#csf rhinorrhea

[drshalabhsharma1]

Understanding CSF Rhinorrhea: Causes, Symptoms, and Treatment

Cerebrospinal fluid (CSF) plays a crucial role in protecting the brain and spinal cord, acting as a cushion against injury and providing essential nutrients. However, when CSF leaks out of the nasal passages, a condition known as CSF rhinorrhea occurs, posing potential risks to health and requiring prompt medical attention. In this article, we delve into the causes, symptoms, and treatment options for CSF rhinorrhea.

What is CSF Rhinorrhea?

CSF rhinorrhea refers to the leakage of cerebrospinal fluid from the skull base into the nasal passages. This leakage can result from a tear or hole in the membranes surrounding the brain and spinal cord, typically caused by trauma, such as a head injury or surgery. In some cases, CSF rhinorrhea can also occur spontaneously without any apparent cause.

Causes of CSF Rhinorrhea:

Trauma: Head injuries, particularly those involving fractures to the skull base, can disrupt the integrity of the membranes that contain CSF, leading to leakage.

Surgery: Certain surgical procedures, such as those involving the sinuses or skull base, can inadvertently cause damage to the membranes, resulting in CSF rhinorrhea.

Congenital Abnormalities: Rarely, individuals may be born with defects in the skull base or the membranes surrounding the brain, predisposing them to CSF leakage.

Idiopathic: In some cases, the exact cause of CSF rhinorrhea remains unknown, and it may occur spontaneously without any preceding trauma or surgery.

Symptoms of CSF Rhinorrhea:

The hallmark symptom of CSF rhinorrhea is the persistent discharge of clear fluid from one or both nostrils. This fluid may increase with changes in position, such as bending forward, coughing, or straining. Other symptoms may include:

Headaches, particularly when lying down

Stiff neck

Sensation of fluid trickling down the throat

Recurrent or severe sinus infections

Taste of saltiness in the back of the throat

It is essential to differentiate CSF rhinorrhea from other causes of nasal discharge, such as allergies or viral infections. Unlike CSF, nasal secretions from these conditions are typically cloudy or colored.

Diagnosis and Treatment:

Diagnosing CSF rhinorrhea often involves a combination of medical history, physical examination, and diagnostic tests. Imaging studies, such as MRI or CT scans, can help identify the site and extent of CSF leakage. In some cases, a specialized test called beta-2 transferrin analysis may be performed on the nasal fluid to confirm the presence of CSF.

Once diagnosed, treatment aims to repair the site of CSF leakage and prevent future episodes. Depending on the cause and severity of the condition, treatment options may include:

Conservative Management: In cases of mild CSF rhinorrhea, conservative measures such as bed rest, elevation of the head, and avoidance of activities that increase intracranial pressure may be sufficient.

Surgical Repair: For persistent or recurrent CSF rhinorrhea treatment, surgical intervention may be necessary to repair the site of leakage. This may involve endoscopic techniques or open surgical procedures, depending on the location and extent of the defect.

CSF Shunting: In rare cases where surgical repair is not feasible or unsuccessful, a CSF shunt may be implanted to divert the flow of CSF away from the nasal passages.

Conclusion:

CSF rhinorrhea is a potentially serious condition that requires prompt medical evaluation and treatment. While it can occur due to various causes, timely diagnosis and appropriate management can help prevent complications and improve outcomes for affected individuals. If you experience persistent nasal discharge or other symptoms suggestive of CSF rhinorrhea, it is crucial to consult a healthcare professional for further evaluation and management.

[kghospital]

Best Neurosurgery Hospital in Coimbatore

At KG Hospital, the Best Neuro Surgery Hospital in Coimbatore, our Minimally Invasive Neurosurgery (MINS) program is at the forefront of modern neurosurgical care. Through the use of advanced technology and minimally invasive techniques, we ensure that patients receive the highest quality care with the least amount of disruption to the body. Our aim is to achieve the best outcomes for our patients while facilitating faster recovery and improved overall well-being.

Minimally invasive neurosurgery has revolutionized the way we treat conditions related to the brain and spine, enabling us to perform surgeries with smaller incisions, reduced blood loss, and minimal damage to surrounding tissues. The result is less postoperative discomfort, shorter hospital stays, and quicker returns to normal activities. At KG Hospital, we offer Best Brain Surgery solutions tailored to your needs.

State-of-the-Art Technology

Our Neuronavigation System plays a crucial role in enhancing the precision and safety of cranial and spinal surgeries. This real-time guidance system provides accurate tracking and visualization of the surgical area, ensuring our Best Neurosurgeons can navigate complex procedures effectively while minimizing risks. With this technology, we can treat a variety of conditions safely and efficiently, providing Best Neuro Treatment for our patients.

Comprehensive MINS Services

KG Hospital offers a wide range of minimally invasive neurosurgical procedures, each tailored to meet the unique needs of our patients. Below is a more detailed look at the services we offer:

Cranial Surgeries

● Head Injury Management: Traumatic brain injuries can be life-threatening and require immediate surgical intervention. Our team provides advanced surgical care using minimally invasive techniques to manage head injuries with the highest level of precision and minimal tissue disruption, ensuring Best Brain Surgery outcomes.

● Brain Tumor Surgery: When it comes to removing brain tumors, we use minimally invasive techniques to access the tumor site through small incisions. This reduces recovery time, minimizes complications, and preserves healthy brain tissue. We are known for offering Best Brain Tumor Treatment.

● Vascular Surgery and Coiling: We treat aneurysms and other vascular abnormalities in the brain using minimally invasive coiling techniques, which offer faster recovery and reduced risk of complications compared to traditional surgery.

● Endoscopic Skull Base Surgeries: Complex skull base tumors can be challenging to remove, but our advanced endoscopic procedures allow for precise access through small incisions, improving safety and reducing recovery times.

● Intraventricular Tumor Excision: Tumors within the brain’s ventricles can be difficult to access. Using cutting-edge technology, we can perform precise removal with minimal disruption to the surrounding structures.

