcoma, Soft Tissue

Sarcomas of Specific Organs

Skin Cancer (Non-Melanoma)

Small Bowel Cancer

Stomach Cancer

Testicular Cancer

Thymoma

Thyroid Cancer

Tuberous Sclerosis Complex

Unknown Primary

Uterine Cancer

Vaginal Cancer

Von Hippel-Lindau Syndrome

Vulvar Cancer

Waldenstrom’s Macroglobulinemia

Werner Syndrome

Wilms Tumor - Childhood

Xeroderma Pigmentosum

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biomedgrid · 5 years ago

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Biomed Grid | A Study to Investigate the Effect of ‘Frontal Lift’ Osteopathic Manipulative Technique (OMT) in Patients with Chronic Sinusitis

Introduction

Chronic sinusitis (CRS) also referred to as rhinosinusitis is a condition involving inflammatory disease of the nose and paranasal sinuses as defined by the Royal College of Surgeons guidelines (RCS) 2016 and cited in earlier research by Mendez-Sanchez et al. [1] and recent research Bergmark & Pynnonen [2]. The etiology of chronic sinusitis is largely unknown or believed to be multifactorial; with inflammation, infection and obstruction of sinus ventilation suggested by RCS (2016). CRS is subcategorized as with and without polyps (Rosenfeld, 2015). CRS can cause two or more persistent symptoms (one of which must be nasal obstruction and/or nasal discharge and/or facial pain/pressure or loss of smell) that last for more than 12 weeks (NICE, 2018) unlike acute sinusitis which has an infective a etiology and commonly resolved within 12 weeks of onset. CRS affecting 1 in 10 UK adults cited the RCS (2016), is reported to have a significant impact on health-related quality of life, high health-care provision and significant days lost to industry.

Primary care for CRS often involves saline irrigation, nasal steroid spray, or both. The repeated use of antibiotics for CRS in primary is not recommended due to limited evidence of efficacy (RCS, 2016, p.6; UWS, 2017, p.47) Surgery for secondary care in UK (RCS) 2016 and similar in US cited in University of Western States (UWS) Clinical Standards, Protocols, and Education (CSPE) Care Pathway (2017). It appears that both the Primary clinical practice guidelines (CPGs) from the RCS (2016) and UWS CSPE Care Pathway (2017) recommend long-term use of nasal steroid spray for CRS. Bergmark & Pynnonen [2] cited few studies have examined the uptake of this recommendation. However, Chong et al. [3] found there was an increased risk of epistaxis (high quality evidence).

Osteopathy is a system of diagnosis and treatment for an extensive range of medical conditions GOsC [8], but high-quality evidence research has been moderate for the efficacy of osteopathic manipulative technique (OMT), with most studies only pointing for relieving low back pain Licciardone et al. [13,14] More recent research on OMT to the head region is based on anatomical, physiological, neurological, vascular, muscular, articular and lymphatic systems Louveau et al. [16]. The rigorous studies of concept or efficacy for OMT have not been robust, as OMT has traditionally had an empirical basis rather than a research basis Ching [3].

The objective of this review focuses on the effectiveness of OMT in certain studies and articles which were assessed using a critical appraisal tool (CASP, 2018). As there is scarce evidence based systemic reviews and meta-analyses in OMT from randomized control trials (RCT’s) to measure the efficacy of OMT on sinus pain and the beneficial outcomes in the United Kingdom, and so the search was expanded to include other manual therapies in European and United States.

Paul, Buser [19] identified the use of OMT (by Osteopathic physicians) in an emergency department for patients with low back pain, chest pain, torticollis, asthma and sinusitis demonstrated related symptoms could be ameliorated or eliminated with OMT. Orlandi et al. (2016) cited both CRS and asthma frequently co-exist in the same patient affected by similar triggers and co-factors, therefore treating either one of the conditions often has a beneficial effect on both. Raghavan and Jones (2000) found that there was little evidence to support the effect of complementary therapies (including osteopathy) over those of the placebo effect, cognitive dissonance and the natural resolution of many disease processes. Folweiler and Lynch (1995) demonstrated nasal specific technique as part of a chiropractic approach may be useful in treating CRS and sinus headache. Lee-Wong et al. [12] study of patients with CRS in outpatient allergy clinic, found OMT utilising direct pressure and sinus drainage technique improved sinus pain/congestions in patients. Jeffrey, et al. (2012) carried out a feasibility study of impact of integrative East-West medicine on Sino nasal symptoms and quality of life for patients with chronic sinusitis.

Mendez-Sanchez et al. [1] study suggested that manual therapy (including manipulation) treatment could be considered as an appropriate alternative treatment of chronic sinusitis. The University of Western States (UWS) Clinical Standards Care Pathway (2017) recommended 2 specific procedures out of 5 were upper cervical spine manipulation (joint dysfunction may be present as a viscera-somatic response to sinus irritation and Eustachian tube manipulation (Eustachian tube dysfunction often a comorbid condition of sinusitis), others were rapid dilation the nasal passages (not sinus balloon dilation); facial massage; lymph drainage and percussion recommended for management of CRS. The more recent observational case control study Petersen et al. [20] of neck pain and cervical musculoskeletal dysfunction, common among patients with self-reported sinus headaches maybe a contributing factor to headaches attributed sinusitis. This highlights a potential research to identify a wider population that could benefit from OMT for pain relief with less medication.

Literature Review

Lee-Wong et al. [12] an allopathic physician (studied OMT during her post-doctoral training) carried out a pilot study on 15 patients (who requested alternative therapies for CRS pain relief) to determine the efficacy of OMT as an adjunct to allopathic therapy to possibly minimize the use additional pain medications for relief of CRS discomfort symptoms. One OMT session only comprising of four direct pressure and ‘milking’ techniques and a sinus drainage technique (a total of 6 maneuvers) for nasal congestion carried out on patients as described in DiGiovanna & Schiowitz [28] or a total of 18 minutes of treatment. The results reported decreased sinus pain/congestion after OMT.

