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Adrenalectomy

Overview

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Adrenal glands

One adrenal gland sits above each of your kidneys. Your two adrenal glands produce various hormones that help regulate your metabolism, immune system, blood pressure, blood sugar and other essential functions.

Most adrenal tumors are noncancerous (benign). You may require surgery to remove an adrenal gland if the tumor is producing excess hormones or is large in size (more than 2 inches or 4 to 5 centimeters). You may also require surgery if the tumor is cancerous (malignant) or suspected to be cancerous. This surgery is called adrenalectomy (uh-dree-nul-EK-tuh-me).You may also need an adrenalectomy to remove cancer that has spread (metastasized) from another location, such as the kidney or lung.

If both adrenal glands are removed, you will need to take supplemental hormone medications. If only one gland is removed, the other will take over full function without the need for ongoing medications.

Types of adrenalectomy

Surgeons may perform an adrenalectomy through minimally invasive (laparoscopic) or traditional open surgery, or use cryoablation. The procedure they recommend depends on the size and type of tumor or the condition affecting your adrenal gland.

  • Minimally invasive surgery. Endocrine surgeons at Mayo Clinic are often able to use minimally invasive (laparoscopic) surgery for tumors of the adrenal gland because the gland is relatively small. Laparoscopic surgery has many benefits, including smaller scars, less pain and a shorter recovery period than traditional open surgery.

    An alternative approach to laparoscopic surgery is a posterior retroperitoneoscopic adrenalectomy (PRA), in which surgeons make small incisions in your back. Sometimes surgeons use the robotic da Vinci Surgical System to perform laparoscopic adrenalectomies.

  • Open surgery. Doctors usually reserve open surgery for large or cancerous (malignant) tumors. They perform open surgery using traditional instruments and incisions.
  • Cryoablation. In addition, Mayo Clinic doctors may use cryoablation to treat adrenal tumors. This procedure uses CT imaging to guide the insertion of a probe that freezes and destroys adrenal tumors. Interventional radiologists may use cryoablation as a treatment option for small tumors that have spread to the adrenal gland (metastasis), particularly when surgery carries a high risk.

Your doctor can explain your treatment options and discuss whether an adrenalectomy is the most appropriate treatment for you.

Autism Spectrum Disorder

Overview

Autism spectrum disorder is a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication. The disorder also includes limited and repetitive patterns of behaviour. The term “spectrum” in autism spectrum disorder refers to the wide range of symptoms and severity.

Autism spectrum disorder includes conditions that were previously considered separate — autism, Asperger’s syndrome, childhood disintegrative disorder and an unspecified form of pervasive developmental disorder. Some people still use the term “Asperger’s syndrome,” which is generally thought to be at the mild end of autism spectrum disorder.

Autism spectrum disorder begins in early childhood and eventually causes problems functioning in society — socially, in school and at work, for example. Often children show symptoms of autism within the first year. A small number of children appear to develop normally in the first year, and then go through a period of regression between 18 and 24 months of age when they develop autism symptoms.

While there is no cure for autism spectrum disorder, intensive, early treatment can make a big difference in the lives of many children.

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Symptoms

Some children show signs of autism spectrum disorder in early infancy, such as reduced eye contact, lack of response to their name or indifference to caregivers. Other children may develop normally for the first few months or years of life, but then suddenly become withdrawn or aggressive or lose language skills they’ve already acquired. Signs usually are seen by age 2 years.

Each child with autism spectrum disorder is likely to have a unique pattern of behaviour and level of severity — from low functioning to high functioning.

Some children with autism spectrum disorder have difficulty learning, and some have signs of lower than normal intelligence. Other children with the disorder have normal to high intelligence — they learn quickly, yet have trouble communicating and applying what they know in everyday life and adjusting to social situations.

Because of the unique mixture of symptoms in each child, severity can sometimes be difficult to determine. It’s generally based on the level of impairments and how they impact the ability to function.