● Endoscopic Third Ventriculostomy (ETV): This procedure is commonly used for patients with hydrocephalus. ETV is a safe and effective option that avoids the need for a shunt, offering long-term solutions without the risk of infection.

● Endoscopic CSF Rhinorrhea Repair: When cerebrospinal fluid leaks through the nasal cavity, an endoscopic repair can address the issue effectively without the need for open surgery.

● Endoscopic Corpus Callosotomy: For patients suffering from epilepsy, endoscopic corpus callosotomy can be performed to alleviate severe seizures while minimizing risk and recovery time.

● Craniosynostosis Correction: In infants, premature fusion of skull bones can result in abnormal head shapes. Our team provides minimally invasive correction to restore normal skull growth without the need for large incisions.

Spinal Surgeries

● Spinal Cord Tumor Surgery: Tumors within the spinal cord are delicate and require precision. We offer minimally invasive tumor removal to ensure that the spinal cord is protected while achieving optimal results.

● Surgery for Spinal Fractures: For patients with traumatic spinal injuries, our team provides comprehensive care, using minimally invasive techniques to stabilize the spine and restore function, often without the need for extensive surgery.

● Navigated Neuro-Spinal Surgery: Utilizing advanced neuronavigation technology, we perform spinal surgeries with high precision, improving safety and outcomes.

● Surgery for Tethered Cord Malformations: Tethered cord syndrome can cause debilitating symptoms. Our team is skilled in minimally invasive release techniques to relieve symptoms and improve quality of life.

Advanced Pain Management

● Microvascular Decompression for Trigeminal Neuralgia: Trigeminal neuralgia is a condition that causes intense facial pain. Using microvascular decompression, we can alleviate nerve compression and provide long-lasting pain relief, offering Best Neuro Treatment for our patients.

Why Choose KG Hospital for MINS?

● Advanced Technology: At KG Hospital, the Best Neuro Surgery Hospital in Coimbatore, we utilize the latest neuronavigation systems, endoscopic equipment, and other cutting-edge tools to improve surgical precision and patient outcomes.

● Expert Team: Our Best Neurosurgeons are highly trained in minimally invasive techniques, ensuring that each patient receives the safest, most effective treatment possible.

● Comprehensive Care: From diagnosis and surgery to rehabilitation, our multidisciplinary team supports every step of your journey toward recovery.

● Faster Recovery: With minimally invasive procedures, patients often experience reduced postoperative pain, shorter hospital stays, and quicker recovery, allowing them to return to their daily lives sooner.

● Patient-Centered Care: At KG Hospital, our focus is not only on advanced surgical techniques but also on providing patient-centered care. We prioritize the comfort, safety, and emotional well-being of our patients throughout their treatment journey.

● Multidisciplinary Collaboration: Neurosurgery often requires the expertise of various specialists. Our multidisciplinary team, which includes neurologists, neurosurgeons, anesthesiologists, and rehabilitation therapists, works closely together to provide a comprehensive treatment plan tailored to each patient’s needs.

● Post-Surgical Rehabilitation and Support: Recovery is a crucial part of the treatment process. Post-surgical rehabilitation is offered through specialized programs that help patients regain strength, mobility, and functionality.

● High Success Rate with MINS Procedures: Thanks to our cutting-edge technology, skilled neurosurgeons, and patient-focused approach, KG Hospital boasts an exceptionally high success rate with minimally invasive neurosurgery. Our patients enjoy quicker recovery, fewer complications, and better long-term results compared to traditional surgical methods.

Learn more Best Neurosurgeons in the Coimbatore Area

You can reach me at

Dr. Rajkumar S

MBBS, M. Ch (Neurosurgery)

Chief Minimally Invasive Neurosurgeon, KG Hospital

[sushrutbrainandspine]

Symptoms of CSF Rhinorrhea Management:

1. Loss of sense of smell (anosmia).

2. Blurred or double vision (diplopia).

3. Changes in hearing or hearing loss.

4. Pulsatile tinnitus.

5. Seizures.

Contact for more information:-

• Phone: +91 9810324401

• Website :- www.thebrainandspine.com

[kims-trivandrum]

Best ENT Hospitals in TrivandrumBest ENT Hospitals in TrivandrumBest ENT Hospitals in Trivandrum | Sinus Infection Treatment | KIMSHEALTH Hospital

The ENT department at KIMSHEALTH care gives comprehensive care for various conditions affecting Ear, Nose and throat. Our department is well equipped with highly qualified and experienced doctors and modern equipment.

Our surgical subspecialty deals with the surgical and medical management of conditions of the head and neck. “Advanced skull base surgery including craniofacial resection, CSF leak repair and extended endoscopic surgeries. we are routinely conducting cochlear implantation for hearing-impaired patients(adult and pediatric) and also micro otologic surgeries including Stapedotomy. We have specialised laryngology services dealing with comprehensive treatment for voice disorders, swallowing disorders and upper aerodigestive diseases.

Procedures & TreatmentsBest ENT Hospitals in Trivandrum

● Unique Procedures: Minimal blood loss adenoidectomy,

● Tonsillectomy cochlear implants,

● Endoscopic and microscopic ear surgeries.

● Functional endoscopic sinus for sinusitis

● Fungal infections and tumours

● Endoscopic nasal polypectomy

● Endoscopic and microscopic surgeries of the ear

● Endoscopic optic nerve decompression

● Endoscopic Sinus Surgery

● Microscopic Ear Surgeries

● Hearing Improvement Surgery

● Stapedotomy

● Endoscopic surgery for nose & sinus tumour

● Cochlear Implant

● Eardrum repair procedures

● Endoscopic lacrimal sac & orbit surgeries

● Endoscopic pituitary tumour removal & other skull base surgeries

● Endoscopic CSF rhinorrhea repair

● Coblation adenoidectomy

● Coblation tonsillectomy

● Audiology Lab

● Surgical Intervention for Snoring and Sleep Apnea

[jcrmhscasereports]

Delayed onset of intracerebral tension pneumocephalus 2 years after an anterior skull base fracture: Case report by Sokchan Sim in Journal of Clinical Case Reports Medical Images and Health Sciences

ABSTRACT

Pneumocephalus, the presence of air within the cranial cavity, is most commonly caused by trauma, tumor, infection and fistulation into the intracranial cavity or secondary to neurosurgery. We describe an unusually delayed neurological deficit from intracerebral tension pneumocephalus, 2 years following a head trauma with anterior skull base fracture. A 22-year-old man presented to our neurosurgical consultation with recurrent seizures and progressive right hemiparesis. The brain CT scan without iv contrast revealed an intracerebral tension pneumocephalus in the left frontal lobe, and a persistent hole in the left anterior frontal skull base connecting to pneumocephalus. We performed a left frontal craniotomy, and dura-plasty using galea flap to cover the skull-base bone defect. The patient has recovered gradually from his motor deficit after this surgery, finally to the level that he could play his favorite guitar. This is a rare case of a delayed development neurological deficit due to pneumocephalus from a “ball-valve” effect secondary to an old anterior skull base fracture.