Limitations

a. The outcome is not statistically significant p=0.0012 (p=<0.0001is significant)

b. Small sample size–15 patients.

c. No control groups included (sham treatment or no treatment for the control group). A suggestion of sham treatment or no treatment for the control groups can provide a new factor to the two groups (Denscombe, 2017). However, difficulty in proving osteopathy efficacy via RCT’s due to the impossibility of double blinding and difficulties in conducting ineffective sham treatments Licciardone & Russon [13].

d. Only a pain scale symptom score card was used for patients before and after OMT. A Sino nasal Outcome Test Questionnaire (SNOT-22) a widely used, self-administered, quality of life questionnaire for patients with CRS could be included for understanding specific patient-reported outcomes. The history and severity of symptoms not included therefore data is difficult to compare in relation to normative data for chronic sinusitis patients.

e. There was no follow up with CRS patients to see how long the improvement of pain lasts.

Strengths

a. This study supports the perpetual argument in the context of more research into the effectiveness of OMT. An allopathic doctor who is interested in OMT and initiated this research for CRS patients with sinus pain. As suggested by King [11] an opportunistic study for encouraging interprofessional dialogue that will enhance the public acceptance of the services of all professions who use their hands in healthcare.

b. A relatively short trial just one session but effective in highlighting and advocating OMT that are commonly taught and used in osteopathic medicine.

c. Potential for further research on OMT that were integral part of osteopathic approach and principle in manual medicine Ward & Greenman [31,34].

Mendez-Sanchez et al. [1] A prospective case series study in reporting manual therapy carried out on 14 patients diagnosed with CRS with craniofacial pain. The rational of the applied manual therapy is based on the premise that inadequate drainage preventing resolution of sinusitis; the autonomic nervous system is influenced by the imbalance of adrenergic, cholinergic, and sensory components; it seems that the parasympathetic stimulation increases nasal-mucosa secretions, whereas sympathetic stimulation causes circulatory vasoconstriction within the nose and sinuses. Hence the reasoning that manual therapy interventions targeting the thoracic and upper cervical segments with spinal manipulation as well as craniosacral treatments may influence the sympathetic and parasympathetic systems and ultimately have a positive effect on the autonomic nervous system. Hence integrating manual therapy with the overall management of symptoms associated with CRS may allow for reduced use of prescription medications.

The manual techniques include:

a. Thoracic spinal manipulation applied over T1-T3;

b. Manipulation of the cervicothoracic junction;

c. Manipulation of the pelvic girdle;

d. Decompression of the temporomandibular joint;

e. Myofascial release of the anterior cervical region;

f. Myofascial release of the hyoid system;

g. Mobilization of the maxilla bones;

h. Mobilization and compression of the frontal bone.

The trials carried out for 7 weeks. Treatment carried out in Session 2, 3 and 5, evaluation only in session 1, 4, 6 and 7. Outcome measure shown a difference after treatment same for pain scores and pressure pain threshold (PPT). The results reported decreased sinus pain/congestion after OMT. P=<0.0015.

Limitations

a. The outcome is not statistically significant p=<0.0015 (p=<0.0001is significant)

b. Small sample size-14 patients

c. No control groups included, cause and effect relationship cannot be determined

d. Complex outcome measures-3 questionnaires and pressure algometry testing at each session.

e. No indication of how long each treatment session took.

Strengths

a. Treatment was based on the presentation of the symptoms of the patient on each session.

b. A combination of local and regional manual therapy interventions appeared to yield improvements in all outcome measures.

c. Manual therapy interventions for patients appeared to fair better than when similar patients are treated with antibiotic drugs or endoscopic surgery.

d. Standardized evaluation methods with all sessions for each patient at the same period in the afternoon to reduce a confounding temporal effect

e. Potential for further research to look at medium- and long-term effects of manual therapy.

Jeffrey et al. (2012) carried out prospective, non RCTs to establish the feasibility of studying the impact of integrative East- West medicine (IEWM) on Sino nasal symptoms and quality of life (QoL) on patients with CRS. Acupuncture, Acupressure, dietary modification and advice on stress management were introduced in addition to the standard medical therapeutic regimen.

Limitations

a. Not RCTs and absence of control groups.

b. Bias selection of study population.

c. Too many modalities of treatment were carried out.

d. Not an efficacy analysis but to obtain an estimate of the effect size and variance necessary to plan a definitive study to test and refine individual components of the IEWM protocol.

e. Small sample size-11 patients.

Strengths

a. First study using Integrated two health care systems – Preliminary data indicates IEWM may improve symptoms and Quality of Life (QoL) for patients with CRS for future research

b. Over 8 weeks of regular reproducible treatment

c. Potential further research integrating OMT and Acupuncture

In summary, there is limited osteopathic research carried out with use of OMT to help reduce CRS and symptoms. The results showed deficiencies in the study design for Systemic Review and Meta-Analysis, the lack of control group in the RCTs. Nevertheless, the studies in this review have shown a clear justification the potential use of OMT along with traditional allopathic medicine, either locally Lee-Wong et al. [12] or locally and regionally Mendez- SSanchez et al. [1] to help easing sinus pain and congestion.

Appendix 1A:‘frontal lift’ OMT versus combined OMT.

Lee-Wong et al. [12] offers a viable opportunity for further research. Building on from this study by investing the effect of ‘frontal lift’ OMT - a craniosacral technique to release restricted side of the frontal bone to achieve balance of both sides to affect sinus congestion in the ethmoid or frontal sinuses cited in DiGiovanna & Schiowitz [28,29] and Greenman [31], the potential benefits of using a streamlined technique requiring less treatment time, may improve patients’ comfort. Therefore, affording the practitioner more time available to treat the patient’s other tissues causing symptoms. This streamlined ‘frontal lift’ OMT to coronal suture claims to open the coronal suture and therefore opens the drainage passages of all sinuses as shown by Lintonbon [15]-See Appendix 1A-to ease facial-maxillary sinus headache. Hence this study is to test the streamlined ‘frontal lift’ OMT use on its own is sufficed, comparing with the combined OMT (Appendix 1B) for CRS patients. Therefore, a shorter treatment time by 60% (reduced from 18 mins to 6 mins). Thereby enhancing patient comfort (Appendix 1A).

Aim of the Quantitative study

The main aim of this study is to investigate the effect of ‘frontal lift’ OMT compared with combined OMT (direct pressure and “milking” techniques and sinus drainage technique) in easing CRS and congestion.

