Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Study protocol neurophysiological findings in rat peri during magnetic resonance imaging in Lumbar Epidural steroid injections for dural scar model buy generic lamotrigine online treatment quadriceps strain. Ronnberg K purchase lamotrigine overnight delivery treatment of shingles, Lind B order 200 mg lamotrigine overnight delivery symptoms ebola, Zoega B, Gade change of the dural sac detected by up steroid injections for lumbar spinal ste holt-Gothlin G, Halldin K, Gellerstedt right myelography? Eur Spine J 2008; properties of selected tests in patients lumbar spinal stenosis. Spine evoked potential to evaluate neuro comes of lumbar microdiscectomy in a (Phila Pa 1976) 2007; 32:1-8. Prevention of cohort study of complications, reopera of spinal stenosis with and without de postlaminectomy epidural fibrosis us tions, and resource use in the Medicare generative spondylolisthesis: Cost-ef ing bioelastic materials. Preserving the liga lumbar fusion surgery for degenerative tell us about low back pain? Do preclinical post laminectomy rat model Surgical versus nonsurgical therapy for diagnostic segmental nerve root blocks mimics the human post laminectomy lumbar spinal stenosis. Influence of needle position on lumbar of the porcine spinal cord: A compari Spine (Phila Pa 1976) 2009; 34:1839-1848. Spread of contrast during L4 Disorders of the Spine and Peripheral Herkowitz H, Weinstein J. Revision lumbar surgery in el Sainio P, Kinnunen H, Kankare J, Da ue of nerve root sheath infiltration. Acta derly patients with symptomatic pseud lin-Hirvonen N, Seitsalo S, Herno A, Orthop Scand Suppl 1993; 251:61-63. The cellular pathobiology in patient selection for lumbar surgery: double-blind study on the variability and of the degenerate intervertebral disc Surgical results. Value Distribution patterns of transforaminal prize winner: Lumbar vertebral endplate of diagnostic lumbar selective nerve injections in the cervical spine evaluated lesions: Associations with disc degener root block: A prospective controlled by multi-slice computed tomography. Signifi injection site and effectiveness-a study tissue origin of low back pain and sci cance of perianular enhancement as with patients and cadavers. Radiology atica: A report of pain response to tis sociated with anular tears on mag 2001; 221:704-711. A prospective study of nerve worth-Heinemann, Oxford, 1997, pp trolled discography. Selective diagnostic cervical ternational Association for the Study 2009; 250:849-855. Nerve root infiltration in the tice Guidelines for Spinal Diagnostic and signal intensity. Spine (Phila Pa 1976) 1997; and cervical radiculopathy: Comparison Pain 2004; 112:225-228. Spine (Phila Pa 1976) 2007; logical association with positive lumbar 32:1094-1099. Psychophysical measurements Miyagi M, Kamoda H, Suzuki M, Na during lumbar discography: A heart 700. Spine (Phila Pa 1976) 2004; surgical decision in patients with chron ic low back pain. A gold standard evaluation of the nostic lumbar facet joint nerve blocks: stages of disc degeneration as revealed An assessment of implications of 50% by discograms. Are lum raphy in detecting radial tears of the an J Spinal Disord Tech 2002; 15:245-251. Reopera phy in the diagnosis of acute intraver the ProDisc prosthesis: A prospective study with 2-year minimum follow-up. Viikari-Juntura E, Raininko R, Videman Inoue G, Yamauchi K, Koshi T, Suzuki M, Orita S, Eguchi Y, Nakamura S, Ya 716. Spine (Phila Pa 1976) 1989; for discogenic low back pain: A random ized study using discography versus 717. The treatment of disabling multilevel lumbar discogenic low back ington State Health Care Authority. Provoca pain with total disc arthroplasty utilizing nal Fusion and Discography for Chronic tive lumbar discography versus func the ProDisc prosthesis: A prospective Low Back Pain and Uncomplicated Lum tional anesthetic discography: A com study with 2-year minimum follow-up. Spinal fusion for Surgery for degenerative lumbar disc in lumbar functional spine units during degenerative disc disease affecting the disease. Should the black disc be graft side bending and axial rotation mo lumbar spine (draft evidence report/ ed? Rev Chir Orthop Reparatrice Appar ments depending on the degree of de technology review prepared for the Mot 1998; 84:583-589. Spine (Phila Pa 1976) 2005; Spinal-fusion surgery: the case