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admin | Bv Homeopathic Treatment | 29.02.2016
Auricular perichondritis is an acute inflammation of the auricular cartilage and its perichondrium It may be due to:1-Infection in auriclar hematoma. Diffuse bacterial otits externa is a diffuse inflammation of the skin of the external auditory canal (EAC). Herpes simplex virus infection of the presents with fever as in viral influenza and skin vesicles in the EAC and the drum which rupture & heal without scar formation. Bullous otitis externa presents with sudden severe ear pain and bloody or serosanguinous discharge which appears after rupture of the bulla.
Headache is commonly defined as head pain (cephalgia) not limited to the distribution of a cranial or cervical nerve (neuralgia). Modern neuroscience has seen much progress in the explanation of the pathogenesis of headaches in the past two decades, but much is still unknown. The pathogenesis of secondary headache relates to nociceptive receptors being activated by an underlying pathology. The differential diagnosis of cephalgia includes primary headache syndromes such as migraine, cluster, and tension headaches, and numerous heterogeneous disorders including infections causing secondary headaches. Clinical history and physical examination are the most important element in headache diagnosis.
The clinician should ask about features of the headache including frequency, severity, location, quality of pain, associated aura and autonomic symptoms. A patient with a primary headache disorder will typically have a reassuring history of similar previous headaches or family members with a similar headache history.
Before the use of antibiotics, acute mastoiditisA A was the most common complication of acute otitis media (AOM). A brain abscessA  A presents clinically in a nonspecific manner, often resulting in a delayed diagnosis (mean 13-14 days after onset of symptoms). If subarachnoid hemorrhage is suspected and CT scan did not reveal hemorrhage, a lumbar puncture should be performed to analyze cell count and xanthochromia (yellowish tinge of CSF that may be related to bilirubin from breakdown of red blood cells). Patients with signs ofA meningitis, encephalitis, significantly immunocompromised states, and those with CSF shunts should undergo lumbar puncture for CSF analysis and pressure measurement.
In a patient over fifty with a new headache associated with fever, visual complaints, or jaw claudication, a diagnostic evaluation for giant cell arteritis (temporal arteritis or GCA) should be initiated.
In patients with malignant external otitis, the ESR is virtually always elevated (unless the patient has received partial antibiotic therapy, often with a quinolone), often approaching 100 mm. Diagnosis of bacterial sinusitis may be made if viral URI symptoms persist for 10 or more days or worsen after 5 to 7 days and are accompanied by the previously mentioned signs and symptoms. Treatment of headaches is based on the type (primary or secondary) and severity of the patient’s headache. The pharmacologic treatment of migraine is divided into acute (abortive, symptomatic) treatment (Table 8) and preventive (prophylactic) treatment (Table 9). Secondary headaches are usually managed with NSAIDS and narcotics while the underlying cause is addressed with appropriate therapy. Elevated intracranial pressure from tumor, optic neuritis, hypertensive encephalopathy, benign intracranial hypertension. It is the biggest salivary gland, located behind the mandibular ramus, below the outer ear, anterior to the mastoid and styloid process and overlying the upper quarter of the sternocleidomastoid muscle. The submandibular duct (Wharton’s duct) arises from the medial surface of the gland and runs approximately 5cm medial to the mylohyoid muscle until it empties into the intraoral cavity, lateral to the lingual frenulum on the anterior floor of mouth. It is located beneath the floor of the mouth, superior to the mylohyoid muscle and anterior to the submandibular gland. Hereby, sialolithiasis has been classified as a noninfectious and nonneoplastic condition to emphasis its mechanical obstructive pathogenesis, but it should be noted that saliva obstruction allows bacterial ascent into the main ducts and is a predisposing factor for salivary gland infection.
Chronic recurrent parotitis in children and adults does not have a fully elucidated pathogenesis, but recent opinions suggest an autoimmune etiology.
