Shamsuddin Akhtar, MBBS

• Associate Professor
• Department of Anesthesiology
• Yale University School of Medicine
• New Haven, Connecticut

The texture (smoothness impotence signs buy cialis canada, crunchiness and firmness) of the mint will be detected by mechanoreceptors in the oral mucosa and the tongue erectile dysfunction remedies fruits buy cialis american express, whilst the tongue moves the object around the mouth erectile dysfunction statistics cdc order generic cialis. The receptors in the tongue will be able to detect the hole in the middle of the mint erectile dysfunction 23 cheap cialis generic. Periodontal ligament mechanoreceptors will also detect the hardness of the mint and erectile dysfunction foods to eat buy cheap cialis 10mg line, if this is bitten impotence at 52 buy cialis toronto, will detect the breaking up of the mint. The majority of the mechanoreceptors in the mouth are innervated by trigeminal nerve. The majority of the cell bodies are again found in the trigeminal ganglion, with a small number of periodontal ligament mechanoreceptor cell bodies in the trigeminal mesencephalic nucleus. Central neuronal connections are located in the trigeminal nuclei, the thalamus and the somatosensory cortex. Warm and cold thermoreceptors are not likely to contribute to the sensations that detect the mint with a hole in it, as the mint will be at room temperature when placed in the mouth; however, if it were heated up or cooled down before it is placed in the mouth, these receptors would be stimulated accordingly. Thermoreceptive afferent neurones from the face and oral cavity form a synapse with second-order neurones in the trigeminal nucleus. These trigeminal thermal neurones ascend further in the trigeminothalamic tract, which terminates in the ventrobasal complex of the thalamus and then project further to the somatosensory cortex. All of these receptor types help the subject detect that the object in the mouth is a mint with a hole in it; this is, of course, appreciated in the light of previous experiences. Question 4 Both mechanisms involve chemical stimuli which interact with the receptor cell surface proteins and cause local transduction pathways to be initiated. In taste, the chemicals are dissolved in saliva or liquids ingested at the same time as the chemicals. In smell, the molecules of the odorous substance are dissolved in the mucus secreted by specialized epithelial cells in the nasal cavity. The two receptor cell types differ in that taste (gustatory) receptor cells are found in taste buds and are specialized neuroepithelial cells with synaptic connections at their basal end with either the facial, glossopharyngeal and vagus nerves, depending on where the taste bud is situated in the oral cavity. The olfactory receptor cells are specialized, elongated nerve cells of the olfactory nerve with direct connections with the olfactory bulbs. There are five basic tastes (salt, sour, sweet, bitter and umami) with a number of well-defined transduction mechanisms, whereas in the olfactory system there are hundreds of different odorant membrane receptors located on the cilia of the olfactory cells and humans can detect over 10 000 different odours. These, like the microvilli in the taste receptors, are bathed in fluid; mucus in the case of the olfactory neurones, and saliva or ingested liquids in the case of the taste receptor cells. Both taste receptor cells and olfactory receptor neurones have a limited lifespan (approximately 10 days for taste receptor cells and 60 days for olfactory neurones). Both gustatory and olfactory central neuronal pathways exhibit selectivity as the neurones synapse at higher levels of the central nervous system. Each olfactory receptor neurone responds, but not equally, to many different odour types. Similarly, in the gustatory system, each neurone responds to more than one basic taste. Both olfactory and gustatory neurones connect to the cortex via neurones in the thalamus and, from the cortex, both systems have neurones that project into the orbitofrontal cortex. There are, however, thought to be more connections from the olfactory system to the limbic system, which may explain the observation that smells can evoke strong feelings of emotion, such as enjoyment and aversion. The facial artery first appears on the face as it hooks round the lower border of the mandible, at the anterior edge of the masseter. It then runs a tortuous course between the facial muscles towards the medial corner of the eye. There is a rich anastomosis with the artery of the opposite side and with additional vessels supplying the face (transverse facial branch of the superficial temporal artery; infra-orbital and mental branches of the maxillary artery; dorsal nasal branch of the ophthalmic artery). The main arteries to the teeth and jaws are derived from the maxillary artery, a terminal branch of the external carotid, running in the infratemporal fossa. The inferior alveolar artery, which supplies the mandibular teeth, is derived from the maxillary artery before it crosses the lateral pterygoid muscle in the infratemporal fossa. A mylohyoid branch is given off before the inferior alveolar artery enters the mandibular foramen in the ramus of the mandible. The inferior alveolar artery passes through the mandibular foramen to enter the mandibular canal and terminates as the mental and incisive arteries. Posteriorly, the buccal gingiva is supplied by the buccal artery (a branch of the maxillary artery as it crosses the lateral pterygoid muscle) and by perforating branches from the inferior alveolar artery. The lingual gingiva is supplied by perforating branches from the inferior alveolar artery and by the lingual artery, a branch of the external carotid artery. The high vascularity explains not only the profuse bleeding that occurs with wounds/trauma to the mouth but also, in part, the remarkable potential for healing. The sensory supply includes the special sense related to taste and the autonomic innervation includes the secretomotor supply of salivary glands. The lymphatic drainage of orodental tissues, although variable, is of great importance to the understanding of the spread of pathologies from the mouth through the lymphatic system. Mechanoreception in the oral cavity is covered in Chapter 15 in association with an account of the periodontal ligament, and oral pain is dealt with in Maxillary teeth and periodontium the posterior superior alveolar artery arises from the maxillary artery in the pterygopalatine fossa. Occasionally, the posterior superior alveolar artery is derived from 67 Six: Vasculature, lymphatics and innervation of the orodental tissues the buccal artery. It courses tortuously over the maxillary tuberosity before entering bony canals to supply molar and premolar teeth. The artery also gives off branches to the adjacent buccal gingiva, maxillary sinus and cheek. The middle superior alveolar artery, when present, arises from the infra-orbital artery (which is itself a branch of the third part of the maxillary artery in the pterygopalatine fossa). The middle superior alveolar artery runs in the lateral wall of the maxillary sinus, terminating near the canine tooth where it anastomoses with the anterior and posterior superior alveolar arteries. The anterior superior alveolar artery also arises from the infra-orbital artery and runs downwards in the anterior wall of the maxillary sinus to supply the anterior teeth. The buccal gingiva around the posterior maxillary teeth is supplied by gingival and perforating branches from the posterior superior alveolar artery and by the buccal artery. The labial gingiva of anterior teeth is supplied by labial branches of the infra-orbital artery and by perforating branches of the anterior superior alveolar artery. The palatal gingiva around the maxillary teeth is