for re tebral discs using axial T2 mapping. Risk factors diagnostic spinal injections to predict ral interactions of degenerative changes for lumbar disc degeneration: A 5-year surgical outcomes. Takatalo J, Karppinen J, Niinimaki J, netic resonance imaging study in pa 27:125-134. Asymptom referred muscle pain syndromes: Pre bar intervertebral disc degeneration atic same-site recurrent disc herniation liminary results of a new referred pain really cause instability? Evaluation of after lumbar discectomy: Results of provocation technique with the aid of a an in vitro database. Eur Spine J 2011; a prospective longitudinal study with Fischer pressure algometer in patients 20:578-584. A prospective bar disc herniation: Comparison study Spine (Phila Pa 1976) 2011; 36:160-169. Oikawa Y, Ohtori S, Koshi T, Takaso M, bar intervertebral foramen due to flex ward C, Rossi M, Hagle C. Can discog Inoue G, Orita S, Eguchi Y, Ochiai N, ion-extension, lateral bending, and axial raphy cause long-term back symptoms Kishida S, Kuniyoshi K, Nakamura J, rotation: An in vitro anatomic and bio in previously asymptomatic subjects?
Sickle hemoglobinopathies compose a group of genetic nature (Maakaron et al order lamotrigine 25 mg on-line symptoms 1974, 2013) diseases order lamotrigine 25 mg on line medicine nausea, consisting of four genotypes: sickle cell anemia iii lamotrigine 25mg sale symptoms after hysterectomy. Primarily affects black populations of African descent as threatening anemia well as people of South and Central American, Caribbean, Mediterranean, Arabian, and East Indian descent (Raj, n. Can last for hours or other symptoms, which can include fever, cough, wheezing, days. Reticulocytes develop and Dactylitis: Swollen, tender digits of the hands and feet, causing mature in the red bone marrow and then circulate for about a severe pain. Vaso-occlusive/sickle cell crisis: Related to infection, dehydra Kyphosis: Exaggerated outward curvature of the spine. Pneumonia, page 129 Psychosocial aspects of care, page 729 Seizure disorders, page 188 Sepsis/septicemia, page 665 Transplantation considerations—postoperative and lifelong, page 719 470 Client Assessment Database Depends on severity of condition and presence of complications. Listlessness, severe weakness, and increasing pallor (aplastic • Loss of productivity crisis) • Decreased exercise tolerance, impaired mobility. Systolic heart murmurs may be heard over entire precordium • Swelling of hands and feet (often initial symptom in infants. Childs height and weight usually in the lower percentiles • Anorexia (Maakaron et al, 2013) • Nausea, vomiting. Mental status usually unaffected except in cases of severe sick • Visual disturbances due to retinal vascular changes ling (cerebral infarction and intracranial hemorrhage) • Tingling in the extremities. Maladaptive pain behaviors—guilt for being ill, denial of any Recurrent, sharp, transient headaches aspect of disease, indulgence in precipitating factors such as • Joint or bone pain may be low-level and chronic or acute and overwork, strenuous exercise accompanied by warmth, tenderness, erythema, and occasional effusions (vaso-occlusive crisis. Acute respiratory distress—dyspnea, chest pain, and cyanosis • History of repeated pulmonary infections, infarctions, pul (especially in crisis) monary fibrosis, pulmonary hypertension or cor pulmonale. Fever with chills (adult with acute chest syndrome) (Bernard, • Jaundice with skin itching 2007) • Leg ulcers. Platelets are ogy, indices, and distribution width index; platelet count and often increased. If the reticulo cyte count is normal, splenic sequestration is the probable cause. If the reticulocyte count is normal, splenic se questration is the probable cause. When an electric charge is passed through tween sickle cell trait and sickle cell anemia. Results may be a solution of hemoglobin, distinct hemoglobins move different inaccurate if client has received a blood transfusion within 3 distances, depending on their composition. However, the iron stores released by hemolysis may be available for reuse; therefore, serum iron deficiency is not always present. A very high iron level is associated with frequent blood transfusions for sickle cell anemia—a condi tion more common in children than adults. Excess iron cannot be excreted without additional medication being given (Mohanty et al, 2008; Iron