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sphincter muscle [keywords]
- Anatomical Considerations of the Longitudinal Pharyngeal Muscles in Relation to their Function on the Internal Surface of Pharynx. [JOURNAL ARTICLE]
- Dysphagia 2014 Aug 21.
The aim of this study was to clarify the topography of the longitudinal pharyngeal muscles and to relate the findings to pharyngeal muscular function. Forty-four specimens (22 right and 22 left sides) from embalmed Korean adult cadavers (13 males, 9 females; age range, 46-89 years; mean age, 69.2 years) were used in this study. The palatopharyngeus muscle originated from the palatine aponeurosis and the median part of the soft palate on oral aspect; it ran downward and lateralward, respectively. The palatopharyngeus muscle, which held the levator veli palatini, was divided into two bundles, medial and lateral, according to the positional relationship with the levator veli palatini. The lateral bundle of the palatopharyngeus muscle was divided into two parts: longitudinal and transverse. The pharyngeal longitudinal muscles were classified into the following four types (I-IV) depending on the area of insertion: they were inserted into the palatine tonsil, epiglottis, arytenoid cartilage, piriform recess, thyroid cartilage, and pharyngeal wall. The transverse part of the palatopharyngeus muscle plays a role as a sphincter. Palatopharyngeus and levator veli palatini muscles help each other to function effectively in the soft palate. The present findings suggest that the pharyngeal muscles are involved not only in swallowing but also in respiration and phonation via their attachment to the laryngeal cartilage.
- Effects of lateral funiculus sparing, spinal lesion level, and gender on recovery of bladder voiding reflexes and hematuria in rats. [JOURNAL ARTICLE]
- J Neurotrauma 2014 Aug 19.
Deficits in bladder function are complications following spinal cord injury (SCI), severely affecting quality of life. Normal voiding function requires coordinated contraction of bladder and urethral sphincter muscles dependent upon intact lumbosacral reflex arcs and the integration of descending/ascending spinal pathways. We previously reported, in electrophysiological recordings, that segmental reflex circuit neurons in anesthetized male rats were modulated by a bilateral spino-bulbo-spinal pathway in the mid-thoracic lateral funiculus. In the present study, behavioral measures of bladder voiding reflexes and hematuria (hemorrhagic cystitis) were obtained to assess the correlation of plasticity-dependent recovery to the degree of lateral funiculus sparing and to the mid-thoracic lesion level. Adult rats received midthoracic level lesions at one of the following severities: complete spinal transection, bilateral dorsal column lesion, unilateral hemisection, bilateral dorsal hemisection, a bilateral lesion of the lateral funiculi and dorsal columns, or a severe contusion. Voiding function and hematuria were evaluated by determining if the bladder was areflexic (requiring manual expression, i.e. "crede maneuver"), reflexive (voiding initiated by perineal stroking), or "automatic" (spontaneous voiding without caretaker assistance). Rats with one or both lateral funiculi spared (i.e. bilateral dorsal column lesion and unilateral hemisection), recovered significantly faster than animals with bilateral lateral funiculus lesions, severe contusion, or complete transection. Bladder reflex recovery time was significantly slower the closer a transection lesion was to T10 suggesting that proximity to the segmental sensory and sympathetic innervation of the upper urinary tract (kidney, ureter) should be avoided in the choice of lesion level for SCI studies of micturition pathways. In addition, hematuria duration was significantly longer in males compared to females despite similar bladder reflex onset times. We conclude that the sparing of the mid-thoracic lateral funiculus on one side is required for the quick recovery of bladder voiding function and the resolution of hematuria.
- Assessment of pubovisceral muscle defects and levator hiatal dimensions in women with faecal incontinence after vaginal delivery. Is there a correlation with severity of symptoms? [JOURNAL ARTICLE]
- Colorectal Dis 2014 Aug 8.
