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You cannot have dilation of the heart without the mitral valve leaflets separating infection xp king purchase fucidin australia. Surgery is the answer when the left ventricular ejection fraction drops below 60 percent or the left ventricular end systolic diameter goes above 40 mm. Surgery should be done in patients with these criteria even if they are asymptomatic. The operative criteria for regurgitant lesions in asymptomatic patients are as follows (repair is preferred to replacement): 75 S3 gallop is associated withfluidoverload states,suchascongestive heartfailureormitral regurgitation. Diagnostic Testing Echocardiography is the diagnostic test to use first, but catheterization is used to determine the degree of left-to-right shunting most precisely. Larger ones may lead to shortness of breath or signs of right ventricular failure, such as shortness of breath and a parasternal heave. Diagnostic Testing Echocardiography is the best initial test to determine the ejection fraction and look for wall motion activity. They are used to decrease the work of the heart; they are not given for their diuretic effect. Hypertrophic Cardiomyopathy this condition presents with shortness of breath on exertion and an S4 gallop on examination. S4 gallop is a sign of left ventricularhypertrophy anddecreasedcompliance orstiffnessoftheventricle. Shortness of breath is the main presenting complaint in all forms of cardiomyopathy. Endomyocardial biopsy is the single most accurate diagnostic test of the etiology. Pericardial Disease Pericarditis Chest pain that is pleuritic (changes with respiration) and positional (relieved by sitting up and leaning forward) is the presentation that is most often given on Step 3. Although any infectious agent, collagen-vascular disease, or trauma can be in the history, remember that Step 3 most often hands you a clear diagnosis and asks what you want to do about it, such as testing and treatment. Physical Exam the only pertinent positive finding is a friction rub, which can have 3 components. Blood pressure is normal, and there is no jugular venous distention or organomegaly. Following are the unique features of tamponade: Pulsus paradoxus: this is a decrease of blood pressure > 10 mm Hg on inhalation. The earliest finding of tamponade is diastolic collapse of the right atrium and right ventricle. Remember that it is normal to have 50 mL or less of pericardial fluid, but there should be no collapse of the cardiac structures. Right heart catheterization will show "equalization" of all the pressures in the heart during diastole. The wedge pressure will be the same as the right atrial and pulmonary artery diastolic pressure. The case may also describe "smooth, shiny skin" with loss of hair and sweat glands, as well as loss of pulses in the feet. Pain+Pallor+Pulseless= Arterialocclusion Marginally effective therapy: Pentoxifylline Ineffective therapy: Calcium channel blocker Acute arterial embolus willbeverysudden in onset with loss of pulse and a cold extremity. Rhythm Disorders Atrial Fibrillation (A-Fib) A-fib presents with palpitations and an irregular pulse in a person with a history of hypertension, ischemia, or cardiomyopathy. Outpatients who are hemodynamically stable should undergo Holter monitoring, which is continuous, ambulatory cardiac rhythm monitoring for 24 hours or longer. Treatment Unstable patients should undergo immediate synchronized electrical cardioversion. Instability is defined as a systolic blood pressure < 90, congestive failure, confusion related to hemodynamic instability, or chest pain. In the acute setting, such as the emergency department, these agents should be given intravenously. If the question does not state the duration, you are to treat it as if it were persisting for longer than 2 days. The long-term use of rate control medications, such as metoprolol, diltiazem, or digoxin, combined with anticoagulation is equal or better than cardioversion with electricity or medications. Even when warfarin is used for atrial fibrillation, there is no need to bolus the patient with heparin. Because atrial fibrillation is a long-term disease that takes months or years to develop a risk of stroke, while full-dose heparin carries a risk of bleeding. The following table shows how to choose the right rate control medication for a-fib and a-flutter. The most important thing to do in syncope is to exclude a cardiac etiology, such as an arrhythmia. The majority (> 80 percent) of mortality from syncope involves a cardiac etiology. If a ventricular dysrhythmia is diagnosed as the etiology of syncope, an implantable cardioverter/defibrillator is indicated. Abnormal glucose tolerance test (2-hour glucose tolerance test with 75 g glucose load) 4. Insulin receptors are a tyrosine kinase, which is neither a peptide nor a steroid hormone receptor. Of patients with type 2, 25 percent can be controlled with exercise and weight loss alone. Metformin is particularly beneficial in obese patients, because it does not lead to added weight gain. Sulfonylurea medications lead to increased weight gain because they increase the release of insulin. He was placed on metformin for type 2 diabetes after not responding to modifications of diet and exercise several months ago. Despite maximal doses of metformin, his blood glucose is > 150 mg/dL, and his HgA1c is above 7 percent. If a patient with type 2 diabetes cannot be adequately controlled with metformin, then add a second medication. If the question describes a patient originally placed on a sulfonylurea but not adequately controlled, then add metformin. The following are the main advantages of starting with metformin: - No risk of hypoglycemia - Does not increase obesity Metformin is contraindicated with the following: - Renal insufficiency: the metformin may accumulate and increase the risk of lactic acidosis. Incretins increase insulin release and decrease glucagon secretion from the pancreas. They can lead to diarrhea, abdominal pain, bloating, and flatulence in much the same way as lactose intolerance. Basic Science Correlate Mechanism of Diarrhea with Glucosidase Inhibitors When acarbose and miglitol block glucose absorption, the sugar remains in the bowel, available to bacteria. If other agents do not sufficiently control the level of glucose, then the patient is switched to insulin. A long-acting insulin, such as insulin glargine, which is a once-a-day injection with an extremely steady-state level of insulin, is used in combination with a very short-acting insulin at mealtime. Type 1 Diabetes (Juvenile Onset) Type 1 diabetes always results from underproduction of insulin. These patients are thin and do not respond to weight loss, exercise, or oral hypoglycemic agents. Sulfonylureas do not work, because there is no functioning pancreas to stimulate to increase insulin release. Type 1 diabetics are more prone to developing diabetic ketoacidosis because of severe insulin deficiency. The patient also has a "fruity" odor of the breath from acetone and possibly confusion from the hyperosmolar state. Diagnostic Testing Best initial test: Serum bicarbonate is the best way to determine the severity of illness.

