Definition

Chemosis of the eye is a medical condition, in which the conjunctiva of the eye becomes swollen. The condition mainly caused by the exudation of the small capillaries of the eye, presenting an abnormal permeability. Chemosis occurs when the eye has been irritated, representing however a nonspecific sign. Upon a closer look, the conjunctiva will appear as if having liquid in it. The inflammation of the conjunctiva leads to an overall gelatinous appearance. The degree of the swelling varies from one patient to the other and, sometimes, it can become so inflamed, that the patient will have difficulties closing the eye (completely or partially). Due to the inflammation, the eyeball might appear as if moved from its original position (it should also be noted that the eyeball is not covered by the excess fluid).

Symptoms of Chemosis

These are the most common symptoms of chemosis:

• Inflammation of the conjunctiva
• The eyes appear to be red and watery
• Excessive tearing can occur because of the inflammation
• Itchiness is also present in some patients (often aggravated by the excessive rubbing of the eyes, predisposing to secondary bacterial infections)
• The vision can be affected by the inflammation of the conjunctiva (blurry or double)
• Gelatinous appearance of the conjunctiva
• The eyeball appear to have moved from its original position, due to the inflammation
• The patient might not be able to close his/her eye, due to the inflammation (the eyelids can become inflamed as well)

If you are experiencing intense pain in the eye or severe inflammation, you might be experiencing a severe allergic reaction. Keep in mind that severe allergic reactions are often accompanied by systemic symptoms, such as the increased heart rate, the wheezing and the swelling of the throat tissues, causing difficulties breathing. Emergency treatment is necessary before the symptoms of the allergic reaction become life-threatening.

Causes

These are the most common causes that lead to the appearance of chemosis:

• Allergy – seasonal allergies can lead to chemosis, as well as to itchiness and watery eyes
• Viral infection – there are different viruses that can lead to the inflammation of the conjunctiva (often transmitted through objects of personal hygiene, such as towels)
• Obstruction of the superior vena cava (the diagnosis can be confirmed if the patient presents facial edema as well)
• Thyroid disorders – the chemosis is present in people who have been diagnosed with hyperthyroidism (the other symptoms of the condition include the bulging of the eyes, the puffiness that surrounds the orbits of the eyes, the retraction or lag of the lids)
• Thrombosis of the cavernous sinus – this is a serious condition, in which a blood clot forms at the level of the cavernous sinus, which is actually a cavity at the base of the brain (drains blood from the brain, sending it to the heart). This condition is often associated with the infection of the paranasal sinuses, leading to a wide range of other symptoms, besides the chemosis: sensory loss at the level of the trigeminal nerve, abnormal movements at extraocular level, hemorrhage at the level of the retina, papilledema, edema around the orbits and bulging of the eyes.
• Carotid-cavernous fistula – this condition has a classic triad of symptoms, including the ocular bruit and the pulsatile bulging of the eyes, besides the actual chemosis
• Cluster headaches – neurological disorder, in which the patient suffers from recurrent headaches, most commonly unilateral and around the eye
• Trichinellosis – parasitic disease, caused by eating infected, raw or undercooked meat (pork/wild game)
• Systemic lupus erythematosus – autoimmune disease of the connective tissue, in which the immune system attacks the healthy tissues of the body
• Angioedema – severe allergic reaction, which can lead to suffocation if emergency treatment is not administered
• Acute glaucoma – increased pressure inside the eye (considered a medical emergency as well)
• Panophthalmitis – inflammation of the eye coats, including at the intraocular level
• Orbital cellulitis – severe inflammation of the eye tissues, often caused by an acute infection that has spread into the eye socket
• Gonorrheal conjunctivitis – infection transmitted through sexual intercourse, may cause extensive damage at the level of the eye, if proper treatment is not administered
• Dacryocystitis – infection of the lacrimal sac, which appears due to the obstruction of the nasolacrimal duct
• Urticaria – dermatologic disorder, often appears as an allergic reaction after the exposure to different allergens
• Rhabdomyosarcoma of the orbit – rare, malignant tumor, presenting a high risk of death.

Diagnosis

The diagnosis of chemosis is made through the following methods:

• Patient anamnesis – the doctor will ask a series of questions, such as:
  • When did you notice the changes in your eyes?
  • Do you present other symptoms, such as itchiness or excess watering?
  • Do you know yourself to be allergic to any substances?
• Physical examination – using specific ophthalmologic instruments, the doctor will take a closer look at the eye
• Biopsy – this is recommended only when there is a suspicion of a tumor

Treatment

In order for the symptoms of chemosis to improve, one must first treat the underlying condition. Symptomatic treatment can also be administered, guaranteeing an improvement in the symptoms experienced by the patient.

These are the most common treatments recommended for chemosis:

Anti-histamines

• These are recommended in patients who suffer from allergies, reducing the inflammation of the conjunctiva and bringing relief from the other symptoms experienced (pain, itchiness)
• May be recommended as oral or topical administration (depending on the severity of the inflammation and the presence of other symptoms)

Antibiotics

• These are recommended in case of secondary bacterial infections, which may appear due to the excessive rubbing of the eyes
• The antibiotics should be taken for as long as they are prescribed, otherwise the bacteria will develop resistance to the treatment
• Probiotics are administered for the duration of the treatment, so as to maintain a healthy intestinal flora

Anti-inflammatory medication

• Topical or oral administration
• Reduce the inflammation and bring the necessary relief from the other symptoms (pain, itchiness)

Adrenaline

• Administered as emergency treatment, in case of severe allergic reactions
• Patients who know that they are allergic usually carry these allergy shots (immediate intervention is necessary, before the symptoms become life-threatening)

When to see a doctor

If you have noticed that the conjunctiva of your eyes has swollen all of a sudden, you must visit the doctor and ask for a consultation. At the same time, it is important to not delay going to the doctor, as you might be experiencing an allergic reaction. The doctor will perform a series of tests, in order to determine the things you are allergic to. If you are having difficulties breathing and you feel like you are suffocating, you are most likely experiencing a severe allergic reaction. In this situation, you have to call 911 and request immediate medical intervention. If the doctor discover that you are allergic to certain products, you will have to avoid them in the future and carry an allergy shot, just in case of emergency.

Chemosis Pictures

Here is how chemosis of the eye looks like…

Definition

Rhabdomyolysis is a medical condition, in which the skeletal muscle tissue that was damaged starts to break down in a fast manner. The breakdown process leads to the release of products, from the damaged muscle tissue into the bloodstream. Among the products that are released, there are proteins, such as myoglobin. These proteins can have a harmful effect for the kidneys, leading to renal insufficiency, among other problems.

As you will have the opportunity to read below, the severity of the symptoms depends on the extensiveness of the muscle damage and also on the appearance of renal insufficiency. Among the most common symptoms of rhabdomyolysis, you will find: mental confusion, vomiting and intense pain at the level of the affected muscles. There are numerous physical factors that can contribute to the appearance of the muscle damage, including: crushing injuries, infection, medication, substance abuse and intense physical exercise. Inherited conditions that affect the muscles can also increase the risk for rhabdomyolysis. The diagnosis of this condition is made with the help of blood tests and analysis of urine samples. The treatment approaches vary, ranging from the administration of intravenous fluids to dialysis or hemofiltration.