MICRO Vascular Decompression

Overview

Microvascular decompression (MVD) is a surgery to relieve abnormal compression of a cranial nerve causing trigeminal neuralgia, glossopharyngeal neuralgia, or hemifacial spasm. MVD involves opening the skull (craniotomy) and inserting a sponge between the nerve and offending artery triggering the pain signals. Medications often provide initial relief, but when drugs become ineffective or cause side effects, MVD is an option.

What is microvascular decompression (MVD)?

MVD is a surgical procedure to relieve the symptoms (pain, muscle twitching) caused by compression of a nerve by an artery or vein. Surgery involves opening the skull (craniotomy) and exposing the nerve at the base of the brainstem to insert a tiny sponge between the compressing vessel and the nerve. This sponge isolates the nerve from the pulsating effect and pressure of the blood vessel.

Trigeminal neuralgia is an irritation of the fifth cranial nerve causing severe pain that usually affects one side of the face, normally in the forehead, cheek, jaw, or teeth (Fig. 1). To treat trigeminal neuralgia, a sponge is placed between the trigeminal nerve and the superior cerebellar artery or a branch of the petrosal vein. By removing the compression, the painful symptoms are relieved.

Figure 1. Trigeminal neuralgia can be caused by an artery or vein compressing the trigeminal nerve root as it originates at the brainstem

What happens during surgery?

Patients are admitted to the hospital the morning of the procedure. You will meet with a nurse who will ask your name, date of birth, what procedure you’re having, and the side of your facial pain. They will explain the pre-op process and discuss any questions you may have. An anesthesiologist will meet with you and explain the effects of anesthesia and its risks. They will place an intravenous (IV) line in your arm and then transport you to the operating room.

There are 5 steps of the procedure. The operation generally takes 2 to 3 hours.

Step 1: prepare the patient
In the OR room, general anesthesia is administered while you lie on the operating table. Once asleep, your body is rolled over on its side and your head is placed in a 3-pin skull fixation device, which attaches to the table and holds your head in position during the procedure. Next, the area behind your ear is prepped with antiseptic. A hair-sparing technique may be used, where only a 1/4-inch wide area along the proposed skin incision is shaved.

Step 2: perform a craniectomy
A 3-inch curved skin incision is made behind the ear. The skin and muscles are lifted off the bone and folded back. Next, a 1-inch opening is made in the occipital bone with a drill (Fig. 2). The bone is removed to expose the protective covering of the brain called the dura. The dura is opened with surgical scissors and folded back to expose the brain.

Figure 2. A skin incision is made behind the ear (dashed line) and a 1-inch craniectomy (solid line) is made in the skull.

Step 3: expose the nerve
Retractors placed on the brain gently open a corridor to the trigeminal nerve at its origin with the brainstem. The surgeon exposes the trigeminal nerve and identifies any offending vessel causing compression (Fig. 3). The vessel and nerve are often restricted by thickened connective tissue that must be dissected free with scissors and knife.

Figure 3. The superior cerebellar artery is adherent to the trigeminal nerve causing compression and painful trigeminal neuralgia attacks.

Step 4: insert a sponge
The surgeon cuts an appropriate size of teflon sponge and inserts it between the nerve and the vessel (Fig. 4). Sometimes a vein is adherent to the nerve and causing compression. In these cases, the vein is cauterized and moved away.

Figure 4. A sponge is inserted between the nerve and the blood vessel causing compression.

Step 5: closure
Once the sponge is in place, the retractor is removed and the brain returns to its natural position. The dura is closed with sutures and made watertight with tissue sealant. Since the bone opening is very small, it is not replaced. Instead, a titanium plate covers the skull opening and is secured with tiny screws (Fig. 5). The muscles and skin are sutured back together. A soft adhesive dressing is placed over the incision.

 

Figure 5. A circular titanium plate secured with screws covers the craniectomy made in the skull.

Mastectomy Surgery (Breast Cancer)

A mastectomy is surgery to remove all breast tissue from a breast as a way to treat or prevent breast cancer.

For those with early-stage breast cancer, a mastectomy may be one treatment option. Breast-conserving surgery (lumpectomy), in which only the tumor is removed from the breast, may be another option.

Deciding between a mastectomy and lumpectomy can be difficult. Both procedures are equally effective for preventing a recurrence of breast cancer. But a lumpectomy isn’t an option for everyone with breast cancer, and others prefer to undergo a mastectomy.

