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The nerve passes through the middle ear and the parotid gland Vagus Spinal accessory Cranial accessory Foramen magnum Internal carotid Cardiac branch External carotid To sternomastoid Pharyngeal and trapezius Superior laryngeal Internal jugular vein Internal laryngeal External laryngeal Cricothyroid Cardiac branch Subclavian artery Recurrent laryngeal (left) Fig buy viagra super active 25mg with mastercard venogenic erectile dysfunction treatment. The spinal root of the accessory is shown in yellow 130 Head and neck • VI discount viagra super active 25mg erectile dysfunction treatment options uk. In terior border of the pons and has a long intracranial course (so is often the neck the vagus (and cranial root of the accessory) gives the follow- the first nerve to be affected in raised intracranial pressure) to the cav- ing branches: ernous sinus, where it is closely applied to the internal carotid artery, • The pharyngeal branch which runs below and parallel to the glos- and thence to the orbit via the superior orbital fissure. It supplies the lat- sopharyngeal nerve and supplies the striated muscle of the palate eral rectus. It reaches thorax to take part in the cardiac plexuses. The former enters the larynx by piercing the the parotid gland, in which it divides into five branches (temporal, thyrohyoid membrane and is sensory to the larynx above the level of zygomatic, buccal, marginal mandibular and cervical) which are the vocal cords, and the latter is motor to the cricothyroid muscle. On the right side it loops under the posterior belly of the digastric. In the middle ear it gives off the greater subclavian artery before ascending to the larynx behind the com- petrosal branch which carries parasympathetic fibres to the mon carotid artery. On the left side it arises from the vagus just sphenopalatine ganglion and thence to the lacrimal gland. In the middle below the arch of the aorta and ascends to the larynx in the groove ear it also gives off the chorda tympani which joins the lingual nerve between the trachea and oesophagus. Sensory fibres in the chorda tympani have nerves supply all the muscles of the larynx except for cricopharyn- their cell bodies in the geniculate ganglion which lies on the facial geus and are sensory to the larynx below the vocal cords. The vestibulocochlear (auditory) nerve: this leaves the brain side of the medulla with the vagus and is distributed with it. The spinal next to the facial nerve and enters the internal auditory meatus. It root arises from the side of the upper five segments of the spinal cord, divides into vestibular and cochlear nerves. It leaves the vagus below the jugular foramen and passes back- the side of the medulla and passes through the jugular foramen. It then wards to enter sternomastoid, which it supplies. It then crosses the pos- curves forwards between the internal and external carotid arteries to terior triangle to supply trapezius (see Fig. It also gives a branch to the carotid body and passes through the hypoglossal canal. It supplies the intrinsic and extrinsic muscles of the tongue. It nerve but the spinal root of the accessory leaves it again almost imme- gives off the descendens hypoglossi but this is actually composed of diately. The cranial root is distributed with the vagus (hence the fibres from C1. This joins the descendens cervicalis, derived from C2 nameait is accessory to the vagus). The vagus carries two ganglia for and 3, to form the ansa cervicalis. From this, branches arise to supply the cell bodies of its sensory fibres. It descends between the internal the ‘strap muscles’, i. Cranial nerves VI–XII 131 59 The arteries I Superficial temporal Foramen spinosum Middle meningeal Maxillary Occipital Facial Tonsillar branch Dorsal Hypoglossal nerve lingual Internal carotid Lingual External carotid Carotid sinus Laryngeal branch Superior thyroid Recurrent laryngeal nerve Thyroid Inferior thyroid Thyrocervical trunk Subclavian Fig. The intracranial parts of the two vertebral arteries are also shown diagrammatically although they are in a different plane 132 Head and neck The common carotid artery • The middle meningeal arteryaruns upwards to pass through the Arises from the brachiocephalic artery on the right and from the arch of foramen spinosum. Inside the skull it passes laterally and then the aorta on the left (Chapter 4). Each common carotid passes up the ascends on the squamous temporal bone in a deep groove, which it neck in the carotid sheath (Fig. The anterior branch passes vein and the vagus nerve.