Key words: Pneumocephalus, hemiparesis, craniotomy, dura-plasty

INTRODUCTION

Pneumocephalus is an air entrapment in the cranial cavity. It is commonly seen after head and facial trauma, ear infections, and tumors of the skull base or neurosurgical interventions. In some extremely rare cases, it happens spontaneously. Pneumocephalus is a complication of head injury in 3.9–9.7% of the cases. The accumulation of intracranial air can be acute (<72 h) or delayed (≥72 h). In tension pneumocephalus, the continuous accumulation of intracranial air is thought to be caused by a “ball-valve” mechanism. In turn, this may lead to a mass effect on the brain, with subsequent neurological deterioration and signs of herniation. Delayed tension pneumocephalus is extremely rare and requires proper neurosurgical attention. Surgical treatment involves aspiration of air into a syringe and closure of the dura defect through a cranial surgery.

CASE REPORT

A 22-year-old male presented to our neurosurgical consultation with chronic headaches, progressive right-sided weakness and occasional seizures. Two years prior to this visit, he suffered a severe traumatic brain injury by motorcycle accident. He had lost his consciousness for three days, and hospitalized in a provincial hospital for two weeks without any surgical intervention. He was then discharged home with persistent rhinorrhea for 10 months before it ceased spontaneously. 18 months after his injury, this patient began having progressive weakness on his right side of the body, and some episodes of seizures. He also reported occasional headaches.  He was otherwise healthy before this accident. On examination, the young man had full consciousness, was alert and oriented. He had grade 3 out of 5 hemiparesis on his right side. A brain CT scan without iv contrast was obtained revealing a large pneumocephalus in the left frontal lobe. We noted a continuity of the air and the anterior skull base defect. (Figure.1)

CSF examination and culture were negative for infection, as well as the nasal swab.

Figure 1: A. Axial view of the CT scan showing hypodensity area in the left frontal lobe, pneumocephalus. B. Sagittal view presenting the large air space with its connection to the frontal skull base. C. Coronal view showing the bony defect of the anterior skull base.

We decided to perform the surgery by doing bi-coronal approach for a left frontal craniotomy and repair of the dura defect on the frontal skull base using the pedunculated galea flap. (Figure.2)

Figure 2 :A. Bi-coronal incision with preservation of large frontal galea. B. Galea still attached to the frontal base is lifted up.

The surgery went well without any complication. The post-operative course was without any significant event. No sign of infection was noticed. The patient recovered gradually from his motor deficit on his right side. The post-operative CT scan showed complete resorption of the intracerebral pneumocephalus. (Figure.3). Intravenous prophylactic antibiotics were used to prevent meningitis.

Figure 3: Post-operative CT scan showing no hypodensity area in the left frontal lobe, complete disappearance of the pneumocephalus A. Axial view B. Sagittal view C. Coronal view. Noted the small bone defect from craniotomy site.

At one-month follow-up, his motor function on the right body became normal that he could play his favorite guitar again. At three-month follow up, he had an episode of new seizures, we controlled his seizures with anti-epileptic drugs for two years afterward.

DISCUSSION

The term “pneumocephalus” was first coined more than one century ago by Luckett and Wolff independently. The term “tension pneumocephalus” was proposed by Ectors, Kessler, and Stern in 1962. Pneumocephalus or also known as pneumatocele or intracranial aerocele is defined as the presence of air in the epidural, subdural, or subarachnoid space, within the brain parenchyma or ventricular cavities. It is a complication of head injury in 3.9 – 9.7% cases. It also appears after supratentorial craniotomy surgery. The accumulation of intracranial air can be acute, less than 72 hours, or delayed, more than 72 hours.

Two mechanisms have been proposed to explain pneumocephalus. In the first mechanism, the pathophysiologic process starts with Cerebro-Spinal Fluid (CSF) leak in the presence of associated discontinuity of the cranium and leptomeningeal disruption. Subsequent development of relative negative Intra-cranial Pressure (ICP) results in a sufficient “vacuum effect” to cause additional accumulation of air within the cranial cavity. This air is generally distributed in the subarachnoid space. The second mechanism is based on the presence of a “one-way valve” at the site of the leptomeningeal tear. In this case, we found on the CT scan images a bone and dura defect in the left anterior skull base, in connection with intracerebral air collection. The air went in, and was trapped inside the frontal cerebral parenchyma. Slowly it became larger and more significant, putting mass effect into the brain tissue of the patient’s frontal lobe. The patient had experienced rhinorrhea (CSF leak through the nose) after the head trauma but disappeared spontaneously after 10 months. He then developed right hemiparesis and experienced episodes of seizures. Recurrent headaches were also a main complaint. These signs and symptoms were described in previous reports about tension pneumocephalus.

The diagnostic imaging for pneumocephalus is CT scan. “Mount Fuji sign” is described when there are bilateral hypoattenuation collections, causing compression and separation of the frontal lobes on CT scan. In our case, an intraparenchymal air-filled long cavity was seen in the left frontal lobe, with its tip connecting to the frontal skull base.

