Misoprostol
"Order misoprostol 200mcg free shipping, gastritis diet options."
By: Randolph E. Regal, BS, PharmD
- Clinical Associate Professor, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan
- Clinical Pharmacist, University of Michigan Health System, Ann Arbor, Michigan
https://pharmacy.umich.edu/people/reregal
Although postmenopausal ovarian steroidogenesis contributes to chronic gastritis risk factors buy generic misoprostol testosterone production no xplode gastritis purchase genuine misoprostol on-line, testosterone levels retain diurnal variation gastritis vs ulcer symptoms purchase misoprostol 200 mcg mastercard, reflecting an ongoing and important adrenal contribution gastritis diet òóò purchase misoprostol without a prescription. Peripheral aromatization of androgens to estrogens increases with age, but because small fractions (2% to 10%) of androgens are metabolized in this fashion, such conversion is rarely of clinical significance. Laboratory Evaluation the 2008 Endocrine Society Clinical Practice Guidelines suggest testing for elevated androgen levels in women with moderate (Ferriman–Gallwey hirsutism score 9 or greater) or severe hirsutism or hirsutism of any degree when it is sudden in onset, rapidly progressive, or associated with other abnormalities such as menstrual dysfunction, infertility, significant acne, obesity, or clitoromegaly. These guidelines suggest against testing for elevated androgen levels in women with isolated mild hirsutism because the likelihood of identifying a medical disorder that would change management or outcome is extremely low (Fig. In clinical situations requiring a testosterone evaluation, the addition of 17-hydroxyprogesterone will screen for adult onset adrenal hyperplasia, when indicated (Table 31. In cases of suspected Cushing syndrome, patients should undergo screening with a 24-hour urinary cortisol (most sensitive and specific) assessment or an overnight dexamethasone suppression test. Cortisol levels of 2 fig/dL or higher after overnight dexamethasone suppression require a further workup for evaluation of Cushing syndrome. Levels greater than 10,000 ng/dL (300 nmol/L) are virtually diagnostic of congenital adrenal hyperplasia. Precocious pubarche precedes the diagnosis of adult onset congenital adrenal hyperplasia in 5% to 20% of cases. Because increased testosterone production is not reliably reflected by total testosterone levels, the clinician may choose to rely on typical male pattern hirsutism as confirmation of its presence, or may elect measures that reflect levels of free or unbound testosterone (bioavailable or calculated free testosterone levels). Total testosterone does serve as a reliable marker for testosterone-producing neoplasms. Total testosterone levels greater than 200 ng/dL should prompt a workup for ovarian or adrenal tumors. Routine determination of androgen conjugates to assess hirsute patients is not recommended, because hirsutism itself is an excellent bioassay of free testosterone action on the hair follicle and because these androgen conjugates arise from adrenal precursors and are likely markers of adrenal and not ovarian steroid production (8). When hirsutism is moderate (>9) or severe or if mild hirsutism is accompanied by features that suggest an underlying disorder, elevated androgen levels should be ruled out. Plasma testosterone is best assessed in the early morning on day 4 to 10 in regularly cycling women. A 17-hydroxyprogesterone is also indicated when symptoms warrant a bioavailable testosterone measurement. The mild form presents with vitalization or precocious puberty without hypertension. Free testosterone is calculated using measurements for total testosterone and sex hormone–binding globulin, whereas bioavailable testosterone is calculated using measured total testosterone, sex hormone–binding globulin, and albumin. Calculated values for free and bioavailable testosterone compare well with equilibrium dialysis methods of measuring unbound testosterone when albumin levels are normal. Bioavailable testosterone is the most accurate assessment of bioactive testosterone in the serum without performing equilibrium dialysis. A random sample is sufficient because the level of variation is minimized as a result of the long half life characteristic of sulfated steroids. In the study, the demographics and the prevalence of hirsutism, acne, oligomenorrhea and amenorrhea were not different in each group. When clinical signs of androgen excess reach the point of virilization or the free testosterone level is above 6. Careful consideration of the sensitivity and specificity, diurnal variation, and age related variation of potentially