Courtesy of Mirjam Weemhoff Hematometra/pyometra This term describes a uterine cavity filled with either MINIMAL CARE/TREATMENT blood or pus and is related to a stenosis of the uterine Management strategies for each gynecological cervix generic 100mg viagra super active with visa erectile dysfunction protocol by jason. In young girls who never menstruated be- problem are based on patient factors and the nature fore viagra super active 50mg lowest price erectile dysfunction treatment in the philippines, hematometra is caused by congenital anomalies of disease presentation. Some of these conditions of the uterus, vagina or hymen as described in need immediate attention and surgical, medical or Chapters 8 and 24. In women of reproductive age or multimodal treatment, e. Treatment not only consists 107 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS Table 7 Further investigations women. They tend to be confined to the ovary, but implants in the abdomen are described. They Chest X-ray, abdominal X-ray (dermoid cyst), intra- have different histological features: venous pyelograph (to look for hydronephrosis) or ultrasound of kidneys (establish the level of obstruction in • Mucinous borderline ovarian tumors are usually case of a hydro-ureter) restricted to one ovary. ECG as appropriate • Serous borderline ovarian tumors are in 25–50% bilateral, and 25–30% of the patients may have Culdocentesis and culdotomy (see Chapters 12 and 18) in some extra-ovarian disease so staging is appro- case of free fluid in Douglas’ pouch 8 priate. Frozen section diagnosis of a low malig- Cystoscopy and rectoscopy if available nant potential tumor of the ovary is changed to CT scan or MRI as appropriate and if available in the a final diagnosis of invasive cancer in approxi- hospital mately 10% of cases. Serous borderline tumors may have (invasive or non-invasive) implants. Explorative laparotomy Most patients present with an asymptomatic pel- vic/abdominal mass. On ultrasound the tumor is mostly multilocular with papillary formations but without ascites, but a non-suspicious cyst does Table 8 Key points in diagnosis and treatment of a not exclude borderline disease. Ca-125 may be swollen abdomen/abdominal mass (slightly) elevated. Look for signs of shock: pallor, low blood pressure and Therapy Surgical staging without pelvic and para- low volume rapid pulse aortal lymph node dissection as this does not influ- Lower abdominal/pelvic tenderness, rigidity, rebound or ence the prognosis9: obtain free fluid or wash the guarding and any mass arising from the pelvis abdomen for cytology, systematically examine Inspect the vulva for any bleeding the whole abdomen (see Chapter 28) and take a biopsy of any suspicious lesion, take biopsies of the Vaginal examination as appropriate +/- swabs peritoneal surface of Douglas’ pouch, the bladder Per rectal examination as appropriate peritoneum, the paracolic gutters and the right dia- phragm. Remove the omentum, the uterus, both Always a pregnancy test in any woman of reproductive age tubes and ovaries (see Chapter 19 for method). Consider a diag- patients who wish to spare their fertility a unilateral nostic peritoneal lavage in case of free fluid either by oophorectomy can be performed and the uterus culdocentesis or abdominal tapping depending on the and the healthy adnexa will not be removed. The most reliable prognostic indi- of dilatation of the cervical stenosis but always in cator for advanced stage tumors is the type of endometrial sampling (see Chapters 20 and 29) and peritoneal implant. Survival of patients with non- cervical examination to exclude malignancy. In cases invasive peritoneal implants is 95%, compared with of pyometra, the pus is most commonly sterile, so 66% for invasive implants, and lymph node involvement was associated with a 98% survival9. It is more important to produce There is no place for adjuvant chemotherapy in a specimen for histology. Treatment of hematometra/pyometra is a care- ful D&C under anesthesia and if possible under Benign ovarian cysts and tumors ultrasound guidance. Persistent or big ovarian cysts Borderline ovarian tumors Persistent or big ovarian cysts with sonographically These are ovarian tumors with low malignant suspicious features (see above) should be assessed by potential that occur mainly in premenopausal surgery (laparotomy or if available laparoscopy 108 Abdominal Masses in Gynecology Table 9 Common gynecological conditions associated with abdominal masses Gynecological condition Common symptoms associated with pelvic mass Uterine fibroids Reproductive age, abnormal uterine bleeding, secondary dysmenorrhea, frequent voiding, constipation, chronic pelvic or back pain, recurrent mis- carriage, infertility Advanced uterine cancer or sarcoma Postmenopausal bleeding, pressure symptoms, pelvic pain, rapid growth of uterine mass in sarcoma Endometriosis Reproductive age, chronic pelvic pain, secondary dysmenorrhea, dyspareunia, infertility Tubo-ovarian abscess, pyosalpinx, Reproductive age, chronic pelvic pain with aggravation, dyspareunia, often hydrosalpinx intermenstrual bleeding, spotting, abnormal vaginal discharge, infertility. A hydrosalpinx is most often symptomless Benign ovarian cysts or tumors Reproductive age, often symptomless, acute or chronic pelvic pain, pressure symptoms, sometimes irregular cycles, spotting Ovarian cancer Peak age postmenopausal, increased abdominal circumference, sometimes dyspnea, postmenopausal bleeding, pressure symptoms, obstipation or ileus by a skilled surgeon). Note however, that you mass you should not attempt this surgery unless you should not attempt doing a mini-laparotomy or are very experienced and able to repair a bowel or unskilled laparoscopy on an ovarian tumor with bladder lesion. If you are able to identify and suspicious sonographic features. If it ruptures intra- mobilize (do this bluntly with your fingers! Tubo-ovarian masses associated with pelvic inflammatory disease Simple ovarian cysts Tubo-ovarian masses associated with pelvic inflam- These are very common in women of reproductive matory disease (PID) are difficult to assess. Reconstructive tubal sur- logical, watchful waiting for two to six cycles is gery to restore tubal patency exists but should be appropriate in an asymptomatic simple cyst of carried out by experienced surgeons. If you try to <5cm diameter in a premenopausal woman. Re- just re-open the hydrosalpinx there is a significant scan after 3 and 6 months. If still persistent after increase in the risk of ectopic pregnancy in that 6 months, surgery may be appropriate. In cases of pelvic abscess do a culdocentesis common practice in many settings to treat simple (see Chapter 12) first and if pus is drained do a cul- ovarian cysts with oral contraceptives but a dotomy as described in Chapter 18.