Most cases of pneumocephalus tend to resolve spontaneously with conservative management. Nonoperative management involves oxygen therapy, maintaining the patient supine or in Trendelenburg position, prophylactic antimicrobial therapy (especially in posttraumatic cases), adequate analgesia, frequent neurologic checks, and repeated CT scans. The use of continuous high concentration inspired oxygen as a treatment modality for traumatic pneumocephalus may have certain theoretical benefits. Prompt decompression of intracranial air is the initial treatment of symptomatic pneumocephalus. The principles of subsequent treatment parallel those for a CSF leak. It is important to identify the site where the communication between the air cavity and the external environment occurs. If the site can be identified, the passage should be sealed off, thereby decreasing the possibility of worsening or recurrent pneumocephalus. Effective therapy of tension pneumocephalus through a controlled decompression using a closed water-seal drainage system has also been described. In our case, we performed a full scale left frontal craniotomy to evacuate air from the intraparenchymal cavity, closure of the skull base defect by using pedunculated galea flap, re-enforced by bio-glue as a sealing material.

CONCLUSION

Tension pneumocephalus is a life-threatening neurosurgical case. Although the development of this massive intracerebral air trap was delayed in this case, it caused significant neurological deficit. The patients who suffer from head trauma, with CSF leak should be subject for long term follow up.

Disclosure: Nothing to disclose, and there was no conflict of interest among the authors.

Research ethics: Informed consent has been obtained from the patient.

For more information: https://jmedcasereportsimages.org/about-us/

For more submission : https://jmedcasereportsimages.org/

[didanawisgi]

2020 Yale-G’s Monthly Clinical Updates According to www.uptodate.com

(As of 2020-11-12, updated in Yale-G’s 6th-Ed Kindle Version; will be emailed to buyers of Ed6 paper books)

       Chapter 1: Infectious Diseases

Special Viruses: Coronaviruses

     Coronaviruses are important human and animal pathogens, accounting for 5-10% community-acquired URIs in adults and probably also playing a role in severe LRIs, particularly in immunocompromised patients and primarily in the winter. Virology: Medium-sized enveloped positive-stranded RNA viruses as a family within the Nidovirales order, further classified into four genera (alpha, beta, gamma, delta), encoding 4-5 structural proteins, S, M, N, HE, and E; severe types: severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV), and novel coronavirus (2019-nCoV, which causes COVID-19). Routes of transmission: Similar to that of rhinoviruses, via direct contact with infected secretions or large aerosol droplets. Immunity develops soon after infection but wanes gradually over time. Reinfection is common. Clinical manifestations: 1. Coronaviruses mostly cause respiratory symptoms (nasal congestion, rhinorrhea, and cough) and influenza-like symptoms (fever, headache). 2. Severe types (2019-nCoV, MERS-CoV, and SARS-CoV): Typically with pneumonia–fever, cough, dyspnea, and bilateral infiltrates on chest imaging, and sometimes enterocolitis (diarrhea), particularly in immunocompromised hosts (HIV+, elders, children). 3. Most community-acquired coronavirus infections are diagnosed clinically, although RT-PCR applied to respiratory secretions is the diagnostic test of choice.              

Treatment: 1. Mainly consists of ensuring appropriate infection control and supportive care for sepsis and acute respiratory distress syndrome. 2. In study: Chloroquine showed activity against the SARS-CoV, HCoV-229E, and HCoV-OC43 and remdesivir against 2019-nCoV. Dexamethasone may have clinical benefit.

Prevention: 1. For most coronaviruses: The same as for rhinovirus infections, which consist of handwashing and the careful disposal of materials infected with nasal sec retions. 2. For novel coronavirus (2019-nCoV), MERS-CoV, and SARS-CoV: (1) Preventing exposure by diligent hand washing, respiratory hygiene, and avoiding close contact with live or dead animals and ill individuals. (2) Infection control for suspected or confirmed cases: Wear a medical mask to contain their respiratory secretions and seek medical attention; standard contact and airborne precautions, with eye protection.

      Hepatitis A: HAV vaccine is newly recommended to adults at increased risk for HAV infection (substance use treatment centers, group homes, and day care facilities for disabled persons), and to all children and adolescents aged 2 to 18 years who have not previously received HAV vaccine.

      Hepatitis C: 8-week glecaprevir-pibrentasvir is recommended for chronic HCV infection in treatment-naive patients. In addition to the new broad one-time HCV screening (17-79 y/a), a repeated screening in individuals with ongoing risk factors is suggested.

      New: Lefamulin is active against many common community-acquired pneumonia pathogens, including S. pneumoniae, Hib, M. catarrhalis, S. aureus, and atypical pathogens.  

      New: Cefiderocol is a novel parenteral cephalosporin that has activity against multidrug-resistant gram-negative bacteria, including carbapenemase-producing organisms and Pseudomonas aeruginosa resistant to other beta-lactams. It’s reserved for infections for which there are no alternative options.

      New: Novel macrolide fidaxomicin is reserved for treating the second or greater recurrence of C. difficile infection in children.       Vitamin C is not beneficial in adults with sepsis and ARDS.    

      Chapter 2: CVD

      AF: Catheter ablation is recommended to some drug-refractory, paroxysmal AF to decrease symptom burden. In study: Renal nerve denervation has been proposed as an adjunctive therapy to catheter ablation in hypertensive patients with AF. Alcohol abstinence lowers the risk of recurrent atrial fibrillation among regular drinkers.

VF: For nonshockable rhythms, epinephrine is given as soon as feasible during CPR, while for shockable rhythms epinephrine is given after initial defibrillation attempts are unsuccessful. Avoid vasopressin use.

All patients with an acute coronary syndrome (ACS) should receive a P2Y12 inhibitor. For patients undergoing an invasive approach, either prasugrel or ticagrelor has been preferred to clopidogrel. Long-term antithrombotic therapy in patients with stable CAD and AF has newly been modified as either anticoagulant (AC) monotherapy or AC plus a single antiplatelet agent.

      Long-term antithrombotic therapy (rivaroxaban +/- aspirin) is recommended for patients with AF and stable CAD. Ticagrelor plus aspirin is recommended for some patients with CAD and diabetes.

VTE (venous thromboembolism): LMW heparin or oral anticoagulant edoxaban is the first-line anticoagulants in patients with cancer-associated VTE.