measureable androgens will aid in choosing the most useful measurements (Table 31. It is characterized by a combination of hyperandrogenism (either clinical or biochemical), chronic anovulation, and polycystic ovaries. It is the most common cause of hyperandrogenism, hirsutism, and anovulatory infertility in developed countries (15,16). The association of amenorrhea with bilateral polycystic ovaries and obesity was first described in 1935 by Stein and Leventhal (17). Their diagnostic criteria recommended clinical and/or biochemical evidence of hyperandrogenism, chronic anovulation, and exclusion of other known disorders. Clinical and/or biochemical signs of hyperandrogenism and exclusion of other etiologies. Clinical hyperandrogenism includes hirsutism, male pattern alopecia, and acne (19). A likely explanation for this discrepancy is the genetically determined differences in skin 5fi-reductase activity (22,23). It is important to measure the basal follicular phase 17-hydroxyprogesterone level in all women presenting with hirsutism to exclude the presence of nonclassic congenital adrenal hyperplasia, regardless of the presence of polycystic ovaries or metabolic dysfunction (24). Classically, the disorder is lifelong, characterized by abnormal menses from puberty with acne and hirsutism arising in the teens. It may arise in adulthood, concomitant with the emergence of obesity, presumably because this is accompanied by increasing hyperinsulinemia (26). The body fat is usually deposited centrally (android obesity), and a higher waist-to-hip ratio is associated with insulin resistance indicating an increased risk of diabetes mellitus and cardiovascular disease (30). Insulin resistance may eventually lead to the development of hyperglycemia and type 2 diabetes mellitus (32). A cross-section of the surface of the ovary discloses a white, thickened cortex with multiple cysts that are typically less than a centimeter in diameter. Microscopically, the superficial cortex is fibrotic and hypocellular and may contain prominent blood vessels. In addition to smaller atretic follicles, there is an increase in the number of follicles with luteinized theca interna. Insulin resistance, in concert with genetic factors, may also lead to hyperglycemia and an adverse profile of cardiovascular risk factors. The serum total testosterone levels are usually no more than twice the upper normal range (20 to 80 ng/dL). The presence and activity of 5fi-reductase in the skin largely determines the presence or absence of hirsutism (22,23). Aromatase and 17fi-hydroxysteroid dehydrogenase activities are increased in fat cells and peripheral aromatization is increased with increased body weight (51,52). With obesity the metabolism of estrogens, by way of reduced 2-hydroxylation and 17fi-oxidation, is decreased and metabolism via estrogen active 16-hydroxyestrogens (estriol) is increased (53). A chronic hyperestrogenic state, with reversal of the E1-to-E2 ratio, results and is unopposed by progesterone. Polycystic ovary syndrome is a complex multigenetic disorder that results from the interaction between multiple genetic and environmental factors. These genes can be grouped in four categories: (i) insulin resistance–related genes, (ii) genes that interfere with the biosynthesis and the action of androgens, (iii) genes that encode inflammatory cytokines, and (iv) other candidate genes (57). Insulin inhibits the hepatic synthesis of sex hormone–binding globulin, the main circulating protein that binds to testosterone, thus increasing the proportion of unbound or bioavailable testosterone (13). Oophorectomy in patients with hyperthecosis accompanied by hyperinsulinemia and hyperandrogenemia does not change insulin resistance, despite a decrease in androgen levels (70,71). This thickened, pigmented, velvety skin lesion is most often found in the vulva and may be present on the axilla, over the nape of the neck, below the breast, and on the inner thigh (72). Multiple other testing or screening schema were proposed to assess the presence of hyperinsulinemia and insulin resistance. In one, the fasting glucose-to-insulin ratio is determined, and values less than 4. When compared to the gold standard measure for insulin resistance, the hyperinsulemic-euglycemic clamp, it shows that the glucose-to insulin ratio does not always accurately portray insulin resistance. This deficient insulin secretion exacerbates the effects of insulin resistance and renders inaccurate the use of hyperinsulinemia as an index of insulin resistance. Interventions Two-Hour Glucose Tolerance Test Normal Glucose Ranges (World Health Organization criteria, after 75-gm glucose load) Fasting 64 to 128 