Newer mastectomy techniques can preserve breast skin and allow for a more natural breast appearance following the procedure. This is also known as skin-sparing mastectomy.

Surgery to restore shape to your breast — called breast reconstruction — may be done at the same time as your mastectomy or during a second operation at a later date.

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Why it’s done

A mastectomy is used to remove all breast tissue if you have breast cancer or are at very high risk of developing it. You may have a mastectomy to remove one breast (unilateral mastectomy) or both breasts (bilateral mastectomy).

Mastectomy for breast cancer treatment

A mastectomy may be a treatment option for many types of breast cancer, including:

  • Ductal carcinoma in situ (DCIS), or noninvasive breast cancer
  • Stages I and II (early-stage) breast cancer
  • Stage III (locally advanced) breast cancer — after chemotherapy
  • Inflammatory breast cancer — after chemotherapy
  • Paget’s disease of the breast
  • Locally recurrent breast cancer

Your doctor may recommend a mastectomy instead of a lumpectomy plus radiation if:

  • You have two or more tumors in separate areas of the breast.
  • You have widespread or malignant-appearing calcium deposits (microcalcifications) throughout the breast that have been determined to be cancer after a breast biopsy.
  • You’ve previously had radiation treatment to the breast region and the breast cancer has recurred in the breast.
  • You’re pregnant and radiation creates an unacceptable risk to your unborn child.
  • You’ve had a lumpectomy, but cancer is still present at the edges (margin) of the operated area and there is concern about cancer extending to elsewhere in the breast.
  • You carry a gene mutation that gives you a high risk of developing a second cancer in your breast.
  • You have a large tumor relative to the overall size of your breast. You may not have enough healthy tissue left after a lumpectomy to achieve an acceptable cosmetic result.
  • You have a connective tissue disease, such as scleroderma or lupus, and may not tolerate the side effects of radiation to the skin.

Mastectomy to prevent breast cancer

You might also consider a mastectomy if you don’t have breast cancer, but have a very high risk of developing the disease.

A preventive (prophylactic) or risk-reducing mastectomy involves removing both of your breasts and significantly reduces your risk of developing breast cancer in the future.

A prophylactic mastectomy is reserved for those with a very high risk of breast cancer, which is determined by a strong family history of breast cancer or the presence of certain genetic mutations that increase the risk of breast cancer.

PAROTID GLAND SWELLING

Your salivary glands make as much as a quart of saliva each day. Saliva is important to lubricate your mouth, help with swallowing, protect your teeth against bacteria, and aid in the digestion of food. The three major pairs of salivary glands are:

  • parotid glands on the insides of the cheeks
  • submandibular glands at the floor of the mouth
  • sublingual glands under the tongue

There are also several hundred minor salivary glands throughout the mouthand throat. Saliva drains into the mouth through small tubes called ducts.

When there is a problem with the salivary glands or ducts, you may have symptoms such as salivary gland swelling, dry mouth, pain, fever, and foul-tasting drainage into the mouth.

Causes of Salivary Gland Problems

Many different problems can interfere with the function of the salivary glands or block the ducts so they can’t drain saliva. The following are some of the more common salivary gland problems:

 

 

Mumps_MED_ILL_EN

Salivary stones, or sialoliths. The most common cause of swollen salivary glands, salivary stones are buildups of crystallized saliva deposits. Sometimes salivary stones can block the flow of saliva. When saliva can’t exit through the ducts, it backs up into the gland, causing pain and swelling. Pain is usually off and on, is felt in one gland, and gets progressively worse. Unless the blockage is cleared, the gland is likely to become infected.

Salivary gland infection, or sialadenitis. Bacterial infection of the salivary gland, most commonly the parotid gland, may result when the duct into the mouth is blocked. Sialadenitis creates a painful lump in the gland, and foul-tasting pus drains into the mouth.

Sialadenitis is more common in older adults with salivary stones, but it can also happen in babies during the first few weeks after birth. If not treated, salivary gland infections can cause severe pain, high fevers, and abscess (pus collection).