Objectives of Quantitative study

From the studies reviewed, a sample size with minimum 16 participants have been chosen. 2 experimental groups, 1 control group. Sample size of 48.

a. To collect data obtained using a Sino nasal Outcome Test Questionnaire (SNOT-22)

b. To use a Numeric Pain Rating Scale (NPRS) experienced by the participants, before and after the application of the ‘frontal lift’ technique on its own compared with pain experienced by participants before and after the application of the ‘combined techniques’ (direct pressure and “milking” techniques and one sinus drainage technique)

c. From the data collected from the 2 experimental groups and a control group, it could be determined which is the more effective technique (s) to reduce symptoms of pain and congestion with chronic sinusitis

d. To select participants and randomly allocate them into 2 different groups, Group A&B as well as a Control Group

e. To apply ‘frontal lift’ technique to Group A; to apply ‘combined techniques (direct pressure and “milking” techniques and sinus drainage technique) to Group B and Control Group with sham treatment or no treatment

f. To compare SNOT-22 questionnaire pre and post treatment and NVPR scores between Group A, Group B and Control Group

g. To analyses the data obtained from the SNOT-22 from the 3 groups

h. To determine if the ‘frontal lift’ OMT on its own is just as effective as using a combined OMT (direct pressure and “milking” techniques and a sinus drainage technique) in easing sinus pain and congestion (Appendix 1B).

Appendix 1B:‘Frontal lift’ OMT versus Combined OMT.

Experimental hypothesis

Using a ‘frontal lift’ OMT is just as effective at reducing the painful symptoms in chronic sinusitis patients at the LSO Clinic, London, in comparison to patients receiving a combined OMT.

Null hypothesis

Using a ‘frontal lift’ OMT is less effective at reducing the painful symptoms in CRS patients at the LSO Clinic, London, in comparison to patients receiving a combined OMT.

Approach & Methodology

The research strategy adopted in this study is a quantitative research approach utilizing a Randomized Controlled Trials (RCTs) experiment design to test the hypothesis. Randomized study design reduces bias and a rigorous tool to examine causeeffect relationships between an intervention and outcome Hariton & Locascio [9]. Other advantages include repeatability of identical procedures, precision and consistency in gathering of data. However, Denscombe [27] also cited disadvantages such as artificial settings, ethics in this instance, the use of control groups with sham or no treatment, therefore control of the relevant variables maybe difficult to achieve. The difficulties in constructing a sham technique, if all touch especially the face can induce reward or placebo – induced pain control, then differentiating the effects of OMT and a sham technique can prove to be tricky (Petrovic, et al., 2002; Zubieta, et al., 2005).

Methods-Participants

My sample size of 48 participants will be determined through LSO Clinic (3 groups of 16 participants in each group). There will be 2 groups of CRS participants and a control group receiving no treatment or sham treatment (Table 1).

Table 1: Eligibility Criteria of Participants for Chronic sinusitis.

Methods-Study Design

Building on from Lee-Wong pilot study a more ‘robust’ study design to include:

1. Participants in the study will be seen once a week for 6 weeks.

2. The use of SNOT-22 before treatment at each week. (Appendix 2)

3. The use of NPRS before and after end of treatment from the 1st week to 6th week to observe an improvement in easing sinus pain and congestion. (Appendix 3). The Numeric Pain Rating Scale (NPRS) has good sensitivity and generates data for analysis Karcioglu et al. [10].

4. Bigger sample size-48

a. Streamlined frontal lift’ OMT (Group A)-16 peopletreatment time: 6 mins each

b. Combined OMT (Group B)-16 people-treatment time: 18 mins each

c. Control group (Group C-sham or no treatment)-16 people

Methods-Outcome Measures

In order to select 48 patients clinically diagnosed with CRS, a Sino nasal Outcome Test Questionnaire (SNOT-22)- Appendix 2-is chosen based on the highest quality for understanding specific patient-reported outcomes during the management (PROM) of chronic sinusitis (CRS) showed in a recent systemic review Rudmik et al. [22] (Table 2 & Appendix 2a).

Appendix 2a:The Sino nasal Outcome Test-22 Questionnaire (SNOT22).

Table 2:

The independent variable includes ‘frontal lift’ OMT and combined OMT which allow the researcher to consider if either one of the two OMT techniques leads to the dependent variable in reduction of pain symptoms. Most importantly, the researcher must investigate whether the independent variable of OMT influences the dependent variable to agree with its experimental hypothesis.

Data Analysis

The data from the SNOT-22 and NPRS will be analysed using SPSS Version 24 software, because of its extensive statistical data analysis capability, as well as effective data management within an excel format (Stehlik-Barry and Babinec, 2017). It will be accessed and interpreted as ordinal data through extensive statistical analysis by using the SPSS software. Using the nomogram (Field, 2017) data will be analysed along this type of format: Ordinal data  Differences between groups  Dependent  ordinal rank  Non-parametric (rank test Wilcoxon matched pairs signed)  Non- Parametric (Friedman’s 2-way analysis of variance by ranks).

The sum test (Wilcoxon rank) will check the frequency of conditions between the two groups e.g. amount of pain reduction. The Friedman’s test will compare the division of the 2 quantitative variables, with analysis of variance (ANOVA) for dependent samples (Flow chart).

Flow Chart:

Resources Required

a. The Sino nasal Assessment Questionnaire (SNOT-22)

b. Numeric Pain Rating Scale (NPRS)

c. SPSS Version 24 Software-download from ARU

d. Access to room at LSO clinic for treatment process

e. Poster advertisements (including any exclusion criteria) of the study placed in LSO’s reception waiting area to invite volunteers to participate in the study.

f. Letter and Consent form (see ethical issues-checklist no.2) (Appendix 2b).

Appendix 2b:Numeric Pain Rating Scale (NPRS).

Literature Search Strategy

An extensive literature search was conducted using several search databases with access gained via Anglia Ruskin University Library, using MEDLINE, PubMed, Google scholar, Science Direct, Cochrane database/library, and Europe PMC. The keywords used (in various combinations) to search the literature were: osteopathic, medicine, osteopathy, Rhinosinusitis, sinusitis, sinus, adult sinusitis, headache, asthma, pain, craniofacial pain, pressure, neck, manipulation, chronic, manipulative, treatment, effects, manual, therapy, techniques, allergy, chiropractic, quality of life, review, outcome, measures, alternative, complementary, randomized controlled trials. Boolean operators (AND and OR) were used e.g. Osteopath# AND Sinus#.