Rhabdomyolysis Symptoms

These are the most common symptoms that lead to the appearance of rhabdomyolysis:

• Pain at the level of the affected muscles
• Tenderness upon touching the affected area
• Weakness
• Inflammation of the muscles
• Systemic symptoms can also be present (especially in those who have suffered from acute injuries, with fluid being delivered to the damaged muscles from the bloodstream) – low blood pressure, vascular collapse, shock
• The release of products from the breakdown process can lead to an imbalance in the level of electrolytes, which can lead to the following symptoms:
  • Nausea and vomiting
  • Mental confusion
  • Coma
  • Abnormal heart rhythm
• Changes in the color of the urine (dark urine) – indicate the presence of proteins that have resulted from the breakdown process (such as myoglobin)
• In case of kidney damage or renal insufficiency, the urine output might be reduced or even absent (depends on the extent of the damage, usually appears between 12-24 hours after the muscle damage)
• Compartment syndrome – the person might experience a loss of sensation in the respective limb or part of the body
• Disseminated intravascular coagulation – this is a complication of the rhabdomyolysis, leading to excessive bleeding.

What are the Causes of Rhabdomyolysis?

These are the most common causes that lead to the appearance of rhabdomyolysis:

• Intense physical exercise (especially if the person does not drink sufficient quantities of water)
• Alcohol withdrawal (this condition is also known as delirium tremens)
• Tetanus
• Epilepsy (especially in the situation of prolonged or frequent epileptic seizures)
• Crush syndrome (acute trauma)
• Blast injury (frequent in situations of explosions)
• Vehicle accidents
• Physical abuse (or even torture)
• Being bedridden (such as it happens with patients who have suffered from a cerebrovascular stroke, those who have undergone different types of surgical intervention etc.)
• Arterial thrombosis
• Embolism
• Artery clamping (during surgical intervention)
• Metabolic changes
  • Hyperglycemia
  • Elevated/reduced sodium levels
  • Reduced potassium levels
  • Low calcium levels
• Hypothyroidism
• Changes in the body temperature
• Medication
  • Statins and fibrates
  • Antipsychotic medication
  • Anesthetics
  • SSRIs
  • Diuretics
• Poisoning
  • Heavy metals
  • Venom (insects/snakes)
• Substance abuse/alcohol intoxication
  • Alcohol
  • Amphetamine
  • Cocaine
  • Heroin
  • LSD
  • Ecstasy
• Infectious microorganisms
  • Coxsackie virus
  • Influenza virus
  • Epstein-Barr virus
• Autoimmune disorders
  • Polymyositis
  • Dermatomyositis

Diagnosis

These are the most common methods used for the diagnosis of rhabdomyolysis:

• Level of creatine kinase in the blood (enzyme released by damaged muscle)
• Level of lactate dehydrogenase (LDH)
• Identification of other markers of muscle damage (in chronic conditions affecting the muscles) – aldolase, carbonic anhydrase type 3 , troponin and fatty acid binding protein
• Liver markers – increased levels of liver enzymes (transaminases)
• Blood testing for potassium levels (commonly high)
• Electrocardiography – identify whether the high potassium levels are affecting the health of the heart
• Urine analysis – changes in color and texture of the urine.

Treatment

These are the most common treatment approaches considered for rhabdomyolysis:

• Administration of intravenous fluids – treatment of the vascular collapse and preservation of the kidney function (isotonic saline)
• Administration of calcium – protection against cardiac complications
• Insulin/salbutamol – compensate for electrolyte imbalances
• Renal replacement therapy – in case of kidney dysfunction
  • Hemodialysis
  • Continuous hemofiltration
  • Peritoneal dialysis
• Surgical intervention – recommended in case of complications, such as:
  • Compartment syndrome – fasciotomy
  • Debridement and skin grafting might also be necessary
• Supportive measures in case of disseminated intravascular coagulation (administration of platelets)

Prevention

These are the best methods to ensure the prevention of rhabdomyolysis:

• Checking the medication you are taking for such side-effects (often a problem with medication intended to lower the high cholesterol levels; talk to your doctor about switching to other medication, without such side-effects)
• Planning your exercise routine in a careful manner, so as to avoid the negative consequences of intense physical exercise
• It is recommended that you avoid performing physical exercise in a hot environment and you drink adequate amounts of water (you can also drink water with electrolytes, so as to compensate for the electrolyte imbalance)
• Do not perform intense physical exercise all of a sudden. Take things gradually and increase the amount of effort on a daily basis. In this way, you will allow for the muscles to build endurance and also to develop cardiovascular resistance to physical effort.
• Eat a healthy diet, especially one that is rich in carbohydrates (necessary for the proper functioning of the muscles)
• Avoid dehydration, as it can have negative effects on the muscles and also on the kidneys
• During physical exercise, wear clothes that are loose, as they allow for a better ventilation effect.

In conclusion, rhabdomyolysis is a medical condition that can affect both people who have suffered from acute injuries but also professional athletes who perform intense physical exercise. The treatment approach depends on the severity of the condition and also on the presence of life-threatening symptoms, as it happens with those who have been victims of earthquakes or other natural disasters. The main objective of the treatment in this case is to stabilize the patient, preventing the vascular shock and keeping the kidneys functioning.

Rhabdomyolysis Pictures

Paraplegia is a medical condition, in which the motor and sensory functions are impaired at the level of the lower extremities. As you will have the opportunity to read in the paragraphs below, this condition is often caused by congenital conditions (such as spina bifida) or by different injuries at the level of the spine. In order for the paraplegia to appear, one has to suffer from an injury at one of the following segments of the spine: thoracic, lumbar or sacral. Depending on the type of injury, the paraplegia can be spastic (rigid muscles) or flaccid (low muscle tone).

In paraplegic patients, the loss of sensation and movement appears due to the damaging of the nervous system. By identifying the level at which the injury has occurred, the doctor will be able to know exactly the parts of the body that are going to be affected (in this case, the lower extremities). In some cases, depending on the level of the injury, the patient might also present poor trunk control (due to the abdominal muscles being affected).

Symptoms of Paraplegia

These are the most common symptoms that appear in patients who suffer from paraplegia:

• Loss of movement and sensation in the lower extremities
• The arms are not affected (different innervation)
• Poor trunk control (lack of abdominal muscle control)
• In case of lower thoracic injuries, the trunk control remains good, as well as the sitting balance
• Reduced control in the flexor muscles of the leg occurs in case of lumbar or sacral injuries
• Dysfunction of the bowel and bladder (lumbar or sacral injuries)
• Sexual functioning – impaired or lost
• The fertility can be impaired as well (in men, not in women)
• Low blood pressure
• Inability of the body to keep the blood pressure within normal levels
• The body temperature cannot be correctly controlled
• Inability to sweat (this occurs below the level of the injury)
• Chronic pain (over spine or along roots)
• Standing and walking are impaired
• The respiratory capacity can be affected in injuries that occur at more superior levels
• Partial trunk movement is possible in lower injuries
• If the injury occurs at a thoracic level, the patient might be able to walk, using a walking frame or crutches
• Hyperesthesia at the level of the injury
• Motor weakness
• Increased tone
• Loss of deep tendon reflexes at the level of the injury
• All reflexes below the level of the injury are lost.