Dosing of warfarin for VTE prophylaxis in patients undergoing total hip or total knee arthroplasty should continue to target an INR of 2.5.

     Chapter 3: Resp. Disorders

Asthma: Benralizumab is an IL-5 receptor antibody that is used as add-on therapy for patients with severe asthma and high blood eosinophil counts.

Recombinant GM-CSF is still reserved for patients who cannot undergo, or who have failed, whole lung lavage.

Pulmonary embolism (PE): PE response teams (PERT, with specialists from vascular surgery, critical care, interventional radiology, emergency medicine, cardiac surgery, and cardiology) are being increasingly used in management of patients with intermediate and high-risk PE.

Although high-sensitivity D-dimer testing is preferred, protocols that use D-dimer levels adjusted for pretest probability may be an alternative to unadjusted D-dimer in patients with a low pretest probability for PE.

     Non-small cell lung cancer (NSCLC): Newly approved capmatinib is for advanced NSCLC associated with a MET mutation, and selpercatinib for those with advanced RET fusion-positive. Atezolizumab was newly approved for PD-L1 high NSCLC.

Circulating tumor DNA tests for cancers such as NSCLC are increasingly used as “liquid biopsy”. Due to its limited sensitivity, NSCLC patients who test (-) for the biomarkers should undergo tissue biopsy.

Cystic Fibrosis (CF): Tx: CFTR modulator therapy (elexacaftor-tezacaftor-ivacaftor) is recommended for patients ≥12 years with the F508del variant.

Vitamin E acetate has been implicated in the development of electronic-cigarette, or vaping, product use associated lung injury.

     Chapter 4: Digestive and Nutritional Disorders

     Comparison of Primary Biliary Cholangitis (PBC) and Primary Sclerosing Cholangitis (PSC):

     Common: They are two major types of chronic cholestatic liver disease, with fatigue, pruritus, obstructive jaundice, similar biochemical tests of copper metabolism, overlapped histology (which is not diagnostic), destructive cholangitis, and both ultimately result in cirrhosis and hepatic failure. (1) PBC: Mainly in middle-aged women, with keratoconjunctivitis sicca, hyperpigmentation, and high titer of antimitochondrial Ab (which is negative for PSC). (2) PSC: Primarily in middle-aged men, with chronic ulcerative colitis (80%), irregular intra- and extra-hepatic bile ducts, and anti-centromere Ab (+).

      CRC: Patients with colorectal adenomas at high risk for subsequent colorectal cancer (CRC) (≥3 adenomas, villous type with high-grade dysplasia, or ≥10 mm in diameter) are advised short follow-up intervals for CRC surveillance. Pembrolizumab was approved for the first-line treatment of patients with unresectable or metastatic DNA mismatch repair (dMMR) CRC.

      UC and CRC: Patients with extensive colitis (not proctitis or left-sided colitis) have increased CRC risk.

      Eradication of H. pylori: adding bismuth to clarithromycin-based triple therapy for patients with risk factors for macrolide resistance.

      Thromboelastography and rotational thromboelastometry are bedside tests recommended for patients with cirrhosis and bleeding.

      Pancreatic cancer: Screening for patients at risk for hereditary pancreatic cancer (PC): Individuals with mutations in the ataxia-telangiectasia mutated gene and one first-degree relative with PC can be screened with endoscopic ultrasound and/or MRI/magnetic retrograde cholangiopancreatography.

      Olaparib is recommended for BRCA-mutated advanced pancreatic cancer after 16 weeks of initial platinum-containing therapy.

      HCC (unresectable): New first-line therapy is a TKI (sorafenib or sunitinib) or immune checkpoint inhibitor atezolizumab plus bevacizumab, +/- doxorubicin. Monitor kidney toxicity for these drugs.

      UC: Ustekinumab (-umab) anti-interleukin 12/23 antibody, is newly approved for the treatment of UC.

      Crohn disease: The combination of partial enteral nutrition with the specific Crohn disease exclusion diet is a valuable alternative to exclusive enteral nutrition for induction of remission.

      Obesity: Lorcaserin, a 5HT2C agonist that can reduce food intake, has been discontinued in the treatment of obesity due to increased malignancies (including colorectal, pancreatic, and lung cancers).

      Diet and cancer deaths: A low-fat diet rich in vegetables, fruits, and grains experienced fewer deaths resulted from many types of cancer.

      Note that H2-blockers (-tidines) are no longer recommended due to the associated carcinogenic N-nitrosodimethylamine.

      Gastrointestinal Stromal Tumors (GIST):

      GIST is a rare type of tumor that occurs in the GI tract, mostly in the stomach (50%) or small intestine. As a sarcoma, it’s the #1 common in the GI tract. It is considered to grow from specialized cells in the GI tract called interstitial cells of Cajal, associated with high rates of malignant transformation.

Clinical features and diagnosis: Most GISTs are asymptomatic. Nausea, early satiety, bloating, weight loss, and signs of anemia may develop, depending on the location, size, and pattern of growth of the tumor. They are best diagnosed by CT scan and mostly positive staining for CD117 (C-Kit), CD34, and/or DOG-1.

Treatment: Approaches include resection of primary low-risk tumors, resection of high-risk primary or metastatic tumors with a tyrosine kinase inhibitor (TKI) imatinib for 12 months, or if the tumor is unresectable, neoadjuvant imatinib followed by resection. Radiofrequency ablation has shown to be effective when surgery is not suitable. Newer therapies of ipilimumab, nivolumab, and endoscopic ultrasound alcohol ablation have shown promising results. Avapritinib or ripretinib (new TKI) is recommended for advanced unresectable or metastatic GIST with PDGFRA mutations.

      Anal Cancer:

Anal cancer is uncommon and more similar to a genital cancer than it is to a GI malignancy by etiology. By histology, it is divided into SCC (#1 common) and adenocarcinoma. Anal cancer (particularly SCC among women) has increased fast over the last 30 years and may surpass cervical cancer to become the leading HPV-linked cancer in older women. A higher incidence has been associated with HPV/HIV infection, multiple sexual partners, genital warts, receptive anal intercourse, and cigarette smoking. SCCs that arise in the rectum are treated as anal canal SCCs.