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Overt ("catch-up") saccades: occur a er head rotation (visible to naked eye); common during acute phase ii antibiotics for uti cvs buy fucidin with mastercard. Covert saccades: occur during head rotation (very dif cult to see); indicate compensated lesion F. Detects changes in its orientation relative to surrounding alternating-current magnetic eld D. Gold standard technique or measuring eye movement, though less-invasive videocapture techniques (described previously) are improving rapidly E. Capable o accurately capturing very ast eye movements (> 300 degree/s) 304 Pa rt 2: Otology/Neurotology/Audiology i. Evaluates saccule (sensitive to vertical linear accelerations) and in erior branch o vestibular nerve d. Contralateral response rom in erior oblique/rectus muscles during upward gaze; air- and bone-conducted stimuli used (research ongoing) b. Evaluates utricle (sensitive to horizontal accelerations) and the superior branch o the vestibular nerve d. Pathway: utricle superior vestibular nerve vestibular nuclei medial longitudinal asciculus oculomotor nuclei (iii) in erior oblique muscle B. Recti cation can be used to remove muscle bias (eg, di erences in muscle tone or e ort) rom resultant wave orms, making asymmetry calculations more reliable (> 40% di erence is abnormal) C. Increased threshold/absent response: middle ear pathology or ossicular chain abnormalities, may also be age-related D. Highly sensitive or detection o damage to utricle and its central connections, particularly during acute stage; can also detect brainstem lesions C. Reverses on upright positioning o the head (ageotropic reversal) r eat ment Spontaneous resolution within a ew months in most cases A. Possible causes: endolymphatic sac in ammation and brosis (autoimmune, in ectious, ischemic), accumulation o glycoproteins, or altered endolymph production rates as possible etiologies or sac dys unction blockage o endolymph reabsorption ii. Characterized by bowing and rupture o Reissner membrane leakage o potassium rich uid (endolymph) into perilymph inter erence with generation o action potential (Na+/K+ intoxication theory) iv. Certain Meniere disease: De nite Meniere disease plus histopathologic con rmation (only detected at necropsy) B. De nite Meniere disease: two or more episodes o spontaneous rotational vertigo that last 20 minutes or longer, with tinnitus or aural ullness in the a ected ear; audiometric hearing loss documented on at least one occasion; other causes excluded C. Probable Meniere disease: one de nitive episode o vertigo and ul llment o other criteria D. Possible Meniere disease: episodic vertigo o the Meniere type without documented hearing loss Pr esent at io n A. Variable requency or recurrent attacks o vertigo, tinnitus, aural ullness and sensorineural hearing loss in the a ected ear B. Otolithic crisis o umarkin = sudden unexplained alls without loss o consciousness or associated vertigo C. Paralytic (dea erentative) phase: later in disease the nystagmus beats toward healthy ear C. Recovery phase: as attack subsides and vestibular unction improves, nystagmus o en reverses toward the a ected ear Inv est igat io ns A. Vestibular symptoms are less requent, vary rom mild to protracted vertigo with vegetative eatures lasting days Late syphilis i. High rate o uctuating sensorineural hearing loss, vertigo plus interstitial keratitis Diagnosis established by serologic testing i. Characterized by attacks o vertigo identical to those o Meniere disease in patients with a prior history o pro ound loss o hearing in one or both ears B. Autoimmune disease characterized by interstitial keratitis (nonsuppurative corneal in ammation), bilateral rapidly progressive audiovestibular dys unction and multisystem involvement rom vasculitis B. Progressive to complete absence o vestibular unction mani ested by ataxia and oscillopsia C. Hearing loss is bilateral and progressive, o en without spontaneous improvement and can become pro ound D. Recurrent attacks o episodic vertigo similar to Meniere without auditory or ocal neurological dys unction. Synonymous with vestibular Meniere, episodic vertigo, vertigo without hearing loss, etc. Complete absence o auditory dys unction (in contrast to a complete labyrinthitis). Surgical trauma such as stapedectomy, cholesteatoma surgery, penetrating middle ear trauma D. Symptoms vary rom mild and inconsequential to severe and incapacitating; include episodic vertigo equivalent to a Meniere attack, positional vertigo, motion intolerance, or occasional disequilibrium B. Introduce positive pressure, either by rapid pressure on tragus, compressing external canal, or via pneumatic otoscope, while eyes observed. Positive stula sign: conjugate contralateral slow deviation o eyes ollowed by three or our ipsilaterally directed beats o nystagmus (high alse-negative rate). Surgical exploration i hearing loss worsens/vestibular symptoms persist 310 Sup A. Classic sound- and pressure-evoked vertigo, hyperacusis, gaze-evoked tinnitus, with chronic disequilibrium. V -A V (V bu M) Association o migraine and vertigo commonly mentioned in literature. Dif cult to know i association is related to the commonality o both conditions in the general population Correlation requires close temporal association o vertiginous attack with migraine. Success ul treatment with anti-migraine therapy provides most reasonable hypothesis that the two conditions are related. Symptoms similar to traumatic perilymphatic stula with episodic attacks o vertigo to extraneous pressure. Unlike traumatic perilymphatic stula, ormation controversy exists or its occurrence. Surgical exploration or con rmation o diagnosis: perilymphatic leak rom oval or round window membranes. What conclusion can be made about a patient with no warm, cool, and ice water caloric responses or right ear irrigation Superior canal dehiscence syndrome is a cluster o symptoms that may include all o the ollowing except: A. Cytomegalovirus In ection Most prevalent environmental cause o prelingual hearing loss in the United States (10%). Hearing loss can be unilateral, uctuating and onset can be delayed or months or years. Five percent to 10% o mothers with rubella in rst trimester give birth to baby with dea ness. Kernicterus wenty percent o kernicteric babies have severe dea ness secondary to damage to the dorsal and ventral cochlear nuclei and the superior and in erior colliculi nuclei. Late congenital syphilis has progressive hearing loss o varying severity and time o onset. Hearing losses that have their onset during early childhood are usually bilateral, sudden, severe, and associated with vestibular symptoms. The late-onset orm (sometimes as late as the h decade o li e) has mild hearing loss. Karmody and Schuknecht also pointed out that the vestibular disorders o severe episodic vertigo are more common in the late-onset group than in the in antile group. Histopathologically, osteitis with mononuclear leukocytosis, obliterative endarteritis, and endolymphatic hydrops is noticed. It has been postulated that the vestibular stimulation is mediated by brous bands between the ootplate and the vestibular membranous labyrinth.