What Causes Paraplegia?

These are the most common causes that lead to the appearance of paraplegia:

• Spinal cord injury
  • Trauma
  • Inflammation that occurs after the trauma
• Congenital conditions
  • Spina bifida
  • Spinal tumors
  • Scoliosis
• Infectious agents
  • Severe bacterial infections
• Poliomyelitis
  • Infectious disease, caused by poliovirus
• Radiculitis
  • Painful syndrome, in which the pain caused by the irritation or compression of a nerve root is transmitted to other parts of the body
• Cauda equina syndrome
  • Medical condition, in which the nerves at the end of the spinal cord are inflamed or compressed by the adjoining structures
• Peripheral neuropathy
  • Occurs due to the damage of the peripheral nerves, leading to a wide range of symptoms (impaired sensation and movement)
• Myasthenia gravis
  • Autoimmune disorder, characterized primarily by muscle weakness and rapid fatigue (voluntary control)
• Lambert-Eaton syndrome
  • Rare autoimmune disorder, in which the immune system practically attacks the neuromuscular junction
• Myopathy
  • Muscular disease in which the muscle fibers stop functioning, the skeletal muscle weakness being one of the primary symptoms
• Meningioma
  • Meningeal tumor, affecting the membrane that surrounds the spinal cord and the brain
• Neurofibroma
  • Benign nerve sheath tumor, localized at the level of the peripheral nervous system
• Arachnoiditis
  • Pain disorder, in which the arachnoid, a membrane that protects the spinal cord, is inflamed
• Pott’s disease
  • Medical condition, that is also known as tuberculous spondylitis (form of tuberculosis that occurs outside of the lungs)
• Vertebral neoplasms (metastasis, myeloma)
• Pachymeningitis
  • Rare condition, in which chronic inflammation leads to the thickening of the dura mater
• Prolapsed intervertebral disc
• Epidural abscess/hemorrhage
• Fracture/dislocation of the vertebra
• Pagets disease
  • Medical condition, in which the bone tissue suffers an abnormal breakdown
• Hematomyelia
  • Hemorrhage that occurs inside the spinal cord, interfusing with the spinal cord substance
• Intramedullary tumor
• Ependymoma
  • Type of glial tumor, occurring at the level of the central nervous system

Treatment

These are the most common measures of treatment undertaken for patients with paraplegia:

• Corticosteroid drugs
  • Administered immediately after the intervention
  • Purpose – reduce the inflammation at the level of the injury
  • Prevent further damage at the level of the spine
• Surgical intervention
  • Stabilization of the spine (prevent further damage to the nerves)
  • Correct the misalignment of the spine
  • Remove the tissue that is causing compression on the nerves
  • Spinal fusion (provide stability to the spinal column) – often performed in patients with herniated discs
• Physical therapy
  • Most essential form of treatment
  • Gain functionality and reach the best level of independence that is possible
  • Physical therapy programs work to increase the range of motion, strengthen the muscles and also to develop transfer skills
  • Learn wheelchair mobility (for some patients, this will remain the only possible form of transportation)
  • Learn basic skills to be independent again
  • Prevent the complications that might occur after the intervention on the spine
• Massage therapy
• Hydrotherapy
• Gait training
  • Recommended for patients who have difficulties walking
  • Teach the patient how to walk using assistive devices (walker, cane, crutches)
• Occupational therapy
  • Learn how to deal with activities of daily living
  • Obtain new skills and adapt the current functionality level for a maximum of independence
  • Teach the patient how to dress and bathe, how to prepare a meal, go to the toilet
• Regeneration of the spinal cord
  • Experimental intervention
  • Olfactory cells were taken from the olfactory bulb (in the brain), grown in the lab and then implanted at the level of the impaired spinal tissue
  • The patient regained both movement and sensation in the lower limbs
• Speech and language therapy
  • Teach the patient how to speak again
  • May include physical adaptation for writing or using a computer (using the muscle groups that are functioning)
• Psychological counselling
  • Provides the necessary emotional support

Complications

These are the complications that can appear in patients with paraplegia:

• Pressure sores
  • Common complication of spinal cord injuries
  • The result of excessive pressure (most commonly at the level of the buttocks)
  • They appear due to the alteration of the muscle tone and the circulatory changes
• Pneumonia
  • Pneumonia or aspiration is common in paraplegic patients
  • Occurs after several years from the injury (progressive condition)
  • The patient has to be closely monitored, in order to reduce the risk of such complications
• Osteoporosis and fractures
  • Appear due to the reduced activity of the muscles
  • Bone loss occurs in a progressive manner
  • The osteoporosis increases the risk for bone fractures (may be decreased by positioning the patient in special devices to maintain the orthostatic position)
• Heterotopic ossification
  • Occurs in acute spinal cord injuries
  • Affects the large joints of the body (hips, knees)
  • Risk for the joints becoming stiff and fusing together
• Spasticity
  • Exaggeration of the normal reflexes
  • Severe spasticity reduces the range of motion at the level of the joints
  • Physical therapy, performed on a daily basis, can reduce the level of spasticity
• Urinary tract infections
  • The bacteria enters the bladder through the urinary catheter
  • The infection has to be treated quickly, so as to reduce the risk of progressing to other organs
  • Antibiotics represent the standard treatment for UTI
• Autonomic dysreflexia
  • The blood pressure and heart function can no longer be correctly controlled
  • Occurred in those who have suffered from spinal injuries above the T6 level
  • Can lead to severe hypertension
• Orthostatic hypotension
  • The circulatory system has difficulties in adapting to the standing position
  • When standing, the person might feel dizzy or even have a fainting sensation
  • Physical therapy can contribute to the improvement of this condition
• Cardiovascular disease
  • Long-term risk of spinal cord injury
  • Caused by the sedentary lifestyle
  • Physical therapy can improve the cardiac functioning, reducing the risk of heart disease
• Syringomyelia
  • Post-traumatic enlargement of the central canal of the spinal cord
  • Affects 1-3% of the individuals diagnosed with paraplegia
  • Primary risk – loss of function above the injury level
• Spinal cord pain
  • Central pain – pins and needles sensation
  • Muscle tension – mechanical pain (aggravated by movement, relieved by rest)
  • Visceral pain
  • Neuropathic pain
• Hyperthermia/hypothermia
  • Altered functioning of the autonomic nervous system
  • The tendency of the temperature to fluctuate is higher, as the level of injury is located at a higher level
  • The fluctuations are influenced by the environmental temperature

Management

In order to prevent the complications of paraplegia and keep the condition under control, physical therapy is essential to be performed on a regular basis. Aside from that, the patient should be positioned in different positions, so as to guarantee the functioning of the circulation and prevent pressure sores. Regular consultations made by the doctor are essential, so as to assess the current level of functioning. The patient has to be encouraged to remain as active as it is possible, so as to avoid depression and other similar problems.

