Computed Tomography and Nasal Endoscopy in Chronic Headache

Computed Tomography and Nasal Endoscopy in Chronic Headache STUDY OF CORRELATION BETWEEN COMPUTED TOMOGRAPHY AND NASAL ENDOSCOPY IN CHRONIC HEADACHE ABSTRACT AIM: To evaluate the correlation between radiological and endoscopic findings in cases of chronic headache Methodology: The study includes 300 patients who presented to the OPD of a tertiary level centre with headache. RESULTS: Endoscopic and CT abnormalities were detected in 265/300 (88.3%) patients. Most common abnormality was a septal spur impinging on lateral nasal wall seen in 94 cases (35.4%), followed by inferior turbinate hypertrophy, concha bullosa, accessory maxillary sinus ostium, paradoxical curved middle turbinate, polyposis and frontal osteoma. A majority of patients had associated changes in the sinuses as well. CONCLUSION: The study highlights the correlation between radiological and endoscopic findings of sinonasal disease as a cause of headache. Abnormalities and variations in endonasal anatomy, functional or anatomical or a combination of these variations caused narrowing of OMU, which predisposed patients to sinonasal disease and headache Key Words: Endoscopy, Headache Introduction Headache is common with high lifetime prevalence in general population. Headache disorders are generally classified as either primary (migraine, tension type and cluster headache) or secondary (infectious, vascular, drug induced). [1] Chronic headache, defined as headache on 15 or more days per month, affects 3% of people worldwide. [2] Sinusitis may constitute one of the most commonly confusing clinical presentation of migraine [3], probably because cranial autonomic symptoms are common in migraine [4] based on activation of the trigeminal-autonomic reflex [5]. Headaches located in the frontal, supraorbital, or infraorbital region are sinus headaches [6]. These headaches are usually recurrent, non-seasonal, and unassociated with fever, localized tenderness, or erythema. [7] Fifty years ago, the extracorporeal cold light and its transmission by glass fibers, along with the hopkins rod lens system, were introduced. The development and application of these technologies to upper airways allowed studying, understanding, and improving knowledge of the anatomy, physiology, and diseases of the nasal cavity and sinuses, in particular, some fundamental concepts of modern rhinology are based on endoscopic nasal findings and messerklinger’s investigations of the pathophysiology of sinus mucosa. These studies radically changed traditional understanding of sinus inflammation and revolutionized its treatment using endoscopic conservative surgical management [messerklinger, 1966, 1967, and 1978]. Whether or not nasal obstruction can lead to chronic headache is controversial [8]. Paradoxically, sinus disease also tends to be underdiagnosed, as sphenoid sinus infection frequently is missed [9] Aim The study was conducted in patients with chronic headache to study the anatomical and pathological abnormalities in nose and paransasal sinuses, to correlate radiological with endoscopic findings and finally to assess type of cases requiring nasal surgery in patients who are not responding to medical treatment. Methodology The study includes 300 patients who presented to the OPD of a tertiary level centre during the period July 2010 to July 2014, who had symptoms and signs of chronic headache. Inclusion criteria: Patients presenting with sinugenic headache. The data is collected on the basis of detailed history, systemic examination, ENT examination and investigations. Diagnostic criteria: Subsequently all the selected candidates were worked up on the history, general examination, and ENT examination carried out. CT PNS was done in all the patients. Diagnostic Nasal endoscopy under local anesthesia was done to record the condition of nasal mucosa, septum, turbinates and to assess the condition of the nasopharynx and eustachian tube opening, to look for the presence of mucopus or polyp in the middle meatus/sphenoethmoidal recess/nasopharynx. Also, any co-existing anatomical variations of the lateral wall of the nose were noted. Once the diagnosis and extent of the disease was established, the patients were taken up for FESS. Results: In present study majority of patients were female. 