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I the bulla does not reach the skull base virus scan purchase fucidin 10 gm amex, a suprabullar recess is ormed between the skull base and superior surace o the bulla. There ore, the "naso rontal or rontonasal duct" is antiquated and obsolete terminology. The anterior cranial ossa dura may invaginate into this attachment with the ol actory lae. This segment is oriented in a near coronal plane anteriorly and an almost horizontal plane more posteriorly. It divides the ethmoid labyrinth into its anterior and posterior components (basal lamella o the middle turbinate). Various posterior ethmoid cells can indent the structure anteriorly and anterior ethmoid cells and the retrobulbar recess can indent the structure posteriorly. This should be care ully evaluated preoperatively by comparing the ratio o the ethmoid height to that o the height o the maxillary sinus. Laterally, the sinus may pneumatize or a variable distance under the middle cranial ossa (lateral recess), in eriorly it may pneumatize to a variable extent into the pterygoid processes, and posteriorly it may pneumatize or a variable distance in erior to the sella turcica. The cell above the septum (E) represents a sphenoethmoidal cell (Onodi cell) that has pneumatized above the sphenoid sinus (S), bringing the ethmoid sinus into close proximity to the optic nerve and carotid artery. The gel and sol layers o the mucus blanket are severely af ected, thereby hindering bacterial removal. The overall anatomy, presence o pathologic secretions or polyps, and the condition o nasal mucosa may be identi ed. In some cases it may also be possible to identi y the nasolacrimal duct within the in erior meatus. T erea er, the scope is advanced through the nasal cavity and toward the nasopharynx. As the scope is advanced into the nasopharynx, the entire nasopharynx, including the contralateral eustachian tube ori ce, can be examined by rotating the telescope. While directing the scope posteriorly, the in erior portion o the middle meatus, ontanelles, and accessory maxillary ostia can be examined. The scope is then passed medial to the middle turbinate and advanced posteriorly to examine the sphenoethmoidal recess. Rotating the scope superiorly and slightly laterally allows or visualization o the superior turbinate and meatus as well as the slit-like or oval ostia o the sphenoid sinus. As the scope is brought back anteriorly, it can requently be rotated laterally under the middle turbinate into the posterior aspect o the middle meatus. The bulla ethmoidalis, hiatus semilunaris, and in undibular entrance are inspected. Withdrawing the telescope urther can provide an excellent view o the middle turbinate, uncinate process, and surrounding mucosa. In selected patients this portion o the examination can be conducted rom an anterior approach, i the anatomy is avorable. Alternatively, additional topical anesthesia may be placed within the middle meatus and in the region o the anterior insertion o the middle turbinate. A small malleable Calgiswab is care ully directed to the middle meatus or other site o origin o purulent drainage and submitted or culture. Not exceeding this s 476 Pa rt 3: Rhinology dosage is very important as seizures and other complications have been noted at higher dosage. In these latter situations, or in revision surgery, the use o computer-aided surgical navigation is also a reasonable consideration. In any case, the surgeon should have a 3D conceptualization o the anatomy be ore starting endoscopic sinus surgery. On the le t side the skull base has been violated (curved arrow), apparently as a result o the limited vertical height posteriorly. The needle tip is used to eel or the oramen and the injection must be per ormed very slowly, a ter aspiration. I site o attachment not evident, it is pre erable to make the incision posterior to its attachment and remove any residual uncinate later. In general, the cells here are larger and the skull base is more horizontal, making identi cation signi cantly easier and sa er than in the anterior ethmoid sinus. Frontal Recess Surgery (Dra ype 1) Because o the di cult anatomic relationships, it is very important to rereview the C and have a 3D conceptualization o the anatomy be ore working in the region o the rontal sinus.

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Tolerance may be marked; high potential for psychological and physiologic dependence antimicrobial 2 discount fucidin 10 gm overnight delivery. Others in group include methicillin (the prototype, rarely used), oxacillin, cloxacillin, dicloxacillin. Naltrexone (orally active), a related compound, is used in ethanol dependency states. Echothiophate is a rarely used organophosphate cholinesterase inhibitor for topical ophthalmic use. Tox: flushing, pruritus, liver dysfunction, increased risk of myopathy when combined with statins. Tox: constipation, headache, tachycardia, arrhythmias (avoid rapid-onset forms, that trigger reflex tachycardia). Adrenoceptor agonist prototype, neurotransmitter: acts at all a adrenoceptors and b1 adrenoceptors; used as vasoconstrictor. Other "prazoles": esomeprazole, dexlansoprazole, lansoprazole, pantoprazole, rabeprazole. Tox: Malignant hypertension with indirect-acting sympathomimetics and tyramine, serotonin syndrome with serotonergic drugs. Serum levels variable because of first-pass metabolism and nonlinear elimination kinetics. Tox: sedation, diplopia, gingival hyperplasia, hirsutism, teratogenic potential (fetal hydantoin syndrome). Drug interactions via effects on plasma protein binding or induction of hepatic metabolism. Phenytoin follows nonlinear (or zero-order) kinetics at therapeutic concentrations. May cause paradoxic hypertension by activating muscarinic excitatory postsynaptic receptors in postganglionic sympathetic neurons. Tox: postural hypotension, dyskinesias (both drugs less toxicity than the ergot bromocriptine). Increases membrane permeability to Ca2+ causing muscle contraction followed by paralysis. Tox: first-dose orthostatic hypotension but less reflex tachycardia than nonselective a blockers. Inhibits thyroid peroxidase reactions, iodine organification, and peripheral conversion of T4 to T3. Tox: hepatic dysfunction, induction of liver drug-metabolizing enzymes (drug interactions), flu-like syndrome with intermittent dosing. Tox: severe hypotension when combined with nitrates, impaired blue-green color vision. Used in estrogen receptor-positive cancers, possibly prophylactic in high-risk patients. Raloxifene is approved for osteoporosis, activates bone estrogen receptors, but is an antagonist of breast and endometrial receptors. Increases bone formation and bone resorption; during first 6 months net gain in bone. Used for mycoplasmal, chlamydial, rickettsial infections, chronic bronchitis, acne, cholera; a backup drug in syphilis. Active against many gram-negative bacteria, including Aeromonas, Enterobacter, H influenzae, Klebsiella, Moraxella, Salmonella, Serratia, and Shigella. Tox: mainly due to sulfonamide; includes hypersensitivity, myelotoxicity, kernicterus, and drug interactions caused by competition for plasma protein binding. A drug of choice for methicillin-resistant