Definition

The phrenic nerve can be defined as one of the nerves that stems from the cervical spinal roots and travels to the thorax, in order to innervate the diaphragm and guarantee the control of the breathing process. Each part of the body (left and right) has its own phrenic nerve. The phrenic nerve is also known in the medical field as the internal respiratory nerve of Bell.

Anatomy

The phrenic nerve has its origin in the cervical roots, mainly C3-C5. From there, it goes to the thorax, passing between the lungs and the heart and reaching the diaphragm. In the majority of the people, the phrenic nerve originates specifically from the C4 nerve root, but the contributions to the nerve also come from the C3 and C5 nerve roots. The phrenic nerve also receives a part of its fibers from both the cervical plexus and the brachial plexus. Just like the other nerves, the phrenic nerve has different types of fibers, such as: motor, sensory and sympathetic. While the phrenic nerve supplies the diaphragm with motor information, its fibers also reach a part of the pericardium and the mediastinal pleura.

The phrenic nerve travels at the same time with the internal jugular vein, crossing the anterior scalene muscle and going into the deeper levels of the cervical fascia, passing by two very important arteries: the cervical and the suprascapular arteries. On the two sides of the body, the phrenic nerve follows a different routes – on the left, it passes by the subclavian artery on the anterior part, while on the right, it crosses by the second part of the same artery. Then, it goes posterior to the subclavian vein and it enters the thorax. From there, it passes between the lungs and the heart, distributing some of its fibers to the pericardium.

At the level of the mediastinum, the phrenic nerve is found alongside the anterior scalene muscle, shielded in the fibrous connective tissue that surrounds the vascular structures of the neck (more commonly known as the carotid sheath). From there, the two phrenic nerves follow different directions one more. The right one will go over the brachiocephalic artery, then pass posteriorly to the subclavian vein and crossing the right lung root. It will leave the thorax passing through the hiatus of the vena cava and enter the diaphragm (T8 level). In leaving the thorax, the right phrenic nerve will pass the right atrium. The left phrenic nerve, on the other hand, will pass over the pericardium (left ventricle level) and enter the diaphragm after that (separate manner). The phrenic nerves are accompanied through their journey by the pericardiacophrenic arteries and veins.

Function

One of the most important functions of the phrenic nerve is related to the breathing. Innervating the diaphragm, the phrenic nerve controls and regulates the breathing process in healthy individuals. The phrenic nerve also provides the innervation of the pericardium, the mediastinal pleura and the diaphragmatic peritoneum.

Phrenic nerve palsy

Symptoms

These are the most common symptoms of the phrenic nerve palsy:

• Dyspnea (shortness of breath)
• Orthopnea (dyspnea that is relieved by assuming the orthostatic position)
• Hiccups (also caused by the irritation of the respective phrenic nerve)
• Diaphragm paralysis (the patient is no longer able to breathe on his/her own)
• Cyanosis can appear in newborns suffering from respiratory distress caused by the phrenic nerve palsy
• Chest wall pain
• Cough
• The symptoms can mimic the ones from cardiac dyspnea
• In case of bilateral phrenic nerve palsy, the patient can also present the following symptoms:
  • Anxiety
  • Insomnia
  • Headaches (predominantly in the morning)

Causes

These are the causes that lead to the appearance of the phrenic nerve palsy:

• Neoplasms (tumor compression of the phrenic nerve)
  • Bronchogenic carcinoma
  • Metastases at pulmonary level
  • Tumors of the mediastinum or at the level of the neck
• Blunt trauma and iatrogenic
  • Injuries with penetrating effect at the level of the chest
  • Inadequate chiropractic manipulation
• Surgical intervention
  • This is a problem that affects approximately 10% of the patients who have undergone surgical intervention for heart problems (cardiac surgery involving hypothermia)
• Central venous catheters
  • Direct trauma to the site of the catheter
  • Hematoma at the site, causing a compression
  • Infiltration of the local anesthetic substance
• Delivery of the newborns using the forceps and other invasive methods
• Neuromuscular medical conditions
  • CIDP (chronic inflammatory demyelinating polyradiculoneuropathy)
  • Parsonage-Turner syndrome
• Inflammatory conditions (pneumonia, emphysema, pleurisy, herpes zoster infection)
• Direct compression (occurs in patients who have been diagnosed with aortic aneurysm and cervical osteophytes)
• Cervical spondylosis
• Rare complication of radiofrequency catheter ablation (procedure recommended for those who are suffering from atrial fibrillation)
• Thoracic outlet syndrome

Treatment

These are the most common measures of treatment undertaken for the phrenic nerve palsy:

• In newborns
  • Continuous positive airway pressure (CPAP)
  • Mechanical ventilation
  • Surgical plication of diaphragm
  • Maintenance intravenous fluids
  • Oxygen support
  • Orogastric feeding tube
• Physiotherapy
  • Recommended in both children and adults
  • Can improve the respiratory capacity and the overall functioning of the diaphragm
• Avery Breathing Pacemaker System
  • Similar to the pacemaker used for those who suffer from cardiac dysfunction
  • Recommended for both adult and pediatric usage
  • Works by stimulating the phrenic nerve, being implanted in a surgical intervention
• The stimulation of the phrenic nerve can be made through two different methods:
  • Distal phrenic nerve stimulation
  • Direct muscular stimulation (implanted electrodes)

In conclusion, the phrenic nerve is a very important nerve of the body, as it provides the innervation of the diaphragm and contributes partially to the innervation of the pericardium, mediastinum and diaphragmatic peritoneum. It is important to acknowledge the symptoms of phrenic nerve palsy, especially in newborns. Otherwise, without the immediate support, serious neurological damage can occur, due to the lack of oxygen to the brain. Newborns are especially at risk for developing respiratory insufficiency and entering into vascular shock, which can threaten their existence. Immediate treatment is necessary to prevent such problems from occurring, with the neurological risk being reduced down to a minimum.

What is a Clavicle Fracture?

This medical condition is referred to as a broken collarbone and is one of the most common shoulder injuries. This is especially true of young people.

Anatomy

Your clavicle extends from your shoulder blade to your breastbone, also known as your sternum. It is seen just below your shoulder and neck. They are found on top of your chest and on both sides in front of your shoulders. It is the only link between your body and your shoulder. It also protects the blood vessels and nerves that go from your neck to the shoulder area. This bone is clearly visible and is only covered with skin so it has very little protection from being fractured.

Pictures – How does Clavicle Fracture look like?

Classification: Types of clavicle fractures

• Midshaft clavicle fracture — this occurs in seventy-five percent of clavicle fractures and is the most common. It can be as simple as being badly displaced to a simple crack in the bone. This fracture becomes concerning when there is significant separation or displacement, multiple breaks in the bone, or shortening of the length of the bone
• Distal clavicle fracture — this occurs in approximately twenty percent of clavicle fractures and occurs in close proximity to the end of your clavicle at your shoulder joint
• Medial clavicle fracture — this occurs in approximately five percent of clavicle fractures and often has a relationship to injury to your sternoclavicular joint, which is the connection of your sternum to your clavicle.