190 were females and 110 were males in a total of 300 patients. Table -1 TABLE -2: ABNORMALITIES ON ENDOSCOPIC AND CT EXAMINATION Endoscopic abnormalities were found in 265/300 patients. Majority of patients had deviated nasal septum with spur impringing on lateral nasal wall, as a most common endoscopic abnormality. Other conditions identified were abnormal middle turbinate, enlarged ethmoid bulla, polyps, inferior turbinate hypertrophy, prominent aggernasi cells and frontal osteoma. Sinus involvement of varying severity was seen in 70% of patients. TABLE-3: COMPARISON OF RADIOLOGICAL ENDOSCOPIC ABNORMALITIES Treatment In present study of 300 patients, all patients underwent medical treatment. The medical treatment included nasal decongestants, steroid sprays, antibiotic therapy and steam inhalation. The minimum duration of medical treatment was 6 months. The end point of medical treatment was a score of more than 5 on pain scale. 265 patients were taken up for surgery. The most common surgical procedure done was septoplasty with turbinoplasty under LA followed by FESS in cases with sinus involvement. The pain score was evaluated 3 months following surgery. We found that majority of patients who had pain score more than 5 at end of 6months of medical treatment were treated with surgery and had a pain score less than 5 at 3 months. Discussion Standard radiography is inadequate for the clinical evaluation of sinusitis because it does not evaluate the anterior ethmoid air cells, the upper two thirds of the nasal cavity, or the infundibular, middle meatus, or frontal recess air passages. [11] CT is the optimal radiographic study to assess the paranasal sinuses for evidence of disease. The mucosa of the normal, non infected sinus approximates the bone so closely that it cannot be visualized on ct. Therefore, any soft tissue seen within a sinus is abnormal [12]. CT may demonstrate mucosal thickening, sclerosis, clouding, or air-fluid levels. Imaging must be performed in the coronal plane to adequately demonstrate the ethmoid complex. It can reveal the extent of mucosal disease in the ostio meatal complex Incidental anatomic abnormalities within the paranasal sinuses are common. Incidental anatomic abnormalities on CT scans occur in 27% to 45% of asymptomatic individuals [13]. Patients undergoing endoscopic sinus surgery for chronic rhinosinusitis were evaluated with CT and staged according to the Lund system. (Each paranasal sinus: anterior ethmoid, posterior ethmoid, maxillary, frontal, and sphenoid sinus for each side was given a score of 0 for no opacification, 1 for partial opacification, or 2 for total opacification) The ostiomeatal complex was assigned a score of 0 for Patent or 2 for obstructed. The Lund score ranged from 0 to 24. Wolff [14] showed that the sinuses themselves are relatively insensitive to pain. The pain associated with sinusitis comes from engorged and inflamed nasal structures: nasofrontal ducts, turbinates, ostia, and superior nasal spaces. Headache associated with paranasal sinus disease usually has a deeper, dull, aching quality combined with a heaviness and fullness. It seldom is associated with nausea and vomiting A severe, intractable, new-onset headache that interferes with sleep and is not relieved by simple analgesics should alert one to the diagnosis of sphenoid sinusitis. The headache increases in severity and has no specific location. Pain or paraesthesias in the facial distribution of the fifth nerve and photophobia or eye tearing are suggestive of sphenoid sinusitis. [15-19] Mcauliffe et al [20] studied the sensitivity of the nasal cavities and paranasal sinuses using touch, pressure, and faradic stimulation. The nasal turbinates and sinus ostia were much more sensitive than the mucosal lining of the septum and the paranasal sinuses. Most of the pain elicited was referred pain. It was of increased intensity, longer duration, and referred to larger areas in subjects who had swelling and engorgement of the nasal turbinates and the sinus ostia. Sschà ¸nsted-madsen et al [21] followed up 444 patients who had nasal obstruction, 157 of whom had headache. Treatment consisted of septo-plastic surgery, reconstruction of the nasal pyramids, or submucosal conchotomy. The headache usually was localized to the forehead, glabella, or above and around the eyes. Headache can be arising from the paranasal sinuses, which may be missed even after careful history. Nasal endoscopy plays an important role in recognizing pathological changes following radiographic investigations. The IHS has established new criteria for acute sinus headache [22} Rhinosinusitis headache Good nasal