supplied primarily by branches of the greater palatine artery, a branch of the third part of the maxillary artery in the pterygopalatine fossa. No accurate description is available concerning the venous drainage of the gingiva, though it may be assumed that the buccal, lingual, greater palatine and nasopalatine veins are involved; apart from the lingual veins which pass directly into the internal jugular veins, these veins run into the pterygoid plexuses. Palate, cheek, tongue and lips the veins of the palate are rather diffuse and variable. However, those of the hard palate generally pass into the pterygoid venous plexus, and those of the soft palate into the pharyngeal venous plexus. Venous blood from the lips drains into the facial veins via the superior and inferior labial veins. Those of the dorsum and sides of the tongue form the lingual veins, which, accompanying the lingual arteries, empty into the internal jugular veins; those of the ventral surface form the deep lingual veins, which ultimately join the facial, internal jugular or lingual veins. Lymphatic drainage of orodental tissues As with the venous system, the lymphatic drainage is extremely variable. Lymphatics from the lower part of the face generally pass through, or around, the buccal lymph nodes to reach the submandibular lymph nodes. However, lymphatics from the medial portion of the lower lip drain into the submental nodes. The lymph vessels from the teeth usually run directly into the submandibular nodes on the same side, although lymph from the mandibular incisors drains into the submental nodes. Occasionally, lymph from the molars passes directly into the jugulodigastric group of nodes. The lymph vessels of the labial and buccal gingivae of the maxillary and mandibular teeth unite to drain into the submandibular nodes, although in the labial region of the mandibular incisors they may drain into the submental nodes. The lingual and palatal gingivae drain into the jugulodigastric group of nodes, either directly or indirectly through the submandibular nodes. Lymphatics from most areas of the palate terminate in the jugulodigastric group of nodes. Vessels from the posterior part of the soft palate terminate in pharyngeal lymph nodes. Lymph from the floor of the mouth region can drain directly to the jugulodigastric nodes. Lymphatics from the anterior two-thirds of the tongue may be subdivided into two groups: marginal and central vessels. The marginal lymphatic vessels drain the lateral third of the dorsal surface of the tongue and the lateral margin of its ventral surface. Central vessels behind the tip drain into Palate, cheek, tongue and lips the palate derives its blood supply from the greater and lesser palatine branches of the maxillary artery. The greater palatine artery anastomoses with the nasopalatine artery at the incisive foramen. The cheek is supplied by the buccal branch of the maxillary artery, and the floor of the mouth and the tongue by the lingual arteries. The lips are mainly supplied by the superior and inferior labial branches of the facial arteries. Venous drainage of orodental tissues Teeth and periodontium the venous drainage of this region is extremely variable. It begins at the medial corner of the eye by confluence of the supraorbital and supratrochlear veins and passes across the face behind the facial artery. Below the mandible, it joins with the anterior branch of the retromandibular vein. Small veins from the teeth and alveolar bone pass into larger veins surrounding the apex of each tooth, or into veins running in the interdental septa. In the mandible, the veins are then collected into one or more inferior alveolar veins, which themselves may drain anteriorly through the mental foramen to join the facial veins or posteriorly through the mandibular foramen to join the pterygoid plexus of veins in the infratemporal fossa. In the maxilla, the veins may drain anteriorly into the facial vein or 68 Innervation of orodental tissues ipsilateral and contralateral submandibular lymph nodes. Some marginal and central lymph vessels pass directly to the jugulodigastric group of nodes (or even the juguloomohyoid nodes). Lymphatics from the posterior third of the tongue drain into the deep cervical group of nodes, vessels centrally draining both ipsilaterally and contralaterally. Knowledge of the ipsilateral and contralateral drainage from the tongue is important clinically where, for example, a tumour near the central part of the tongue may be associated with spread into lymph nodes on both sides. At the oropharyngeal isthmus lie the palatine tonsils between the pillars of the fauces and the lingual tonsils on the pharyngeal surface of the tongue. The other components are the tubal tonsils and adenoid tissue (pharyngeal tonsils) located in the nasopharynx. Knowledge of these areas, and of the specific branches involved, is important clinically for assessing the effects of nerve damage and for an understanding of the successful anaesthetization of the buccal, infra-orbital and inferior alveolar (mental) nerves during dental treatment. The areas supplied by the three divisions of the trigeminal nerve also relate to aspects of the development of the face. Inferior alveolar nerve the inferior alveolar nerve courses through the mandible in a mandibular canal. The distribution of nerves to the mandibular premolars and molars is variable, dental branches coming either directly from the inferior alveolar nerve by short or long branches or indirectly through several alveolar branches. In rare instances, the nerve to the mandibular third molar may arise from the inferior alveolar nerve before it enters the mandibular canal. Communications between the inferior alveolar nerve and nerves from the temporalis and lateral pterygoid muscles have been described, the nerves penetrating the mandible through foramina in the region of muscle attachments. It has been suggested that such nerve connections might explain why, in approximately 5% of patients, the teeth may not be anaesthetized after the main trunk of the inferior alveolar nerve has been blocked at the mandibular foramen by the injection of local anaesthetic solution. It is said that, in any one individual, the mandibular canal remains in a relatively fixed position with respect to the lower border of the mandible. Indeed, the roots of lower third molars may even be perforated by the mandibular canal. In the premolar region, the main trunk of the inferior alveolar nerve divides into mental and incisive nerves. The mental nerve runs for a short distance in a mental canal before leaving the body of the mandible at the mental foramen to emerge on to the face. In about 50% of cases, the mental foramen lies on a vertical line passing through the mandibular second premolar. In an adult with a full dentition, the mental foramen usually lies midway between the upper and lower borders of the mandible. During the first and second years of life, as the prominence of the chin develops, the opening of the mental foramen alters in direction, from facing forwards to facing upwards and backwards. As well as supplying the skin of the lower lip, the mental nerve provides fibres to an incisor plexus, which innervates the labial periodontium of the mandibular incisors. Six Innervation of orodental tissues Excepting regions around the oropharyngeal isthmus, the sensory innervation of the oral mucosa is derived from the maxillary and mandibular divisions of the trigeminal nerve. The trigeminal nerve also supplies the teeth and their supporting tissues (see Table 6. Both the major and the minor salivary glands are supplied by secretomotor parasympathetic fibres from the facial and glossopharyngeal nerves. The motor innervation of the muscles of the jaws and oral cavity is from the trigeminal, facial, accessory and hypoglossal nerves.