staphylococci and effective in antibiotic-induced colitis. Diltiazem, like verapamil, has more depressant effect on heart than dihydropyridines (eg, nifedipine). As in an actual examination, clinical descriptions, tables, or graphs are provided in many of the question stems. A patient is admitted to the emergency department for treatment of a drug overdose. The identity of the drug is unknown, but it is observed that when the urine pH is alkaline, the renal clearance of the drug is much greater than when the urine pH is acidic. The drug is probably a (A) Strong acid (B) Weak acid (C) Nonelectrolyte (D) Weak base (E) Strong base 3. A 66-year-old woman is in the coronary care unit after an acute myocardial infarction. She has developed signs of pulmonary edema of rapidly increasing severity and several drugs have been suggested. A 45-year-old man with a duodenal ulcer and laboratory evidence of Helicobacter pylori infection was treated with omeprazole, clarithromycin, and amoxicillin. A patient discharged from the hospital after a myocardial infarction had been receiving small doses of procainamide to suppress a ventricular tachycardia. One month later, his local physician prescribed high-dose hydrochlorothiazide therapy for ankle edema, which was ascribed to congestive heart failure. Three weeks after beginning thiazide therapy, the patient was readmitted to the hospital with a rapid multifocal ventricular tachycardia. The most probable cause of this arrhythmia is (A) Procainamide toxicity caused by inhibition of procainamide metabolism by the thiazide (B) Direct effects of hydrochlorothiazide on pacemaker cells of the heart (C) Direct effects of procainamide on pacemaker cells of the heart (D) Block of calcium current by the combination of procainamide plus thiazide (E) Reduction of serum potassium caused by the diuretic action of hydrochlorothiazide Examination 1 519 7. A 37-year-old female presented with epigastric pain for the last 3 days and two episodes of bilious vomiting. Treatment was started with insulin, telmisartan, atorvastatin, and a low-fat diet. Which of the following additional drugs is required to fully treat her dyslipidemia While on vacation, a 35-year-old man with a 10-year history of myasthenia gravis loses his supply of medications. He is now admitted to the emergency department complaining of diplopia, dysarthria, and difficulty swallowing. The most appropriate drug from the following list for reversing myasthenic crisis in this patient is (A) Calcium (B) Neostigmine (C) Pralidoxime (D) Succinylcholine (E) Vecuronium 9. A 4-year-old child was brought to an emergency department after ingesting a product found in the home. Her signs and symptoms include an elevated temperature; hot, dry skin; moderate tachycardia; and mydriasis. The most likely cause of these symptoms is (A) Acetaminophen overdose (B) Amphetamine-containing diet pills (C) Exposure to an organophosphate-containing insecticide (D) Ingestion of a medication containing atropine (E) Ingestion of phenylephrine-containing eye drops 10. A patient is admitted to a hospital emergency department 2 h after taking an overdose of diazepam. The plasma level of the drug at time of admission is 40 mg/L, and the apparent volume of distribution, half-life, and clearance of diazepam are 80 L, 40 h, and 35 L/day, respectively. A semiconscious patient in the intensive care unit is being artificially ventilated. Random spontaneous respiratory movements are rendering the mechanical ventilation ineffective. A child with strabismus ("wandering eye") is to be treated pharmacologically for a prolonged period. Which of the following drugs is used by the topical route in ophthalmology and causes mydriasis and cycloplegia lasting more than 24 h A 55-year-old surgeon has developed symmetric early morning stiffness in her hands. She wishes to take a nonsteroidal anti-inflammatory drug to relieve these symptoms. A 72-year-old man with atrial fibrillation required oral anticoagulation to reduce his risk of ischemic stroke.

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After appropriate samples are sent to the laboratory for culture necro hack infection best buy for fucidin, the patient is hospitalized, and antimicrobial therapy is started with intravenous ampicillin and gentamicin. If the antibiotic regimen in this patient is modified to include metronidazole (A) Ampicillin should be excluded from the regimen (B) Coverage will be extended to methicillin-resistant staphylococci (C) Gentamicin should be excluded from the regimen (D) Metronidazole should not be administered intravenously (E) the patient should be monitored for candidiasis 4. Which compound is the safest drug to use topically to treat scabies and pediculosis The reason they lack systemic antibacterial action is that they are (A) Converted to formaldehyde only at low pH (B) Metabolized rapidly by hepatic drug-metabolizing enzymes (C) More than 98% bound to plasma proteins (D) Not absorbed into the systemic circulation after oral ingestion (E) Substrates for active tubular secretion 6. A 22-year-old man with gonorrhea is to be treated with cefixime and will need another drug to provide coverage for possible urethritis caused by C trachomatis. Which of the following drugs is least likely to be effective in nongonococcal urethritis While blood is being drawn from this patient, the syringe is accidentally dropped, contaminating the floor, which is made of porous material. The best way to deal with this is to (A) Clean the floor with a 10% solution of household bleach (B) Clean the floor with soap and water (C) Completely replace the contaminated part of the floor (D) Neutralize the spill with a solution of potassium permanganate (E) Seal the room and decontaminate with ethylene oxide 10. Neuropathies are more likely to occur with this agent when it is used in patients with renal dysfunction. Pseudomonas and other gram-negative bacteria have caused infections after the use of cationic surfactants such as benzalkonium and cetylpyridinium chlorides, partly because they form a film on the skin under which microorganisms can survive. In addition, some gram-negative bacilli are able to grow in solutions containing benzalkonium salts. Abdominal sepsis is commonly a mixed infection; the most likely pathogens are Bacteroides fragilis, Enterobacteriaceae, and Enterococcus faecalis. An antibiotic regimen that includes only ampicillin and gentamicin does not control B fragilis. Empiric treatment in this case should include a drug active against this pathogen (eg, metronidazole, cefoxitin, cefotetan, or clindamycin). Fungal superinfections, especially from Candida albicans, occur frequently during treatment with metronidazole. In most cases of abdominal sepsis, metronidazole would be given by slow intravenous infusion. Both ampicillin and gentamicin should be maintained until the infection is controlled, at which time surgery is indicated. The combination of ampicillin, gentamicin, and metronidazole does not provide coverage for methicillin-resistant staphylococci. Of the agents listed, both lindane and permethrin are effective scabicides and pediculicides. However, there is some concern about systemic absorption of lindane, which may