Disorders Institute, 2006. May demonstrate bone infarction, osteomyelitis, avascular necro sis of hip, and so forth. May confirm presence of acute chest syndrome if infiltrate ac companied by other symptoms such as chest pain, elevated temperature, or hypoxemia (Ellison, 2012. This spinal abnormality develops in many adults and some adoles cents with sickle cell anemia, leaving the vertebrae resem bling logs that form the corner of a cabin (Nurses 3-minute Clinical Reference, 2008. Also identifies bone marrow changes due to acute and chronic bone marrow infarction, marrow hyperplasia, osteomyelitis, and osteonecrosis (Maakaron et al, 2013. Disease process, future expectations, potential complica tions, and therapeutic regimen understood. Auscultate breath sounds, noting presence or absence, and Development of atelectasis and stasis of secretions can impair adventitious sounds. Changes in vital signs and development of dysrhythmias reflect effects of hypoxia on cardiovascular system. Reflective of developing acute chest syndrome, which in Observe for signs of increased fever, cough, and adventi creases the workload of the heart and oxygen demand. Brain tissue is very sensitive to decreases in oxygen, and changes in mentation may be an early indicator of developing hypoxia. Promotes optimal chest expansion, mobilization of secretions, and aeration of all lung fields; reduces risk of stasis of secre tions and pneumonia. Evaluate activity tolerance; limit activities to those within Reduction of the metabolic requirements of the body reduces clients tolerance or place client on bedrest. Protects from excessive fatigue and reduces oxygen demands Schedule rest periods, as indicated. Demonstrate and encourage use of relaxation techniques, such Relaxation decreases muscle tension and anxiety and, hence, as guided imagery and visualization. Promote adequate fluid intake, such as 2 to 3 L/day within Sufficient hydration is necessary to provide for mobilization of cardiac tolerance. Maximizes oxygen transport to tissues, particularly in presence of pulmonary insults or pneumonia. The hemoglobin S molecule has a low affinity for oxygen (which allows for adequate tissue oxygenation. During a vaso-occlusive crisis, a clients Hgb level often declines by at least 1 g per dL. Exchange blood trans fusions are indicated when the clients condition is deterio rating and may be done for cases of stroke and acute chest syndrome. Note: Partial transfusions are sometimes used prophylactically in high-risk situations, such as chronic, severe leg ulcers, preparation for general anesthesia, and third trimester of pregnancy. Administer medications, as indicated, for example: Antipyretic, such as acetaminophen (Tylenol) Maintains normothermia to reduce metabolic oxygen demands without affecting serum pH, which may occur with aspirin.
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American College of Radiology Appropriateness Criteria – Acute Chest Pain–Suspected Pulmonary Embolism buy lamotrigine 200mg overnight delivery symptoms stomach flu. American College of Radiology Appropriateness Criteria – Acute Chest Pain–Low Probability of Coronary Artery Disease generic lamotrigine 200 mg mastercard medicine used to treat bv. Guidelines on diagnosis and management of pulmonary embolism discount lamotrigine 25 mg visa symptoms quadriceps tendonitis, European Heart Journal, 2000; 21:1301-1336. Institute for Clinical Systems Improvement, Health Care Guideline: Venous thromboembolism diagnosis and treatment. Effectiveness and acceptability of a computerized decision support system using modified wells criteria for evaluation of suspected pulmonary embolism, Ann Emerg Med, 20011; 57:613-621. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism, Ann Emerg Med, 2001; 57:628-652 78580 Pulmonary Perfusion Imaging Page 728 of 794 78582 Pulmonary Ventilation (e. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism, Thorax, 2003; 58:470-484. Pre-operative assessment for planned segmental, lobar or lung 1,2 removal References: 1. These are inpatient studies ordered to confirm brain deaths for patients on life support systems whose anatomic imaging generally shows diffuse edema and brain stem herniation. Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria – Dementia and Movement Disorders. This clinical evaluation should also include family history and (whenever possible) the accounts of eyewitnesses to the event(s. First-time seizure in child in child <12 months of age that has no known cause and is not associated with fever if the infant has an open fontanelle. Neuroimaging should not be performed in the routine evaluation of children with simple febrile seizures 3, 13-32 V. Due to the length of time for image acquisition and the need for the patient to lie still, anesthesia is required for almost all infants and young children (age <7 years), as well as older children with delays in development or maturity. Transcranial Doppler ultrasonography has some utility in select populations of older children with known or suspected intracranial vascular disease D. Suspected obstruction of nasolacrimal duct due to excessive tearing References: 1. Positron emission testing for six cancers (brain, cervical, small cell lung, ovarian, pancreatic and testicular), prepared for the Agency for Health Care Research and Quality. Ing C, DiMaggio C, Whitehouse A et al, Long-term differences in Language and Cognitive Function After Childhood Exposure to Anesthesia, Pediatrics 2012 Sep;130 (3) :e476-e485. Monteleone M, Khandji A, Cappell J et al, Anesthesia in children: Perspectives From Nonsurgical Pediatric Specialists, J Neurosurg Anesthesiol 2014;26 (4) :396-398. New York State Department of Health, Guidelines for Determining Brain Death, December 2011, Available at: https://www. Society of Nuclear Medicine procedure guideline for brain death scintigraphy, Version 1. Diagnosing idiopathic normal-pressure hydrocephalus, Neurosurgery 2005;57 (3 Suppl): S2-4-S2-16. Infrequently performed studies in nuclear medicine: Part 2, J Nucl Med Technol 2009 Mar; 37: 1-13. Suspected normal pressure hydrocephalus with gait disturbance and one of the following 1. Patient with a shunt (ventriculo-peritoneal, ventricular-pleural or 3 ventricular venous) that may be blocked [Certify 78645] References: 1. Diagnosing idiopathic normal-pressure hydrocephalus, Neurosurgery, 2005; 57:S2-4-S2-16. Infrequently performed studies in nuclear medicine: Part 2, J of Nuclear Medicine Technology, 2008; 36:132-143. Mostly pediatric patients with prior pyelonephritis causing scarring, or known ureteral reflux that could lead to pyelonephritis and scarring. Acute pyelonephritis with bacteriuria for children age 2 months to 3 years may be performed 4-6 months after the infection to 1-4 detect scarring V. American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children, Pediatrics, 1999, 103:843-852. Acute pyelonephritis as a second line test to detect renal 2-5 cortical scarring V. Assessment of global and differential renal function to estimate prognosis for recovery References: 1. Expert Panel on Pediatric Imaging, American College of Radiology Appropriateness Criteria – Urinary Tract Infection – Child. American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Urinary Tract Infection, Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children, Pediatrics, 1999, 103:843-852. Acute pyelonephritis history of urinary tract infection in child 2 1 months to 3 years 4-6 months ago References: 1. Society of Nuclear Medicine Procedure Guideline for Renal Cortical Scintigraphy in Children, version 3. Suspected obstructive uropathy (78708 or 78709 renal scan with pharmacologic intervention) V. Society of Nuclear Medicine Procedure guideline for diagnosis of renovascular hypertension, version 3. American College of Radiology Appropriateness Criteria – Renovascular Hypertension. European Association of Urology, European Society for Paediatric Urology, Guidelines on Paediatric Urology, 2009. Refractoriness to aggressive medical therapy (usually failure to respond to 3 drug therapy) B.
Despite the difficulty in creating clear and robust dividing lines between what constitutes ?cosmetic? and ?therapeutic? procedures (see paragraphs 7 cheap 100mg lamotrigine amex medications gabapentin. In other words purchase lamotrigine 100 mg with amex medications list, they are not perceived as being made available in response to medical need buy lamotrigine cheap online ad medicine. Indeed, they are often marketed as consumer goods: presented, for example, either as a casual consumer choice (such as ?lunch hour? procedures) or on a par with more expensive consumer purchases such as luxury handbags693 (see paragraph 3. Any decision to undertake such a procedure should thus