endoscopic examination, with CT PNS wherever necessary, has proved best modality for comprehensive diagnosis of chronic inflammatory disease of PNS. Following these definitive reliable techniques with adequate diagnostic information, to determine which treatment modality is required or necessary and also can avoid radical surgery in majority of instances. Jakobsen and Svendstrup (2000) (23) conducted a prospective study on 237 consecutive patients suffering from chronic sinusitis and or nasal polyposis. Nasal obstruction was the most frequent symptom (61%) followed by purulent nasal discharge, anosmia, frontal pain, headache and maxillary pain. Duration of symptoms averaged 9.3years. At the end of 1 year follow up 45% were totally satisfied with the results and were symptom free and 44% were definitely feeling better. Damm et al (2002) (24) conducted a study on patients with CRS to assess impact of FESS on the symptoms profile. Leading symptoms of CRS were nasal obstruction (92%) and postnasal drip (87%). Furthermore, patients reported dry upper respiratory tract syndrome in 68%, hyposmia in 66%, and headache in 64% and asthmatic complaints in 34%. After a mean postoperative follow up of 31.7 months, an improvement in quality of life was achieved in 85%, no change in 12% deterioration in 3% mainly responsible for this improvement was the postoperative decrease of nasal obstruction (84%), headache (82%) and postnasal drip (74%) (All symptoms; p Conclusion In present study 265 patients were found to have abnormal pathological findings, and 5 patients had typical structure of lateral nasal wall. Among anatomic variants, deviated nasal septum with mucopurulent discharge followed by abnormal uncinate process, abnormal middle turbinate resulted in significant narrowing of OMC. Most of these patients were not relieved with medical treatment had anatomical variations and such patients were posted for surgical treatment. To conclude, combination of thorough nasal endoscopic examination and CT of PNS for diagnosis of functional status of nasal and PNS as well as surgical treatment of functional and anatomical variations including postoperative follow up minimal conservative resection of anatomical abnormalities or small pathological lesions in intricate lateral wall of nose may only be required to alleviate nagging chronic intractable headache. So, nasal endoscopy is useful for the diagnosis as well as for surgical intervention and management of sinugenic headache. Bibiography 1 Martin V, Elkind A. Diagnosis And Classification Of Primary Headache Disorders.In Standards Of Care For Headache Diagnosis And Treatment. Chicago (Il): National Headache Foundation: 2004 P. 4-18 2 Stovner L, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher A, Etal. The Global Burden Of Headache: A Documentation Of Headache Prevelance And Disability World Wide. Cephalgia 2007; 27(3): 193-210 In 3. Bcps; Powers C, Schreiber Cp, Hutchinson S, Webster Cj, Ames M,Richardson Ms, Pharm D (2004) Prevalence Of Migraine In Patients With Ahistory Of Self-Reported Or Physician-Diagnosed Sinus Headache. Arch Intern Med 164:1769–1772 4. Peter Jg (2009) Lacrimation, Conjunctival Injection, Nasal Symptoms Cluster Headache, Migraine And Cranial Autonomic Symptoms In Primary Headache Disorders- Whats New? J Neurol Neursurg Psychiatry 80:1057–58 5. May A, Goadsby Pj (1999) The Trigeminovascular System In Humans: Pathophysiological Implications For Primary Headache Syndromes Of The Neural Influences On The Cerebral Circulation. J Cereb Blood Flow Metab 19:115–127 6. Dadgarnia Mh, Atighechi S, Baradaranfar Mh (2010) The Response To Sodium Valproate Of Patients With Sinus Headaches With Normal Endoscopicand Ct Findings. Eur Arch Otorhinolaryngol 267:375–379 7. Levine Hl, Setzen M, Cady Rk, Et Al. (2006) An Otolaryngology, Neurology,Allergy And Primary Care Consensus On Diagnosis And Treatment Of Sinus Headache.A Literature Review. Otolaryngol Head Neck Surg 134:516–52.3 [8] Schà ¸nsted-Madsen U, Stoksted P, Christensen Ph, Koch-Henriksen N. Chronic Headache Related To Nasal Obstruction. J Laryngol Otol 1986;100:165–70. [9] Lew D, Southwick Fs, Montgomery Ww, Weber Al, Baker As. Sphenoid Sinusitis:A Review Of 30 Cases. N Engl J Med 1983;19:1149–54. 