Clinical features and diagnosis: 1. Bleeding (#1) and itching (often mistaken as hemorrhoids). Later on, patients may develop focal pain or pressure, unusual discharges, and lump near the anus, and changes in bowel habits. 2. Diagnosis is made by a routine digital rectal exam, anoscopy/proctoscopy plus biopsy, +/- endorectal ultrasound.

Treatment: Anal cancer is primarily treated with a combination of radiation, chemotherapy, and surgery—especially for patients failing the above therapy or for true perianal skin cancers.

     Chapter 5: Endocrinology

      Diabetes (DM):       Liraglutide can be added as a second agent for type-2 DM patients who fail monotherapy with metformin or as a third agent for those who fail combination therapy with metformin and insulin.       Metformin is suggested to prevent type 2 DM in high-risk patients in whom lifestyle interventions fail to improve glycemic indices.       Metabolic (bariatric) surgery improves glucose control in obese patients with type 2 DM and also reduce diabetes-related complications, such as CVD.       Teprotumumab, an insulin-like growth factor 1 receptor inhibitor, can be used for Graves’ orbitopathy if corticosteroids are not effective. Subclinical hypothyroidism should not be routinely treated (with T4) in older adults with TSH <10 mU/L.

        Chapter 6: Hematology & Immunology

       Anticoagulants: Apixaban is preferred to warfarin for atrial fibrillation with osteoporosis because it lowers the risk of fracture. Rivaroxaban is inferior to warfarin for antiphospholipid syndrome.

      Cancer-associated VTE: LMW heparin or oral edoxaban is the first-line anticoagulant prophylaxis.

      NH-Lymphoma Tx: New suggestion is four cycles of R(rituximab)-CHOP for limited stage (stage I or II) diffuse large B cell non-Hodgkin lymphoma (DLBCL) without adverse features. New suggestions: selinexor is for patients with ≥2 relapses of DLBCL, and tafasitamab plus lenalidomide is for patients with r/r DLBCL who are not eligible for autologous HCT.

      Chimeric antigen receptor (CAR)-T (NK) immunotherapy is newly suggested for refractory lymphoid malignancies, with less toxicity than CAR-T therapy. Polatuzumab + bendamustine + rituximab (PBR) is an alternative to CAR-T, allogeneic HCT, etc. for multiply relapsed diffuse large B-C NHL.

      Refractory classic Hodgkin lymphoma (r/r cHL) is responsive to immune checkpoint inhibition with pembrolizumab or nivolumab, including those previously treated with brentuximab vedotin or autologous transplantation.

      Mantle cell lymphoma: Induction therapy is bendamustine + rituximab or other conventional chemoimmunotherapy rather than more intensive approaches. CAR-T cell therapy is for refractory mantle cell lymphoma.

      AML: Gilteritinib is a new alternative to intensive chemotherapy for patients with FLT3-mutated r/r AML.

      Oral decitabine plus cedazuridine is suggested for MDS and chronic myelomonocytic leukemia.  

      Multiple myeloma (MM): Levofloxacin prophylaxis is suggested for patients with newly diagnosed MM during the first three months of treatment. For relapsed MM: Three-drug regimens (daratumumab, carfilzomib, and dexamethasone) are newly recommended.

      Transplantation: As the transplant waitlist continues to grow, there may be an increasing need of HIV-positive to HIV-positive transplants.

      Porphyria:       Porphyria is a group of disorders (mostly inherited) caused by an overaccumulation of porphyrin, which results in hemoglobin and neurovisceral dysfunctions, and skin lesions.       Clinical types, features, and diagnosis:  I. Acute porphyrias: 1. Acute intermittent porphyria: Increased porphobilinogen (PBG) causes attacks of abdominal pain (90%), neurologic dysfunction (tetraparesis, limb pain and weakness), psychosis, and constipation, but no rash. Discolored urine is common. 2. ALA (aminolevulinic acid) dehydratase deficiency porphyria (Doss porphyria): Sensorimotor neuropathy and cutaneous photosensitivity. 3. Hereditary coproporphyria: Abdominal pain, constipation, neuropathies, and skin rash. 4. Variegate porphyria: Cutaneous photosensitivity and neuropathies.  II. Chronic porphyrias: 1. Erythropoietic porphyria: Deficient uroporphyrinogen III synthase leads to cutaneous photosensitivity characterized by blisters, erosions, and scarring of light-exposed skin. Hemolytic anemia, splenomegaly, and osseous fragility may occur. 2. Cutaneous porphyrias–porphyria cutanea tarda: Skin fragility, photosensitivity, and blistering; the liver and nervous system may or may not be involved.  III. Lab diagnosis: Significantly increased ALA and PBG levels in urine have 100% specificity for most acute porphyrias. Normal PBG levels in urine can exclude acute porphyria.       Treatment: 1. Acute episodes: Parenteral narcotics are indicated for pain relief. Hemin (plasma-derived intravenous heme) is the definitive treatment and mainstay of management. 2. Avoidance of sunlight is the key in treating cutaneous porphyrias. Afamelanotide may permit increased duration of sun exposure in patients with erythropoietic protoporphyria.

 Chapter 7: Renal & UG

Membranous nephropathy (MN): Rituximab is a first-line therapy in patients with high or moderate risk of progressive disease and requiring immunosuppressive therapy.

      Diabetes Insipidus (DI): Arginine-stimulated plasma copeptin assays are newly used to diagnose central DI and primary polydipsia, often alleviating the need for water restriction, hypertonic saline, and exogenous desmopressin.

      Prostate cancer: Enzalutamide (new androgen blocker) is available for metastatic castration-sensitive prostate cancer. Cabazitaxel, despite its great toxicity, is suggested as third-line agent for metastatic prostate cancer. Either early salvage RT or adjuvant RT is acceptable after radical prostatectomy for high-risk disease.

      UG cancers: Nivolumab plus ipilimumab is suggested in metastatic renal cell carcinoma for long-term survival.