Infections. Viral infections such as mumps, flu, and others can cause swelling of the salivary glands. Swelling happens in parotid glands on both sides of the face, giving the appearance of “chipmunk cheeks.”

Salivary gland swelling is commonly associated with mumps, happening in about 30% to 40% of mumps infections. It usually begins approximately 48 hours after the start of other symptoms such as fever and headache.

Occipital Neuralgia

Occipital neuralgia is a condition in which the nerves that run from the top of the spinal cord up through the scalp, called the occipital nerves, are inflamed or injured. You might feel pain in the back of your head or the base of your skull.

 

 

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People can confuse it with a migraine or other types of headache, because the symptoms can be similar. But treatments for those conditions are very different, so it’s important to see your doctor to get the right diagnosis.

Symptoms

Occipital neuralgia can cause intense pain that feels like a sharp, jabbing, electric shock in the back of the head and neck. Other symptoms include:

  • Aching, burning, and throbbing pain that typically starts at the base of the head and goes to the scalp
  • Pain on one or both sides of the head
  • Pain behind the eye
  • Sensitivity to light
  • Tender scalp
  • Pain when you move your neck

Causes

Occipital neuralgia happens when there’s pressure or irritation to your occipital nerves, maybe because of an injury, tight muscles that entrap the nerves, or inflammation. Many times, doctors can’t find a cause for it.

Osteochondral ankle defects(OCD): Symptoms & Treatments

A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. It is also called an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). “Osteo” means bone and “chondral” refers to cartilage.

Talar dome lesions are usually caused by an injury, such as an ankle sprain. If the cartilage does not heal properly following the injury, it softens and begins to break off. Sometimes a broken piece of the damaged cartilage and bone will float in the ankle.

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Symptoms:

Unless the injury is extensive, it may take months, a year or even longer for symptoms to develop. The signs and symptoms of a talar dome lesion may include:

  • Chronic pain deep in the ankle—typically worse when bearing weight on the foot (especially during sports) and less when resting
  • An occasional clicking or catching feeling in the ankle when walking
  • A sensation of the ankle locking or giving out
  • Episodes of swelling of the ankle—occurring when bearing weight and subsiding when at rest

Treatments may include debridement (removing injured cartilage and bone), fixation of the injured fragment, microfracture or drilling of the lesion, and/or transfer or grafting of bone and cartilage. You and your orthopaedic foot and ankle surgeon can discuss these treatment options and decide which one is best.

VP SHUNT Surgery

Ventricular-operational shunting

Ventricular-operational shunting is surgery to treat excess cerebro spinal fluid (CSF) in the cavities (ventricles) of the brain (hydrocephalus).

Description

This procedure is done in the operating room under general anesthesia. It takes about 1 1/2 hours. A tube (catheter) is passed from the cavities of the head to the abdomen to get rid of the excess cerebrospinal fluid (CSF). A pressure valve and an anti-syphon device ensure that just the right amount of fluid is drained.

The procedure is done as follows:

  • An area of hair on the head is shaved. This may be behind the ear or on the top or back of the head.
  • The surgeon makes a skin incision behind the ear. Another small surgical cut is made in the belly.
  • A small hole is drilled in the skull. One end of the catheter is passed into a ventricle of the brain. This can be done with or without a computer as a guide. It can also be done with an endoscope that allows the surgeon to see inside the ventricle.
  • A second catheter is placed under the skin behind the ear. It is sent down the neck and chest, and usually into the belly area. Sometimes, it stops at the chest area. In the belly, the catheter is often placed using an endoscope. The doctor may also make a few more small cuts, for instance in the neck or near the collarbone, to help pass the catheter under the skin.
  • A valve is placed underneath the skin, usually behind the ear. The valve is connected to both catheters. When extra pressure builds up around the brain, the valve opens, and excess fluid drains through the catheter into the belly or chest area. This helps lower intracranial pressure. A reservoir on the valve allows for priming (pumping) of the valve and for collecting the CSF if needed.
  • The person is taken to a recovery area and then moved to a hospital room.

Down’s Syndrome in Children

People with Down syndrome tend to have certain physical features in common. For example, they often have flat noses and small ears.