The following table summarises the usual presentation of each aforementioned clinical condition. According to the clinical findings a simplified diagnosis and treatment strategy can be outlined. Ultrasound (US) is a primary imaging tool that acts as a guide to the need and choice for further imaging and can be used harmlessly on children and pregnant woman. Magnetic resonance (MR) is the most proficient imaging modality when it comes to spatial resolution and capability of contrast. Computer tomography (CT) is cheaper, less time-consuming and more available compared to MRI. Sialography is only adequate for assessing chronic sialadenitis thats etiology has been not been elucidated by other imaging methods. In a chronic setting, the gland may appear atrophic with focal calcifications, strictures and ductal stenosis or dilations, hyperdense in CT scan, with increase contrast enhancement. If a sialolith is present it appears as a hyperechoic mass with posterior shadowing in US and hyperdense in CT scan.
Fine needle cytology has a reasonable specificity and sensitivity for histological assessment of salivary gland lumps and is regularly performed for surgical planning.
In case of sialoadenitis, blood tests may show systemic signs of inflammation with leukocytosis and elevated C-reactive protein. Curiously, owing to the easiness of saliva sampling, there has been growing interest into the possibility of indentifying biomarkers of systemic conditions, using different methods (eg: sialochemistry, immunological tests), aiming for the detection of HIV antibodies, hormones, alcohol and illicit drugs. It was classically an infantile disease but recently there have been outbreaks in young adults (18-24 years old) most of them college students, already under two-dose vaccine coverage.
Mumps is an enveloped RNA virus restricted to human beings that is transmitted by airborne saliva droplets and acquired through inoculation and replication of the virus in the nasal or upper respiratory tract mucosa. Being a self limiting disease, treatment is mainly supportive with analgesics and anti-inflammatory drugs (eg: acetaminophen, ibuprofen). Intravenous immunoglobulin may be used to treat autoimmune complications such as post-infectious encephalitis, Guillain-Barré syndrome or idiopathic thrombocytopenic purpura.
Natural infection confers lifelong immunity, meanwhile vaccination induced immunity may wane.
Despite developed countries already have a high two-dose childhood vaccination coverage, there have been recent outbreaks in young adults as aforementioned. Dehydration is the main cause, leading to reduced flow and thickening of the saliva which in turn promotes ascending ductal infection. The most common microorganisms are Staphylococcus aureus, Steptococcus viridians, Streptococcus hemolyticus and Streptococcus Pneumonia. CT scan reveals an enlarged right parotid gland with a hypodense area corresponding to an abscess (red arrow). For the sake of brevity, there is a short description of the most frequent salivary gland neoplasms, which are both benign conditions. It is the most common neoplasm of the salivary glands, accounting for 70% of cases and the majority (90%) in the superficial lobe of parotid gland. A pleomorphic adenoma is not completely encapsulated, therefore enucleation carries a risk of tumor cell transfer with high probability of tumor recurrence. Partial or complete parotidectomy is the mainstain therapy and should not be deferred due to the risk of malignant degeneration.
Right: macroscopical features of the lesion after its surgical excision (right, top), including a transverse cut to show its inner aspect (right, bottom). It is a painless bilateral parotid swelling which may involve the submandibular glands at times. Regardless of age, the clinical presentation is similar between the forms, characterized by an alternating unilateral or bilateral gland enlargement that may last for 2 weeks and spontaneous remission and recurrence. It is a chronic autoimmune disease affecting multiple organs and can be associated with other systemic autoimmune disorders such as rheumatoid arthritis, lupus erythematosus and scleroderma.

The salivary gland is infiltrated by mononuclear cells, responsible for inflammatory duct obstructions and decrease of salivary flow leading to xerostomy. Clinically it presents as an intermittent swelling which lasts for weeks to months, is moderately painful and exacerbated by eating. Diagnostic investigation includes lip or parotid biopsy showing a mononuclear infiltration, serum autoantibodies (rheumatoid factor, antinuclear antibody, anti- SS-A and anti-SS-B antibodies) and eventually a sialometry. It is a multiple organ chronic granulomatous inflammation with a predilection for the lungs and hilar lymph nodes, with bilateral parotid enlargement in up to 30% of patients and can also affect the other major and minor salivary glands. It is a multiple organ necrotizing granulomatous inflammation, characterized by vasculitis of the small and medium sized arteries with a predilection for the kidneys and respiratory tract.