In this clot impotence erectile dysfunction order cialis 10mg mastercard, granulation tissue will form and stem cells and osteoprogenitor cells will soon appear impotence yeast infection discount cialis 20mg on-line. The initial immature (woven) bone will ultimately be remodelled to form mature erectile dysfunction drugs australia cheap cialis 2.5 mg on line, fine-fibred bone erectile dysfunction opiates generic cialis 5mg online, having served its purpose by achieving an initial rapid fracture repair erectile dysfunction and coronary artery disease in patients with diabetes generic 20mg cialis with visa. In some clinical situations erectile dysfunction natural remedies diabetes order 5mg cialis with visa, in particular the replacement of bone lost in trauma or malignant disease, the need for larger amounts of bone may require additional techniques. Requirements may be met by either autologous bone grafts (taken from the patient), allografts (taken from another person) or xenografts (taken from a different species, typically BioOss-bovine bone chips). However, major advances are being made in the application of tissue engineering techniques. These employ laboratory-based materials to either substitute for bone or provide scaffolds and stimuli to promote rapid bony healing in adverse lesions (and those otherwise too large to heal themselves). The three components to be considered in tissue engineering are the scaffold, the cells and additional molecules to drive osteogenesis. The rate of fracture repair appears to slow down with age, the precise reason for which remains to be clarified. It may be that there is a reduction in the number of viable stem cells in bone with age. When adequate length has been achieved, the two bone ends are immobilized for some weeks to allow the woven bone callus to be reinforced and ultimately replaced by mature, dense lamellar bone. Although this technique was initially developed to increase the length of long bones, it has been adapted for use in craniofacial situations where there is marked bony underdevelopment, such as the small mandible of micrognathism. The mandible can be increased in length and height, depending on the orientation of the pre-planned osteotomies. In such cases, distraction osteogenesis may allow for an increased alveolar height to render the site suitable for implants. The rate at which the osteoblast/stromal cells release these factors is influenced by parathormone, whose receptors lie on the osteoblast cell membrane. Many complex membrane interactions must occur when cells are undergoing fusion to become multinucleated. Following its resorptive phase, osteoclasts are thought to be removed by apoptosis. In this respect, it is worth noting that the activity of a number of cytokines and growth factors results in the release of hydrogen ions from the affected cells. There is evidence to suggest that a reduction in oxygen levels in the microenvironment of bone tissue provides a stimulus for osteoclasis, although the mechanism is poorly understood. The importance of factors listed above in association with the formation and activity of osteoclasts has been deduced from studies designed to produce deficiencies or over-expression of the factor. Their teeth may be prevented from erupting (due to the inability to resorb bone overlying the erupting teeth), but this can be corrected by restoring the missing factor. In many regions, a third layer (the submucosa) is found between the lamina propria and the underlying bone (palate) or muscle (cheeks and lips). The submucosa consists of a looser connective tissue containing the main nerves and blood vessels, as well as glands. Within the oral cavity about 60% of the mucosa is lining mucosa, about 25% of the mucosa is masticatory mucosa and the remaining 15% is specialized mucosa. Granular layer Above the prickle cell layer lies the granular layer (stratum granulosum). The cells of the granular layer show a further increase in maturation compared with those of the basal and prickle cell layers. Many organelles are reduced or lost, such that the cytoplasm is predominantly occupied by the cytokeratin tonofilaments and tonofibrils. The cells are larger and flatter, and contain numerous small granules called keratohyaline granules. These contain profilaggrin, the precursor to the protein filaggrin that eventually binds the cytokeratin filaments together into a stable network. Synthesis increases of the additional proteins, loricrin and involucrin, first apparent in the prickle cell layer. Epithelium Oral epithelium is classified as a stratified squamous epithelium, as it has several layers of cells with distinct morphologies. Masticatory epithelium For masticatory epithelium, four layers are present: Basal layer the basal layer (stratum germinativum or stratum basale) is the single cell layer adjacent to the lamina propria and is demarcated from it by a basement membrane. It consists of low columnar/cuboidal cells, among which is a population of stem cells. On mitosis, stem cells give rise to two daughter cells, one of which remains a stem cell. Stem cells generate transit-amplifying cells that will undergo a number of further cell divisions, migrate from the basal cell layer and differentiate to give rise to replacement keratinocytes in the epithelial layers above. The cells of the basal layer are the least differentiated within the oral epithelium. Cell contacts in the form of desmosomes, hemidesmosomes, intermediate and gap junctions are present, allowing for adhesion and cell signalling. Keratinized layer the most superficial layer in masticatory epithelium is the keratinized layer (cornified layer, stratum corneum). In this final stage in the maturation of the epithelial cells, there is loss of all organelles including the nucleus. This mixture of proteins is collectively called keratin; it contributes to the mechanical and chemical resistance of the layer. The cells of the keratinized layer are shed (squames), necessitating the constant turnover of epithelial cells. In some areas such as the gingiva, the nuclei may be retained in the cornified layer. These cells are described as parakeratinized (in contrast to the more usual orthokeratinized cells without nuclei). Prickle