Also, London School of Osteopathy (LSO) library resources were used to access hard copy materials such as books and journals for additional evidence (Table 3 & Table 4). The database search dates were conducted from March 9th -1st May 2019 for further citations of this research.

Table 3: Inclusion and Exclusion criteria for relevance.

Table 4:Literature search strategy.

Osteopathic Relevance

DiGiovanna et al. [28] found that chronic sinusitis is almost always associated with somatic dysfunction of the cervical spine. Sympathetic innervation to the sinuses arises from the upper thorax and travels through the cervical region. Hence treating cervical somatic dysfunction and performing sinus drainage techniques helps to relieve pain and as well as assist in the drainage of the sinuses. These techniques used are fully explained in most osteopathic handbooks. However, none of them fully explain the effectiveness of one technique over another. This study is to investigate a shorter treatment with one technique as opposed to using several. This would deliver maximum pain relief from OMT and therefore improve the patients’ comfort leading to improved treatment outcome in a shorter time scale allowing the practitioner to work on associated tissues causing symptoms.

From a quantitative perspective, the study design will contribute towards creating additional research towards the field of osteopathy by assessing if a streamlined OMT is just as effective compared with a combined OMT technique therefore potentially to improve patients’ comfort with less treatment time. This could support the relevance of osteopathy in establishing whether this manual technique ‘frontal lift’ can be a significant factor contributing towards an individual’s health. Osteopathy is widely used as a therapeutic tool; however, its reliability as a form of treatment remains unconfirmed. Therefore, research regarding chronic sinusitis treatment using OMT should be conducted to highlight future research priorities.

Limitations

Despite the best intentions and following the guidelines, the lack of recent research in the osteopathic field. Hence the generation of a hypothesis from the data collected is rather subjective. Also, the use of a placebo, control group and sham treatments have been overlooked/not included by the researchers in the reviewed articles.

Conclusion

The use of ‘frontal lift’ OMT appears to be less invasive and suitable for a wide range of CRS patients. The shorter the time of treatment allowing the practitioner to work on the potential maintaining factors thereby working on the body as a whole – one of the core principles of osteopathy. The extra time generated also allows the practitioners to explore the patient’s biopsychosocial aspects of the patient.

Read More About this Article: https://biomedgrid.com/fulltext/volume3/a-study-to-investigate-the-effect-of-frontal-lift-osteopathic-manipulative-technique.000665.php

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juniperpublishers-oajnn-blog · 5 years ago

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Isolated Spinal Rosai-Dorfman Disease: Challenge of Management

Authored by Alhareth Ma'aya

Abstract

Rosai-Dorfman disease (RDD); an uncommon disease of idiopathic histoproliferative disorder that typically presents with systemic symptoms and painless cervical lymphadenopathy. Spinal involvement is comparatively rare and isolated spinal RDD is extremely rare entity. We present our case of isolated spinal RDD in a 35-year-old man presented with extradural spinal lesion.

Keywords: Rosai-dorfman disease; Sinus histocytiosis; Lymphadenopathy

Abbreviations: RDD: Rosai Dorfman Disease; EBRT: External Beam Radiotherapy; MRI: Magnetic Resonance Imaging; CNS: Central Nervous System; ESR: Erythrocyte Sedimentation Rate

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Introduction

Rosai-Dorfman disease (benign lymphohistiocytosis) typically involves lymph nodes, clinically present as painless cervical lymphadenopathy, and fever (massive lymphadenopathy with sinus histocytiosis). Blood tests show leukocytosis, elevated ESR and polyclonal hypergammaglobulinemia. First reported by Destombes in 1965. In 1969, two pathologists, Juan Rosai and Ronald Dorfman, reported a distinct histiocytic disorder in several patients with massive enlargement of the lymph nodes, as well as other symptoms. They named this condition sinus histiocytosis with massive lymphadenopathy, and thus have since come to be known as Rosai-Dorfman disease.

The case

A 35 years old man presented to outpatient clinic with 2 months' history of progressive low back pain and asymmetrical lower limb weakness with no sphincters disturbances, with no history of prior illnesses. Neurological examination revealed power 4/5 in right foot dorsi and planter flexion and 4+/5 in left foot dorsi and planter flexion. MRI of lumbosacral area showed homogenous enhancing extradural lesion extending from L3 level till the sacrum with bony invasion. The extradural lesion was hypointense on T1WI, hypointense on T2WI with homogeneous enhancement in post contrast images (Figure 1 & 2). Routine hematological and biochemical studies were normal. The patient underwent microscopic excision of the extradural lesion with subtotal excision of the lesion, which was insignificantly vascular, firm and grayish-yellow in color. Postoperative course was uneventful. Histopathology revealed a mixed lymphoplasmacytic inflammatory infiltrate containing sheets of large and foamy histiocytes; some of these histiocytes engulfed a large number of lymphocytes and plasma cells, corresponding to emperipolesis. By immunohistochemistry, histiocytic cells were positive for S100 protein (Figure 3), as well as for CD68 (Figure 4).

Post operatively back pain and weakness improved significantly, no lymphadenopathy or systemic masses were identified on admission and on follow up. The case was discussed with oncology team and the patient was treated with a course of EBRT to L4-S4 area (20 Gray/5 Fractions) which was tolerated with no major side effect. Follow up MRI revealed reduction in the size of the lesion (Figure 5).

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Discussion

RDD mainly presents in children and young adult (mean age of 20.6 years and range 1-74 years old), here is a slight male predominance (male: female = 1.4: 1) [1]. CNS involvement is reported in less than 5% and extranodal involvement in more than 90% of patients presenting with cervical lymphadenopathy, and in 43% of cases including paranasal sinuses, skin, bone and Orbit [2].

MR imaging characteristics of RDD can be variable showing either low or isointense on T1- and T2-weighted images with an intense and uniform contrast enhancement [3]. Microscopically RDD is characterized by infiltration of histiocytes, B and T lymphocytes and plasma cells. Emperipolesis is typical of RDD of the leptomeninges but is absent in 30% of cases [3]. By immunocytochemical Studies, expression of CD68, CD31, a1 antitrypsin and a1 antichymotrypsin are positive both for mononuclear cells and dendritic cells, but a positive expression of S100 is found only for dendritic cells.