be taken with the same degree of careful consideration as for any medical procedure or possibly, indeed, more so in the absence of any clinical benefit. Any practices, on the part either of individual practitioners or of organisations offering access to cosmetic procedures, that minimise or underplay the risks and uncertainties associated with invasive cosmetic procedures, must be unacceptable. While practitioners (whether doctors, nurses, dentists, or beauty therapists) have legitimate interests in practising their professions undisturbed, the public health responsibilities of the state provide a strong justification for intrusion where poor practice puts users at risk of harm. Responsibilities with respect to children and young people ?Encouraging children to change their appearance perpetuates a culture of perfectionism which is particularly damaging to children 694 who are more susceptible to social pressures. Moreover, we know that adolescents are particularly susceptible to peer and social pressures; are heavy users of the forms of social media and the rating and monitoring apps that have been linked both with increasing appearance anxiety and greater interest in cosmetic procedures; and are at a stage in their lives when they are particularly tentative and malleable with respect to their sense of their own identity. We suggest, therefore, that there are powerful reasons why the state should take a proactive role with respect to children?s and young people?s access to cosmetic procedures. However, while young people over the age of 16 are deemed in law to be competent to make healthcare decisions for themselves,697 and those under the age of 16 may demonstrate such competence in connection with a particular decision,698 the legal justification for recognising medical decision-making capacity in younger people is premised on the assumption that proposed treatment is recommended by a health professional and is in the child?s best interests. While there is generally understood to be a wide zone of parental discretion in terms of the decisions parents take for children, and the values that underpin those decisions, this zone is not boundless. In terms of access to medical procedures, health professionals are not required by law (and indeed would be acting against their ethical codes) to provide procedures that they do not believe are in a child?s interests. There are strong arguments, encapsulated in the concept of a ?child?s right to an open future?703 why there should be limitations on the freedom of parents to make decisions for their children that can reasonably be deferred. These arguments are particularly powerful with respect to decisions that, once taken, are irreversible; and in cases where a child might potentially take a very different view from a parent on what constitutes his / her interests, either at the time or later. As we argued in our 2015 report Children and clinical research: ethical issues, even very young children have a stake in decisions made about their own lives and want to ?have a say?, even though their wishes cannot always be determinative. See: Section 1, Age of Legal Capacity (Scotland) Act 1991; Sections 1 and 2, Children (Scotland) Act 1995. Also in older adolescence, orthognathic surgery and orthodontic work will take place over a course of two years, after which restorative dentistry may be considered. When the patient reaches their early 20s, soft tissue surgeries to modify the patient?s lips and nose may be undertaken by a plastic surgeon. Alternatively, the patient may choose to avoid further surgery or to undergo autologous fat transplants to add volume to areas of their face as an alternative to surgery. However, for pragmatic reasons, both law and policy frequently need to draw ?bright line? distinctions based on age, including determining the age at which in law, childhood and the associated parental responsibility comes to an end. In terms of procedures concerned with appearance, established law prohibits both access to sunbeds and tattooing for people under the age of 18, and the beauty industry has also, of its own initiative, developed age-based criteria for some procedures such as intimate waxing (see paragraph 4. We therefore suggest that there are strong justifications for similarly limiting access to cosmetic procedures to people over the age of 18, with exceptions only for cases