      Enfortumab vedotin is suggested in locally advanced or metastatic urothelial carcinoma. Maintenance avelumab is recommended with other chemotherapy in advanced urothelial bladder cancer. Pyelocalyceal mitomycin is suggested for low-grade upper tract urothelial carcinomas.

Chapter 8: Rheumatology

Janus kinase (JAK) inhibitors (upadacitinib, filgotinib) are new options for active, resistant RA and ankylosing spondylitis.

Graves’ orbitopathy: new therapy–teprotumumab, an insulin-like growth factor 1 receptor inhibitor.

Chapter 9: Neurology & Special Senses

Epilepsy: Cenobamate, a novel tetrazole alkyl carbamate derivative that inhibits Na-channels, provides a new treatment option for patients with drug-resistant focal epilepsy. A benzodiazepine plus either fosphenytoin, valproate, or levetiracetam is recommended as the initial treatment of generalized convulsive status epilepticus.

Migraine: Lasmiditan is a selective 5H1F receptor agonist that lacks vasoconstrictor activity, new therapy for patients with relative contraindications to triptans due to cardiovascular risk factors.

      Stroke: New recommendation for cerebellar hemorrhages >3 cm in diameter is surgical evacuation.       TBI: Antifibrolytic agent tranexamic acid is newly recommended for moderate and severe acute traumatic brain injury (TBI).

      Ofatumumab is a new agent that may delay progression of MS.

 Chapter 10: Dermatology

 Minocycline foam is a new topical drug option for moderate to severe acne vulgaris.

       Melanloma: Nivolumab plus ipilimumab in metastatic melanoma has confirmed long-term survival. With sun-protective behavior, melanoma incidence is decreasing.

       New: Tazemetostat is suggested in patients with locally advanced or metastatic epithelioid sarcoma (rare and aggressive) ineligible for complete surgical resection.

       Psoriasis: New therapies for severe psoriasis and psoriatic arthritis: a TNF-alpha inhibitor (infliximab or adalimumab, golimumab) or IL-inhibitor (etanercept or ustekinumab) is effective. Ixekizumab is a newly approved monoclonal antibody against IL-17A. Clinical data support vigilance for signs of symptoms of malignancy in patients with psoriasis.

     Chapter 11: GYH

      Breast cancer:        Although combined CDK 4/6 and aromatase inhibition is an effective strategy in older adults with advanced receptor-positive, HER2-negative breast cancer, toxicities (myelosuppression, diarrhea, and increased creatinine) should be carefully monitored. SC trastuzumab and pertuzumab is newly recommended for HER2-positive breast cancer.

      Whole breast irradiation is suggested for most early-stage breast cancers treated with lumpectomy. Accelerated partial breast irradiation can be an alternative for women ≥50 years old with small (≤2 cm), hormone receptor-positive, node-negative tumors.

      Endocrine therapy is recommended for breast cancer prevention in high-risk postmenopausal women.

      Uterine fibroids: Elagolix (oral gonadotropin-releasing hormone antagonist) in combination with estradiol and norethindrone is for treatment of heavy menstrual bleeding (HMB) due to uterine fibroids.

      Chapter 12: OB

      Table 12-6: Active labor can start after OS > 4cm, and 6cm is relatively more acceptable but not a strict number.

      Table 12-7: Preeclampsia is a multisystem progressive disorder characterized by the new onset of hypertension and proteinuria, or of hypertension and significant end-organ dysfunction with or without proteinuria, in the last half of pregnancy or postpartum. Once a diagnosis of preeclampsia is established, testing for proteinuria is no longerdiagnostic or prognostic. “proteinuria>5g/24hours” may only indicate the severity.

      Mole: For partial moles, obtain a confirmatory hCG level one month after normalization; for complete moles, reduce monitoring from 6 to 3 months post-normalization.

      Chapter 14: EM

SHOCK RESUSCITATION

Emergency treatment—critical care!

“A-B-C”: Breathing: …In mechanically ventilated adults with critical illness in ICU, intermittent sedative-analgesic medications (morphine, propofol, midazolam) are recommended.

 Chapter 15: Surgery

      Surgery and Geriatrics: Hemiarthroplasty is a suitable option for patients who sustain a displaced femoral neck fracture.

    Chapter 16: Psychiatry

     Depression: Both short-term and maintenance therapies with esketamine are beneficial for treatment-resistant depression.

Schizophrenia: Long-term antipsychotics may decrease long-term suicide mortality.

Narcolepsy: Pitolisant is a novel oral histamine H3 receptor inverse agonist used in narcolepsy patients with poor response or tolerate to other medications. Oxybate salts, a lower sodium mixed-salt formulation of gamma hydroxybutyrate is for treatment of narcolepsy with cataplexy.

     Chapter 17: Last Chapter

PEARLS—Table 17-9:  Important Immunization Schedules for All (2020, USA)

Vaccine                 Birth       2M          4M          6M          12-15M                 2Y          4-6Y       11-12Y       Sum

HAV                                                                                       1st                          2nd (2-18Y)                            2 doses

HBV                      1st           2nd                        3rd (6-12M)                                                                             3 doses

DTaP                                    1st            2nd         3rd          4th (15-18M)                        5th                             + Td per 10Y

IPV                                       1st           2nd         3rd (6-18M)                                         4th                             4 doses

Rotavirus                            1st           2nd                                                                                                         2 doses

Hib                                       1st           2nd         (3rd)       (3-4th)                                                                    3-4 doses

MMR                                                                                    1st                                         2nd                              2 doses

Varicella                                                                              1st                                         2nd                        + Shingles at 60Y

Influenza                                                            1st (IIV: 6-12Y; LAIV: >2Y                (2nd dose)               1-2 doses annually

PCV                                     1st           2nd         3rd          4th                                                                        PCV13+PPSV at 65Y

MCV (Men A, B)                                                                                                                                1st         Booster at 16Y

HPV                      9-12Y starting: <15Y: 2 doses (0, 6-12M); >15Y or immunosuppression: 3 doses (0, 2, 6M).

Chapter 17 HYQ answer 22: No routine prostate cancer screening (including PSA) is recommended and answer “G” is still correct–PSA

screening among healthy men is not routinely done but should be indicated in a patient with two risk factors.