CD1a is not expressed by any cells in RDD as explained by Purav et al. [4] in a recent series including 10 cases of RDD in the central nervous system. RDD diagnosis is based entirely on histopathology and immuno histochemistry [4]. Most of spinal RDD are managed surgically with variable degrees of tumor excision and many of the cases benefit from postoperative steroids, adjuvant radiotherapy and chemotherapy with vinca alkaloids and alkylating agents [5]. Horneff et al. reported a good response of RDD to methotrexate and mercaptopurine. Aouba et al. noted a patient with systemic RDD was asymptomatic after 3 cycles of cladribine treatment.

The etiology of RDD is presumed to be reactive in nature, as no evidence of clonality has been demonstrated by molecular analysis. There is possible association with infective agents like human herpes virus 6 and parvovirus B19 have been suggested in few studies [6]. Roy et al [7] reviewing the literature reveled at least 35 previously reported cases with spinal involvement, although isolated spinal involvement was seen only in six cases of them [7]. Therefore, our case is the eighth case with isolated spinal involvement reported in the literature.

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Conclusion

The diagnosis of Spinal RDD is challenging and preoperatively the condition is often mistaken for meningioma or other extradural lesions. Because this disease is so rare, no large studies have been performed, and there is no established, widely accepted treatment. Surgical removal of spinal lesions is an effective treatment. Post-operative radiotherapy appears effective; however, more research is needed to clarify their use and the effectiveness of other treatment options such as chemotherapy, as well as long term outcomes after treatment [8].

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biogetica-stylein-yahoopart-blog · 8 years ago

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Why do I Have Pain in my Cheekbones?

There are several reasons you could develop facial pain or pain in your cheek bones. The exact type of pain would depend on the causative factor and could range from a dull throbbing ache to a sharp stabbing one. Sometimes pain could radiate from the head or ears to your face.

It is very important to understand the root cause of the pain since an incorrect course of treatment will only aggravate your condition and potentially end in irreversible damage.

Facial pain as a result of any condition is very agonizing and difficult to bear. A lot of patients have reported that the pain becomes so unbearable that it hinders daily activities and people end up severally compromising their quality of living. Some even find it difficult to perform mundane actions like brushing, eating, drinking, shaving, washing the face etc.

Painkillers such as NSAIDS and opioids are often the first line of treatment to subside the pain. Sometimes antidepressants and antiepileptic drugs are also given to address nerve pain. However, these at best provide temporary relief since the root cause is not addressed and moreover, they are known to cause a host of unpleasant side effects.

On the other hand, numerous natural ingredients like Harpagophytum procumbens, Hypericum perforatum, Symplocos racemosus, Aegle marmelos, Apis Mellifica , Spigelia, Thymus vulgaris, Ginkgo biloba, Glycyrrihiza glabra, etc have been clinically tested for their analgesic, anti-inflammatory, and rejuvenating properties. These remarkable ingredients have also been studied for conditions like trigeminal neuralgia, sinusitis, gingivitis, tinnitus etc.

In fact, with growing awareness and research, many doctors have started prescribing natural ingredients for their numerous versatile and beneficial properties. Biogetica, an ardent follower of natural medicine, undertakes relentless efforts to highlight the indigenous properties of plants, herbs and other natural ingredients. We’ve conducted copious amount of research and have several published patents in the field. Our protocols are formulated to balance the physical, energetic and informational spectra of your life and include evidence based ingredients from 3 distinct healing methodologies – ayurvedic herbs, homeopathic attenuations and cutting edge nutraceuticals. Together, these components work synergistically to help promote freedom and wellbeing to our patient community. To know more about our groundbreaking, natural and multi-disciplinary kits, visit www.biogetica.com.

Get a Free Consult with One of Our Homeopathic or Ayurvedic Specialists Here!

Medical Conditions That Lead to Cheekbone Pain

Trigeminal neuralgia: This painful condition involving the trigeminal nerve of the face causes unbearable agony and distress. A person afflicted with Trigeminal neuralgia may experience sharp, short and unpredictable attacks lasting from a few seconds to minutes. This disease is a common cause of cheek bone pain and rehabilitation is a very arduous process, since, none of the conventional treatments have been able to provide complete relief. In contrast, a research study reported that trigeminal neuralgia patients obtained an overall reduction of more than 60% in pain intensity and attack frequency using natural remedies.

Temporomandibular joint (TMJ) syndrome: This is a disorder of the TMJ joint that connects your jaw and skull. Injury to this joint can lead to localized pain. The arising pain is dull and often radiates to the ear and side of the head. Biogetica’s Neuralease possesses a potent combination of herbs including Bacopa monnieri, Pluchea lanceolata, Pheonix farinifera, Vitis vinnifera, and Glycyrrihiza glabra that may provide support to the joint and rejuvenate it for optimal functioning.

Physical trauma: Injuries due to accidents, surgical complications, etc can also cause pain in the cheekbones. A fracture to the cheekbone may lead to severe pain and discomfort. Biogetica’s homeopathic combinations including sarcodes of bodily tissues and other nutritional ingredients may strengthen the bones, promote regeneration and provide nutrients for a healthy musculoskeletal system.

Sinusitis: Inflammed paranasal sinuses are a common cause for cheek bone pain as inflammation of the mucous membrane results in fluid build-up blocking the sinus cavity and disturbing normal drainage of the mucous.

Apart from the above causes, pain in your cheekbones may be attributed to any of the following causes:

Tooth infection

Impacted tooth

Tooth abscess

Gingivitis

Periodontitis

Parotitis

Otitis media, otitis externa (ear infection)

Tonsillitis

Mumps

Mastoiditis

If facial pain is ignored, it could lead to further damage and degeneration of the affected region. Chronic pain can also adversely affect the quality of your life and result in several other health problems such as depression, weight loss, insomnia, fatigue and isolation. It is therefore important to address cheekbone pain promptly to avoid further complications and live a pain free life.

In order to follow the right course of treatment, it is very important to evaluate the definite cause of facial pain. Biogetica’s experienced panel of Ayurvedic and Homeopathic practitioners are available for free consultations round the clock and can assist you in diagnosing your condition and recommending protocols best suited for you based on the cause and severity of your condition. Speak to one of them now for more information, assessment of your health condition, answers to any of your health related concerns and personalized recommendations.