Symptoms

The pain most often associated foremost with a clavicle fracture is severe pain, especially on the front part of your upper chest or with upper extremity movements. Other symptoms may include:

• Having trouble moving the arm and shoulder
• Displacement or visible bulge in the collarbone
• If severe the bone may pierce the skin
• Tenderness
• Bruising due to possible ruptured blood vessels that overtime may extend down your armpit and chest
• If extreme pain you may experience dizziness and nausea
• Swelling
• After the swelling has gone down you may be able to feel the fracture through your skin
• Having sharp pain when you move it
• Dull to extreme ache in and around your clavicle area including the muscles

Some people who have a clavicle fracture may experience all of these symptoms while other with a less severe fracture may not has many or as severe symptoms.

Causes

A clavicle fracture can happen in many different ways but most often it is the result of a hard fall on your shoulder when you fall with your hand outstretched. Other ways a person can suffer a clavicle fracture can include:

• During birth when the baby is passing through the birth canal
• The clavicle does not mature in young children and teenagers until late adolescence
• Simple random fall while taking part in an activity like sports with athletes who participate in soccer, basketball, wrestling, and football being some of the ones who commonly have this type of fracture
• Being involved in a motor vehicle accident
• Getting hit on the outside part of your shoulder

Treatment

The best treatments that work to heal a clavicle fracture are conservative treatments but in order to restore normal functionality in a severe fracture you may need surgery. With conservative treatment methods these can include:

• Applying ice packs to help reduce the swelling
• Taking an over-the-counter or prescription pain reliever to help reduce the inflammation and discomfort
• Resting the arm and shoulder is normally mandatory
• Wearing a sling to immobilize the injured shoulder

Most clavicle fractures will only need to be treated with pain medication and immobilization. When using conservative treatment measures your progress will be monitored with an x-ray every two weeks.

Surgery

Having surgery to fix a clavicle fracture is usually only done when there is a severe break or when it will cause future problems. During the surgery you may need to have rods and screws inserted to help stabilize the bones while they are healing. It is considered a serious or severe clavicle fracture is when the bone is broken in more than one place or the bone is sticking out of your skin. If you have to have surgery it will be done using either local or general anesthesia. The surgeon then will make cuts or incisions in the skin to access the clavicle fracture. Before repairing your clavicle fracture the wound will be cleaned. At this time the surgeon will usually attach a steel or titanium plates to the fractured clavicle using pins or screws. These will stabilize the bone so it can heal faster better than if just a sling was used. If the recovery is good sometimes the plate can be removed during the post healing of the clavicle fracture but it is rarely required to remove it.

Healing time

It typically takes twelve weeks for the fractures to heal but some can return to their regular activities in six weeks. How long the recovery process takes also depends on your overall health and age. For example if you are in your twenties and in good health you will have a faster recovery than someone who is sixty and in fair health. Many times, in order to get complete strength back in your arm and shoulder, can take nine to twelve months. As the treatment progresses the pain you are feeling will decrease. If you are required to use a sling and immobilization instead of having surgery it can take a few months to completely heal.

Management

After surgery the incision is closed with sutures and then the surgeon will wrap a bandage around the area in order to prevent an infection. Until the condition is back to normal your arm will be put into a sling for three to four weeks

In addition there are certain things that you should not do such as:

• First four weeks—do not elevate the arm above seventy degrees for any plane
• First six weeks—do not live any object over five pounds, avoid repeated reaching
• Ice should three to five times a day for fifteen minutes each to help control inflammation and swelling
• After fourteen days you will have the sutures removed
• At one month, three months, and one year you will have the clavicle fracture checked to make sure that it is healing
• Exercise program three times a day

Complications

These complications do not necessarily happen after surgery. They can happen anytime you have a clavicle fracture. For example, if nerves or blood vessels become pinched by the broken bone you can develop serious complications. Some of the symptoms of this type of complication are tingling or numbness in your arm or hand. If you have this type of complication you will need to have surgery to repair any of those nerves or blood vessels. You could also develop difficulty in swallowing or breathing as a result of the clavicle fracture being near your sternum, which surgery is also required.

Prognosis

Many times when someone has undergone clavicle fracture surgery they will heal faster than those who do not and use other methods to treat their clavicle fracture. If immobilization is used as treatment you may have a visible bump in the area but if you had surgery to fix the clavicle fracture you will little to no visible bumps.

Notalgia Paresthetica is a chronic sensory neuropathy, with a characteristic location on the middle part of the back and primarily in the infrascapular area (unilateral involvement). This condition is also known as the hereditary localized pruritus, posterior pigmented pruritic patch or subscapular pruritus. It is a very common condition, affecting mainly those who are older.

Pathophysiology

It is believed that notalgia paresthetica occurs due to the increased sensory innervation existing in a certain skin area. The second possible mechanism has been connected to the degenerative disc disease that might affect the cervical or thoracic area, including a pinched nerve among other modifications.

Imaging investigations, such as X-rays have demonstrated that people who present their sensory neuropathy, also present degenerative changes in their vertebrae. The vertebrae that were affected by these problems corresponded to the dermatomes of the lesions present on the skin. Moreover, the histopathological analysis revealed the post-inflammatory hyperpigmentation at the level of the skin.

The symptoms that appear in patients diagnosed with notalgia paresthetica might also be related to the increased sensory innervation in the respective area. This has been encountered in patients diagnosed with lichen amyloid, this condition being caused in its turn by excessive scratching of the skin.

Notalgia paresthetica is believed to be a similar condition to the brachioradial pruritus, which is a localized pruritus syndrome as well. The latter has been found in association with degenerative disc disease (cervical) as well, which strengthened the idea that this might be a neuropathy as well and found in association with notalgia paresthetica. However, there is a main difference to be considered between these two medical conditions – notalgia paresthetica has a characteristic unilateral involvement whereas brachioradial pruritus can either have unilateral or bilateral involvement.

Symptoms of Notalgia Paresthetica

These are the most common symptoms present in patients diagnosed with notalgia paresthetica:

• Itch in the interscapular area (corresponds to the thoracic dermatomes, between T2 and T6)
• In some patients, the itch can extend to the other parts of the body, especially on the shoulders and the rest of the back, or even on the upper part of the chest; in very rare cases, the neck and the scalp might be involved
• The itchiness can be quite intense, causing the patient to scratch and rub the skin
• Most common – left part of the body, just below the shoulder blade
• Other symptoms that may accompany the itch include:
  • Pain
  • Paresthesia – the patient describe the sensation as ‘pins and needles’
  • Hyperesthesia – increased sensitivity to different stimuli (temperature – hot or cold, touch or pain)
• Due to the constant scratching or rubbing, the skin presents hyperpigmentation in the respective area
• The patient might describe a spider-bite sensation or a prickly feeling
• Female patients mistake the symptoms, considering they are caused by allergy to clothing tags or bras
• The itchiness can be accompanied, in some cases, by a mild burning sensation or numbness
• Patients might also describe a general discomfort in the respective area
• Affected skin area ranges between 3 and 10 cm
• Excoriations may occur on the skin due to the incessant scratching and rubbing
• Other modifications that may occur on the skin include:
  • Lichenification
  • Lichen amyloid
  • Eczema
  • Xerosis
• Tenderness can be present to the touch
• The range of motion in the neck can be affected and cervical muscle spasms are present (degenerative disc disease symptoms)
• The constant scratching and rubbing of the skin can predispose the patient to secondary bacterial infections.