cell layer Above the basal layer lies the prickle cell layer (stratum spinosum). The cells of this region show the first stages of maturation, being larger and rounder than those in the basal layer. The transition from basal to prickle cell layer is characterized by the appearance of new cytokeratin types. They contribute to the formation of the tonofilaments, which become thicker and more conspicuous towards the surface. In the upper part of the prickle cell layer, small, intracellular membrane-coating granules appear. These granules are rich in phospholipids and, in the more superficial layers of the stratum spinosum, come to lie close to the cell membrane. Within the prickle cell layer, desmosomes increase in number and eventually occupy about 50% of the intercellular space. They may show features similar to that of the basal layer and may undergo cell proliferation. Lining epithelium In lining epithelium, the cells are non-keratinized at the surface. Like the cells in keratinized epithelia, cells from the basal layer enlarge and flatten as they shift towards the surface. The surface layers differ from the cells of keratinized epithelia in that they lack keratohyaline granules. This accounts for the less developed and dispersed tonofilaments present in lining epithelium. There are also more organelles in the surface layers compared with those in keratinized cells, although there are still considerably fewer than in the basal layer. Membrane-coating granules are smaller and lack the lipid-rich lamellar structure of those in keratinizing epithelia. This is thought to account for the greater 236 Regionalvariation permeability of lining epithelium compared to keratinized epithelium. Lining epithelium generally lacks the proteins filaggrin and loricrin, but contains involucrin. Turnover time of the epithelium is fastest in the region of the junctional and sulcular epithelia (about 5 days), which are located immediately adjacent to the tooth surface. This is probably about twice as fast as that seen in lining mucosa, such as the cheek. Turnover time in masticatory mucosa is a little slower than that in non-masticatory (lining) mucosa. Merkel cells Merkel cells are found in the basal layer, often closely apposed to nerve fibres. Merkel cells are common in masticatory epithelia but less frequently found in lining mucosa. Ultrastructurally, the nucleus of the Merkel cell is often deeply invaginated and may contain a characteristic rodlet. The cytoplasm contains a collection of electron-dense granules, which may liberate a transmitter towards the adjacent nerve terminal, giving the cell a sensory function. Free nerve endings not associated with a Merkel cell are also found within the epithelium. Cytokeratins Within epithelial cells, cytokeratin intermediate filaments function as components of the cytoskeleton and cell contacts (desmosomes and hemidesmosomes). Seventeen Inflammatory cells Some inflammatory cells may also be found in the epithelium, having migrated through it from the underlying lamina propria. Lymphocytes are the most common type of inflammatory cell, though polymorphonuclear leukocytes and plasma cells may also be encountered. Lamina propria the lamina propria underlying the oral epithelium provides mechanical support for the epithelium, as well as nutrition. Its ridges, the dermal papillae, interdigitate with the epithelial folds or rete; the folding in masticatory mucosa is more pronounced than in lining mucosa. Its nerves have an important sensory function, while its blood cells and salivary glands have important defensive roles. The principal cells of the lamina propria are fibroblasts, responsible for the production and maintenance of extracellular matrix. As with all general connective tissues, the usual defence cells are present, such as macrophages, mast cells and lymphocytes. Inflammatory cells will increase dramatically in inflammation, such as following gingivitis. Non-keratinocytes As many as 10% of the cells in the oral epithelium are nonkeratinocytes, and include melanocytes, Langerhans cells and Merkel cells. They are dendritic cells, having long processes that extend in different directions and across several epithelial layers. Melanocytes characteristically contain pigment that is packaged in small granules termed melanosomes. The pigment is passed to adjacent keratinocytes when the tips of the dendrites are actively phagocytosed. In dark-skinned patients, patches of melanin pigment may be seen in the mouth, particularly in the gingiva. Regional variation There is regional variation in the structure of the oral mucosa related to different degrees and types of stress during mastication, speech and facial expression. As a consequence, the structure of the oral mucosa varies in terms of the thickness of the epithelium, the degree of keratinization, the complexity of the connective tissue-epithelium interface, the composition of the lamina propria, and the presence or absence of the submucosa. Langerhans cells Langerhans cells are dendritic cells situated in the layers above the basal layer. The mucosa of the gingiva and palate is masticatory, the bulk of which is firmly bound down to underlying bone by dense collagen bundles forming a mucoperiosteum. In the roof of the hard palate, however, a submucosa is present, within which is found the main neurovascular bundles. There are also minor mucous glands (predominantly posteriorly) that open on to the surface by ducts, and adipose tissue (predominantly anteriorly). The lamina propria associated with the junctional epithelium has a rich blood supply arranged as a complex anastomosing network. The vessels of the plexus are very sensitive to stimulation and are likely to vasodilate under the slightest of insults. In response to plaque, they may become more permeable, increasing the production of crevicular fluid. Gingiva the majority of the gingiva surrounding the neck of the tooth is attached to the tooth and alveolar bone, with no submucosa. Its external surface (oral gingival epithelium) is a masticatory mucosa that may show orthokeratinization or parakeratinization. Its margin (1 mm) is the free gingiva, which may be demarcated from the attached gingiva by the free gingival groove.