The masseter muscles rest closely to the parotid glands and their hypertrophy may lead to a misdiagnosis. Primary headaches such as migraines and tension type headaches are the most common headaches, and have a benign nature. It has been reported that 15% of adults have been absent from work in the past twelve months due to headache (13). Primary headache pathogenesis is complex involving sterile neurogenic inflammation with resultant plasma extravasation (11). Brain parenchyma itself is not capable of relaying nociceptive information, rather it relies on intracranial pain sensitive structures such as the dura matter, cervical and cranial arteries and veins, the ear, the eye and orbits, and portions of the cranial and cervical nerves.
In patients with recurring headaches, features most suggestive of migraine include nausea, phonophobia, photophobia, exacerbation by physical activity, and an aura (Table 5) (12).
It can occur from extension of infection from the paransasal sinuses or external auditory canal (malignant external otitis). Headache is the most common symptom, usually localized to the side of the abscess, and its onset can be gradual or sudden. Neuroimaging, lumbar puncture, serology and other studies will be directed by these clinical clues. Neuroimaging can be pivotal in the diagonsis of subarachnoid hemorrhage, brain tumor or abscess, malignant external otitis, skull-based osteomyelitis and sinusitis. When performing lumbar puncture it is useful to check the cell counts in the first and fourth tubes in order to ease assessment of traumatic lumbar puncture. Standard CSF testing should include cell counts (in 1st and 4th tubes), glucose, protein, andA gram stainA and culture (Table 7). CT scan is not as sensitive as MRI for the diagnosis of brain abscessA  A but can frequently be obtained more easily on an emergent basis (8). The acute oral treatment of migraine headache is typically accomplished with NSAIDS, triptans, narcotics, antiemetics and occasionally steroids. Many of the abortive agents used to treat cluster headache do not reach effective serum concentrations until after the headache has begun to spontaneously resolve. In the case of temporal arteritis, early diagnosis and treatment are essential to prevent blindness.
Antibiotics should not be delayed while awaiting lumbar puncture, but lumbar puncture should be done within two hours of first antibiotic dose to avoid interference with cultures. Lifetime Prevalence of Migraine and Tension-Type Headaches in the General Population, by Gender. It turns medially and pierces the buccinator muscle at the level of the second maxillary molar where it opens onto the oral cavity. Its medial face lies at digastric, mylohyoid, hyoglossus muscles and pharynx lateral wall. The saliva drains by 15 to 30 secretory ducts, one of which tends to be more prominent and therefore called the major submandibular duct, which opens close to the Wharton’s duct orifice. It presents with similar clinical signs and symptoms as infectious salivary gland swellings. Its disadvantages include the unreliability for evaluating deep masses or directly visualising the facial nerve. Therefore it is considered the best option when there is clinical suspicion of neoplastic mass, particularly in the parotid gland, because of its fatty hyperintense background on T1-weighted images allowing adequate delineation of the tumor interface. Is it contraindicated in acute inflammation because the retrograde injection can force inflammatory products into more peripheral parenchyma.
The salivary gland is diffusely or focally enlarged, enhancing avidly in contrast enhanced CT which is the modality of choice when there is suspicion of abscess.
Core biopsies are usually avoided in parotid lumps sampling due to the delicate position of the facial nerve. It can occur even in asymptomatic cases of sialoadenosis secondary to chronic alcoholism, anorexia nervosa or bulimia, or other conditions without evidence of salivary gland involvement such as postoperative states, lactic acidosis, malignant neoplasms that secrete amylase. Infected patients are most contagious 1 to 2 days before the onset of clinical symptoms and for several days afterwards.
95% of those will have parotitis which usually starts unilaterally, but in 90% of cases will progress into a bilateral enlargement. It should be noted that serological tests used for diagnosis do NOT inform on immunity protection. In complicated cases, it should be upgraded to a triple antibiotic coverage adding metronidazole and an aminoglycoside, if renal function allows to). The masseter and internal pterygoid muscle show inflammatory stranding, accounting for the aforementioned trismus. They are more common in men and those over the age of 40, but can also be seen in children. The mass is round, well-defined hypointense in T1 weighted images, hyperintense in T2 weigheted images, and with discrete heterogeneity in constrast enhanced images.