10. Second Headache Classification Subcommittee.The International Classification Of Headache Disorders.Cephalalgia.2004;24(Suppl 1):1-150 [11] Zinreich Sj. Paranasal Sinus Imaging. Otolaryngol Head Neck Surg 1990;103:863–9 [12] Schatz Cj, Becker Ts. Normal Ct Anatomy Of The Paranasal Sinuses. Radiol Clin Northam 1984; 22:107–18 [13] Bhattacharyya N, Fried Mp. The Accuracy Of Computed Tomography In The Diagnosis Ofchronic Rhinosinusitis. Laryngoscope 2003;113:125–9. [14] Wolff Hg. Wolff’s Headache And Other Head Pain. 1st Edition. New York: Oxford University Press; 1948 [15] Lew D, Southwick Fs, Montgomery Ww, Weber Al, Baker As. Sphenoid Sinusitis: A Review Of 30 Cases. N Engl J Med 1983;19:1149–54. [16] Kibblewhite Dj, Cleland J, Mintz Dr. Acute Sphenoid Sinusitis: Management Strategies.J Otolaryngol 1988;17:159–63 [17] Goldman Ge, Fontanarosa Pb, Anderson Jm. Isolated Sphenoid Sinusitis. Am J Emergmed 1993;11:235–8 [18] Deans Jaj, Welch Ar. Acute Isolated Sphenoid Sinusitis: A Disease With Complications.J Laryngol Otol 1991;105:1072–4. [19] Nordeman L, Lucid E. Sphenoid Sinusitis, A Cause Of Debilitating Headache. J Emerg Med1990;8:557–9. [20] Mcauliffe Gw, Goodell H, Wolff Hg. Experimental Studies On Headache: Pain From The Nasal And Paranasal Structures. Res Publ Assoc Res Nerv Ment Dis 1943;23:185–206. [21] Schà ¸nsted-Madsen U, Stoksted P, Christensen Ph, Koch-Henriksen N. Chronic Headache Related To Nasal Obstruction. J Laryngol Otol 1986;100:165–70. [22] Headache Classification Committee Of The International Headache Society. Classification And Diagnostic Criteria For Headache Disorders, Cranial Neuralgia, And Facial Pain. Cephalalgia 1988;8(Suppl 7):1–96 (23) Jakobsen J, Svendstrup F. Functional Endoscopic Sinus Surgery In Chronic Sinusitis-A Series Of 237 Patients Consecutive1y Operated Patients. Actaotolaryngol, Suppl. 2000; 543: 158-161. (24) Damn M, Quante G, Jangehuelsing M, Stennert E.Impact Offunctional Endoscopic Sinus Surgery On Symptoms And Quality Of Life In Chronic Rhinosinusistis. Laryngoscope, Feb 2002; 112: 310-315.

The Cycle of Vengeance in Aeschylus’s Oresteia Essay -- Oresteia Essay

The Cycle of Vengeance in Aeschylus’s Oresteia    The cyclic thread of vengeance runs like wild fire through the three plays in Aeschylus’s Oresteia. This thread, with its complexity of contemporary and universal implications lends itself quite well to – in fact, almost necessitates – deeply interested study. While a brief summary of the Oresteia will inevitably disregard some if not much of the trilogy’s essence and intent, on the positive side it will establish a platform of characters, events, and motives with which this paper is primarily concerned. As such, I begin with a short overview of the Oresteia and the relevant history that immediately precedes it. The house of Atreus is cursed, it would seem, with the perpetual cycle of vengeance, the law of an eye for an eye. The curse originated with Tantalus, who angered the gods by feasting them on the flesh of his own son, Pelops. Pelops was restored by the gods and effected the birth of two sons, Thyestes and Atreus. Thyestes angered his brother by seducing his wife and challenging his claim to the throne. Consequently, Thyestes was banished from the kingdom, only to be summoned back by Atreus in false friendliness. Atreus, in the mode of his grandfather, feasted the unknowing Thyestes on small bits of Thyestes’ own children. Upon discovery of his doing, the distraught Thyestes fled into exile with his only remaining son, Aegisthus. The Agamemnon picks up with Agamemnon and Menelaus, sons to Atreus, who joined together in the war of Troy after Paris, son of Priam, seduced Helen, wife to Menelaus. Angered by his ruthless man-sacrifices in the war, Artemis required that Agamemnon take the life of his daughter Iphigeneia in order to save the army and fleet o... ...y nature one who questions, one who hesitates, one who considers his own actions from a variety of perspectives. This, by far, appears to be both the simplest and most sound argument. As Oedipus’s persistent pursuit of truth and constantly questioning nature made him a hero in Sophocles’ Oedipus, so did the similar nature of Orestes in the Oresteia.    Works Cited          Aeschylus. â€Å"The Oresteia.† Aeschylus: The Oresteia. Tran. Robert Fagles. New York: Penguin Books, 1979. 99-277.    Aristotle. Poetics. Tran. Gerald F. Else. Ann Arbor: Ann Arbor Paperbacks, 1986.    Finley, John H. Jr. Pindar and Aeschylus. Cambridge: Harvard UP, 1955.    ---. Four Stages of Greek Thought. Stanford: Stanford UP, 1966.    Pollitt, J. J. Art and Experience in Classical Greece. London: Cambridge UP, 1979.    Taplin, Oliver. Greek Tragedy in Action. London: Routledge, 1993.