Aneurysms are reported especially in sub-Saharan Africa and can be atypically located and multiple best herbal erectile dysfunction pills best buy for cialis. Often several coexisting organisms are isolated impotence symptoms signs purchase 20mg cialis visa, including bacteria erectile dysfunction wife cheap 5mg cialis with visa, mycobacteria and fungi erectile dysfunction in 60 year old order discount cialis. Specimens should be sent for virological erectile dysfunction age 36 order generic cialis on-line, bacterial impotence viriesiem purchase cialis 20mg otc, mycobacterial, fungal and histopathological studies. Raised lesions may cause obstruction with wheezing, cough and recurrent bacterial infections. It is common for several pathogens to coexist, and failure to respond to first-line therapy necessitates further investigations for other pathogens and pathologies. Both show an extensive mid- and lower zone perihilar interstitial process typical of P. Oesophagoscopy is the procedure of choice as a definitive diagnosis (or diagnoses) may be obtained by biopsies and brushings. As 10 per cent of patients have multiple pathologies, specimens must be sent for mycobacterial, viral, fungal and histological testing. Nausea and epigastric pain commonly accompany the dysphagia but may occur independently. Abdominal Pain Pain commonly presents as: (1) epigastric pain with or without oesophageal symptoms, (2) right upper quadrant pain with or without jaundice, (3) left or right iliac fossa pain, or (4) diffuse abdominal pain. As inflammation and ulceration of the colon progresses, acute ischaemic colitis may occur. This can result in severe pain, massive haemorrhage, toxic megacolon and perforation. Diarrhoea Chronic diarrhoea (lasting for more than 1 month) is extremely common and affects at least 40 per cent of patients with advanced immunodeficiency. Spore-forming protozoa, especially cryptosporidia, microsporidia and less commonly isospora and cyclospora, can cause severe and prolonged gastroenteritis. While treatment is available, end-stage liver failure and hepatocellular carcinoma are increasingly seen due to the late diagnosis of co-infection. Biliary Disease Small bowel and biliary tract disease caused by opportunist infections is common and debilitating. Endoscopic retrograde cholangiopancreatography, biopsies and duodenal aspirates provide an essential definitive diagnosis where pathogens have invaded the mucosa. Acalculous cholecystitis is now a frequently diagnosed condition, causing symptoms indistinguishable from those of gallstone disease. Emergency cholecystectomy is often required to prevent fatal peritonitis following gallbladder rupture. Confirmation is by endoscopic retrograde cholangiopancreatography, which shows beading of the bile ducts and/or an oedematous and swollen ampulla. Sphincterotomy may allow biliary drainage and pain relief, while biopsy is required to isolate the causative agent(s) if possible. Flexible sigmoidoscopy and biopsy are key investigations in a stool-negative patient. It is commonly caused by alcohol abuse, gallstones, high lipid levels and medications, especially the antiretroviral agent didanosine. Other opportunists and malignancies that cause ampullary mass lesions need to be excluded. Perianal abscesses may not demonstrate the typical features of fluctuance so a high degree of suspicion is needed. Inadequate management of perianal abscesses can readily lead to the development of fistulas and might be complicated by septicaemia, especially in resource-poor settings. Visible warts can be extensive and frequently fail to clear with conventional therapies. Staphylococcus aureus and Enterococcus faecalis were isolated from the abscess swabs. The differential diagnosis includes herpes simplex virus and lymphogranuloma venereum. Multiple and atypical organisms can present as persistent or recurrent urinary tract infections, persistent/recurrent urethritis, acute and chronic prostatitis and pelvic inflammatory disease. Common surgical manifestations of renal disease presenting to urologists are renal abscess and renal calculi. Renal calculi have been related to the antiretroviral agents indinavir and atazanavir. Continuous ambulatory peritoneal dialysis might be preferred over haemodialysis in some patients with endstage renal disease, including intravenous drug users and those with hepatitis B/C co-infection. Mortality from cervical carcinoma is high in populations where there is inadequate screening. Treponemal disease, especially syphilis, needs to be considered as a cause of bone lesions in areas of high prevalence. Muscle and joint infections, such as pyomyositis, psoas abscess and septic arthritis, also occur, as does gangrene secondary to arteritis. There is a predilection for the upper tibial and lower femoral metaphyses bilaterally. Staphyloccocus aureus, non-typhoid Salmonella species and other gram-negative organisms have all been isolated from aspiration or incision specimens. Enteric organisms are isolated in up to 10 per cent of affected patients, but the most common cause remains Staphylococcus aureus. Intracranial Mass Lesions the discovery of one or more space-occupying lesions on brain imaging is a common finding in patients who present with focal neurological symptoms or signs. However, a brain biopsy should be considered where there is any doubt about the diagnosis or where dual pathology is suspected. The risk of pathological fracture is increased especially among postmenopausal women and men over 50 years. Orthopaedic complications occur in relation to fractures and the insertion of surgical prostheses. Closed fractures usually heal normally, but open fractures have a high incidence of non-union and sepsis. External fixation carries an increased risk of sepsis, and late sepsis of implants has been reported. It classically presents with rapid-onset headaches, low-grade pyrexia and focal neurological signs. Note that progressive multifocal leukoencephalopathy can be focal or diffuse, but in the latter it is usually asymmetrically distributed. The radiographic signs are characteristic enough that a trial of therapy should be commenced in the presence of positive Toxoplasma serology. Cerebral lymphomas can be difficult to differentiate from toxoplasmosis both clinically and radiologically. Toxoplasmosis usually involves multiple lesions while cerebral lymphomas are single lesions, but this is not