It has strong association with cigarette smoking which explains the recent demographic shift from male predominance to equal sex incidence. There is no size fluctuation with meals and salivary ducts are patent with a free and fluid salivary flow. In children all attempts should be made to avoid it as after puberty symptoms tend to wane and there is a high probability of spontaneous healing. Its mechanism is not fully understood but difficult intubation with increased intraoral pressure and decreased muscle tone of Stensen's duct orifice may allow air reflux. High concentrations of iodide (following iodide contrasting dyes or kidney impairment) lead to increased concentration in the salivary gland, which in turn causes inflammation and glandular swelling.
The muscle hypertrophy is a consequence of its continuous exertion by constant clenching, bruxism or gum chewing. 3-Postoperative (in case of absence of antiseptic precaution or if stitches pass through cartilage) 4-Idiopathic. Primary headache disorders are diagnosed by clinical history and physical examination using the diagnostic criteria as set forth in the International Classification of Headache Disorders (ICHD) (5). Dysregulation of pain mediating neuropeptides such as calcitonin gene-related peptide (CGRP) is a contributing factor (11). These patients may require prompt laboratory or radiographic investigation, empiric therapy, or both.
Cluster headaches typically have a distinct clinical pattern of unilateral symptoms lasting 45 minutes to 3 hours peaking within 10 to 15 minutes to an excruciating periorbital quality. Earache and temporomandibular joint pain may accompany the headache, and these are clues for this rare infection. Signs of classic mastoiditis include: postauricular fluctuance, bulging erythematous tympanic membrane,A erythemaA and tenderness over the mastoid area, and protrusion of the auricle. These infections cause an inflammatory response involving the mucosa of the nose and paranasal sinuses, which results in symptoms such as nasal obstruction, purulence, postnasal drip, facial pressure and pain, alteration in the sense of smell, cough, fever, halitosis, fatigue, dental pain, and ear pressure and fullness.
Cranial CT is faster and more readily available and is therefore done prior to cranial MRI.

Other tests that may be considered depending on the clinical situation include cryptococcal antigen, India ink stain, HSV PCR, VDRL, stain and culture for AFB, fungal culture, and cytology. It is elevated to greater than 50 in 96% of cases (15) while elevation of C-reactive protein may aid in diagnosis of those with unimpressive ESR’s.
Imaging studies, such as plain film radiographs, CT scansA  , and magnetic resonance imaging (MRI) may be helpful in the management of rhinosinusitis, but because they cannot differentiate between viral and bacterial causes of rhinosinusitis, they are not generally recommended for routine management.
If a brain abscess is in the differential diagnosis and MRI cannot be performed, then CT scan with contrast is the diagnostic test of choice. Intravenous treatment of the acute migraine may involveA dihydroergotamine (DHE), narcotics, antiemetics, fluids, anticonvulsants (such as valproate), steroids, and antipsychotics such as chlorpromazine (Thorazine). Accordingly, fast acting abortive agents such as oxygen, IM sumatriptan, IV narcotics and fluid in the inpatient setting, and appropriate prophylactic therapy with agents such as calcium channel blockers and lithium are important in the treatment of cluster headaches. If a patient has symptoms and findings consistent with temporal arteritis, immediate therapy with prednisone 60mg per day should be initiated. Patients who clinical scenario suggests a secondary cause of headache should undergo appropriate imaging studies and potentially a lumbar puncture. Therefore, the levels of this isoenzyme should be interpreted along with clinical systemic signs, pancreatic isoamylase, lipase or trypsin and renal function.
Primary headache disorders, by definition and by diagnostic criteria, cannot be attributed to another disorder. Two percent of all patients presenting to the emergency room have headache as their chief complaint (9).
Ultimately, the caudal trigeminal nucleus is the neuronal structure responsible for nociceptive information of the cranial structures. Abrupt onset of headache suggests a secondary cause and thus a higher potential for being disabling if not rapidly diagnosed and treated (4).
Purulent otorrhea is usually present at some point in the past medical history and the patient is classically an elderly diabetic.
