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Appropriate or tumors originating rom clivus blood pressure medication migraines buy 4 mg aceon mastercard, upper posterior neck or extending posteroin eriorly rom the temporal bone arrhythmia prevalence order aceon amex. Incision is a question mark beginning high in the occiput and coursing around the postauricular area descending to the upper neck. The bone o the spinous processes o the cervical spine is care ully drilled with care not to injure the vertebral artery. I vertebral artery sacri ce is anticipated, a preoperative balloon occlusion test should be per ormed to establish the sa ety o sacri cing the artery. I not sacri ced the artery is mobilized to the oramen magnum and the atlantooccipital joint is exposed. The lateral mass o the atlas is drilled away with care not to injure the occipital emissary vein and the hypoglossal canal. Can extend resection up to the temporal bone with a mastoidectomy to expose the jugular bulb. Neurosurgeon can per orm an occipital-spinal usion i concern or spinal instability. The occipital bone gra is replaced and the muscles are reapproximated be ore closure. Presence o tachycardia, arrhythmias, ushing or liable hypertension should prompt analysis o 24 hour urine specimen or vanillylmendelic acid, metanephrine and normetanephrine levels. It involves an extensive in ratemporal ossa dissection with mobilization or resection o the petrous carotid artery and middle and posterior ossa craniotomy. Cha pter 43: Skull Base Surgery 761 umors of the Internal Auditory Canal and the Cerebellopontine Angle · 90% o tumors at the cerebellopontine angle are acoustic schwanommas. The sigmoid sinus is skeletonized and only a very thin wa er o bone is le covering the sinus (Bill island). Dura is exposed anterior and 2 cm posterior to the sinus allowing compression o the sinus or improved exposure. All bone covering the dura rom the sigmoid sinus to the porus acousticus is removed as well as the bone covering the middle ossa dura. The epitympanum is lled with temporalis ascia and open air cell tracts are occluded with bone wax. A 4-cm-by-4 cm craniotomy is per ormed immediately posterior to the sigmoid sinus. The cerebellum is covered with a cottonoid and retracted posteriorly with a at blade retractor. At this point, tumor can be excised, vestibular nerve sectioned, or the trigeminal, acial, or vestibular nerve can be decompressed. The operculum is an important landmark, which identi ed the entry point o the endolymphatic duct. The craniotomy de ect is lled with bone chips or a cranioplasty is per ormed, with hydroxylapatite cement and the wound closed. Retrolabyrinthine Approach Originally described by Hitselberger and Pulec in 1972 or section o the h nerve, use o this approach has been expanded. Presently its use is limited to vestibular nerve sections and management o hemi acial spasm by microvascular decompression. There are minimal advantages to this approach and a signi cant disadvantage o limited visualization. The dura is skeletonized along posterior ossa and superiorly along the middle ossa dura. The sigmoid sinus is decorticated and retrosigmoid air cells are removed to expose the retrosigmoid dura. A dural ap is made parallel to the sigmoid sinus (behind the endolymphatic sac) up to the level o the superior petrosal sinus. The cerebellum is retracted and the arachnoid incised, exposing the seventh to eighth nerve complex. The wound is closed with silk sutures on the dura; abdominal at may be used to obliterate the surgical de ect prior to layered closure. Approaches to the Petrous Apex Evaluation o the patient with pathology at the petrous apex must include consideration o lesions involving the clivus, pituitary, nasopharynx, sphenoid, temporal bone, and meninges. Lesions of the Petrous Apex · Cholesteatoma (a) Arise rom the oramen lacerum rom the epithelial elements congenitally included in Sessel pocket o the cephalic exure o the embryo. In racochlear Supralabyrinthine Retrolabyrinthine Middle cranial ossa rans-sphenoid Partial labyrinthectomy ranscochlear In ratemporal ossa The ranscochlear Approach this approach provides access to the skull base medial to the porus acusticus and anterior to the petrous apex and brain stem. The acial nerve is skeletonized rom the stylomastoid oramen to the geniculate ganglion. Bone covering the posterior ossa dura, sigmoid sinus, and middle ossa dura is removed. The chordae tympani and greater super cial petrosal nerves are divided and the acial nerve is mobilized posteriorly. The dissection is bounded by the carotid artery anteriorly, the superior petrosal sinus above, the jugular bulb below, and the sigmoid sinus posteriorly; the medial extent is the petrous apex just below Meckel cave. Following tumor removal, the wound may be lled with harvested at and closed in layers. Surgery for Vertigo Only in persistent incapacitating vertigo which has ailed medical management surgical intervention considered. Medical management includes low-salt diet (< 2000 mg/d), diuretics, stress reduction, vestibular rehabilitation therapy. Other possible medical therapies include corticosteroids, (both systemic and intratympanic) and Meniett therapy (micropressure therapy). Di erential diagnosis includes autoimmune inner ear disease, tertiary syphilis, vestibular schwannoma, perilymphatic stula, basilar migraine.