involving a multidisciplinary approach as described above. There are 13 centres in England, one in Wales, two in Scotland, and one in Northern Ireland. Rather, the awareness that adults, as well as children, may find themselves in situations of vulnerability highlights the importance of the responsibilities of practitioners in the way that they respond to requests for treatment. Practitioner / user relationships ?Cosmetic surgery is a personal choice, and I would hesitate to judge someone for choosing it. Similarly a friend of mine who had a front tooth implant and even had the imprint of the original tooth was most annoyed when the dentist made the implant suit his, the dentist?s, idea of what a tooth should look like. However, it is also necessary to recognise that, given the social nature of interest in and concern with appearance, people will continue to seek, and may indeed derive benefit from, the cosmetic procedures that are made available to them. It is hard to imagine demand for invasive cosmetic procedures ever disappearing altogether, although the nature of that demand is likely to evolve and change. How can the starting point of users be strengthened to promote a more equal relationship between user and practitioner? What would an ?ethical encounter? between practitioner and user of cosmetic procedures look like? They cannot be held primarily responsible for the many and various social factors that we have identified as contributing to growing anxiety about appearance, although their role in reinforcing these factors through the provision of cosmetic procedures should not be overlooked. However, they can, and must, hold themselves responsible for the ethical consequences of their own practice, ensuring that the way that they practise does not make them ?part of the problem?. The fact that cosmetic procedures constitute a physical intervention whose hoped-for benefits are primarily psychological (see paragraphs 5. Throughout this report we have identified ways in which concerns about appearance may be prompted or exacerbated by multiple social factors, and how cosmetic procedures are promoted and marketed, by industry and others, as a solution to those concerns. It is important for practitioners to recognise that such influences may potentially have the effect of limiting, rather than enhancing, people?s choices. This places a heavy responsibility on the practitioner to take particular care in the way in which they share information with the potential user, including, where appropriate, challenging the users? assumptions about their need for treatment. In 2009, for example, the percentage of women choosing immediate reconstruction (as opposed to delayed reconstruction or mastectomy only) varied between nine per cent and 43 per cent across the 30 English Cancer Networks. According to an investigation by the New York Times, ?while plastic surgeons and oncologists aggressively promote breast reconstruction as a way for women to ?feel whole again,? some doctors say they are beginning to see resistance to the surgery. The practitioner brings their clinical perspective and technical knowledge, while the user discusses their expectations for outcome, lifestyle goals and preferences for treatment.
Defintive treatment: Transnasal: the transnasal route entitles the use of burrs or laser to perforate and widen the occluding plate under microscopic or endoscopic visualization buy 100mg lamotrigine with amex medicine rock. Inflammations of the Nose Furunculosis of the vestibule It is an infection of a hair follicle in the nasal vestibule caused mainly by staphylococcus aureus buy generic lamotrigine canada symptoms viral infection. The extreme tenderness is due to the tight attachment of the skin to the underlying cartilage 200 mg lamotrigine visa treatment chlamydia. The patient is advised not to squeeze the furuncle as there is a potential risk of spreading infection to the cavernous sinus via the facial and ophthalmic veins (dangerous area of the face. Rhinitis the term rhinitis implies an inflammation of the lining membrane of the nose. Actually the nasal mucous membrane is continuous anatomically with the paranasal sinuses mucous membrane. So every case of rhinitis is accompanied by a degree of sinusitis, also every case of sinusitis is associated with a variable degree of rhinitis. So the term (rhinosinusitis) is commonly used