cause neurotoxicity and hematotoxicity. Ascorbic acid is sometimes given with methenamine salts to ensure a low urinary pH. Resistance emerges very slowly when nitrofurantoin is used as a urinary antiseptic. There is no cross-resistance between the drug and other drugs used in the treatment of bacterial infections of the urinary tract. No antiseptic in current use is able to promote wound healing, and most agents do the opposite. In general, cleansing of abrasions and superficial wounds with soap and water is just as effective as and less damaging than the application of topical antiseptics. Urinary tract infections resulting from C trachomatis are likely to respond to all of the drugs listed except nitrofurantoin. However, nitrofurantoin is effective against many bacterial urinary tract pathogens with the exception of Pseudomonas aeruginosa and strains of Proteus. A 1:10 dilution of bleach is effective for disinfection of a direct blood spill on a porous surface. Severe polyneuropathies may occur with nitrofurantoin, and they are more likely to occur in patients with renal dysfunction. List the agents used as antiseptics and disinfectants and point out their limitations. Empiric Antimicrobial Therapy Empiric antimicrobial therapy is begun before a specific pathogen has been identified and is based on the presumption of an infection that requires immediate drug treatment. Before initiation of such therapy, accepted practice involves making a clinical diagnosis of microbial infection, obtaining specimens for laboratory analyses, making a microbiologic diagnosis, deciding whether treatment should precede the results of laboratory tests, and, finally, selecting the optimal drug or drugs. A variety of publications and the internet provide updated lists of antimicrobial drugs of choice for specific pathogens. Such lists can provide a useful guide to empiric therapy based on presumptive microbiologic diagnosis. Principles of Antimicrobial Therapy Antimicrobial therapy in established infections is guided by several principles. Susceptibility testing-The results of susceptibility testing establish the drug sensitivity of the organism. The 2 most common methods of susceptibility testing are disk diffusion (Kirby-Bauer) and broth dilution. For severe infections caused by certain bacteria (eg, gram-positive cocci, Haemophilus influenzae), a direct test for beta-lactamase is used to aid in the selection of an appropriate antibiotic. Drug concentration in blood-The measurement of drug concentration in the blood may be appropriate when using agents with a low therapeutic index (eg, aminoglycosides, vancomycin) and when investigating poor clinical response to a drug treatment regimen. Serum bactericidal titers-In certain infections in which host defenses may contribute minimally to cure, the estimation of serum bactericidal titers can confirm the appropriateness of choice of drug and dosage. Serial dilutions of serum are incubated with standardized quantities of the pathogen isolated from the patient; killing at a dilution of 1:8 is generally considered satisfactory. Route of administration-Parenteral therapy is preferred in most cases of serious microbial infections. Monitoring of therapeutic response-Therapeutic responses to drug therapy should be monitored clinically and microbiologically to detect the development of resistance or superinfections. The duration of drug therapy required depends on the pathogen (eg, longer courses of therapy are required for infections caused by fungi or mycobacteria), the site of infection (eg, endocarditis and osteomyelitis require longer duration of treatment), and the immunocompetence of the patient. Clinical failure of antimicrobial therapy-Inadequate clinical or microbiologic response to antimicrobial therapy can result from laboratory testing errors, problems with the drug (eg, incorrect choice, poor tissue penetration, inadequate dose), the patient (poor host defenses, undrained abscesses), or the pathogen (resistance, superinfection). Bactericidal versus bacteriostatic actions-Antibiotics classified as bacteriostatic include clindamycin, macrolides, sulfonamides, and tetracyclines. For bacteriostatic drugs, the concentrations that inhibit growth are much lower than those that kill bacteria. Antibiotics classified as bactericidal include the aminoglycosides, beta-lactams, fluoroquinolones, metronidazole, most antimycobacterial agents, streptogramins, and vancomycin. For such drugs, there is little difference between the concentrations that inhibit growth and those that kill bacteria. Bactericidal drugs are preferred for the treatment of endocarditis and meningitis and for most infections in patients with impaired defense mechanisms, especially immunocompromised patients. Some bactericidal agents (aminoglycosides, fluoroquinolones) cause concentration-dependent killing. Maximizing peak blood levels of such drugs increases the rate and the extent of their bactericidal effects. Other bactericidal agents (beta-lactams, vancomycin) cause time-dependent killing. Drug elimination mechanisms-Changes in hepatic and renal function-and the use of dialysis-can influence the pharmacokinetics of antimicrobials and may necessitate dosage modifications. In anuria (creatinine clearance <5 mL/min), the elimination half-life of drugs that are eliminated by the kidney is markedly increased, usually necessitating major reductions in drug dosage. Erythromycin, clindamycin, chloramphenicol, rifampin, and ketoconazole are notable exceptions, requiring no change in dosage in renal failure. Drugs contraindicated in renal impairment include cidofovir, nalidixic acid, long-acting sulfonamides, and tetracyclines. Dosage adjustment may be needed in patients with hepatic impairment for drugs including amprenavir, chloramphenicol, clindamycin, erythromycin, indinavir, metronidazole, and tigecycline. Drugs that are not removed from the blood by hemodialysis include amphotericin B, cefonicid, cefoperazone, ceftriaxone, erythromycin, nafcillin, tetracyclines, and vancomycin. Pregnancy and the neonate-Antimicrobial therapy during pregnancy and the neonatal period requires special consideration.