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The myelin sheath consists of multiple double membranes wrapped radially around axons arteria apendicular 8 mg aceon sale. Importantly blood pressure 4080 4 mg aceon buy visa, because white matter abnormalities form a constant part of many if not most inborn metabolic diseases, it is imperative that the radiologist have a firm grasp on normal patterns of myelination. Brain myelination is an event involving more than oligodendrocytes; it is an interaction between oligodendrocytes, axons, astrocytes, and many soluble factors. Normal myelination follows a typical topographical pattern, progressing from inferior to superior, central to peripheral, and posterior to anterior. The lateral cerebral (sylvian) fissures may be slightly prominent but generally resemble those seen in older children. The frontal subarachnoid spaces and basal cisterns often appear prominent up to 1 year of age. The anterior limbs are beginning to myelinate and are not well seen between the hypointensity of the caudate and putamen. Note the normal prominence of the frontal and interhemispheric subarachnoid spaces. Certain diffusion patterns are strongly suggestive of specific inborn errors of metabolism [e. The dentate nuclei of the cerebellum consist of gray matter and thus also appear hypointense. Normal T2 hypointensity is seen at birth within the brainstem cranial nerve nuclei and within the inferior and superior cerebellar peduncles. At birth, the rolandic and perirolandic gyri of the cortex appear quite hypointense. The last normal regions of T2 hypointensity are the orbital region of the frontal lobes and the most anterior temporal lobes. This normal progression of T2 hypointensity may not be complete until 28-30 months. Potential diagnostic pitfall: normal tiny foci of T2 hypointensity may be seen immediately anterior to the frontal horn tips in preterm and term newborns. These represent small aggregates of germinal matrix and typically vanish by 44 postconceptual weeks. Imaging of Normal Myelination Selected major milestones of normal myelination on T1- and T2-weighted images are summarized earlier in the chapter (Table 31-1) and discussed in greater detail here. Although a nonspecific finding, disordered myelination is common among many inborn metabolic errors or inborn errors of metabolism. Compared with the timing of neuronal migration and sulcation, normal myelination lags in the fetus. However, during the early third trimester, the dorsal brainstem myelination is advancing. In the newborn posterior fossa, look for T1 hyperintensity within the brachium of the inferior colliculus and within the inferior and superior cerebellar peduncles. At birth and throughout the first month of life, there is progressive hyperintensity within the central cerebellar hemispheres. The corona radiata is almost completely hyperintense except for its most anterior and peripheral fibers. Inherited Metabolic Disorders Continued normal progression of T1 hyperintensity within the subcortical white matter is seen through the seventh month of life in the occipital white matter and through 8-11 months in the frontal and temporal white matter. The caveat or pitfall is the persistence of T2 hyperintensity that is seen in the normal terminal zones (see below). In some cases, brain, skin, or muscle biopsy may be necessary to establish a definitive diagnosis. In this chapter, we consider the major and some of the less common but important inherited neurometabolic diseases, summarizing the pathoetiology, genetics, demographics, clinical presentation, and key imaging findings of each. The term terminal zones was coined due to the fact that some axons in these association regions may not stain for myelin until the fourth decade of life. These are We begin by considering several approaches to classifying these unusual but fascinating disorders. Hyperintensity extends into the subcortical Ufibers in the occipital and parietal lobes to the undersurface of the cortex. Patchy hyperintense foci posterosuperior to the lateral ventricles are age appropriate. Persistent hyperintensity in the