We assessed pubovisceral muscle (PVM) defects, levator hiatal dimensions, and anal sphincter defects using 3-D endovaginal and anorectal ultrasonography in women with previous vaginal delivery and faecal incontinence to determine the relationship between anatomic/functional findings and severity of faecal incontinence symptoms.This was a prospective, observational study including 52 women with faecal incontinence symptoms who had undergone vaginal delivery. Asymptomatic nulliparous women (n=17) recruited served as controls to provide reference values for pelvic floor measurements. All participants underwent 3-D endovaginal and anorectal ultrasonography. We used an ultrasound score to identify and quantify the extent of pubovisceral muscle defects and sphincter damage and to measure levator hiatal dimensions. Incontinence was assessed with the Cleveland Clinic Florida Incontinence Scale.Defects of the PVM were identified with 3-D endovaginal in 27% of women with faecal incontinence who had undergone vaginal delivery. The incontinence score and the ultrasound score were significantly higher in women with a PVM. A significant positive correlation was found between the incontinence and ultrasound scores. The levator hiatal dimensions were significantly greater and the position of the anorectal junction and bladder neck was lower in women who had undergone vaginal delivery than in nulliparous women.As determined by 3-D ultrasound score, severity of incontinence is related to the extent of damage of the PVM as well as of the anal sphincters. Additionally, vaginal delivery results in enlargement of the levator hiatus and a lower position of the anorectal junction and bladder neck compared with nulliparous women. This article is protected by copyright. All rights reserved.
- Treatment of interstitial cystitis/painful bladder syndrome as a neuropathic pain condition. [Journal Article]
- Indian J Urol 2014 Jul; 30(3):350-3.
A lady of 52 years with painful bladder syndrome/interstitial cystitis (PBS/IC) presented with chronic pelvic pain, irritative voiding with sphincter dominance on urodynamics. 3 yrs of oral analgesics, antispasmodics and intravesical therapy was ineffective. We surmised her pain, and irritative voiding to be secondary to constant straining against a dysfunctional pelvic floor. We treated PBS/IC as a neuropathic phenomenon with a combination of neuromodulator medications and continuous caudal epidural analgesia to reduce the pain induced peripheral and central sensitisation. Botulinum toxin type A injection into pelvic floor muscles appeared to address their dysfuction. Clinical and urodynamics response was encouraging.
- Neurophysiological monitoring of the spinal sensory and motor pathways during embolization of spinal arteriovenous malformations--propofol: a safe alternative. [Journal Article]
- Neurodiagn J 2014 Jun; 54(2):125-37.
Embolization of a spinal cord arteriovenous malformation (AVM) is considered a high-risk procedure due to the potential risk of spinal cord injury. We present two cases illustrating the benefits of utilizing pharmacologic provocative testing under general anesthesia with continuous neurophysiologic monitoring of somatosensory evoked potentials (SSEPs) and transcranial electrical motor evoked potentials (TCeMEPs) to identify the functional territory of the catheterized vessels prior to embolization.Case #1: A 28-year-old male presented with a progressive right lower leg numbness followed by weakness with impaired sphincter control. The MRI and angiogram of the spine showed an arteriovenous malformation (type 4) (subtype 2). Case #2: A 31-year-old male presented with sudden occipital, neck, right shoulder and back pain. He was neurologically intact. MRI and angiogram showed a predominantly right sided arteriovenous malformation. INTERVENTIONAL PROCEDURE: After intubation, bilateral posterior tibial and median nerve SSEPs were recorded. TCeMEP and electromyogram (EMG) were monitored from upper and lower extremity muscles bilaterally. Total intravenous anesthesia was used with propofol and remifentanil infusion. Neuromuscular blockade was used only for initial intubation. A train of four was maintained during the procedure. Pre-incision baselines were obtained with good morphology of waveforms. Selective spinal Wada tests were performed prior to embolization with lidocaine and propofol. Neurophysiological monitoring was performed for any changes.Complete occlusion of the AVM was achieved. As no changes occurred during provocative testing, all branches were treated with Onyx embolization. At six-month post-operative follow-up, both patients had total relief of symptoms.Multimodality IONM with continuous SSEP, TCeMEP, and EMG monitoring was utilized effectively during provocative testing with lidocaine and propofol. IONM helped in predicting and preventing post-operative neurological deficits due to ischemia to the spinal cord.