mg/dL One hour 120 to 170 mg/dL Two hour 70 to 140 mg/dL Two-Hour Glucose Values for Impaired Glucose Tolerance and Type 2 Diabetes (World Health Organization criteria, after 75-gm glucose load) Normal (2-hour) <140 mg/dL Impaired (2-hour) = 140 to 199 mg/dL Type 2 diabetes mellitus (2-hour) fi200 mg/dL Abnormal glucose metabolism may be significantly improved with weight reduction, which may reduce hyperandrogenism and restore ovulatory function (74). In obese, insulin-resistant women, caloric restriction that results in weight reduction will reduce the severity of insulin resistance (a 40% decrease in insulin level with a 10-kg weight loss) (75). This decrease in insulin levels should result in a marked decrease in androgen production (a 35% decrease in testosterone levels with a 10-kg weight loss) (76). In addition to addressing the increased risk for diabetes, the clinician should recognize insulin resistance or hyperinsulinemia as a cluster syndrome called metabolic syndrome or dysmetabolic syndrome X. Recognition of the importance of insulin resistance or hyperinsulinemia as a risk factor for cardiovascular disease led to diagnostic criteria for the dysmetabolic syndrome. The more dysmetabolic syndrome X criteria are present, the higher the level of insulin resistance and its downstream consequences. The presence of three of the following five criteria confirm the diagnosis, and an insulin lowering agent and/or other interventions may be warranted (19). Dietary management of obesity should focus on reducing body weight, maintaining a lower long-term body weight, and preventing weight gain.
He was found to gastritis best diet buy discount misoprostol online have suppurative arthritis of the right hip stomach ulcer gastritis symptoms trusted 200 mcg misoprostol, which was too painful to gastritis weight loss buy discount misoprostol 200mcg on-line move gastritis or gallbladder buy cheapest misoprostol. Septic arthritis is more common in the disadvantaged and If you fail to aspirate a joint that you think is infected, malnourished and also in infancy and old age. Culture the synovial fluid (30% +ve most frequent organism in newborns, but is seldom seen in result) and blood (14%). You may see the first signs of new bone formation as early as the 5th day in an infant, but it will not appear before the 10th day in an older child, and may take longer. Try to isolate the organism, otherwise cloxacillin or chloramphenicol are most suitable. If, when you drain an infected joint and wash out the pus, its joint surfaces are smooth, there is a good chance of having a normal or nearly normal joint. The prognosis is worse if cartilage has been lost, if the joint surfaces are rough, if the bone is soft, or if the radiograph shows severe joint destruction. Use a tourniquet where possible, and if the hand is involved, watch out for its nerves. The linear incision you have just made will become elliptical, and you will see the cartilage underneath. If the joint surfaces feel rough but some cartilage still covers the bones, there may still be useful function in the joint. G kindly contributed by Jack if it is done too early, there will be growth problems so delay this as long as possible. The position of function is the best position for a joint to be in if it is going to be fixed, or if its movement is going 7. It is also called the position for (except the hip) ankylosis Joints need to be in particular positions for particular the position of rest is the most comfortable position for a purposes, so be sure to get it right. Put it into this position if it has to be rested for coincide with one another, and the position of function is any reason, but is in no danger of ankylosing. Keeping the Any kind of ankylosis, stable or unstable, is a dreadful needle horizontal, push it 30fi medially into the joint space, disability if the joint becomes fixed in the wrong position, from a point just under the postero-inferior border of the so make sure that, if it is going to ankylose, it does so in acromion (7-15G). The position of function varies Anterior route: this is easier but more hazardous. You never know for sure when a joint space between the pectoralis major and deltoid muscle. Slope it laterally 30fi and knee just short of full extension; splint the right push it backwards, until it enters the loose pouch under the (or dominant) elbow flexed. Do not leave this task to a physiotherapist in the hope that it will be achieved later! Put the shoulder into a spica in 45fi of abduction, with the elbow just anterior to the coronal plane, in 70fi of medial rotation so that the hand can reach the mouth. Feel for the head of the radius, the olecranon