peritrigonal zones typically myelinates by 5 years. Although intellectually sound, these methods lack the kind of pragmatic approach needed by the radiologist to be a contributing member of the clinical care team. To this end, we will emphasize-and advocate the use of-an approach to imaging analysis pioneered by A. Some mitochondrial disorders predominantly or exclusively affect striated muscle and therefore are not discussed in this text. Lysosomal Diseases Lysosomal disorders are characterized by abnormal lysosomes and disordered carbohydrate metabolism. Some are far more frequent in certain locations because of the high prevalence of founder mutations. They result from deficiencies of enzymes involved in the degradation of mucopolysaccharides (glycosaminoglycans). Incompletely degraded mucopolysaccharides accumulate in the lysosomes, which often become enlarged and vacuolated.

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Blood blister-like aneurysms are thin-walled hemispheric bulges that-as the name suggests-resemble cutaneous blood blisters in appearance normal blood pressure chart uk 8 mg aceon buy with mastercard. Fusiform aneurysms are focal dilatations that involve the entire circumference of a vessel blood pressure basics generic aceon 8 mg buy online, extend for relatively limited distances, and do not arise at branch points. Fusiform aneurysms are most often secondary to atherosclerosis but can also occur with nonatherosclerotic vasculopathies. Ectasias refer to generalized arterial enlargement without focal ("aneurysmal") dilatation. Although ectasias can affect any intracranial vessel, the most common site is the posterior circulation. Ectasias are not true aneurysms, so they are discussed in Chapter 10 on vasculopathy. Occasionally an aneurysm ruptures directly into the brain parenchyma rather than the subarachnoid space. Varying degrees of arterial narrowing caused by vasospasm may be present (see below). These "sentinel headaches" are sudden, intense, persistent, and may represent minor bleeding prior to aneurysm rupture. Grade 2 represents moderate to severe headache with nuchal rigidity and/or cranial nerve palsy. Grade 4 equates to stupor, moderate to severe hemiparesis, and an Clinical Issues Epidemiology. Nonspecific headache is a common presenting complaint in emergency departments, accounting for approximately 2% of all visits. Despite advances in diagnosis and treatment, in-hospital mortality continues to exceed 25%. Without treatment, ruptured saccular aneurysms have a rebleed rate of 20% within the first 2 weeks following the initial hemorrhage. The basal cisterns-especially the suprasellar cistern-are generally filled with blood (6-4). Vertebrobasilar aneurysms often fill the fourth ventricle, prepontine cistern, and foramen magnum with blood. Focal parenchymal hemorrhage is uncommon but, if present, is generally predictive of aneurysm rupture site. Stepwise increases in modified Fisher grade Nontraumatic Hemorrhage and Vascular Lesions 128 have a moderately linear relationship with the risk of vasospasm, delayed infarction, and poor clinical outcome. It occurs with hemorrhage, meningitis, carcinomatosis, hyperoxygenation, stroke, and gadolinium contrast (blood-brain barrier leakage or chronic renal failure). Blood is most prominent along the left sylvian, inferior interhemispheric fissures. Temporal horns of the lateral ventricles are enlarged by early obstructive hydrocephalus. Immediate Cerebral Ischemia Recent studies have stressed the importance of the initial ischemia that occurs immediately after aneurysmal rupture. Putative mechanisms involved in early brain injury include micro-thrombo-emboli, activation of inflammatory responses. Multiple segments of vascular constriction and irregularly narrowed vessels are typical findings (6-8C). Traditional treatment strategies have included "triple H" therapy (hypervolemia, hypertension, and hemodilution). Imaging studies show increased periventricular extracellular fluid with "blurred" lateral ventricle margins. Yet most investigators implicate venous-not aneurysmal-rupture as the most likely