for description of inflammations of the nose and paranasal sinuses. However for simplification of the subject we use the term (rhinitis) when the main lesion is in the nose while the term (sinusitis) is used when the main lesion is in the sinuses. Those particularly implicated are, adenovirus, rhinovirus, respiratory syncytial virus and para 83 influenzae virus. Hyperaemic stage: nasal obstruction, watery discharge and general symptoms of mild toxaemia and fever. Stage of secondary infection: the discharge thickens, diminishes and becomes mucopurulent. Resolution stage: the symptoms and signs gradually diminish and recovery takes place after 5-10 days. Nasal diphtheria is an inflammation of the nasal mucous membrane caused by Corynebacterium diphtheriae. The nasal symptoms are obstruction and fetid discharge which is watery at first and later becomes blood stained and mucopurulent. The inferior turbinate, the floor of the nose and sometimes the septum are covered with a greyish adherent membrane. Treatment: Systemic antibiotics, usually parentral penicillin and nasal toilet. Atrophic rhinitis (Ozaena): Atrophic rhinitis is a chronic non-specific rhinitis characterized by progressive atrophy of the nasal mucosa and underlying bony turbinates. Aetiology: Primary atrophic rhinitis more common in females the aetiology of atrophic rhinitis is still unknown but may be due to:-. Infection: cocobacillus ozaenae, klebsiella ozaenae and other gram negative organisms have been isolated from cultures. Sense of nasal obstruction; in spite of roomy nose due to dullness of sensation of air on the atrophic mucosa, epistaxis on removing the crusts and sore throat, due to associated atrophic pharyngitis. Treatment: Conservative: Regular nasal douching with an alkaline solution should be considered twice daily. Other measures include 25% glucose in glycerine pack, topical oestrogen, oral potassium iodide and human placental extracts. Surgical: Different surgical procedures have been tried aiming at narrowing the nasal cavities or temporary closing the nostrils for 6-12 months. Chronic Specific Rhinitis Rhinoscleroma (Nasal Granuloma) An endemic chronic specific infection of the nose in Egypt. Pathology: Submucosal chronic inflammatory cellular infiltration characterized by: Mikulicz cells: (large foamy cells containing the Frisch bacilli within its vacuoles) Russel bodies: (red-stained degenerated plasma cells), Plasma cells, lymphocytes and fibroblasts. Hypertrophic (granulation) stage: Bilateral hard, non-ulcerating submucous granulomatous nodules appear at the muco-cutaneous junction, then spread and coalesce to fill the nasal cavities and broaden the nose. Nodules may spread to the subcutaneous tissues of the nasal tip, upper lip and dorsum of the nose. Fibrotic (Cicatrizing) stage: Dense fibrosis leading to nasal stenosis and external nasal deformity. Sequelae: It may spread to: the pharynx (pharyngoscleroma), larynx (laryngoscleroma), rarely middle ear (tympanoscleroma) or lacrimal sac (dacryoscleroma. Medical: long course of antibiotics for a minimum 4-6 weeks as the Frisch bacilli are intracellular and the antibiotics do not reach it easily. Tracheostomy in case of severe laryngoscleroma with upper respiratory obstruction. Clinical picture: Nasal obstruction and nasal discharge with apple-jelly nodules at the muco-cutaneous junction of the vestibule and nasal septum. They appear on blanching them by pressing it with glass slide or decongestive drops. Later on it gives, nodular ulceration with perforation of the cartilaginous septum and atrophic rhinitis. Classification: Sinusitis is classified according to the duration of symptoms into acute (less than 4 weeks), subacute (between 4 -12 weeks) and chronic (more than 12 weeks. Acute Sinusitis Acute inflammation of the mucoperiosteum lining the nasal sinuses. Oro-antral fistula after extraction of the upper second premolar or first molar teeth. Oedema leads to occlusion of the ostium and retention of exudates inside the sinuses. Oedema and redness of the skin over the affected sinus, tenderness over the cheek in maxillary sinusitis, floor of the frontal sinus in frontal sinusitis or inner canthus in ethmoiditis. Mucopurulent or purulent discharge in middle meatus: in maxillary, frontal and anterior ethmoidal sinusitis, superior meatus in posterior ethmoiditis, sphenoethmoidal recess in sphenoiditis.