and the lateral epicondyle of the humerus. Using these points of a triangle, push the needle through its centre into the posterolateral aspect of the joint. Stay close to the olecranon, and remember that the posterior interosseous nerve winds round the neck of the radius 3cm distal to its head. A, notice that the shoulder is abducted, the right elbow is Keep the arm in a sling in 90fi of flexion. For example, Muslims and many other With the knee extended, make a 5cm incision 2cm behind peoples write and eat with their right hands and use their the medial edge of the patella and its tendon. If so, the right elbow should the quadriceps expansion, longitudinally, and put a curved be more flexed than the left. The dominant elbow will haemostat into the suprapatellar pouch, under the surface probably be most useful if it is flexed 10fi beyond a right of the patella. Put your finger into the joint and use it to angle, with the forearm pronated 45fi so that feeding, remove the pus. Dress the wound and apply skin traction, If both the elbows are going to ankylose, arrange their or a plaster backslab. Without one or other a painful positions so that the dominant arm can reach the mouth. Leave the drain in for Let the non-dominant elbow fuse in 10fi short of full 4-7days. Feel for the radial styloid; it will show you the line of the If there is already a flexion contracture following septic joint. With luck, a painless bony between extensor pollicis longus and the index tendon of ankylosis will develop. If this does not happen, extensor digitorum into the joint inclining it proximally a compression arthrodesis of the knee will be necessary. Keep the mcp joints nearly fully flexed, the pip and 4th metatarsal, lateral to the extensor tendons of the toes. Keep the thumb well forward of Divide the superior and inferior extensor retinaculum as the palm in opposition to the fingers, with its pulp about far as is necessary, so as to expose the capsule of the ankle 4cm from them. Keep the ankle in neutral, without any flexion, extension, inversion, or eversion. If the leg turns to external rotation as you do this, the head of the femur may have slipped. Confirm this by taking a An acutely tender hip in varying degrees of flexion, ‘frog-leg view’ radiograph. If this is acutely painful, suspect that the hip there are 2 choices: is infected. If there is septic arthritis or osteomyelitis (a) Fuse the hip in the position of function by applying a tapping the greater trochanter lightly with your clenched spica for 3 months or more. A, lie the patient flat, place your hand on the thighs and try to roll the leg to and fro. This can happen spontaneously in teenagers; it also happens in late septic arthritis. Draining the pus in these cases is just as important; removing the prosthesis is difficult and may not be necessary: it is anyway something for an expert! If you do not treat septic arthritis of the hip early, any of these things may happen: (1);A flexion contracture may develop, which will be a great disability, if you let it become permanent. Later in the course of the disease there is a useful test to find out if it is slipping. Anteriorly, feel for the femoral artery 2ficm below the inguinal ligament midway between the anterior iliac spine and the pubic tubercle. Insert the needle 1ficm lateral to the artery (and thus lateral to the femoral nerve). If you cannot feel the femoral artery, insert the needle 2ficm below and 2ficm lateral to the mid-inguinal point. To prove that the needle is in the cartilage, rotate the thigh internally a little. Feel for the posterior inferior iliac spine and the centre of the greater trochanter. If you can safely anaesthetize a prone patient, the posterior approach is easier, because it allows better drainage but the anterior approach is safer in children. Use the supine position, but with a tilt to the opposite side by putting a sandbag under the affected hip. Use a periosteal elevator to separate the gluteus medius and tensor fascia lata from the iliac crest. Continue the dissection distally between the tensor fascia lata posterolaterally, and the sartorius and rectus femoris anteromedially. C, be careful not Insert 2 bone levers on each side round the upper shaft of to injure the sciatic nerve. Insert a suction drain from the joint to the surface, margin obliquely up towards a point on the iliac crest 6cm and leave it in for 5-7days. Separate the fibres of the gluteus maximus using Close the skin with 2/0 monofilament. Put the hip in a minimum amount of flexion, preferably none, 5fi of abduction, and no rotation. However, do not apply a spica with the hip in the position of function, especially in a child.