The direct evidence (trials or observational studies) generally pooled results for the antitumor necrosis factor drugs adalimumab viagra super active 50 mg on-line what causes erectile dysfunction, etanercept buy 100mg viagra super active overnight delivery erectile dysfunction hotline, and infliximab most often compared with disease-modifying antirheumatic drugs and with minimal analyses comparing the drugs to each other. Analyses using indirect evidence from placebo-controlled trials were available for all drugs except alefacept and natalizumab. Outcomes in observational studies included serious infections, malignancies, and cardiovascular events. Few trials used objective scales to assess adverse events. Evidence on subgroups is primarily focused on the difference in the efficacy and harms of patients 65 years and older compared with those younger than 65. For racial groups, the evidence is limited mostly to placebo controlled trials in Asian patients with plaque psoriasis and rheumatoid arthritis with adalimumab being the most commonly used drug. The evidence on comorbid conditions is found primarily in rheumatoid arthritis patients with comorbid respiratory disease or diabetes. The evidence most represents the antitumor necrosis factor drugs infliximab and etanercept. Methodological Limitations This review has several limitations that should be noted. We did not include studies published in languages other than English, and we did not systematically search for unpublished studies. Few direct head-to-head comparisons of the included drugs have been conducted, which limits our conclusions to indirect comparisons of placebo controlled trials for most outcomes. Evidence suggests that adjusted indirect comparisons agree with head-to-head trials if component studies are similar and treatment effects are expected to be consistent in patients included in different trials. Nevertheless, findings must be interpreted cautiously. This uncertainty lowers the strength of the evidence due to heterogeneity of trial populations, interventions, and outcome measures. Finally, the individual studies included in our review had methodological limitations, with most receiving only a fair rating for internal validity. Relevant Trials in Progress The following trials were published after our searches and will be considered for inclusion in any further updates: Ash Z, Gaujoux-Viala C, Gossec L, et al. A systematic literature review of drug therapies for the treatment of psoriatic arthritis: Current evidence and meta-analysis informing the EULAR recommendations for the management of psoriatic arthritis. Gallego-Galisteo M, Villa-Rubio A, Alegre-del Rey E, et al. Targeted immune modulators 112 of 195 Final Update 3 Report Drug Effectiveness Review Project Kremer JM, Blanco R, Brzosko M, et al. Tocilizumab Inhibits Structural Joint Damage in Rheumatoid Arthritis Patients With Inadequate Responses to Methotrexate Results From the Double-Blind Treatment Phase of a Randomized Placebo-Controlled Trial of Tocilizumab Safety and Prevention of Structural Joint Damage at One Year. Summary of the evidence by key question Strength of Key question evidence Conclusion 1. Comparative efficacy for Moderate Based on 1 randomized controlled trial, no difference rheumatoid arthritis in efficacy between abatacept and infliximab. Low Based on 2 observational studies similar effectiveness between adalimumab and etanercept Low Based on 2 observational studies, greater effectiveness of adalimumab than infliximab Moderate Based on 2 trials and 5 observational studies, greater effectiveness of etanercept than infliximab. Low Based on indirect comparisons, greater effectiveness of etanercept than abatacept; etanercept than anakinra; and etanercept than tocilizumab. Low Based on indirect comparisons, similar efficacy between abatacept and adalimumab; abatacept and anakinra; abatacept and tocilizumab; adalimumab and anakinra; adalimumab and tocilizumab; anakinra and infliximab; anakinra and tocilizumab; and infliximab and tocilizumab. Insufficient No evidence available for all other comparisons. Comparative effectiveness Insufficient No comparative evidence available. Comparative effectiveness Insufficient No comparative evidence available. Comparative effectiveness Low Based on indirect comparisons and a prospective for psoriatic arthritis registry study, no difference in effectiveness between adalimumab, etanercept and/or infliximab.