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Avoid fluid overload Consider flumazenil for benzodiazepine overdose Control seizures infection 4 weeks after abortion 10 gm fucidin with amex, hypertension, and hyperthermia Stop offending drug, supportive management, and antidote with cyproheptadine Control seizures. Correct acidosis and cardiotoxicity with ventilation, sodium bicarbonate, and norepinephrine (for hypotension). Whole bowel irrigation with a balanced polyethylene-glycol electrolyte solution can enhance gut decontamination of iron tablets, enteric-coated pills, and illicit drug-filled packets. Cathartics such as sorbitol can decrease absorption and hasten removal of toxins from the gastrointestinal tract. For example, alkaline diuresis is effective in toxicity caused by fluoride, isoniazid, fluoroquinolones, phenobarbital, and salicylates. Urinary acidification may be useful in toxicity caused by weak bases, including amphetamines, nicotine, and phencyclidine, but care must be taken to prevent acidosis and renal failure in rhabdomyolysis. What is the connection between the management of cyanide poisoning and the drugs amyl nitrite and nitroprusside Since the duration of action of some antidotes is shorter than that of the intoxicant, the antidotes may need to be given repeatedly. A 2-year-old girl presented with lethargy, increased respiratory rate, and an elevated temperature that appeared to result from a drug poisoning. The anion gap in this patient is (A) -60 mEq/L (B) -20 mEq/L (C) +5 mEq/L (D) +30 mEq/L (E) +304 mEq/L 2. The osmolar gap in this patient is (A) -40 mOsm/L (B) -5 mOsm/L (C) +15 mOsm/L (D) +60 mOsm/L (E) +305 mOsm/L 3. In this case, the most appropriate antidote is (A) Atropine (B) Esmolol (C) Glucagon (D) Naloxone (E) Neostigmine 5. An 81-year-old woman with type 2 diabetes presents to the emergency department in a coma and with tachypnea, tachycardia, hypotension, and severe lactic acidosis approximately 9 h after ingesting a number of her metformin tablets. The procedure that is most likely to improve her condition is (A) Administration of activated charcoal (B) Administration of glucagon (C) Administration of syrup of ipecac (D) Gastric lavage (E) Hemodialysis 6. A 24-year-old female was rushed to the emergency department after she was found in her room hypotensive, with seizures. In the emergency department, the electrocardiogram confirmed ventricular arrhythmias. An overdose of which of the following drugs is the most likely cause of her symptoms Pharmacokinetic parameters for digoxin in this patient include a clearance of 7 L/h and an elimination half-life of 56 h. If no procedures are instituted to decontaminate this patient, the time taken to reach a safe level of digoxin will be approximately (A) 3. A patient is brought to the emergency department having taken an overdose (unknown quantity) of a sustained-release preparation of theophylline by oral administration 2 h previously. He has marked gastrointestinal distress with vomiting, is agitated, and exhibits hyperreflexia and hypotension. The plasma level of theophylline measured immediately upon hospitalization was 80 mg/L. If the oral bioavailability of theophylline is 98%, the clearance is 50 mL/min, volume of distribution is 35 L, and the elimination half-life is 7. Anion gap is calculated by subtracting measured serum anions (bicarbonate plus chloride) from cations (potassium plus sodium). Increases in anion gap above normal are due to the presence of unmeasured anions that accompany acidosis. In this case, the measured osmolality is 300 mOsm/L, whereas the calculated osmolality is 305 mOsm/L; the difference is -5 mOsm/L. Of the drugs listed, the 2 that are likely to cause an anion gap are aspirin and ethylene glycol. However, if the child had ingested ethylene glycol, she would be expected to exhibit a significant osmolar gap. The anion gap, lethargy, tachypnea, and hyperthermia all are consistent with aspirin poisoning. In this woman with severe signs of poisoning due to the ingestion of metformin, hemodialysis can be used to accelerate the elimination of both metformin and lactic acid. Since most of the metformin has been absorbed by the time she presented (9 h after drug ingestion), efforts to decontaminate her gastrointestinal tract with activated charcoal, gastric lavage, or syrup of ipecac are unlikely to be beneficial. Furthermore, syrup of ipecac has fallen out of favor and should not be used in unconscious patients. In addition to hypotension, seizures, and cardiac arrhythmias, the tricyclics have strong antimuscarinic effects. Estimations of the time period required for drug or toxin elimination may be of value in the management of the poisoned patient. If no procedures were used to hasten the elimination of digoxin in this patient, the time taken to reach a safe plasma level of the drug (12. Estimations of the quantity of a drug or toxin ingested may be of value in the management of the poisoned patient. Applying toxicokinetic principles, a rough estimate of ingested dose of theophylline could be made by multiplying the peak plasma level of the drug (80 mg/L) by its volume of distribution (35 L) to give a value of 2800 mg, or 2. Because only about one-fourth of a half-life has passed since ingestion, the amount eliminated since that time will be rather small. The short-acting blocker esmolol helps reverse the tachycardia and possibly the vasodilation associated with an overdose of theophylline. Neither gastric lavage nor syrup of ipecac should be used in patients who have ingested a corrosive because of the risk of esophageal damage. Gastric lavage can be used in a comatose patient if the airway has been protected with a cuffed endotracheal tube. The nitrites convert hemoglobin to methemoglobin, which has a higher affinity for the cyanide ion (forming cyanomethemoglobin) than cytochrome oxidase. It is the inhibition by cyanide of cytochrome oxidase that blocks oxidative metabolism and causes much of the toxicity. A newer cyanide antidote kit contains hydroxocobalamin, a form of vitamin B12 that rapidly reacts with cyanide to form the nontoxic cyanocobalamin. Nitroprusside, a compound with 5 cyanide molecules in addition to nitric oxide complexed to a central iron atom, is often considered the drug of choice in severe hypertension. Prolonged use of nitroprusside may result in toxicity caused by the release of cyanide. Identify toxic syndromes associated with overdose of the major drugs or drug groups frequently involved in poisoning. Outline methods for identifying toxic compounds, including descriptive signs and symptoms and laboratory methods. Describe the methods available for decontamination of poisoned patients and for increasing the elimination of toxic compounds. This chapter mentions them and discusses in more detail others that do not fall into the classes of agents described previously. Antacids-Antacids are weak bases that neutralize stomach acid by reacting with protons in the lumen of the gut and may also stimulate the protective functions of the gastric mucosa. When used regularly in the large doses needed to significantly raise the stomach pH, antacids reduce the recurrence rate of peptic ulcers. Magnesium hydroxide has a strong laxative effect, whereas aluminum hydroxide has a constipating action. These drugs are available as single-ingredient products and as combined preparations. Calcium carbonate and sodium bicarbonate are also weak bases, but they differ from aluminum and magnesium hydroxides in being absorbed from the gut. Because of their systemic effects, calcium and bicarbonate salts are less popular as antacids. H2-receptor antagonists-Cimetidine and other H2 antagonists (ranitidine, famotidine, and nizatidine) inhibit stomach acid production, especially at night. Although they are still used widely, their clinical use is being supplanted by the more effective and equally safe proton pump inhibitors. Proton pump inhibitors-Omeprazole and other proton pump inhibitors (esomeprazole, (dex)lansoprazole, pantoprazole, and rabeprazole) are lipophilic weak bases that diffuse into the parietal cell canaliculi, where they become protonated and concentrated more than 1000-fold. Oral formulations of these drugs are enteric coated to prevent acid inactivation in the stomach.