A decision in many instances will have to gastritis workup cheap misoprostol online visa be based on clinical evaluation of inadequate case information gastritis symptoms home treatment misoprostol 200 mcg with visa. Evaluation of expectedness will probably remain subject to gastritis uti buy misoprostol 100mcg visa high variability between assessors gastritis diet áîáôèëüì order 200mcg misoprostol overnight delivery. Case Follow-up Approaches Introduction the information from adverse event cases when first received will generally be incomplete. Ideally, comprehensive information would be available on all cases, but in practice efforts are needed to seek additional information on selected reports. The extent and nature of follow-up is driven by the nature of the case and consideration of the value of learning more detail, tempered by insight into the likelihood of success at such attempts. Although procedures are already in place within companies and regulatory authorities, guidance is needed to ensure that resources for case follow-up are focussed on the most relevant data elements for the most important cases for both marketed and investigational drugs. Busy professionals will be more willing to offer further details if questions are asked on important information in clinically important cases and if they are not approached with redundant queries. In addition to the nature of the case, there are many other influences and factors to consider when deciding on the appropriate type of follow-up: o source of the report: literature, newspaper or other media, consumers, pharmacists, physicians, dentists, other healthcare 31 professionals, company representatives, or from the patient’s lawyers. Following extensive discussion, and because there are different mechanisms for dealing with misprescribing in individual countries, the Working Group was not able to reach consensus on this important matter. There is, however, an obvious public health need to address this risk communication issue, which is beyond the scope of the Working Group. General Considerations for Follow-up Practices In any scheme to optimize the value of follow-up, the first consideration is prioritization of case reports as they are brought to the attention of the companies and regulators. Once they are classified in order of importance, decisions must be made on the minimal amount of information that should be sought for the different categories of cases; thus, not all reports warrant the same effort to obtain follow-up nor is it necessary that the same type and depth of information be sought for all types of cases that are followed-up. For example, because a good narrative description is required for, among others, expedited reports to regulators, more information is needed for those cases than, for example, non-serious expected cases. If there is any level of doubt, which will depend on the information received with the case, follow-up is in order. Well documented serious expected cases are potentially of epidemio logical interest in helping to identify risk factors. Non-serious unexpected cases are also of potential interest for detecting a new signal. It is suggested that once a case is entered into a database, triage by computer can be used to indicate, based on the case content, whether it should be handled on an urgent basis (requiring a telephone call or a visit, for example), whether it might need a letter requesting follow-up information (which could be computer generated as well), or whether the case information is sufficient. For some spontaneous cases, especially those which are not serious, are already expected (labeled), and are the subject of many previous reports, a computer generated acknowledgement letter to the reporter may be 125 all that is needed provided the original information is adequate (see below). Proposals are also needed on the best methods for follow-up and the proper frequency (how many attempts) with respect to the various parties in the communication link (original case reporters, companies, regulators). The challenge is to obtain as much useful information as possible without pestering reporters, such that he or she might be disinclined to cooperate and be discouraged from future reporting. Partly for this reason, three levels of case information (data elements) have been developed that are tailored to the specific types of cases according to priority and importance (see below and Appendix 7). Finally, the Working Group considers it important to develop a position on whether and under what circumstances rechallenge or re exposure should be considered as part of a follow-up routine. At a slightly lower priority are serious, expected and non-serious, unexpected cases. In general, any cases for which additional detail might lead to a labeling change decision should be considered at a high priority level. However, in addition to seriousness and expectedness as criteria, cases ‘‘of special interest’’ also deserve extra attention. Cases of ‘‘special interest’’ include those which the company is actively monitoring as a result of a previously identified signal (even if non-serious and expected). For instance: concern over excessive drowsiness which could possibly lead to accidents; drug interactions; drug misuse; or a contra indication. Events of special interest, especially if they concern a new indication, new dosage regimen, or new