What are the Causes of Notalgia Paresthetica?

The exact etiology of notalgia paresthetica has yet to be identified. However, the appearance of this condition is considered to be a dermatological sign, suggestive of an underlying systemic disease.

It is important to understand that notalgia paresthetica is not a skin disease on its own but rather a part of a sensory neuropathic syndrome, often found in association with degenerative diseases of the spine. It is believed that the main cause behind the appearance of these symptoms is the actual nerve impingement that occurs due to the collapse of the vertebral body, but further research is required in order to confirm this theory.

Treatment

These are the treatment solutions used for patients diagnosed with notalgia paresthetica:

• Topical steroids – not all patients respond well to this treatment (partial response)
• Topical anti-itching creams – reduce the itchiness and soothe the skin, as they contain menthol and camphor
• Topical capsaicin might be provided as a treatment to those who are suffering from intense itchiness
• Gabapentin – this is a treatment recommended for those who are also experiencing neuropathic pain
• NSAIDs – for the symptoms associated with the itchiness; recommended choices include: ibuprofen, celecoxib and ketorolac
• Oral muscle relaxants – these are recommended to be administered in case of muscular spasms
• Treatment of the underlying systemic disease (degenerative disease of the spine)
  • Orthopedic and neurological
  • Physical therapy
  • Cervical muscle strengthening
  • Spinal manipulation
  • Massage
  • Exercises to the increase the ROM (range of motion)
  • TENS (transcutaneous electrical nerve stimulation)
  • Cervical discectomy with fusion

Exercises

As notalgia paresthetica is often found in association with degenerative diseases of the spine (cervical, thoracic or cervico-thoracic), the exercises are recommended to improve the symptoms of the underlying systemic disease. After a thorough assessment of the spine, the physical therapist will jot down all the problems that have to be corrected: range of motion, muscle strengthening and functionality. All of these are going to become objectives of the treatment program, helping the physical therapist provide you with the best exercises for your problem.

Here are several exercises you can consider for your problems:

• Lying on the mat, with the hands resting near the body, raise your head and try to bring your chin as close to the chest as you can. Do not force to go yourself over the limit of pain. Allow the range of motion to increase progressively. Repeat between 5-10 times.
• Lying on the mat, with the hands spread from the body, maintained in horizontal abduction. Raise your hands in the air, bringing them into midline, with the palms facing each other. Lower your hands and repeat 5-10 times.
• Lying with the face down on the mat, with the hands near your body, try raising your head as much as you can. Once again, avoid going farther than you can. Lower your head and repeat 5-10 times.

These exercises are meant to increase your range of motion in a gradual manner and strengthen your paravertebral muscles. As you progress with your physical therapy program, the therapist will also show you exercises that are meant to increase your overall functionality. Once the underlying condition improves, so will the sensory neuropathy.

Pictures

Definition

This is a medical condition where the hyperextension of your knee is greater than five degrees. It is also referred to as back knee or knee hyperextension. It appears to occur more in females than it does in males. When this medical condition occurs it can cause stress in your posterior knee structures and your anterior cruciate ligaments (ACL) and possibly cause permanent damage of the joint. Having genu recurvatum could also cause other medical conditions such as knee osteoarthritis or knee pain. Genu recurvatum can be mild, moderate, or severe.

Types

There are three types of genu recurvatum which are:

• External rotary deformity (ERD) — this is when your foot remains in an equinovarus position when walking, which is the posture of a club foot. Your foot makes ground contact on the outer edge of your foot. This type of genu recurvatum is normally seen in a stroke patient whose foot movements are abnormal because of their abnormal pattern of muscle tone.
• Internal rotatory deformity (IRD) — this type is when you start with an abnormal gait in which your forefoot is rotated outward. This will cause you to compensate by overextending your knee and leading to this type of deformity.
• Non-rotatory deformity (NRD) — your ankle and foot are positioned normally with your knee being the primary abnormality. What causes this type of genu recurvatum is an injury that forces the hyperextension of your knee.

Symptoms

• Pain in your inner-leg portion of your knee called the medial tibiofemoral joint
• Pain in your outer back portion of your knee called the posterolateral ligamentous structures
• Extension gait pattern
• Pinching in the front of your knee
• Having difficulty in carrying out endurance activities
• Your knee can give way into hyperextension

Causes

Some of the causes of genu recurvatum can include:

• Misalignment of your ankle joint
• Knee injuries that involve hyperextension of your knee
• Excess laxity in your knee joint
• Postural habits
• Abnormal ankle and foot position when walking
• Knee joint instability
• Weakness in your quadriceps femoris muscle or hip extensor muscles
• Congenital/birth defect
• Connective tissue disorders
• Discrepancy in lower limb length
• Certain medical diseases such as muscular dystrophy, multiple sclerosis, and cerebral palsy

Diagnosis

To diagnosis genu recurvatum the physician uses magnetic resonance imaging (MRI) or x-rays along with gait analysis. These tests can also help to classify the type of genu recurvatum you have.

Treatment

It is important that you get a timely diagnosis of genu recurvatum and treat it promptly because if not it can lead to increased tissue damage. Any type of genu recurvatum deformity will place a strain on your knee and cause increasing joint deformity if you do not correct it and this deformity could become permanent.

• ERD — this can lead to increasing soft tissue damage as well as genu valgum of your knee, which is the medical terminology for knock knees. This is where your lower legs angle outward.
• IRD — this type produces a less-severe recurvatum and genu varum, which is the medical terminology for bow legs.
• NFD — this type produces increasing stress to the posterior soft tissue structures of your knee.

Treatment often requires physical therapy so the therapists will brace or tape the knee along with providing muscle balance correction, gait training, and proprioceptive training, which is training that is designed to increase your balance, agility, strength, coordination, and to help prevent further injuries.

If a person has IRD or ERD they will usually need fort orthotics to correct the positioning of their ankles. For the more severe type you may require a knee brace. Exactly which treatment would be used would depend on the severity and type of genu recurvatum you have. There are some cases of genu recurvatum that would require surgery to repair the damage to your knee.

Prevention

Because genu recurvatum may occur due to an injury or genetically it is not possible to prevent this from happening or having a recurrence of the deformity. Wearing braces or undergoing rehabilitation can help to limit the hyperextension of your knee joint.

Pictures: This is how Genu Recurvatum looks like

Acanthamoeba keratitis is an infection that occurs at the level of the eyes, affecting in the majority of the cases those who wear contact lenses. Even though it is believed that this condition affects only those who use contact lenses, there have been many cases reported of people diagnosed with such problems, without wearing such visual aids. The improper handling of the contact lenses and the inadequate hygiene are believed to be primarily responsible for this infection.

How common is Acanthamoeba keratitis?

This is a rare condition, that was first recognized in 1973 and the parasitic infection can threaten the vision. It is very difficult to diagnose and treat.