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greatbasementdelusion · 6 years ago

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Cancer treatment

Tumor treatment is an essential topic but to understand it is necessary for us that people have enough knowledge about tumors. so first we give a short intro if malignancy then we will give you information about malignancy treatment.

cancer treatment

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cancer treatment

Types of cancer and its treatment

Chondrosarcoma Ewing’s sarcoma Malignant fibrous histiocytoma of bone/osteosarcoma Osteosarcoma Rhabdomyosarcoma Heart cancer Astrocytoma Brainstem glioma Pilocytic astrocytoma Ependymoma Primitive neuroectodermal tumor Cerebellar astrocytoma Cerebral astrocytoma Glioma Medulloblastoma Neuroblastoma Oligodendroglioma Pineal astrocytoma Pituitary adenoma Aesthetic pathway and hypothalamic glioma Breast cancer Invasive lobular carcinoma Tubular carcinoma Invasive cribriform carcinoma Medullary carcinoma Male breast cancer Phyllodes tumor Inflammatory Breast Cancer Adrenocortical carcinoma Islet cell carcinoma (endocrine pancreas) Multiple endocrine neoplasia syndromes Parathyroid cancer Pheochromocytoma Thyroid cancer Merkel cell carcinoma Uveal melanoma Retinoblastoma Anal cancer Appendix cancer cholangiocarcinoma Carcinoid tumor, gastrointestinal Colon cancer Extrahepatic bile duct cancer Gallbladder cancer Gastric (stomach) cancer Gastrointestinal carcinoid tumor Gastrointestinal stromal tumor (GIST) Hepatocellular cancer Pancreatic cancer, islet cell Rectal cancer Bladder cancer Cervical cancer Endometrial cancer Extragonadal germ cell tumor Ovarian cancer Ovarian epithelial malignancy (surface epithelial-stromal tumor) Ovarian germ cell tumor Penile cancer Renal cell carcinoma Renal pelvis and ureter, transitional cell cancer Prostate cancer Testicular cancer Gestational trophoblastic tumor Ureter and renal pelvis, transitional cell cancer Urethral cancer Uterine sarcoma Vaginal cancer Vulvar cancer Wilms tumor Esophageal cancer Head and throat cancer Nasopharyngeal carcinoma Oral cancer Oropharyngeal cancer Paranasal sinus and nasal cavity cancer Pharyngeal cancer Salivary gland cancer Hypopharyngeal cancer Acute biphenotypic leukemia Acute eosinophilic leukemia Serious lymphoblastic leukemia Serious myeloid leukemia Serious myeloid dendritic cell leukemia AIDS-related lymphoma Anaplastic large cell lymphoma Angioimmunoblastic T-cell lymphoma B-cell prolymphocytic leukemia Burkitt’s lymphoma Chronic lymphocytic leukemia Chronic myelogenous leukemia Cutaneous T-cell lymphoma Diffuse large B-cell lymphoma Follicular lymphoma Hairy cell leukemia Hepatosplenic T-cell lymphoma Hodgkin’s lymphoma Hairy cell leukemia Intravascular large B-cell lymphoma Large granular lymphocytic leukemia Lymphoplasmacytic lymphoma Lymphomatoid granulomatosis Mantle cell lymphoma Marginal zone B-cell lymphoma Mast cell leukemia Mediastinal large B cell lymphoma Multiple myeloma/plasma cell neoplasm Myelodysplastic syndromes Mucosa-associated lymphoid tissue lymphoma Mycosis fungoides Nodal marginal zone B cell lymphoma Non-Hodgkin lymphoma Precursor B lymphoblastic leukemia Primary central nervous system lymphoma Most important cutaneous follicular lymphoma Major cutaneous immunocytoma Main effusion lymphoma Plasmablastic lymphoma Sézary syndrome Splenic marginal zone lymphoma T-cell prolymphocytic leukemia Basal-cell carcinoma Melanoma Skin cancer tumor (non-melanoma) Bronchial adenomas/carcinoids Small cell lung cancer Mesothelioma Non-small cell lung cancer Pleuropulmonary blastoma Laryngeal cancer Thymoma and thymic carcinoma AIDS-related cancers Kaposi sarcoma Epithelioid hemangioendothelioma (EHE) Desmoplastic small circular cell tumor Liposarcoma

cancer treatment

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The post What Everyone Must Know About CANCER TREATMENT appeared first on Treatment Guides.

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nirajsuri-blog · 6 years ago

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Stapes Surgery Hospital in Ahmedabad

Radiology represents a branch of medicine that deals with radiant energy in the diagnosis and treatment of diseases. This field can be divided into two broad areas – diagnostic radiology and interventional radiology. A physician who specializes in radiology is called radiologist. The outcome of an imaging study does not rely merely on the indication or the quality of its technical execution. Diagnostic radiology specialist represents the last link in the diagnostic chain, as they search for relevant image information to evaluate and finally support a sound diagnosis.

Stapes Surgery Hospital in Ahmedabad, Stapes Surgery Hospital in Gujarat, Ossiculoplasty Surgeon in Ahmedabad, Ossiculoplasty Doctor in Ahmedabad

Endoscopic Anterior Skull Base Surgery: Endoscopic endonasal surgery is a minimally invasive techniques used mainly for fixing brained defects & removing tumour in the anterior skull base.

FESS: Functional endoscopic sinus surgery (FESS) is a surgical treatment of sinusitis and nasal polyps, including bacterial, fungal, recurrent acute, and chronic sinus problems. FESS uses nasal endoscopes to restore drainage of the paranasal sinuses and ventilation of the nasal cavity. This procedure is generally used for inflammatory and infectious sinus disease.

CSF Rhinorrhoea

Endoscopic DCR: Endoscopic dacryocystorhinostomy (DCR) is used to treat patients diagnosed with lacrimal sac or nasolacrimal duct obstruction (NLDO). This can be caused by chronic stenosis of the nasolacrimal duct and can be congenital or acquired.

Endoscopic Septoplasty: Patients with a deviated septum may experience nasal congestion, nosebleeds and frequent or recurring sinus infections or ear pressure or plugged sensation in the ears as a result of their uneven nasal passages.