dosage form, should be given the same attention as serious, unexpected reactions. The extent to which regulatory authorities themselves follow up cases varies widely. On occasion, regulators may request the manufacturer to follow up a case; if so, the same algorithms and logic proposed here for cases received directly by companies should be used. With permission, a regulator can divulge the name and address of the reporter to enable any necessary company-initiated follow-up. If required, a regulator may also be able to 126 assist the company if requests for information have been rejected by the reporter. If assistance from the regulators is requested — for cases received directly by companies or by regulators — it is suggested that the company provide specific questions it would like answered. It must be recognized, however, that in some instances, the reporter’s identity will be unavailable and follow-up not possible. There are also circumstances in which, even though the reporter’s identity is known, detailed efforts at case follow-up are not expected or required under conditions of a post-marketing surveillance study protocol. For case reports forwarded from regulators to companies, it should not be assumed that regulators will conduct any needed follow-up. Companies often receive partial reports from many sources such as published line listings; the information provided may be insufficient to characterize the event for purposes of ascertaining expectedness, an important determinant for priority of handling and possible regulatory reporting. However, expectedness may be country-specific in view of differences between local data sheets. As already mentioned, the extent of detail needed for a given case should be driven by its seriousness and expectedness. The Working Group has developed what it believes to be rational and practical sets of data elements, specifically targeted for different categories of cases, that should be considered sufficient to characterize the cases. The lists of data elements are referred to as Lists A, B and C, with A containing the least and C the most called-for information. Of course any data obtained that are not on the lists should also be recorded and reported as appropriate; however, follow-up is recommended only when the data elements on the Lists are missing or incomplete. However, it is not expected that all such information would be available for most cases; indeed, it would be rare. Although the items in the Lists are regarded as reasonable and sufficient for the purpose of characterizing different types of cases, the data elements are not expected to serve as automatic check-lists against which, for example, regulatory compliance is assessed. They are presented here as a practical expediency to assist in the follow-up process. Thus, in addition to the items in List A, the following should be available (List B): List A Plus: o Daily dose of suspected medicinal product and regimen o Route of administration o Indication(s) for which suspect medicinal product was prescribed o Starting date (and if relevant, time of day of treatment;. Autopsy and hospital discharge summaries need not be submitted but the obligatory narrative should highlight the findings and state whether or not the detailed reports are available on request. When laboratory or other tests are conducted specifically to investigate the case, results should be obtained for all such tests. Specific investigative tests should be the focus and must not be confused with routine tests conducted independently of the adverse event. Medical confirmation should be sought from a medically qualified healthcare professional involved in the patient’s care if the report originates from other than a physician if the case is serious or medically significant. Because each clinical situation will be unique and require judgment, more specific guidance on how long to follow-up is not appropriate. Only if the fields identified in the Lists A, B and C are updated should the new information be submitted. Conversely, it is unnecessary to send a follow-up regulatory report if non-significant data elements not included in the Lists (such as height) subsequently become known or require correction. If a follow-up report with pertinent information is sent to regulators, then all available information should be submitted (even height, for example). As part of follow-up procedures, is it appropriate to request that a patient be rechallenged with a drug suspected of causing the reported event(s)fi In general, with or without a company’s or regulator’s involvement, should physicians conduct rechallenge experimentsfi It is commonly believed that one of the most powerful pieces of evidence to ascertain drug causality for an adverse event is the subsequent readministration of the medicine, a technique commonly referred to as 33 ‘‘rechallenge. A decision to readminister a drug that is suspected of causing an adverse reaction is dependent on many factors. Obviously, careful judgment by the treating physician will be needed on a decision to carry out a rechallenge procedure; referral to an ethics review committee (for clinical trials) and patient-informed consent are advised, particularly if the suspect reaction is serious or otherwise medically important.
Buy misoprostol overnight delivery. Eric Helms on his experience with post contest binge eating & weight gain.