invariable. If any doubt exists about the diagnosis or if a 2-week course of empirical toxoplasmosis treatment has failed, a rapid definitive diagnosis can be made by a stereotactic brain biopsy. Respiratory symptoms and abnormal chest radiographs provide important clues to the diagnosis, but their absence or the lack of a positive diagnostic test. Various other brain abscesses occur, depending on the geographical location and population involved. Several pathologies that cause meningitis, encephalitis and intracranial mass lesions can result in raised intracranial pressure and hydrocephalus. Brain biopsy is essential to exclude other pathogens, such as bacteria, mycobacteria, Toxoplasma, Cysticercus (particularly in African patients) and Nocardia. Complaints of visual blurring or distortion, visual field loss or an increased number of floaters necessitate urgent retinal examination by an ophthalmologist. Ideally, all lesions should be photographed and monitored by slit-lamp examination on a regular basis. Blindness is uncommonly caused by Toxoplasma choroidoretinitis, a condition that also implies a high likelihood of cerebral toxoplasmosis. With herpes virus infections, the most common presentation is herpes zoster ophthalmicus, but progressive outer retinal necrosis can occur due to varicella-zoster, and acute retinal necrosis can be due to herpes simplex or zoster. A suspicion of any of these infections should lead to prompt referral to an ophthalmologist. It may present as chronic uveitis, and the diagnosis is dependent on a vitreous biopsy. The risks of immunosuppressive therapy are reduced with various screening measures and with prophylaxis for opportunist infections. Patients can present to surgical specialties with conditions caused by ageing, including those that might compromise operative outcomes. Clinicians are thus being faced with a new spectrum of pathology, and the need for surgical interventions such as coronary revascularization is likely to rise. An increased uptake of testing is seen as being vital for individual and public health. Greyish-white granular lesions with exudates and retinal opacification are visible. There is a potential risk of transmission through percutaneous or mucous membrane exposure to many body fluids and materials, including amniotic fluid, blood, cerebrospinal fluid, exudative or other tissue fluid from burns or skin lesions, human breast milk, pericardial fluid, peritoneal fluid, pleural fluid, saliva in dentistry, semen, synovial fluid, unfixed human tissues and organs, vaginal secretions and any other body fluid if it is visibly bloodstained. Reports suggest a substantial rate of potential exposures in trainees, many of whom are unaware of appropriate protocols and do not fully utilize protective measures. Double gloves, aprons and goggles or visors are key protective equipment, while noncutting and non-suturing techniques, as well as a deliberately measured or cautious technique, are also recommended where possible. Routine testing has been found to be cost-effective with both patients and their sexual partners where the local prevalence is above 1 per cent. Universal Precautions Universal precautions are based on the premise that all patients are potentially infectious. The application of universal precautions to all patients does not negate the responsibility of hospitals to protect health workers, particularly in operating and emergency rooms. All staff should be familiar with procedures for handling sharp instruments and for protection from the dissemination of body fluids. However, extensive formal counselling is generally not required before tests and for negative results. According to ten prospective studies, the risk of seroconversion following a single parenteral occupational exposure with a hollow-bore needle is 0. Approximately 80 per cent of seroconversions in health workers have been shown to follow percutaneous exposure. These usually include first aid, reporting, baseline testing, postexposure prophylaxis with antiretroviral drugs and follow-up. Testing of the patient for any blood-borne viral infections and consent to inform the exposed individual must be achieved, with the consent being obtained by a health worker other than the person who sustained the injury. Routine testing prior to surgery due to concerns over occupational transmission is unethical. Post-exposure Prophylaxis Many exposures result from a failure to follow recommended procedures so prevention of exposure is of prime importance. Where available, post-exposure prophylaxis with combination antiretroviral agents, if initiated early after injury (within hours if possible) and continued for 4 weeks, is strongly recommended. Toxicity and side-effects are common so the use of local guidance is imperative to judge when the benefits of post-exposure prophylaxis outweigh the risks. Comprehensive retrospective investigations, particularly among doctors engaged in invasive procedures, have not identified additional cases. The absence of transmission to patients and the availability of effective treatment for the surgeon called into question whether his surgical practice should be restricted. The surgeon was allowed to resume his surgical practice with no restrictions on the types of surgery he could perform. Confidentiality Confidentiality is the right of every individual under medical care. Permission should be sought from the patient before information is passed to any person who does not need to know, including relatives and health workers, or to other services. In all instances, the surgeon involved should act on advice from the appropriate governing or professional body, for example the Royal College of Surgeons in England. However, other general risk factors, such as nutritional status, might have more influence on the risk of complications of, for example, sepsis and delayed wound healing. Preoperative assessment is key to identifying the likelihood of postoperative complications, and includes the following. Neutropenia must be excluded prior to surgery or invasive clinical procedures such as rectal examination or central line insertion. If surgical intervention or the presenting complaint puts the patient in a state of further increased catabolism, early interventional feeding should be considered, for example after polytrauma. The risks of parenteral feeding should always be weighed against the risks of further malnutrition.