Our brains are naturally configured to process sound from two ears. This is called binaural hearing. Hearing with only one ear is much harder for us to do.

People who listen with both ears can tell intuitively where sounds are coming from. They instinctively identify which sounds are important and which can safely be ignored. As a result, they feel less vulnerable and more in control than those who hear with just one ear.

Binaural hearing is also important to help people hear in noisy conditions, such as listening to the teacher in the classroom, or having a conversation in a busy office. Hearing with two ears is how the brain separates the sounds you want, from ones you don��t.

Main advantages of binaural hearing:

» Abilities to localise sound

» Able to “tune- in” to sounds with background noise

» Having more natural sound with two listening ears.

http://www.drneerajsuri.com/other-surgery-for-deafness.php

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ayushman01 · 4 years ago

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Nose Disease in Dwarka

Diseases can be of any types whether it is nose, throat, ear , skin, tongue etc. Particularly if we talk about the nose disease in Dwarka, it could be allergies, nasal blockage, sinusitis, cold as well as difficulty while breathing because nasal passage is related to lungs which cause respiratory problems. The mucus cannot flow away and chronic sinusitis can develop. The causes of nasal diseases include a deviated septum, swollen nasal conchae, enlargement of the nasal conchae, polyps, chronic inflammatory rhinitis and, rarely, tumours. Due to the swelling of the nasal mucous membranes, the narrow openings of the paranasal sinuses are also affected and swell. The consequences are headaches, olfactory disturbances, watery eyes and inflammations in the paranasal sinuses.

nose disease in Dwarka, there are some nasal disorders like nasal obstructions , chronic sinusitis , sleep disordered breathing and snoring , nasal fractures called as broken nose . In sinus ,use X-rays or a CT scan to diagnose disease. Treatment in Dwarka involve antibiotics, decongestants, nasal steroid sprays, antihistamines and irrigations. But if still not treated by medication ,your doctor perform endoscopic sinus surgery (ESS). Second nose disease in Dwarka is deviated septum , blockage of one or both nostrils , nose congestion , noisy breathing during sleep could be a cause . Next disorder is nasal polyps , these are non cancerous growth on the lining of the nose which is happen due to inflammation and allergies. Surgical removal is solution for this . Bloody noses are caused when the tiny blood vessels in the nose break due to dry air, irritants, chemicals and various other factors. Minor infections at the opening of the nose is known as nasal vestibulitis, which produce pimples at the base of nasal hairs (folliculitis) and sometimes crusts around the nostrils. Bacitracin ointment or mupirocin ointment heals nasal vestibulitis. The ointment may need to be used for many weeks.

Other more serious infections result in boils in the nasal vestibule. Nasal furuncles may develop into infection under the skin at the tip of the nose.A person with a nasal furuncle usually takes an antibiotic by mouth and applies mupirocin ointment and also moist hot cloths 3 times a day for about 15 to 20 minutes at a time.

There are many services offered in Dwarka :-

Out-Patient Department (OPD) Services: The OPD is available 6 days a week and the process of admission is quick and simple. Services offered for nose disease in Dwarka are as follows :-

· Audiology

· Endoscopy

· Outpatient procedures

· Otology

· Neurotology

· Auditory Implantation

· Rhinology

· Laryngology

· Bronchoesophagology

· Pediatric otolaryngology

Thus, there are various hospitals and clinics where nose disease can be cured and treated with effective and economical way.

https://www.ayushmanhhs.in/

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saltyloverrebel · 7 years ago

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Reckeweg R49 Sinus Drops, Homeopathy Sinus Congestion Medicine

Reckeweg R49 Sinus Drops, Homeopathy Sinus Congestion Medicine treats signs of sinus infection and catarrh through a proprietary blend of several homeopathic herbs. R49 is also used to treat formation of polypus in children which is abnormal painless growth in inflamed tissue of the nasal mucosa due to allergies & asthmatic conditions. Symptoms include lack of smell (olfaction)and taste. …

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i-am-very-very-tired · 7 years ago

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International Journal of General Medicine Dove Press Chronic rhinosinusitis and emerging treatment options Patorn Piromchai, Pornthep Kasemsiri, [...], and Sanguansak Thanaviratananich Additional article information Abstract This review describes the epidemiology and various treatments in chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). Evidence for short-term use of systemic corticosteroids has been shown to be favorable in CRSwNP, but still limited in CRSsNP. Topical corticosteroids improve symptom scores in both CRS subgroups. The role of microbes in CRS is still controversial. Culture-directed antibiotics are recommended for CRSsNP with exacerbation. Long-term use of low dosage antibiotics is recommended for CRSsNP for their anti-inflammatory effects. Other emerging treatment options are also discussed. Keywords: rhinosinusitis, chronic, nasal polyps, therapy, sinus Clinical characteristics of chronic rhinosinusitis Rhinosinusitis is an inflammatory disease of the nasal and paranasal sinus mucosa. It is defined as chronic when it lasts longer than 3 months without complete symptom resolution. Diagnostic criteria consist of the presence of symptoms including purulent nasal discharge, nasal obstruction, facial pain/pressure/fullness, and/or decreased sense of smell plus either endoscopic findings of inflammation, purulent discharge or edema of the middle meatus or ethmoid region, polyps in the nasal cavity or the middle meatus, and/or radiographic imaging showing inflammation of the paranasal sinuses.1,2 Chronic rhinosinusitis (CRS) is further divided into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). As for the use in epidemiologic studies, CRS is defined as the presence of two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip) and/or facial pain/pressure and/or reduction or loss of smell for more than 12 weeks with validation by telephone or interview.1,3 The pathogenesis of CRS remains controversial. Multifactorial factors altering the host-environment interaction such as bacteria, fungi, viruses, allergens, or environmental toxins may trigger the inflammatory process. Epidemiology of chronic rhinosinusitis and associated complications CRS is a common health problem which significantly affects quality of life. CRS has a significant impact on patients in seven of eight domains of the 36-item short form health survey (SF-36).4 Patients have significantly higher bodily pain and decreased social function compared to other chronic diseases (congestive heart failure, angina, chronic obstructive pulmonary disease, and back pain) (P

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cbdoilforpain · 7 years ago

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Quiet Discoveries Lead to Fast Sinus Relief

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It's amazing what you can find when you start your search a little outside the bulls eye. While clicking through Magnetic Resonance Imaging research online, my colleagues and I found some intriguing scientific studies completely by accident!