Symptoms

These are the symptoms of Acanthamoeba keratitis:

• The conjunctiva of the eyes is red
• Intense pain appears in the eyes after the contact lenses are removed
• Excessive tear can occur
• Increased sensitivity to light
• Blurred vision or other changes of vision
• Sensation that there is something in the eye (foreign body sensation)
• Discharge from the eye
• Ring-like ulceration of the corneal tissue
• Edema of the lid can also be presented
• Formation of cataract can occur in more severe cases

Causes

These are the causes that lead to the appearance of Acanthamoeba keratitis:

• Using water from contaminated sources in order to wash the contact lenses
• Cleaning the contact lenses with homemade solutions (containing sodium chloride)
• Improper storage of the cleaning solutions for the contact lenses
• Wearing contact lenses while you are in the hot tub
• Swimming or showering while wearing the contact lenses
• Storing the contact lenses in a dirty case (source of infection)
• The disinfecting substances that are added in the water can actually increase the risk for Acanthamoeba being present in the said water
• The usage of ‘no-rub’ lens care system (increased risk of infection, due to the reduced efficiency of the cleaning and disinfecting of the contact lenses)
• Exposure to the infectious microorganism (often through contaminated water)
• Trauma to the cornea, followed by the exposure to Acanthamoeba

Those who present a compromised immune system are also at risk of developing an infection. The risk is higher in patients who have been diagnosed with the following conditions: AIDS, chronic disease of the liver, organ transplantation, diabetes, systemic lupus erythematosus, cancer and malnutrition.

Diagnosis

The diagnosis of Acanthamoeba keratitis is often difficult to be made and this is the reason why it is also delayed. The doctor will first perform a clinical examination and, if there is the suspicion of an infection with Acanthamoeba, he/she will scrape the involved area of the cornea with a sterile instrument. This diagnosis procedure is performed under topical anesthesia and it allows for the identification of infectious microorganism. The infection with Acanthamoeba can also be diagnosed with the help of confocal microscopy but this does not provide the desired results in all cases.

The early diagnosis is essential in order to maintain a good visual acuity. In general, one of the earliest signs of infection is a specific pattern on the corneal epithelium. Biopsy samples can also be taken in order to confirm the infection with Acanthamoeba. In case that the corneal specimens do not provide the expected results, one can also analyze the contact lenses and the saline solutions used for the cleaning of the lenses. The diagnosis can be complicated by secondary bacterial infections.

Treatment

These are the most common treatments recommended for Acanthamoeba keratitis:

• Antibiotics – in case of secondary bacterial infection
• Antiviral medication
• Antifungal medication
• Antiparasitic medication
• Recommended topical medications include:
  • Brolene
  • Neomycin-Polymyxin B-Gramicidin
  • Polyhexamethylene biguanide (topical cationic antiseptic agent)
  • Chlorhexidine
  • Voriconazole
• The duration of the treatment might last between six months and a year
• Oral ketoconazole is also recommended
• Topical antimicrobial treatment is administered immediately after the debridement of the cornea, so as to reduce the risk of infection
• Corticosteroids are not recommended, as they can make the condition worse (they inhibit the immune response of the body, allowing for the infection to progress)
• Anti-inflammatory medication can be administered, in order to provide patients with the necessary pain relief; topical cycloplegic solutions can also be administered with the purpose of pain relief
• Surgical intervention might be recommended in the case of corneal perforation
  • Penetrating keratoplasty – last alternative, recommended for patients who present significant corneal scarring (useful for restoring visual acuity)
  • Corneal transplantation might also be performed in the patients who do not respond to other methods of treatment (however, there is a high risk of the new cornea becoming infected with the same microorganism)

Is Acanthamoeba keratitis contagious?

Acanthamoeba keratitis is a condition caused by an infectious microorganism but this does not mean that the condition is transmitted from one person to the other. As you might have understood by now, the condition mainly appears in those who wear contact lenses. These can be contaminated by the infectious microorganism, as well as the special substances that are used for cleaning. However, the contact lenses should not be shared, as this can definitely increase the risk of contagiousness. The contact lenses should be strictly reserved for individual wear, so there is no risk of spreading the condition to other people.

In conclusion, Acanthamoeba keratitis is a rare condition, with a high risk of serious problems, including loss of vision. If you want to protect yourself against such problems, you need to take good care of your contact lenses. This means that you should always follow the advice of the doctor in regard to the contact lenses care. You should never clean your lenses with tap water, as this might be contaminated with different infectious microorganisms, including Acanthamoeba. In fact, the contact lenses should not be exposed to any kind of water, which makes it essential to take them out if you are entering in the hot tub or you are planning on going swimming. The disinfecting solution should be approved by the doctor and you should avoid using homemade solutions. Never handle your contact lenses with dirty hands, as this too can increase the risk for infection. Always clean your lenses, as soon as you have removed them from your eyes and keep your contact lens case clean as well.

Pictures

Subungual melanoma is a type of cancer that involves the nail unit or matrix, hence the name. This type of melanoma is believed to be a variant of other types of cancer, such as: desmoplastic melanoma, nodular melanoma or acral lentiginous melanoma (the latter being the type of cancer that affects the palms of the hands and the soles of the feet). In the majority of the patients, subungual melanoma appears at the level of the big toe nail or at the thumb nail. This has led scientists to believe that trauma might represent a risk factor for the development of subungual melanoma, given the increased incidence of big toe/thumb involvement. However, it is important to remember that any nail can become affected.

This condition is considered to be extremely rare, affecting only 1% of the general white population. The interesting thing is that it affects people of all races, no matter if they are white or dark skinned. In fact, it is one of the most common types of melanomas diagnosed in dark-skinned individuals, even though the incidence is basically the same. In general, subungual melanoma is diagnosed in older individuals and it is believed that not only trauma contributes to its appearance but also prolonged exposure to the sun.

Symptoms of Subungual Melanoma

These are the most common symptoms that are characteristic for the patients with subungual melanoma:

• Wide pigment band appears on the middle of the nail (melanonychia)
• With the progression of the condition, the band will become even wider, especially at the level of the nail cuticle
• The band starts to change its color, becoming more pigmented (dark brown color)
• If the band extends so far as to involve the adjacent nail fold, this is known as the Hutchinson sign
• The nail bed might suffer from changes – nodules or ulcerations may appear, leading to eventual bleeding
• If the nodule is larger in size, it may cause the nail plate to lift (onycholysis)
• The nodule may resemble a wart in appearance (confusion of diagnosis with verrucous lesions)
• The nail plate might start to thin and cracks might appear, distorting the overall appearance of the affected nail (modification known as nail dystrophy)
• No pain is present, with the exception of advanced cases, in which the cancerous growth has reached all the way to the bone (in this case, the patient might suffer from really intense pain)

Keep in mind that, in over half of the patients who suffer from subungual melanoma, there is no pigmented band to draw attention to the problem.