Signs of latent mastoiditis include: no external signs of mastoid inflammation, infected or normal-appearing tympanic membrane, recurrent fever. Patients with suspected trauma related headaches should undergo urgent CT imaging of the head. Remaining CSF fluid after initial testing should be preserved for potential expansion of laboratory evaluation.
In the setting of focal signs, symptoms orA papilledema,A a lumbar puncture is contraindicated (6).
However it is expensive, with limited availability and is incompatible in patients with magnetic devices. Kernig’s sign is positive when the patient is lying supine with leg bent at the hip and knee at 90 degree angles and subsequent extension in the knee is painful.
The main risk factors are  tobacco, alcohol misuse, irradiation, previous history of cancer and HIV infection.
Secondary headache disorders result when another underlying organic disorder leads to cephalgia.
Neuronal activity may be dysregulated within this nucleus as well as with its relationship with higher order pathways involving the midbrain in patients with primary headache disorders (11). Additionally, patients with known systemic disease or immunocompromised state are more likely to have secondary headaches and underlying causes should be carefully evaluated. Autonomic symptoms such as rhinorrhea and lacrimation are noted by up to 80% of these patients.
The neurologic examination is typically nonfocal, though, cranial nerve involvement is possible with advanced disease.
Mental status changes are indicative of cerebral edema while vomiting is associated with increased intracranial pressure (2).
CT without contrast is sufficient to rule out hemorrhage but if tumor or abscess is suspected and MRI is not easily available (or the patient has a contraindication to MRI), CT with contrast should be considered.
The temporal artery is often segmentally affected; therefore the biopsy must be of adequate size, usually at least 2 cm. CT scan with contrast or MRI should be performed prior to lumbar puncture in this situation to exclude a focal cerebral lesion.
Migraine may be triggered by the meningitis and should not be overlooked as migraine specific treatments in these patients may be more useful. Brudzinski’s sign is positive when the patient is lying supine and passive flexion of the neck causes involuntary flexion of the legs. Rapidly growing mass, pain, facial nerve involvement and cervical lymphadenopathy are suspicious symptoms and signs of malignancy.
Secondary headaches may require additional tests beyond history and physical examination to confirm or exclude certain etiologies.
Fifteen percent of patients will have neck stiffness, especially when purulence has leaked into a lateral ventricle.
When the CT does not reveal abnormalities and diagnosis is still uncertain, MRI with and without contrast should be considered.
It is unnecessary to delay treatment with prednisone while awaiting the performance or results of a biopsy as the diagnostic findings on biopsy are often present as long as two weeks after initiating corticosteroids (14). The usual metastatic sites from salivary gland carcinomas are lymph nodes, lungs, liver and bone.
Secondary headaches may be associated with significant morbidity and therefore warrant more urgent evaluation and perhaps even empiric treatment. Tension headaches are recurrent non-pulsatile bilateral headaches of mild to moderate severity that are not aggravated with routine physical activity (5). In adults, benign tumors of the parotid (pleomorphic adenoma and Warthin's tumor) are the most frequent. Many have established histories of chronic primary headache disorder and present with recurrent headache.
The probability of malignancy rises in the submandibular gland (50%), minor salivary glands (up to 80%) and sublingual gland (up to 90%). Underlying central nervous system disease is relat ively uncommon in the population of patients suffering from headache. In patients with suspected aneurysm or arterial dissection, angiography should be considered.
However, up to one-third of patients presenting to emergency rooms with a chief complaint of abrupt onset headache, may have potentially fatal or disabling intracranial pathology (4).
90% of the malignant cases are made up by mucoepidermoid carcinomas, adenoid-cystic carcinomas and acinic cell carcinomas (the corresponding figure in adults is only 45%). In the case of giant cell arteritis (temporal arteritis), the incidence increases with age, peaking in the range over seventy years old. The most frequent benign conditions in children are: pleomorphic adenomas, haemangiomas and lymphangiomas. Acupuncture , heat , electrical stimulation channels of energy , body's internal organs, correct imbalances digestion, absorption, and energy production activities, circulation of their energy .
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