General sensation (and taste) for most of the posterior third of the tongue is associated with the glossopharyngeal nerves impotence pregnancy cheap cialis 2.5 mg online. That for the most posterior part of the tongue erectile dysfunction va disability rating 5 mg cialis visa, close to the epiglottis erectile dysfunction lawsuits cialis 2.5 mg generic, is associated with the vagus nerves insulin pump erectile dysfunction generic cialis 20 mg visa. The circumvallate papillae erectile dysfunction drugs names purchase discount cialis on line, although lying in the anterior two-thirds of the tongue immediately in front of the sulcus terminalis impotence 60 years old purchase cialis 5 mg without prescription, have taste buds innervated by the glossopharyngeal nerves. General sensation to the ventral surface of the tongue is associated with the lingual nerves from the anterior divisions of the trigeminal nerves. Note that these nerves also innervate the anterior two-thirds of the dorsum of the tongue (although not for taste) and the mucosa over the floor of the mouth. All the intrinsic muscles that change the shape of the tongue are innervated by the hypoglossal nerves. The palatoglossus muscle is the exception to the rule that the extrinsic muscles of the tongue are supplied by the hypoglossal nerve. Palatoglossus, being a muscle of the soft palate, is innervated by the pharyngeal plexus. The structure labelled E, the sublingual fold, indicates the position of the sublingual salivary gland and the course of the submandibular duct. The mucosa lining the ventral surface of the tongue has a non-keratinized (lining) stratified squamous epithelium. A sublingual abscess, located above the mylohyoid muscle in the floor of the mouth, may spread to become a submandibular abscess in the suprahyoid region of the neck by passing around the posterior free edge of the mylohyoid muscle. Complex bitter molecules such as quinine and urea involve membrane receptors linked to G-proteins and second messengers. These transmitter substances are released when the potential inside becomes more positive (becomes depolarized). In close association with these regions are the endings of the sensory nerve fibres (intragemmal nerve fibres), which make a synaptic-like connection with the receptor cells. The released neurotransmitter elicits generator potentials and hence action potentials in the primary afferent neurones, thereby transmitting impulses into the central nervous system. In most cases, the depolarization of the gustatory cell leads to an action potential followed by an increase in intracellular Ca2+ within the cell; there is a subsequent release of the neurotransmitter. The descendens hypoglossi (label J) communicates with the ansa cervicalis nerve plexus in the neck. Damage to the descendens hypoglossi would result in partial paralysis of strap (infrahyoid) muscles and some problems for movements of the larynx during and after swallowing. The sublingual salivary gland also produces a mixed saliva, but with more mucous than serous elements. On occasion, both glands are fused to form a submandibular-sublingual salivary complex. Here, the frenum extends across the floor of the mouth to become attached to the lingual alveolus behind the mandibular incisors. Tongue-tie may severely limit movements of the tongue and hence could affect speech. Blocking the inferior alveolar and buccal nerves will have no effect on the tongue. However, blocking the lingual nerve affects both general sensation and taste to the anterior two-thirds of the tongue (dorsal and ventral surfaces). The effects on taste relate to the fact that the chorda tympani nerve joins (and runs with) the lingual nerve. Outline essay answers Theme: Muscles of the tongue the essay should be introduced by highlighting the complexity of the innervation of the tongue and the fact that this complexity can be explained by recourse to an understanding of the embryological development of the tongue. A particularly important principle is that a structure/organ maintains its innervation according to its embryological origin. A description of the embryological development of the tongue should follow (to include diagrams). Mention must be made of the contributions of the first pharyngeal (branchial) arch (distal tongue buds/lateral lingual swellings and median tongue bud/tuberculum impar) and the contributions of 3rd/4th pharyngeal arches (hypobranchial/ hypopharyngeal eminence). The facial nerve is the nerve of the 2nd pharyngeal arch that does not contribute to the development of the tongue. However, the chorda tympani nerve is a pretrematic branch of the facial nerve that invades 1st pharyngeal arch territory. The glossopharyngeal nerve is the nerve of the 3rd pharyngeal arch and the vagus nerve is the nerve of the 4th pharyngeal arch. A brief mention could be made of the fact that the muscles of the tongue arise embryologically from occipital myotomes and that these myotomes are associated with the hypoglossal nerve. For the final paragraph of the essay, the effects of dental anaesthesia on the tongue should be described to complete the answer. Dental anaesthesia in the infratemporal fossa Theme: Innervation of the tongue A brief introduction should be provided to highlight the fact that mastication, swallowing and speech are amongst the most complex movements in the body. The role of the tongue in mastication should highlight movements of the food bolus between the teeth and the complementary role played by the buccinator muscles. The role of the tongue in swallowing should highlight the positioning of the bolus of food in the centre of the tongue and the movement of the tongue backwards towards the oropharyngeal isthmus to expel the food into the oropharynx. The role of the tongue in speech should highlight the part the tongue plays in articulation of consonant sounds. Theme: Taste Gustatory receptors (taste buds) involved in taste sensation, are found in the stratified epithelium of the tongue, soft palate, pharynx, larynx and epiglottis. They are innervated by the facial, glossopharyngeal and vagus nerves, depending on where the end organs are situated. All the primary afferent nerve fibres have their first synaptic connection in the nucleus of the solitary tract; the second-order neurones project to most medial part of the ventroposterior medial nucleus of the thalamus, with further projections to the brain-stem reticular formation, the parabrachial nucleus and the cranial nerve nuclei involved in the reflexes 65 Five:Tongue,flavour,thermoreceptionandspeech associated with gustation. The thalamic neurones project to the primary gustatory cortex, which includes a region just anterior to the somatosensory area for the tongue, as well as to the nearby frontal operculum and anterior insular secondary cortex. These receptors and central pathways will signal the senses of sweet, sour, salt, bitter and umami generated by the object in the mouth. Olfactory receptors involved in the sensation of smell are to be found in the olfactory epithelium and mucosa in the nasal cavity on a thin bony partition called the central septum of the nasal passage. These specialized, elongated olfactory receptors are innervated by the olfactory nerve. The olfactory nerve is short and ends in the olfactory bulbs, a pair of small swellings underneath the frontal lobes. The primary olfactory neurones terminate in the spherical glomeruli and terminate on so-called mitral and tufted cells. The connections from the thalamus are to the primary olfactory cortex (the anterior olfactory nucleus, the olfactory tubercle and the piriform, periamygdaloid and entorhinal cortices). There are additional projections, via the