cause. The typical presentation is mild to moderate headache with Hunt and Hess grade 1-2. It is usually more peripheral, lying primarily within the sylvian fissure and over the cerebral convexities. During closed head injury, the midbrain may be suddenly and forcibly impacted against the tentorial incisura. Also note subtle "track-like" hypointensities coating the pial surfaces of several other parallel sulci (cortical superficial siderosis). The brainstem and cerebellum are covered with brown-staining hemosiderin deposits. They may also show evidence of siderosis and prior lobar hemorrhages of differing ages. Accelerated cerebellar ferritin synthesis and chronic intrathecal bleeding overload the ability of the microglia to biosynthesize ferritin, resulting in subpial iron excess. This facilitates free radical damage, lipid peroxidation, and neuronal degeneration. Other terms for this condition include subarachnoid hemosiderosis and sulcal siderosis. There are two types of siderosis, which differ in underlying pathologies and clinical presentation. Brownish yellow and blackish gray encrustations cover the affected structures, layering along the sulci and encasing cranial nerves (6-17). Hemosiderin deposition is also present in the choroid plexus of the fourth ventricle. Other than minimal right temporal siderosis, the supratentorial brain and subarachnoid spaces appeared normal. Occasionally, iron deposition is severe enough to cause hyperattenuation along brain surfaces.

Syndromes

• Dry cotton-like mouth
• Acute infection
• Rapid heart rate
• Persons with poorly controlled epilepsy should not drive. Each state has a different law about which people with a history of seizures are allowed to drive.
• Checking the smallerst letters that can be read (visual acuity)
• Appearance is a major concern.
• Your symptoms get worse or do not improve with treatment
• Anti-inflammatory medications such as montelukast (Singulair) and roflimulast are sometimes used
• Hallucinations
• Related species

Redundancy excised with blade beveled caudally to excise 1 to 2 mm more muscle than skin to avoid bulging ridge o muscle at incision line blood pressure watches buy aceon 2 mg with mastercard. Canthoplasty or lid shortening procedure should be per ormed i there is any indication o lax lower lid in order to avoid postoperative lid retraction arrhythmia recognition poster purchase discount aceon on-line. The incision can be placed 2 mm below the tarsal plate to create a pre-septal plane, or 4 mm below the tarsal plate to create a postseptal plane whereby the at compartment is directly entered. Excess eyelid skin can be resected through a "skin pinch" where excess skin is gathered and excised below the lash line externally. Complications · Dry eyes · Lid rounding/retraction · Ectropion · Epiphora · Hematoma · Poor scarring · Milia · In erior oblique injury The Lower Face Analysis o the aging ace by zones allows proper management o each segment. The lower third o the ace plays host to a series o age-related abnormalities which can be categorized and addressed as needed. Rhytidectomy alone will not correct many issues o the cervicomental angle and adjunctive procedures such as submental liposuction, direct excision o submental at, platysmaplasty, and or genioplasty may be necessary. Plane o Dissection-Subcutaneous Surgical technique-The standard procedure involves elevation o anterior (temporal and preauricular) and posterior (postauricular and cervical) skin aps. The incision courses rom the temporal region (either within or just along the temporal tu o hair), along the margin o the root o the helix, posterior to the tragus, around the lobule, and onto the postauricular sur ace o ear. The skin is elevated just deep to the hair ollicles in the hair-bearing portion o the ap, and just deep to the subdermal plexus in the remaining portion. The aps are then redraped and tailored prior to closure while avoiding any tension on the skin. The skin aps are then redraped and tailored without skin tension prior to closure. Because these nerves are innervated on their deep sur aces, the risk o acial nerve injury