What did we find? Well, let's just say if you've got a stuffy nose you should try magnets before sniffling through that bottle of nasal spray!

Did you know that every year, more than 35 million Americans suffer from sinusitis? It's one of the leading chronic diseases in the United States [1]. And it's no wonder, as bacteria, viruses, cigarette smoke, and allergens like pollen, mold, dust mite feces and pet dander are all common causes of this condition [2]. Unless you live in a bubble, there's really no escaping these tiny antagonists.

The sinuses are actually four pairs of hollow spaces in the bones of the face. Connected to the nose, air is allowed to flow in and out of these spaces. To help warm and filter the air, each sinus is lined with a mucous-producing membrane, called the mucosa [3].

Acute sinusitis occurs when the mucosa is irritated and inflamed. The small openings from the nose to the sinus cavities become congested (or even completely blocked), causing the facial pain and pressure most of us have experienced at some point in time. Mucus production is often increased as well, adding to the pressure, and causing that annoying runny nose symptom [3].

Many people turn to preventive methods like HEPA air filters, or frequent cleaning of carpets and bed sheets to reduce household allergens [4]. Decongestants, saline nasal sprays, and vaporizers are commonly used to treat the symptoms--but as you and I know, they take time to work.

This is where those studies come in. There's an interesting, but little known fact about the sinuses: they are magnetically sensitive.

Based on our own research and experiences with clients and health practitioners over the years, we've observed that sinus congestion is dramatically improved or completely relieved with the application of magnetic therapy. In fact, taking about 20-30 minutes on average, it's one of the conditions that biomagnetics alleviates quickest.

Until recently, though, we didn't have much research to back these findings (other than our own records). But, while sifting through online abstracts from MRI research, I happened to stumble upon this:

Dating back to 1983, a study was conducted to assess the influence of magnetic fields on the physiology and behavior of biological organisms, and to search for possible magnetic sources within the organisms themselves.

It was found that a wide range of life forms could detect and orient to magnetic fields. (Like having a built-in compass.) Results showed magnetic orientation by bacteria was due to the presence of particles of magnetite (ferric/ferrous oxide) within the organisms.

The same magnetic material was also found in bees, homing pigeons, dolphins and other organisms--including humans. More specifically, the researchers found that "the bones of the sphenoid/ethmoid sinus complex of humans are magnetic and contain deposits of ferric iron". (The sphenoid/ethmoid sinuses are located between the eyes and progress inward towards the back of the head [3].)

Refining our search, we were able to uncover other MRI studies confirming this finding. Here's a brief timeline of what was found:

1986 - "Magnetic Resonance Imaging [using a 1.5 Tesla (15,000 Gauss) magnet and a spin echo technique] has revealed a remarkably intense signal from abnormal tissue in the human paranasal sinuses. Inflammatory disease in the maxillary, sphenoid, ethmoid, and frontal sinuses has been detected and demonstrated with greater clarity than any other available technique."

1990 - A study conducted at the UCLA School of Medicine tested conditions affected by MRI field strength. Results illustrated that "magnetic susceptibility artifacts are prevalent on the boundary of air-containing paranasal sinuses".

1995 - Research at Uppsala University in Sweden discovered that "large, local magnetic field variations up to 3 parts per million were found in the human brain near interfaces between air or bone and brain tissues".

2002 - An Ohio State University study compared differences in magnetic field susceptibility at tissue interfaces in the human head. "Considerable magnetic field inhomogeneities were observed in the inferior frontal lobes and inferior temporal lobes, particularly near the sphenoid sinus and the temporal bones."

These four independent studies all relate to the notion that human sinuses are magnetically sensitive. When compared to other regions of the head, more intense magnetic field readings are seen, and conditions of inflammation are more easily observed.

So how does this lead to sinusitis relief?

Magnetic therapy is proven to be effective in reducing inflammation, a primary symptom of sinusitis. By reducing inflammation of the mucosa, mucous blockages can be drained and the sinus cavities reopened. This, allows you to breathe freely again, while eliminating the facial pain caused by pressure build-up.

When applied properly, magnetic therapy products can relieve sinus congestion in as little as 15 minutes. That's faster than any decongestant or vaporizer, lasts longer than most nasal sprays, and is completely free of any side effects (like dryness or burning). Not to mention, you won't need to worry about buying refills or possible addiction to certain nasal decongestants.

What Therion products work best to help relieve sinusitis?

The Eye & Sinus Mask is designed specifically for relief of your sinus congestion. Inside it has 28 neodymium magnets covering areas around your eyes, forehead and upper cheeks. (The magnetic field has an effective penetration depth up to 2.5 inches.) You can expect sinus and headache relief within 15-25 minutes of wearing it.

For even faster relief plus more restful sleep, Therion 's magnetic dual contour pillow is the perfect choice. The visco elastic (memory) foam is soft and comfortable, but also supportive. You'll actually feel it adjusting and conforming to the shape of your head and neck. It's ideal to use as a regular sleeping pillow, as the magnetic field reaches the pineal gland. This is a magnetically sensitive area in the brain that functions to induce sleep by secreting melatonin. (See the article "Having Trouble Sleeping" found in the Learning Center at http://www.therionresearch.com.

So before you open that box of 'non-drowsy' decongestants or reach for the nasal spray on your nightstand, give magnetic therapy a try. If it's fast acting with no side effects, and never needs a refill, what do you have to lose?

See you soon at http://www.therionresearch.com

SOURCES:

1 - Sinus News: Sinus Pressure

2 - Sinus News: Sinus Facts Overview

3 - The Sinus Treatment Center

4 - The Allergy Relief Center

1983 -- PubMed: Magnetic bones in human sinuses.

1986 -- PubMed: High-field magnetic resonance imaging of paranasal sinus inflammatory disease.

1990 -- PubMed: Effect of field strength on susceptibility artifacts in magnetic resonance imaging.

1995 -- PubMed: Measurements of magnetic field variations in the human brain using a 3D-FT multiple gradient echo technique.

2002 -- PubMed: Three-dimensional numerical simulations of susceptibility-induced magnetic field inhomogeneities in the human head.

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Post Source Here: Quiet Discoveries Lead to Fast Sinus Relief

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