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There is no specific antidote antibiotics for acne how long should i take it 10 gm fucidin with mastercard, and supportive measures are directed toward protection against cardiac arrhythmias and seizures and control of body temperature. Acetylcholinesterase inhibitors do not reverse skeletal muscle relaxation caused by succinylcholine. Both drugs are -receptor activators, equivalent in terms of analgesic activity and reversible by naloxone. C (23) Mental retardation, microcephaly, and facial dysmorphia are characteristics of fetal alcohol syndrome, caused by excessive use of ethanol during pregnancy. D (27) In phase I block, the action of succinylcholine is not reversed by acetylcholinesterase inhibitors. C (7, 8, 27) the acetylcholinesterase inhibitor pyridostigmine can reverse skeletal muscle relaxation (caused by vecuronium) but may also cause bradycardia. The later effect can be prevented by use of glycopyrrolate, which has muscarinic receptor blocking action. E (29) Significant weight gain and hyperglycemia due to a diabetogenic action occur with several atypical antipsychotics, especially clozapine (not listed) and olanzapine. E (30, 31) Naloxone is an opioid -receptor antagonist and will oppose the actions of opioids at this class of receptors including analgesia, miosis, and symptoms of opioid overdose including respiratory depression. However, respiratory depression due to nefazodone is not exerted via the -opioid receptor. C (28) Entacapone is a catechol-O-methyltransferase inhibitor that enhances the action of levodopa by preventing its metabolism in the blood and peripheral tissues. A (43, 46) the drugs of choice for treatment of gonorrhea currently are the cephalosporins ceftriaxone and cefixime. A (44) the only drug likely to be effective in nongonococcal urethritis in a single dose is azithromycin, which has an elimination half-life of several days. Other drugs used in nongonococcal urethritis include clindamycin, ofloxacin, and the tetracyclines. B (45) the aminoglycoside antibiotics are bactericidal inhibitors of protein synthesis. Recall that their actions continue well beyond their short half-lives because they exert a postantibiotic action. D (44) Tetracycline use during pregnancy is discouraged since fetal exposure to these antibiotics may ultimately lead to irregularities in bone growth and dentition. In addition, gastrointestinal effects and the potential for hepatic dysfunction are increased in the pregnant patient. B (39) Long-term use of prednisone has several side effects such as growth inhibition, diabetes, muscle wasting, and osteoporosis. Choice D is incorrect because it describes congenital adrenal hyperplasia, a condition in which the adrenal gland fails to make the hormones cortisol and aldosterone. B (42) the bisphosphonates can cause esophageal irritation, which is managed by drinking lots of fluids and staying upright after taking the drug. Priapism can be caused by sildenafil in combination with nitrates, and tendinitis is a side effect for fluoroquinolones. B (43, 44, 46) In a community-acquired pneumonia, the wider spectrum cephalosporin ceftriaxone would cover typical organisms, and erythromycin would be active against the atypical organisms. E (43, 44, 46) Single antimicrobial drug therapy would be inadequate coverage in a hospital-acquired pneumonia that could include possible infection due to multidrug-resistant staphylococci as well as gram-negative bacilli such as Pseudomonas aeruginosa. Vancomycin should cover gram-positive organisms, and piperacillin plus the penicillinase inhibitor would be active against most strains of likely gram-negative pathogens. It is the drug of choice for treatment and secondary prophylaxis against cryptococcal meningitis. E (54) Bleomycin is one of the 4 drugs for which myelosuppression is not dose-limiting. The 3 others are cisplatin for nephrotoxicity, doxorubicin for cardiotoxicity, and vincristine for peripheral neuropathy. C (54) the toxicity of doxorubicin (one of the 4 drugs with unique dose-limiting toxicity; see Question 71) can be mitigated by dexrazoxane. C (40) Progestin acts on the endometrium, where estrogen agonists can induce proliferation and endometrial cancer. D (16) Diphenhydramine is a first-generation anti-H1 blocker with significant anti-motion sickness and sedative actions. Dexamethasone is an orally active corticosteroid, lithium is a mood stabilizer, and propranolol is a -blocker capable of inhibiting the peripheral conversion of T4 to T3. E (31) Meperidine is a strong opioid agonist with analgesic efficacy equivalent to that of morphine. The drug has a muscarinic blocking action and does not cause miosis or contraction of biliary smooth muscle. With long-term use, its metabolite normeperidine accumulates and may cause seizures. D (34) Heparin is negatively charged and will be effectively complexed with the positively charged protamine. If the effect of warfarin is too great, vitamin K1 supplements or parenteral phytonadione (vitamin K1) can be added in addition to dose reduction. For urgent reversal of anticoagulation by any drug, fresh frozen plasma may be used. D (40) Combination hormonal contraceptives have clinical uses and beneficial effects in treatment of acne, hirsutism, and dysmenorrhea. In addition, with long-term use, they have been shown to reduce the risk of ovarian and endometrial cancer. Dabigatran, an oral thrombin inhibitor, carries the risk of bleeding and not thrombosis. Heparin is the only drug on this list that can also cause thrombosis, but in the case of heparin, it is mediated not through protein C but rather through an immunologic reaction against heparin-platelet complexes. D (24) A number of antiseizure drugs have caused serious toxicities including hepatotoxicity with both valproic acid and felbamate. In the case of lamotrigine, which has been commonly used in the myoclonic seizures, toxic epidermal necrolysis (Stevens-Johnson syndrome) has occurred. A (14) Adenosine is favored for the prompt conversion of atrioventricular nodal rhythms to normal sinus rhythm. D (28) Pramipexole is a non-ergot dopamine agonist with high affinity for the D3 receptor. It is used as monotherapy in mild parkinsonism and together with levodopa in more advanced disease. Mental disturbances such as confusion, delusions, and impulsivity are more common with pramipexole than with levodopa. D (33, 58) In cyanide poisoning, the vitamin B12 analog hydroxocobalamin reacts with cyanide to form cyanocobalamin, another form of B12 that is stored in the liver. Note that the dose-limiting toxicity of cyclophosphamide is bone marrow suppression. A (54, 55) Allopurinol interferes with the metabolism of azathioprine, increasing plasma levels of 6-mercaptopurine, which may result in potentially fatal blood dyscrasias. B (36) Treatment of gout falls into 2 categories: 1) to treat the acute attack where the goal is to reduce pain and inflammation, and 2) to prevent attacks by reducing the uric acid pool through inhibition of uric acid buildup (allopurinol and febuxostat) or by enhanced elimination (probenecid). Morphine will reduce only the pain but not the inflammation, and methotrexate is more effective for immuno-inflammatory disorders. C (33) Deficiencies of folic acid or vitamin B12 are the most common causes of megaloblastic anemia. If a patient with this type of anemia has a normal serum vitamin B12 concentration, folate deficiency is the most likely cause of the anemia. Deficiency of folic acid during early pregnancy is associated with increased risk of a neural tube defect in the newborn. Desmopressin, a selective vasopressin V2 receptor agonist, can be administered orally, nasally, or parenterally to treat central diabetes insipidus. Onset of effect is rapid since both release and synthesis of hormones are inhibited. The effects are transient as the gland "escapes" from the iodide block after several weeks of treatment. Choice D is incorrect; propylthiouracil is the preferred thioamide treatment in pregnancy because it is less likely to cross the placenta and into breast milk.