It’s bounded laterally and posteriorly by the inferior constrictor and the most distal part of the middle constrictor gastritis from diet pills order misoprostol 100 mcg on-line. Upward of two-thirds of cancers in the United States are located in the pyriform sinus with another 20% arising from the posterior pharyngeal wall gastritis jugo de papa generic 100mcg misoprostol otc. Rarely collagenous gastritis definition order misoprostol us, cancers of the minor salivary gland gastritis sore throat misoprostol 100 mcg, neuroendocrine tumors, or lymphomas can also arise. Patients commonly present with dysphagia, sore throat, referred otalgia, dysphonia from vocal cord paralysis, and weight loss. On initial examination, patients should undergo fiberoptic examination of the pharynx and larynx to assess tumor location and extent in addition to evaluation of vocal cord mobility. Numerous partial open pharyngectomy procedures can be found in head and neck surgical textbooks along with descriptions of transoral techniques. As a result, most patients with early and advanced disease are treated nonsurgically with either radiation alone or concurrent chemoradiation with high-dose cisplatin. For the most advanced cancers (mostly T4) causing vocal cord paralysis, laryngeal cartilage destruction, and/or pretreatment evidence of aspiration, surgery consisting of total laryngectomy with partial or total pharyngectomy is the treatment of choice and is often followed by adjuvant radiation or chemoradiation. For 305 recurrent cancers after nonsurgical treatment, total laryngectomy is arguably the only option though partial laryngectomy procedures may be considered in highly select cases. Considered as a group, 5-year survival is less than 50% with most patients dying from a second primary tumor, from recurrent disease, or from distant metastases. These in turn explain differences in the clinical behavior of cancers that can occur in each subsite. The supraglottis is composed of the epiglottis, aryepiglottic folds, arytenoid cartilage, false vocal cords, and the upper half of the laryngeal ventricle. The supraglottis has rich lymphatic drainage, which in part explains the more aggressive behavior of cancers in this area, particularly those arising in the “marginal zone” (the suprahyoid epiglottis and aryepiglottic folds). The glottis includes the lower half of the ventricle, the vocal cords including the anterior and posterior commissure, and the area extending 1 cm below the apex of the ventricle. The vocal cords (or folds) are comprised of several layers: epithelium, a gelatinous superficial layer, and more dense intermediate and deep layers (called the vocal ligament). The conus elasticus extends from the superior edge of the cricoid cartilage to the inferior surface of the vocal cord to merge with the vocal ligament. This structure is a strong barrier to lateral extension of cancer from the glottis and subglottis and also accounts for the relative paucity of lymphatic drainage in the area. Lastly, the subglottis extends from the inferior margin of the glottis to the inferior border of the cricoid. Over 13,000 new cases are currently diagnosed annually in the United States, with approximately 60% starting in the glottis and 35% to 40% in the supraglottis. Men are much more likely to develop both glottic and supraglottic cancer than women though the ratios are gradually declining. Overall, the incidence of laryngeal cancer is falling by 2% to 3% per year, in large part due to fewer smokers, which is the predominant risk factor and is dose-dependent. Alcohol has a synergistic effect with tobacco, particularly for cancers of the supraglottis. Certain occupational exposures are also known to be risk factors including wood and cement dust, asbestos, and certain fuels or industrial solvents. The initial presentation of patients with laryngeal cancer depends in part on the anatomic location, though common symptoms include dysphagia or odynophagia, dysphonia, otalgia, weight loss, hemoptysis, and local pain. Patients with glottic cancer more often present with early-stage disease, 307 since lesions cause a change in voice, while patients with supraglottic cancer may be asymptomatic and present at a later stage. Evaluation of these patients should include laryngoscopy, ideally guided by a flexible or rigid laryngoscope, to precisely determine the location and size of the lesion in addition to the mobility of the vocal cords. Advanced lesions also require evaluation of swallowing function to determine the presence of clinical or subclinical aspiration prior to treatment. Patients require cross sectional imaging of the neck and larynx for locoregional staging as well as imaging of the chest to assess for metastasis or secondary malignancies. Lastly, patients may require examination under anesthesia to establish a diagnosis or to assist with accurate delineation of tumor anatomy. In cases where airway compromise is impending or represents a significant risk, tracheotomy may be placed. As would be anticipated, either surgery or radiation can be reasonable primary treatment of laryngeal cancer depending on multiple