is limited. In the neck, a preplatysmal plane is elevated centrally, and sub-platsymal plane elevated laterally. Advantage: allows repositioning o the cheek at pad, and thus has a more dramatic e ect on the nasolabial old. Submentoplasty: midline platysma plication or imbrication +/- in erior cutback, +/- subplatysmal direct at removal Complications A. Hematoma: Occurs in 3% to 15% o cases, mani ests with unilateral pain or swelling. When untreated, necrosis o overlying skin aps may occur causing permanent scarring and/or cutaneous irregularity. Skin necrosis: Occurs in setting o excessive tension on skin, or poor local or systemic vascularity. Hair loss: Alopecia may occur in hair-bearing areas i hair ollicles are traumatized during ap elevation. Incisions should be made parallel to hair ollicles and cautery should be avoided in hair-bearing regions. Sensory-the most common nerve injury is to the great auricular nerve (7% incidence) which may be encountered during ap elevation over the sternocleidomastoid. Other complications: In ection, prolonged edema/ecchymosis, hypertrophic or widened scarring, "wind-swept" or over-done look. Rhinoplasty Incisions · Marginal: ollow the caudal edge o lower lateral cartilage · Intercartilaginous: incision between lower and upper lateral cartilage · rans/intracartilaginous: incision through lower lateral cartilage · ranscolumellar: used or open approach rhinoplasty, inverted V or stairstep · rans xion and hemitrans xion: between caudal portion o septum and medial crura through-and-through, or on one side only Rhinoplasty Approaches Closed (Endonasal) · Nondelivery: intercartilaginous incisions are made between upper and lower lateral cartilages (a) Advantage: no major tip support disrupted, no external scar, preserved intact caudal rim (b) Disadvantage: minimal exposure o lower lateral cartilage, limited tip modi cation possible, potential vestibular valve scar · Delivery: combined intercartilaginous and marginal incisions, to allow delivery o lower lateral cartilage as a bilateral pedicled chondrocutaneous ap (a) Advantages: improved visualization o entire lower lateral cartilage, good access to nasal tip and dome, no external incision (b) Disadvantages: compromise one major tip support mechanism (attachment o lower lateral cartilage to upper lateral cartilage), limited tip modi cation possible, higher revision rates than open Open (External) · ranscolumellar and bilateral marginal incisions · Indications: signi cant tip work, revision rhinoplasty, cle nose, non-Caucasian nose, crooked nose, teaching yoursel and others (a) Advantages: complete exposure o nasal tip structures, cartilaginous and bony nasal dorsum, good or teaching purposes, allow or precise gra and suture placement, lower revision rates than closed (b) Disadvantages: external scar, potentially more postoperative edema Which approach to use I you can diagnose the de ormities and correct them as well with a closed approach, do it closed. Common Indications or Rhinoplasty Nasal Dorsal Hump · Can be bony or cartilaginous (more common) · For bony hump reduction, can use Rubin osteotome and/or nasal rasp with serially smaller teeth to create a smooth sur ace Correction o Crooked Nose · Management depends on etiology, may include one or a combination o below techniques · Goal is to create a smooth brow-nose aesthetic line Cha pter 48: Fa cial Plastic Surgery 927 (a) Upper third: osteotomies (b) Middle third: spreader gra s, septoplasty, onlay gra s (c) Lower third: septoplasty, camou age gra, nasal tip work Osteotomies · Indications: close an open roo de ect, straighten a crooked nose, narrow a broad upper third · Medial osteotomy: completed in absence o an open roo, between upper lateral cartilage and nasal septum and continue through the nasal bones to ree it rom perpendicular plate o ethmoid · Lateral osteotomy: low to high cut along nasomaxillary groove, initiating above the level o in erior turbinate to prevent nasal obstruction · Intermediate osteotomies: indicated or excessively wide or convex nasal bone, or asymmetry o nasal side wall ip Modi cation · The key to modi ying the