anterior commissures, to the contralateral olfactory bulb. The sense of smell will detect the many different constituents of the mint-flavoured sweet, in particular the mint flavouring. The common chemical sense will also contribute to the overall appreciation of the flavour of the object in the mouth by stimulation of free nerve endings innervated by the trigeminal nerve. These free nerve endings are found throughout the oral cavity and are stimulated normally by noxious chemical stimuli, but are also stimulated by menthol and peppermint. The trigeminal fibres have cell bodies in the trigeminal ganglion and send impulses, via the main sensory nucleus, to the thalamus and the somatosensory cortex. Receptors involved in mechanoreception will also be involved in sensing the object in the mouth. This nerve primarily supplies the incisors and canines but may also supply the first premolar. In some instances, the canine may be supplied directly from the inferior alveolar nerve. The remainder of the hard palate is supplied by the greater palatine nerves emerging onto the palate at the greater palatine foramina. The soft palate is supplied by the lesser palatine nerves emerging onto the palate via the lesser palatine foramina. Although the maxillary division of the trigeminal nerve supplies most of the palate, there is evidence to suggest that some areas supplied by the lesser palatine nerves may also be innervated by fibres from the facial nerve. The posterior part of the soft palate and the uvula are also supplied by the glossopharyngeal nerve, providing the anatomical basis for the gag reflex. The mucosa of the upper lip is supplied by the infraorbital branch of the maxillary division of the trigeminal nerve. That of the lower lip is supplied by the mental branch of the mandibular division of the trigeminal nerve. The mucosa of the cheeks is supplied by the buccal branch of the mandibular division of the trigeminal. The mucosa on the floor of the mouth is innervated by the lingual branch of the mandibular division of the trigeminal nerve. The mucosa over the pillars of the fauces (the oropharyngeal isthmus) is supplied by the glossopharyngeal nerve. Superior alveolar nerves Supplying the maxillary dentition there are usually three superior alveolar nerves. The posterior superior alveolar nerve arises from the maxillary nerve in the pterygopalatine fossa, whence it passes through the pterygomaxillary fissure to descend on the posterior wall (tuberosity) of the maxilla. The dental branches of the nerve enter the maxilla and run in narrow posterior superior alveolar canals above the roots of the molar teeth. A gingival branch does not enter the bone, however, but runs downwards and forwards along the outer surface of the maxillary tuberosity. The dental branches of the posterior superior alveolar nerve may arise from a common nerve trunk within the bone or on the tuberosity before entering bone, or alternatively may appear as separate nerve trunks from the main trunk of the maxillary nerve in the pterygopalatine fossa. It generally arises from the infra-orbital nerve in the floor of the orbit/roof of the maxillary air sinus, although it may arise from the maxillary nerve in the pterygopalatine fossa. The nerve may run in the posterior, lateral or anterior walls of the maxillary sinus. The anterior superior alveolar nerve arises from the infra-orbital nerve within the infra-orbital canal, generally as a single nerve, but occasionally as two or three small branches. The nerve leaves the infra-orbital canal near its termination and then, diverging laterally from the infraorbital nerve, runs in the anterior wall of the maxillary sinus. It terminates near the anterior nasal spine after giving off a small nasal branch. The superior alveolar nerves form a plexus above the root apices of the maxillary teeth. From this plexus nerves pass to the teeth, although it is difficult to trace the precise innervation of the teeth from specific superior alveolar nerves. As a general rule, however, the incisors and canines are supplied by the anterior nerve, the molars by the posterior nerve, and intermediate areas by the middle nerve. Secretomotor innervation of the salivary glands Parotid gland the secretomotor supply of the parotid gland is derived through the otic parasympathetic ganglion. This ganglion is situated in the roof of the infratemporal fossa, close to the foramen ovale and the mandibular division of the trigeminal nerve. Like other parasympathetic ganglia in the head, three types of nerve fibre are associated with it: parasympathetic, sympathetic and sensory. The preganglionic parasympathetic fibres to the otic ganglion originate from the inferior salivatory nucleus in the brain stem and pass with the glossopharyngeal nerve via its lesser petrosal branch. The sympathetic root of the otic ganglion is derived from postganglionic fibres from the superior cervical ganglion and reaches the otic ganglion via the plexus around the middle meningeal artery in the infratemporal fossa. The sensory root is derived from the auriculotemporal branch of the mandibular division of the trigeminal nerve. The postganglionic parasympathetic fibres (with sensory and sympathetic fibres) reach the parotid gland through the auriculotemporal branch of the mandibular nerve. Submandibular and sublingual glands the secretomotor supply of the submandibular and sublingual glands is derived through the submandibular parasympathetic ganglion. This ganglion is situated, with the lingual nerve, on the hyoglossus muscle in the floor of the mouth above the deep part of the submandibular gland. The preganglionic parasympathetic fibres to the ganglion originate from the superior salivatory nucleus in Sensory nerves to oral cavity the sensory nerve supply to the palate is derived from the maxillary division of the trigeminal nerve via branches of the pterygopalatine ganglion. A small area behind the incisor teeth is supplied by terminal branches of the nasopalatine nerves. These nerves emerge onto the palate at the incisive 70 the trigeminal nerve (maxillary and mandibular divisions) the brain stem and pass with the nervus intermedius of the facial nerve, and subsequently its chorda tympani branch, to reach the lingual nerve in the infratemporal fossa. It is via the lingual nerve that the preganglionic fibres are conveyed to the submandibular ganglion. The sympathetic root of the ganglion is derived from postganglionic fibres from the superior cervical ganglion and reaches the submandibular ganglion via the plexus around the facial artery. The postganglionic parasympathetic fibres (with sensory and sympathetic fibres) pass directly to the adjacent submandibular gland, but reach the sublingual gland after re-entering the lingual nerve. This is reflected in the number and variety of muscles found around the mouth and by the range of cranial nerves that innervate them. Floor of mouth Hyoglossus Styloglossus Palatoglossus Mylohyoid Geniohyoid Palate Tensor veli palatini Levator veli palatini Palatoglossus Palatopharyngeus Musculus uvulae Hypoglossal Accessory (cranial part) Mandibular division of trigeminal Hypoglossal (C1 fibres) Mandibular division of trigeminal Accessory (cranial part) Six the trigeminal nerve (maxillary and mandibular divisions) Maxillary division the maxillary division of the trigeminal nerve contains only sensory fibres. It supplies the maxillary teeth and their supporting structures, the palate, the maxillary air sinus, much of the nasal cavity, and the skin overlying the middle part of the face. The nerve emerges into the pterygopalatine fossa through the foramen rotundum of the sphenoid bone.

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