Causes

These are the most common causes that can lead to the appearance of subungual melanoma:

• Trauma to the respective finger/toe (can be acute or chronic)
• Prolonged exposure to the sun
• Inadequate footwear (ill-fitting shoes)
• Foreign body into the finger/toenail
• Radiation therapy for other types of cancer
• Hormonal disorders
• AIDS (Acquired immunodeficiency syndrome)
• Chronic fungal infections of the nail bed

The main two causes incriminated in the appearance of subungual melanoma remain the trauma to the fingers or to the toes (predominantly in the big toe or thumb) and the prolonged exposure to the sun (both factors can be kept under control, thus reducing the risk of subungual melanoma actually appearing).

Diagnosis

These are the most common measures used for the diagnosis of subungual melanoma:

• Medical history of the patient (anamnesis)
  • Medication
  • Treatments taken in the past
  • Illnesses
  • Family history of medical problems
  • History of trauma to the respective toe/finger
  • Prior history of nail biopsies (results as well)
  • Number of nails affected
  • Bacterial or fungal infections
  • Changes of the nails identified over time
  • History of longitudinal melanonychia, with recent changes in color, bleeding or ulceration
• Physical examination
  • Identification of the pigmented band on the nail (>3mm wide)
• Dermoscopic examination
  • Closer look at the pigmented band
  • Offers valuable information about the actual color of the band and also determines its width/spacing with precision
• Nail matrix/bed biopsy
  • The biopsy is generally used for the confirmation of the diagnosis
  • The investigation is performed by a dermatopathologist (difficult diagnosis)
  • Useful in determining the type of subungual melanoma (in-situ or invasive)
  • The biopsy should provide information about the thickness of the cancerous growth (mm) and also about the other tissues that have been invaded by the melanoma
• Dermoscopy
  • Useful to make the differential diagnosis between subungual melanoma and hematoma

The differential diagnosis should be made with the following conditions:

• Subungual hematoma
• Onychomycosis
• Nevus of the nail matrix
• Melanotic macule of the nail unit

The ABCDEF rule is generally used for the diagnosis of the clinical subungual melanoma. This includes: A (age – 40-70), B (brown band, with width over 3mm), C (change in the morphology of the nail bed), D (involvement of the digits), E (extension of the band to the adjacent nail folds) and F (family history of melanoma).

Treatment

These are the most common methods used for the treatment of subungual melanoma:

• Surgical removal
  • For the best prognosis, the entire nail apparatus will have to be removed
  • May require the amputation of the finger/toe end (distal phalanx amputation)
• Sentinel node biopsy
  • Performed in patients who present severe cases of subungual melanoma, so as to determine whether the cancer has spread to the lymph nodes in the area
• Mohs micrographic surgery
  • Alternative to the classical surgical removal for subungual melanoma that is in-situ
• The total nail excision, followed by the reconstruction with the full-thickness graft is an option for treatment.

Subungual melanoma vs Hematoma

Subungual hematoma is a medical condition in which a bleeding has occurred under the nail, leading to the appearance of a purple mark on the respective nail. If the doctor cannot confirm for certain whether it is this condition you are suffering from, he/she will monitor the nail for a couple of weeks. With the retraction of the hematoma, the nail will be observed growing healthy, something that does not happen in patients who are suffering from subungual melanoma. The differential diagnosis between subungual melanoma and hematoma can be made with the help of dermoscopy, as the latter does not respect the band-like pattern commonly seen in patients who suffer from subungual melanoma.

Pictures

How does Subungual Melanoma look like?

What is Turbinate Reduction?

This is a procedure that shrinks the turbinates to help alleviate chronic nasal obstruction and nasal congestion. It is a surgery that has few risks of complications and a high success rate.

Nasal turbinates and why they are important

Your turbinates are the small mucus-and cartilage-covered curved bones that extend horizontally along the walls of your nasal passage. Your turbinates are important because they filter and humidify the air you inhale through your nose. They are useful in protecting your body against irritants and infections within the inhaled air. They also effectively direct the flow of air.

Types of turbinates

In your nose there are three sets, which include:

• Inferior turbinates
• Middle turbinates
• Superior turbinates

Why you might need turbinate reduction surgery

There are many reasons why you may need this type of surgery such as:

• Abnormally large turbinates that do not respond to traditional therapies like antibiotics or antihistamines
• Reducing headaches
• Reduce or stop snoring
• Helping with sleep apnea

Surgery

The reason to have turbinate reduction surgery is to reduce the size of the turbinates and still be able to maintain their functions. It is also done to relieve symptoms like post-nasal drip and nasal drainage.

What to do before turbinate reduction surgery?

What exactly you will have to do depends on the surgeon but generally a patient will have to:

• Not take certain medications like blood thinner (aspirin) or diabetic medications (insulin) before surgery
• What medications you can take
• When to stop eating and drinking before the surgery

You need to make sure that you follow your surgeon’s detailed instructions precisely to avoid any complications or problems with the surgery or not having it done because of not following the instructions. You may also have to fill out a health questionnaire answering specific questions about your medical history. This will help to determine if you need any pretests before you have your surgery.

On the day of the surgery before the procedure is done you will need to remove any contact lenses, dentures, glasses, and jewelry.

Procedure

When having turbinate reduction surgery it is often done in conjunction with a septoplasty, which is a surgical procedure to treat a deviated nasal septum. Before having the turbinate reduction surgery your physician will take an evaluation of your medical history and do a physical exam. The surgeon will put you under local anesthetic and put you in a reclining chair. Saline spray will be given in order to break up any mucus in your nose and to give the surgeon better access to the area. When having the surgery the surgeon will insert an endoscope through your nostrils in order to provide visual access to your turbinates. An endoscope is a thin small tube that is equipped with a tiny camera and light source so they surgeon can see better. By doing it this way there are no visible incisions on the outside of your nose. An incision, using a dissolving stitch, will be made in the turbinate to remove a small amount of mucous membrane or excess bone. It is a relatively low-risk surgery. If there is bleeding within your nose the surgeon will use either radiofrequency or cautery treatment to stop the bleeding. The surgery is done on an outpatient basis.

Risks

As with any surgery there are risks such as:

• Infection
• Inability to correct your breathing abnormalities
• Bleeding, which can take several weeks to stop completely
• Occasionally the turbinate tissue will re-grow making another surgery necessary
• Having a continual dry nose

Cost

What it costs to have turbinate reduction surgery would depend on the surgeon you choose, and if there were any complications. If the surgeon does it under general anesthesia in a hospital setting instead of local anesthesia in their office it will be more because you are having it done a hospital operating room. If you have insurance check with your company as they may cover the surgery.

Recovering after the surgery

Some of the things you might experience after turbinate reduction surgery can include:

• Many patients will experience discomfort in the area treated but the pain can be managed through prescription pain medications
• Dizziness, drowsiness, vomiting, and nausea
• Nasal discharge, which can lead to crusting around your nostrils. Do not attempt to pick this off as it could cause bleeding. If it is bothersome talk to your physician as to what you can do. Your surgeon may recommend using Vaseline around your nostrils to help prevent this or to use a cool mist humidifier
• Your eyes may appear bruised or swollen

Recovery time

In most cases the things you experience after surgery will go away on its own after a few days. Approximately a week after turbinate reduction surgery the surgeon will remove any dressings or packing so they can evaluate the healing process. Most patients recover within two weeks after having turbinate reduction surgery.