[mcatmemoranda]

It was a kid who got hit in the head with a metal baseball bat. As soon as it said he had clear rhinorrhea and bruises around his eyes, I knew it was a basilar skull fracture.

In basilar skull fracture, there is a fracture through the base of the skull involving the sphenoid bone, ethmoid bone, temporal bone, and/or the occipital bone. These types of fractures require a high mechanism of injury and can cause tearing of the meninges which can cause leaking of cerebrospinal fluid. The cerebrospinal fluid can build up behind the tympanic membrane and leak out the eustachian tube resulting in CSF rhinorrhea. If there is a rupture of the tympanic membrane, the patient will display CSF otorrhea. The patient can also have CSF rhinorrhea if there is a fracture of the anterior skull. One can tell if the ear or the nose are leaking CSF fluid by placing a drop of the fluid on a paper towel. The blood should coalesce in the center and form a ring of clear fluid on the periphery indicating CSF fluid. Other signs of basilar skull fracture include: Seventh cranial nerve palsy, hemotympanum (visual blood behind the tympanic membrane), periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), vertigo. Management includes performing a CT scan of the head, cervical spine, and facial bones to look for other pathology, consultation with a neurosurgeon, and airway management if necessary. Consider a discussion of prophylactic antibiotics with the neurosurgeon.

Bottom Line: Basilar skull fractures should be suspected in patients with periorbital ecchymosis, otorrhea, rhinorrhea, battle's signs. Although the above injuries can occur when a patient has a basilar skull fracture, none of the other injuries will cause findings of battle's signs, periorbital ecchymosis, etc.

[thebrainandspine]

The Brain and Spine, Max Super Speciality Hospital in Delhi has specialized facility of operation theatres and well equipped departments. The Cerebrospinal Fluid Leak Treatment in India is given by the hospital by best doctors appointed here. Visit The Brain and Spine in Delhi for the best treatment.

[mayomhospital05]

Dr. Manish Prakash is the First ENT Surgeon in Gurgaon to have done an Endoscopic Transnasal Repair of CSF Rhinorrhea, Stapedotomy, And Endoscopic DCR and has more than 1000 satisfied patients to date. | ENT Gurgaon

[drshalabhsharma1]

Understanding CSF Rhinorrhea: Symptoms, Diagnosis, and Treatment in India 

Introduction to CSF Rhinorrhea

Our brain and spinal cord are surrounded by a protective fluid called cerebrospinal fluid, which acts as a cushion. Sometimes, due to injury or other factors, this fluid can leak out of the skull and flow through the nose, a condition known as CSF rhinorrhea.

Causes of CSF Rhinorrhea

The most common known cause of CSF rhinorrhea is head trauma. It can also occur after certain surgeries or due to conditions like a tumor.

Recognizing CSF Rhinorrhea Symptoms

How do you know if you might have CSF rhinorrhea? One significant sign is clear, watery fluid dripping from the nose. Unlike regular nasal discharge, this fluid is usually tasteless and non-sticky, which are key CSF rhinorrhea symptoms to be aware of.

The Importance of Prompt Medical Attention

If you suspect CSF rhinorrhea, it is crucial to seek medical attention promptly. The leak exposes the brain to potential infections which can be serious and even life-threatening, making CSF leak treatment a priority.

CSF Rhinorrhea Diagnosis Process

Diagnosis often involves imaging like a CT scan or MRI to locate the source of the leak, which are essential steps in CSF rhinorrhea diagnosis.

Treatment Options for CSF Rhinorrhea

Treatment varies depending on the severity and cause. Minor cases might heal on their own, whereas larger leaks may require surgical intervention either by an open approach or an endoscopic approach. The surgeon may use tissue grafts, synthetic materials, or a combination of both to seal the breach and reinforce the protective barrier. Advances in medical technology have made these procedures, crucial aspects of CSF rhinorrhea treatment in Delhi, increasingly successful and less risky.

Conclusion: The Significance of Addressing CSF Rhinorrhea

In summary, CSF rhinorrhea is like a leak in the barrier between the brain and nose, allowing brain fluid to escape through the nose. Prompt diagnosis and treatment significantly improve outcomes for individuals with CSF rhinorrhea. Ignoring the symptoms or delaying medical attention may increase the risk of complications.

[mayomhospital73]

Dr. Manish Prakash is the First ENT Surgeon in Gurgaon to have done Endoscopic Transnasal Repair of CSF Rhinorrhea, StapedotomyAnd Endoscopic DCR and has more than 1000 satisfied patients to date. | Ear Nose Piercing in Gurgaon

[sushrutbrainandspine]

"Effective Management of CSF Rhinorrhea through Surgical Techniques: Endonasal-Endoscopic and Trans-cranial Repair Methods"

Contact for more information:-

• Phone: +91 9810324401

• Website :- www.thebrainandspine.com

[mayomhospital71]

Dr. Manish Prakash is the First ENT Surgeon in Gurgaon to have done an Endoscopic Transnasal Repair of CSF Rhinorrhea, Stapedotomy, And Endoscopic DCR and has in excess of 1000 fulfilled patients to date. | Ear Nose Piercing in Gurgaon | ENT Gurgaon

[mayomhospital69]

Dr Manish Prakash is the First ENT Surgeon in Gurgaon to have done Endoscopic Transnasal Repair of CSF Rhinorrhea, StapedotomyAnd Endoscopic DCR and has more than 1000 satisfied patients to date. | Mayom Hospital

[mayomhospital6]

Dr. Manish Prakash is the First ENT Surgeon in Gurgaon to have done an Endoscopic Transnasal Repair of CSF Rhinorrhea, Stapedotomy, And Endoscopic DCR and has more than 1000 satisfied patients to date. | Mayom Hospital

[mayomhospital65]

Dr. Manish Prakash is the First ENT Surgeon in Gurgaon to have done an Endoscopic Transnasal Repair of CSF Rhinorrhea, Stapedotomy, And Endoscopic DCR and has in excess of 1000 fulfilled patients to date. | Mayom Hospital