Their mental abilities will vary, but most have mild to moderate issues with thinking, reasoning, and understanding. They’ll learn and pick up new skills their whole lives, but may take longer to reach important goals like walking, talking, and developing social skills.

Many people with Down syndrome don’t have any other health issues, but some do. Common conditions include heart problems and trouble hearing and seeing.

Causes

Normally, each cell in your body has 23 pairs of chromosomes. One chromosome in each pair comes from your mother. The other comes from your father.

But with Down syndrome, something goes wrong and you get an extra copy of chromosome 21. That means you have three copies instead of two, which leads to the signs and symptoms of Down syndrome. Doctors aren’t sure why this happens.

It varies, but people with Down syndrome often share certain physical traits.

For facial features, they may have:

  • Eyes shaped like almonds (may be shaped in a way that’s not typical for their ethnic group)
  • Flatter faces, especially the nose
  • Small ears, which may fold over a bit at the top
  • Tiny white spots in the coloured part of their eyes
  • A tongue that sticks out of the mouth

Proton treatment

Proton therapy, also called proton beam therapy, is a type of radiation therapy. It uses protons rather than x-rays to treat cancer.

A proton is a positively charged particle. At high energy, protons can destroy cancer cells. Doctors may use proton therapy alone. They may also combine it with x-ray radiation therapy, surgery, chemotherapy, and/or immunotherapy.

Like x-ray radiation, proton therapy is a type of external-beam radiation therapy. It painlessly delivers radiation through the skin from a machine outside the body.

How proton therapy works

A machine called a synchrotron or cyclotron speeds up protons. The high speed of the protons creates high energy. This energy makes the protons travel to the desired depth in the body. The protons then give the targeted radiation dose in the tumor.

With proton therapy, there is less radiation dose outside of the tumor. In regular radiation therapy, x-rays continue to give radiation doses as they leave the person’s body. This means that radiation damages nearby healthy tissues, possibly causing side effects.

What to expect

People usually receive proton therapy in an outpatient setting. This means they do not need to have treatment in the hospital. The number of treatment sessions depends on the type and stage of the cancer.

Sometimes, doctors deliver proton therapy in 1 to 5 proton beam treatments. They generally use larger daily radiation doses for a fewer number of treatments. This is typically called stereotactic body radiotherapy. If a person receives a single, large dose of radiation, it is often called radiosurgery.

Treatment planning

Proton therapy requires planning. Before treatment, you will have a specialised computed tomography (CT) or magnetic resonance imaging (MRI) scan. During this scan, you will be in the exact same position as during treatment.

Movement should be limited while having the scan. So you may be fitted with a device that helps you stay still. The type of device depends on where the tumor is in the body. For example, a person may need to wear a custom-made mask for a tumor in the eye, brain, or head. He or she would also need to wear this device later for the radiation planning scan.

During a radiation planning scan, you will lie on a table and the doctor will figure out the exact places where the radiation therapy will be given on your body or the device. This helps make sure your position is accurate during each proton treatment.

The devices are designed to fit snugly so there is no motion during the radiation treatment. But the health care team wants each person to be as comfortable as possible during treatment. It is important for you to talk with the team to find a comfortable position for treatment.

Some people, particularly with tumours around the head and neck region, feel anxious when they need to lie still in one position with the device. It is important to talk with your medical team if this causes you anxiety. Your doctor can give medication to help you relax for the scans.

The health care team will use the radiation treatment scan to mark where the tumours are on the body. They will also mark where the normal tissues are so they can avoid that area. This process is similar to the radiation planning process with x-rays.

Receiving treatment

People receive proton therapy in a special treatment room. For each treatment, a member of the health care team will place the person into the device on the treatment table in the room. For some areas around the head and neck such as the eye, the person is positioned in a special chair, instead of on a table.

The treatment team will make sure the person is in the correct position before starting treatment. This involves using a laser to center on the marks that were placed on the body or the device during the treatment planning scan. The team takes x-rays or CT scan pictures before every treatment. This helps them position the person in the exact same position for every treatment. This is so that the protons hit the tumour and not the tissues near the tumour.