2 Random Speeches Bob Marley and Beauty (Ideas)

Speech September 27, 2012 Bob Marley the Rastafarian I. Nesta Robert Bob Marley was born February of 1945. Bob Marley was born in Jamaica. You might know him as a singer, song writer, a rhythm guitarist, and lead singer of the Wailer’s. He stayed with the group through most of his life. Bob is the go to guy for spreading Jamaican music and the Rastafarian movement. Some of his most popular songs are: I Shot the Sheriff, No Women No Cry and Jamming to name a few, I listen to some of his music, which for me is inspirational. Gives me something to think about, what was going on in his mind mentally and the thoughts about war, peace and love.II. One of my favorite quotes from Bob is â€Å"I don’t have prejudice against white people because then I would have prejudice against myself. My father is white my mother is black. I’m not on the black men side or the white men, I’m God’s side. Bob Marley was raised Catholic, but became a devoted Rastafarian and started growing dreads, which is very important to them, it’s like the anatine tuning meaning you’re into the universe. Rastas are also vegetarian. Bob was a jiglo with eleven kids, some you might know like Damien Marley and Ziggy Marley. III.Rastafarians also were avid pot heads which is a Rastafarian belief were ganja or that kush is a holy sacrament. The difference between Rastas and non Rastas are that they smoke for religious and medicinal purposes. Another quote I like is â€Å"why do government people want the herb to be illegal, why something that makes people so happy, so relax so illegal? Some people smoke weed because you rebel makes you question what is and what isn’t. Exercise your mind frees your mind in a society that tries to involve it’s self in everyday life telling you what is right and wrong! † IV.In July 1977 Bob found out that out that he had cancer all throughout his body, he even had spots his brain the size of quarters that the doctor didn’t understand how he last so long without any medication or medicine assistance. He was buried near his birth place; his last words were to his son â€Å"mommy can’t buy life†! I know that for me inner beauty supposed to shine through to reveal your outer beauty; and it’s taken me awhile for me to truly understand why men and women choose physical beauty over inner beauty. Physical beauty and inner beauty can be similar and dissimilar.Inner beauty are the actions we take, whether it’s giving up a smile to a stranger, eating the right foods, wearing clothes that shows our physique, or using the right hair tools: such as curling irons, flat iron, and gel. These are things we do to take care of ourselves, and they add up to make us the unique person that we and you are! Physical and inner beauty can be similar or dissimilar: they both attract people. People in general are attracted to both physical and inner beauty. I may be drawn to M orris Chestnut’s appearance; while my big sister will love his personality. Physical and inner beauty are both equally important though.Let’s take for example: Beyonce, who many young girls and women admire for her unique sense of style (myself included). I’ve never met her in person, but it seems to me that she has this balance of inner and outer beauty. As the face of L'Oreal, a brand known for their quality cosmetics: hair and nail colors; we have seen Beyonce’s alter ego Sasha Fierce! She’s a bad Bitch! She also appears to be very comfortable in her own skin either portraying Etta James in Cadillac Records or Deena Jones in Dream Girls. When I watch Beyonce being interviewed, she seems very genuine, candid, and confident when sharing bits and pieces about her life.I sense that she pay close attention to details: hair, make-up, perfume and the clothes she wears. Finding balance between inner and outer beauty doesn’t just happen overnight. It’ll take some inner soul searching and discovering of our own uniqueness: hat beauty could be in the form of how we dress or the way we shine! Most importantly it’s the way we feel about ourselves, and having the awareness that beauty consists of both the inner and outer, we are the first step to becoming more authentic and the real person that we were meant to be, Beautiful!

How Apple Has Become For Successful Companies Growing Up...

Introduction Apple has always been one of the most influential, innovative, successful companies growing up. I, as an individual have watched this Company mature and specifically remember when Apple has blown up in the industry. Before the world knew it, Apple has become something that is well known amongst many people. I feel that it is important to learn how Apple has become to achieve such greatness. Steve Jobs and Stephen Wozniak founded Apple in 1976. These two men were dropouts in college at the time. Jobs had worked for a gaming company called Atari and Wozniak worked for Hewlett-Packard. With prior knowledge of technology, their version of technology bore fruit. They had started to work on an Apple computer prototype in Job’s garage. It wasn’t a smooth ride; Apple had a tough time starting out. Steve Jobs struggled to continue his company without the right funding, so he had to reach out to people who can. 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