factors including the location and stage of the cancer, its etiology and the presence of comorbidities, and the patient’s pretreatment swallowing and respiratory status. Early cancers may be amenable to excision via transoral or open techniques or radiation alone. Endoscopic and partial open laryngectomies are technically challenging procedures that demand specific discussion outside the limits of this chapter. Lesions of the supraglottis may extend into the pre-epiglottic or paraglottic spaces and also have bilateral lymphatic drainage. For these reasons, surgical resection of early lesions must be carefully selected. Early glottic lesions are approached similarly with regard to surgical resectability, though regional lymphatics are not a concern with smaller glottic tumors. Narrow-field radiation fields are used in these tumors, which spares some of the chronic sequelae of radiation. Treatment of T1a lesions may have better voice results with radiation alone, though it may prohibit use of radiation for future malignancy in high-risk patients. It is debatable whether lesions involving the anterior commissure have a higher propensity for recurrence given spread through Broyles ligament, though these are more challenging to resect and functional outcomes may be inferior to radiation. Several large studies in the United States and Europe have demonstrated the feasibility of two nonsurgical approaches, namely induction chemotherapy followed by radiation, or concurrent chemoradiation. Specific results from these trials and the implications of their results can be found in the recommended readings. The goal of therapy for most patients with T1–T3 cancers is tumor eradication with preservation of laryngeal function. Total laryngectomy is often recommended for patients who have poor function, those with T4 cancers (usually from laryngeal cartilage destruction), and others who would not be able to tolerate nonsurgical treatment. Functional outcomes including speaking (or voice rehabilitation) and swallowing are a primary concern for laryngeal cancer survivors. Salivary Glands Tumors of the salivary glands can arise in any of the paired major salivary glands, the parotid, submandibular, or sublingual glands, or the minor salivary glands found throughout the mucosa of the upper aerodigestive tract. Cancer of the salivary glands is rare and is comprised of a heterogeneous group of malignancies with different biologic behavior. Upward of 70% of salivary gland tumors are found in the parotid gland, the majority of which are benign compared to the minor salivary glands, which are mostly malignant. Of note, the parotid gland is divided into two lobes, superficial and deep, by the course of the facial nerve. The superficial lobe contains lymph nodes that serve as the primary echelon of nodal drainage for anterolateral scalp, lateral face, and auricular cutaneous malignancies, meaning that a superficial parotidectomy should be included in surgical treatment of these malignancies when there is evidence of regional metastasis. Pain, facial nerve weakness (parotid), weakness or numbness of the tongue (submandibular or sublingual), or hypomobility of the mass are indicators of possible malignancy. Certain histologies may have a predilection for perineural spread such that numbness in the distribution of trigeminal nerve branches may be the only symptom. Risk factors include prior radiation exposure and smoking (for Warthin tumors) though most salivary gland neoplasms have no known environmental etiology. Among benign tumors, pleomorphic adenoma (also known as benign 310 monomorphic adenomas can also occur. In the case of a benign mixed tumor, there is approximately a 10% risk of malignant transformation over a 15-year period. Even though each of these malignant tumors have different defining characteristics with regard to propensity for locoregional recurrence or distant metastasis, surgery represents the mainstay of primary therapy in virtually all locoregional cases amenable to resection. Tumors of the superficial lobe of the parotid gland are addressed with superficial parotidectomy while total parotidectomy is reserved for lesions involving the deep lobe and/or those requiring facial nerve sacrifice. In general, all attempts are made to preserve the facial nerve in cases where it is functioning properly prior to surgery. For extensive tumors this may require identification of the facial nerve within the temporal bone through mastoidectomy. Similarly, submandibular gland tumors require excision of the entire gland at a minimum but extension of tumor into the surrounding tissues may require en bloc resection including surrounding soft tissue and potentially the hypoglossal, lingual, or marginal mandibular nerves if there is preoperative evidence of dysfunction or histologic involvement with tumor at the time of surgery. Surgery for tumors of the minor salivary gland tumors is also performed in en bloc fashion (with the possible exception of endoscopic endonasal resection). Tumor grade is often important for treatment planning including need for neck dissection and use of adjuvant radiation therapy.