nasal tip is to achieve appropriate nasal tip shape and position, without losing signi cant tip support. The healing process stimulates production o new collagen and a resur aced epidermis rom deeper, less sun-damaged cells, to result in cosmetic improvement in actinically damaged, aged or scarred skin. These methods include dermabrasion which causes mechanical injury, chemical peel (chemex oliation) and laser, which causes thermal injury. Skin Anatomy · Epidermis (a) Stratum corneum (b) Stratum granulosum (c) Stratum lucidum Cha pter 48: Fa cial Plastic Surgery 931 (d) Stratum spinosum (e) Stratum basale · Dermis (a) Papillary dermis: thin, loose collagen surrounding adnexal structures; abundant elastic bers (b) Reticular dermis: thick, compact collagen. The Fitzpatrick skin s type system is one o the most commonly used classi cation systems. This induces new collagen and resur aced epidermis rom deeper, less damaged cells to yield cosmetic improvement. This is limited to the papillary dermis (pinpoint bleeding) or super cial reticular dermis to avoid scarring. Adjuncts include preoperative topical tretinoin treatment or 2 weeks, and reezing o skin prior to abrading to allow or rigid sur ace. Indications · Postacne scarring · Scar revision · Actinic keratosis · Seborrheic keratosis · Photodamaged skin · Pigment irregularities Common Chemical Peel Agents · Classi ed by depth o penetration · Very superf cial: ex oliate stratum corneum down to stratum granulosum · Superf cial: necrosis o stratus granulosum and basal cell layer · Medium: necrosis o epidermis and wounding o papillary dermis · Deep: necrosis and wounding rom epidermis through papillary dermis and into reticular dermis Depth o Penetrating Factors · Chemical agent, skin thickness, use o retinoic acid or lactic acid, use o prepeel agent (enhance peels), occlusion versus nonocclusion Contraindications · Active herpetic lesions · History o keloids · Collagen vascular disease · Pustular acne · Prior radiation Common Peels Super cial Chemical Peeling · Ex oliation o stratum corneum to basal cell layer to encourage regrowth with less photodamage and a more youth ul appearance. Laser utilizes the concept o selective thermolysis which is determined by absorbance o skin constituents (chromophore, oxyhemoglobin, and melanin), the power and spot size. Ablative lasers target and remove the epidermis and portions o the super cial dermis. This induces collagen remodeling and new collagen production in the months a er the procedure. The advantage o ablative skin resur acing relate to the ability to produce results in a precise and controlled ashion at the appropriate depth. Best outcome in terms o removing severe sun damage and correction o elastosis and deeper wrinkling o skin v. Postoperative downtime: 10 to 14 days is required or reepithelialization, ollowed by erythema that may last 1 to 3 months b.

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An in ant presents to your o ice with 3 weeks o increasing stridor but no cyanosis or apneic episodes blood pressure chart medication 8 mg aceon buy amex. This allows or a better understanding o prognosis and accurate patient counseling arteria carotis communis order aceon from india. Finally, it is use ul or strati ying cancers or clinical research and or measuring outcomes to various treatment options. There are seven categories: X (primary tumor cannot be assessed), 0 (no evidence o primary tumor) is (tumor in situ), 1, 2, 3, and 4. Depth o invasion is not included in the staging system as it relates to primary tumor size. Modi ers "a" (less severe) and "b" (more severe) can be used within some categories to urther describe the tumor. This is basically described by size o the lymph nodes and is modi ed by location o the involved nodes. Evaluation o surgically excised lymph nodes by a pathologist can urther a ect N stage. The "p" pre x re ers to staging based on pathological examination a er surgical resection. Lips, oral cavity, pharynx, and larynx (ables 36-1 to 36-7) Nasal cavity and paranasal sinuses (ables 36-8 and 36-9) Major salivary glands (able 36-10) T yroid gland (able 