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Imaging Computed tomography (C) Advantages: Evaluating tumor involvement o the paranasal sinuses antibiotic used for mrsa order fucidin 10 gm line, the boney skull base and the retro-orbital and orbital apex region. Limitations: De ning so tissue disease in areas o high contrast in tissue density (ie, dental llings); evaluating orbital oor because o "partial volume averaging" o thin bone, demonstrating intracranial tumor extension; determining invasion o periorbita; and separating tumor rom post obstructive sinus disease. On C most malignant lesions cause bony destruction; however, benign tumors, minor salivary gland carcinomas, extramedullary plasmacytomas, large cell lymphomas, hemangiopericytomas, and low-grade sinonasal sarcomas cause tissue remodeling. O en on C imaging o inverted papillomas, hyperostotic bone can be ound at the site o origin. Histopathologic Markers on Biopsy or Ol actory Groove Cancers Pathologic sub categorization or skull base malignancies is imperative or management and prognostication o these aggressive tumors. Endoscopic, mid acial degloving and trans acial (rom least invasive to most) approaches can be per ormed. Nasal Cavity and Ethmoid Sinus T Staging 1: umor restricted to one subsite with or without boney invasion. Distant metastasis Pa rt 3: Rhinology reatment reatment o benign tumors ranges rom observation, to partial resection or obstructive sinonasal disease, to complete resection with margins (inverted papillomas). Radiation is reserved or symptomatic tumors in nonsurgical candidates or or radiation sensitive tumors such as plasmacytomas. Surgery or benign tumors must be match with the biology o the tumor and the speci c patient. For sinonasal cancers, the acceptable risks o surgery are signi cant o en putting the eyes and brain at risk. This balanced with the issue o local tumor resection and the need to obtain negative margins. However, the oncologic outcomes and treatment morbidity o patients with sinonasal cancer has been improving over the last several decades. This likely attributable to improved diagnostic imaging, more e ective surgical treatment, the use o vascularized aps or reconstruction, and more e ective adjuvant therapy. For high-grade cancers, o en tri-modality therapy provides the best cancer outcomes. The same surgical risks to the vision, cranial nerves and the brain/brainstem are also risks with radiation therapy. Proton radiation therapy has the theoretical advantage o being more con ormable with less dosage to nontumor involved sites such as the eye and brain. The limitation o proton radiation is its relative unavailability across the country, limited outcomes studies and overall higher cost. Approach must allow adequate exposure while preserving unctional tissue and cosmetic results, i possible. Preoperative consultation with neurosurgery, maxillo acial prosthodontist (i obdurator required), plastic and reconstructive surgery and radiation oncology i needed. Cha pter 28: Tumors of the Parana sa l Sinuses 517 Extirpative options Maxillectomies should be individualized to the anatomy o the tumor and the need to obtain negative margins. Skull base tumor surgery, especially o the anterior cranial ossa, began with a combination o approaches via acial incisions and rontal craniotomies. These two approaches then collided with the standard anterior cranio acial resection, which provides excellent access to the entire anterior cranial ossa, orbits and sinonasal cavities. The cranio acial resection is the gold standard or this approach with the sinonasal portion o the tumor dissected via a trans acial approach and the dural/skull base portion o the tumor dissected via a rontal craniotomy, allowing or en-bloc removal o the skull base/sinuses and dura. The cranio acial resection also allows or direct access or reconstruction o the skull base and dural de ect with a pericranial ap. Several modi cations o the open anterior cranio acial approach have been modi ed to reduce brain retraction, acial scarring and minimize (but not eliminate) this morbidity. Over the last decade, there have been signi cant advances in the area o endoscopic cranial base surgery. These include an improved understanding o endoscopic anatomy, the development o new instrumentation, and the description o new endonasal surgical approaches and surgical techniques. Endoscopic approaches o er potential advantages such as no acial incisions, no need or craniotomy, no brain retraction, and excellent visualization and magni cation using the endoscope. However, even through endoscopic skull base surgery does not have dis guring incisions the risks o traditional skull base surgery and neurological complications are still very applicable. Also all patients undergoing endoscopic transcribri orm cranio acial resections should have been counseled and in ormed consent obtained to convert to a standard open approach i needed to clear margins. Endoscopic transnasal transcribri orm cranio acial resection Indications: Initially thought to be only or those patients with low stage disease with no intracranial involvement; however, recent results with endoscopic dural and intradural resections have shown promise or highly experienced skull base surgery programs. There ore, the overall permanent morbidity (14 patients) and mortality (7 patients) was 2. The underlying principle o multilayered reconstruction to reestablish natural tissue barriers should be preserved. The use o vascularized reconstruction optimizes healing and minimizes postoperative complications (especially in the setting o radiotherapy). Cranio acial resection or malignant paranasal sinus tumors: report o an international collaborative study. What site o involvement within the paranasal sinuses pretends the worst prognosis What would be an absolute contraindication or a solely endoscopic approach or sinonasal cancer resection Which small round blue cell tumor is most correlated with the immunohistochemical staining pattern o cytokeratin positive, neuron speci ic immunomarker negative This increase has led to an interest in surgical resection o tumors through an endonasal approach. Advantages such as improved surgical exposure, decreased duration o hospitalization, elimination o external incisions, and decreased overall morbidity have led to the insertion o endoscopic skull base surgery into mainstream practice. It articulates with the roo the ethmoid sinus anteriorly and the sella posteriorly. An onodi cell is a posterior ethmoid cell with superolateral pneumatization into the sphenoid sinus, creating a horizontal septation. Identi cation o an onodi cell is important in skull base surgery as this may be disorienting to the normal anatomy o the sphenoid sinus. Technique (a) o access the sella the in erior, middle, and superior turbinates must be lateralized. Technique (a) Begin with an anterior and posterior ethmoidectomy creating complete exposure o the skull base. This dissection should include the ethmoid bulla, suprabullar cells, and posterior ethmoid cells posterior to the basal lamella. A modi ed Lothrop procedure may be required i the lesion extends into the rontoethmoid region or an obstructing mucocele has ormed. During this procedure the naso rontal beak is drilled out and the intersinus septum is removed. Cha pter 29: Endoscopic Skull Base Surgery 525 Osteotomies are then per ormed with a diamond burr and Kerrison rongeur ensuring an appropriate margin around the tumor. Technique (a) For lesions limited to the medial cavernous sinus, a sellar approach per ormed as previously described. I a supreme turbinate is present it should be removed and a posterior ethmoidectomy per ormed. The bony covering over the carotid protuberance and lateral nasal wall are then removed using a diamond drill. Clival Region (a) The posterior cranial ossa rom an endoscopic skull base prospective extends rom the dorsum sellae to the craniovertebral junction. When entering the pterygopalatine ossa this nerve is located in erior to the intrapetrous carotid artery. Technique (a) The anterior wall o the sphenoid sinus is opened and a posterior septectomy is per ormed using the technique described above.