Some proton treatment rooms have a machine called a gantry. It rotates around the person. This way, the treatment is delivered to the tumor from the best angles. During treatment, the gantry will also rotate around the person so that the machine’s nozzle is in its proper position. The nozzle is where the protons come out of the machine.,

Once the person is positioned, the team will leave the treatment room and go to the delivery controls outside the room. They will use these controls to deliver the proton treatment. The team will be able to see and hear you through a video placed inside the treatment room.

 

 

The protons travel through the machine and then magnets direct them to the tumour. Sometimes the gantry will also be used. During the treatment, the person must stay still to avoid moving the tumour out of the focused proton beam.

Time needed for each treatment

In general, a proton radiation treatment lasts about 15 to 30 minutes, starting from the time you enter the treatment room. The time will depend on the part of the body being treated and the number of treatments. It will also depend on how easily the team can see the tumour site with x-rays or CT scans during the positioning process.

Ask your health care team how long each treatment will take. Sometimes, the doctor will need to give treatment from different gantry angles. Ask your team if this will happen for your treatment. Find out if they will come back into the room during treatment to move the gantry or if the gantry will be rotated around you.

It is also important to know that total time in the treatment room may vary from day to day. This is because the doctor may target different areas that require other radiation “fields.” This may require using various kinds of proton beam segments. For example, one treatment may deliver a part of the total radiation dose to lymph nodes and healthy tissues around the tumour that may contain tiny amounts of tumour. Another treatment may deliver a radiation dose to the main tumour.

Other factors can also affect the total time needed, such as waiting for the proton beam to be moved after another person’s treatment is finished. Most proton treatment centres have only one proton machine.

In centers that have more than one treatment room, the protons are magnetically steered from one room to the next. On some days, 2 rooms may be ready at nearly the same time to deliver the proton treatment to the person in each room. This means that one person may have to wait a couple of minutes until the other person’s treatment has been delivered.

Side effects

The treatment itself is painless. Afterwards, you may experience fatigue. You may also have skin problems, including redness, irritation, swelling, dryness, or blistering and peeling.

You may have other side effects, especially if you are also receiving chemotherapy. The side effects of proton therapy depend on the part of the body being treated, the size of the tumour, and the types of healthy tissue near the tumour. Ask your health care team which side effects are most likely to affect you.

Cancers treated with proton therapy

Proton therapy is useful for treating tumours that have not spread and are near important parts of the body. For instance, cancers near the brain and spinal cord. It is also used for treating children because it lessens the chance of harming healthy, growing tissue. Children may receive proton therapy for cancers of the brain and spinal cord. It is also used for cancer of the eye, such as retinoblastoma and orbital rhabdomyosarcoma.

Proton therapy also may be used to treat these cancers:

  • Central nervous system cancers, including chordoma, chondrosarcoma, and malignant meningioma
  • Eye cancer, including uveal melanoma or choroidal melanoma
  • Head and neck cancers, including nasal cavity and paranasal sinus cancer and some nasopharyngeal cancers
  • Lung cancer
  • Liver cancer
  • Prostate cancer
  • Spinal and pelvic sarcomas, which are cancers that occur in the soft-tissue and bone
  • Noncancerous brain tumours

Risks and benefits

Compared with x-ray radiation therapy, proton therapy has several benefits:

  • Usually, up to 60% less radiation can be delivered to the healthy tissues around the tumour. This lowers the risk of radiation damage to these tissues.
  • It may allow for a higher radiation dose to the tumour. This increases the chances that all of the tumour cells targeted by the proton therapy will be destroyed.
  • It may cause fewer and less severe side effects such as low blood counts, fatigue, and nausea during and after treatment.

But there are also some drawbacks to proton therapy:

  • Because proton therapy requires highly specialised and costly equipment, it is available at just a few medical centres in the United States. Find a list of centres that currently offer proton therapy.
  • It may cost more than x-ray radiation therapy. Insurance provider rules differ about which cancers are covered and how much a person needs to pay. Talk with your insurance provider to learn more.
  • Not all cancers can be treated with proton therapy.
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