36-11) Nodal staging (able 36-12) and stage groupings (ables 36-13 and 36-14) are shown in subsequent tables. Table 36-1 Lips and Oral Cavitya 1 2 3 < 2 cm > 2 cm and < 4 cm > 4 cm 4a Moderately advanced local disease (lip). Invades through bone, in erior alveolar nerve, f oor o mouth or skin (oral cavity). Invades adjacent structures only, such as bone, extrinsic tongue muscles, and skin 4b Very advanced local disease. Invades larynx, extrinsic tongue muscles, medial pterygoid, hard palate, or mandible Very advanced local disease. Invades cartilage, hyoid bone, thyroid gland, or central compartment so tissue, including strap muscles Very advanced local disease. Invades anterior orbit, skin, pterygoid plates, rontal or sphenoid sinus, and extends minimally into anterior cranial ossa Very advanced local disease. Invades anterior orbit, skin, pterygoid plates, rontal or sphenoid sinus, and cribri orm plate Very advanced local disease. Invades skull base, pterygoid plates, or encases carotid artery Includes: parotid, submandibular, and sublingual Table 36-11 T yroid 1 1a 1b 2 3 4a 4b < 2 cm < 1 cm > 1 cm but < 2 cm > 2 cm or < 4 cm > 4 cm or minimal extrathyroid extension (eg, sternothyroid muscle) Moderately advanced local disease. Extends beyond thyroid capsule to invades subcutaneous so tissue, larynx, trachea, esophagus, or recurrent laryngeal nerve Very advanced local disease. Invades prevertebral ascia, encases carotid or mediastinal vessels Note: Nodal status is either N0 or no regional lymph node metastasis or N1a or pretracheal/paratracheal lymph nodes and N1b or other cervical or mediastinal lymph node. A 65-year-old patient with hoarseness is noted to have a 1-cm lesion on the le t vocal cord, extending toward the anterior commissure. Laryngoscopy shows a tumor o the right alse vocal cord extending to true vocal cord and medial wall o pyri orm sinus on the same side. C neck reveals a right larynx mass with extension into the paraglottic space and a 1. On ultrasound, it measures 16 mm × 14 mm and no enlarged lymph nodes are identi ied. A 75-year-old smoker is seen or an ulcerative mass o the right oral tongue and loor o mouth. Highest incidence in areas with high sun-exposure and populations with air skin (eg, Australia). Risk Factors · Sun-exposure (a) Frequent, intermittent exposure to intense sunlight appears to be the highest risk actor. Imatinib or other kit inhibitors may have activity in melanomas with activating c-kit mutations (more common in acral lentiginous and mucosal melanomas). Melanoma Subtypes · Lentigo maligna melanoma (a) Least common, 5% to 10% o all cases. Cha pter 37: Maligna nt Mela noma of the Head and Neck 677 (c) Histology: spindle-shaped tumor cells among a brous stroma, may show neuronlike di erentiation. Di erential Diagnosis Benign lesions · Sebhorreic keratosis (a) Light brown lesions, "stuck-on" appearance · Pigmented actinic keratosis · Benign melanocytic lesions (a) Mongolian spot: congenital patch o melanocytes, completely benign (b) Blue nevus A rest o melanocytes; rare lesion, but more common in Asian patients. Melanoma has been called a "great mimicker," and belongs in the di erential diagnosis o any undi erentiated tumor. Evaluation History and Physical Examination · T orough history to determine risk o melanoma (see risk actors). Include parotid lymph nodes, especially or anterior scalp, temple, or cheek melanomas occipital nodes, especially or retroauricular or posterior scalp lesions. There ore, obtain in any patient with thick lesions, evidence o local invasion, or evidence on clinical examination or regional metastasis. It is also a use ul marker to ollow or the development o metastatic disease during ollow-up. Biopsy · All lesions suspicious or malignant melanoma should undergo biopsy by a method that will give a de nitive diagnosis and provide in ormation on depth o invasion. Staging · The most important prognostic actors in malignant melanoma are depth o invasion, ulceration, mitotic index, satellitosis, degree o lymph node involvement, and distant metastasis.

References

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