- Modified Expansion Sphincter Pharyngoplasty for Treatment of Children With Obstructive Sleep Apnea. [JOURNAL ARTICLE]
- JAMA Otolaryngol Head Neck Surg 2014 Jul 31.
Lateral pharyngeal wall collapse has been implicated in the pathogenesis of obstructive sleep apnea (OSA). Modified expansion sphincter pharyngoplasty (ESP) is a simple procedure and can be considered in the surgical management of children with severe OSA.To describe a modified ESP addressing lateral pharyngeal muscle wall collapse in the treatment of children with OSA.Retrospective review of the medical records of children with OSA and lateral pharyngeal muscle wall collapse who underwent modified ESP and children who had tonsillectomy and adenoidectomy (TA) for OSA between 2008 and 2013 at a tertiary care children's hospital.Modified ESP.The primary outcome measure was the rate of cure, which was defined as an apnea-hypopnea index (AHI) lower than 1. Other outcomes were differences in preoperative and postoperative AHI, minimum saturation of peripheral oxygen, and percentage of total sleep study time with oxygen saturation less than 90%.Twenty-five children who had modified ESP and 25 AHI-matched children who had TA for severe OSA were identified. The postoperative AHI was lower than the preoperative AHI in both groups. Preoperative AHI was similar between modified ESP and TA groups. The mean (SD) postoperative AHI of the modified ESP group (2.4 [3.9]) was lower than that of the TA group (6.2 [6.0]) (P < .001). Cure rates for the modified ESP group (AHI <1, 64%; AHI <2, 72%; and AHI <5, 80%) were greater than those for the TA group (AHI <1, 8%; AHI <2, 44%; and AHI <5, 60%).Modified ESP provided objective clinical improvement of OSA in children with severe OSA and lateral pharyngeal wall collapse and might serve as an effective alternative to TA for treatment of OSA.
- Pathologic t1 subclassification of ampullary carcinoma with perisphincteric or duodenal submucosal invasion: is it t1b? [Journal Article]
- Arch Pathol Lab Med 2014 Aug; 138(8):1072-6.
Context.-In ampullary carcinoma staging, T1 is defined as a tumor limited to the ampulla of Vater or the sphincter of Oddi, and T2 is defined as invasion into the duodenal wall. However, the definition of duodenal wall invasion is vague. Ampullary carcinoma that invades beyond the sphincteric of Oddi (perisphincteric invasion) or into the duodenal submucosa could be considered pT1b because submucosal invasion is classified as pT1b in gastrointestinal tract tumors. However, there are no data regarding T subclassifications for ampullary carcinoma with perisphincteric or duodenal submucosa invasion.
Objectives.-To determine the T subclassification of ampullary carcinoma that invades into perisphincteric or duodenal submucosa. Design.-Pathologically proven ampullary carcinomas with T1 or T2 were reviewed (n = 105). We reclassified tumors as pT1a that were limited to within the sphincter of Oddi (n = 40; 38%), as pT1b for tumors that invaded beyond the sphincter of Oddi or into the duodenal submucosa (n = 25; 24%), and as pT2 for tumors that invaded into duodenal proper muscle (n = 40; 38%).
Results.-Lymph node metastasis and recurrence were absent in ampullary carcinoma with pT1a, whereas nodal metastasis were noted in 24% (6 of 25) and 40% (16 of 40) of the ampullary carcinomas with pT1b and pT2, respectively. Tumor recurrence/metastasis rate of ampullary carcinoma with pT1b and pT2 was 44% (11 of 25) and 40% (16 of 40), respectively. The 5-year disease-free-survival rates from ampullary carcinoma with pT1a, pT1b, and pT2 were 95% (38 of 40), 56% (14 of 25), and 58% (23 of 40), respectively (P = .003). The 5-year overall survival from ampullary carcinoma with pT1a, pT1b, and pT2 was 98% (39 of 40), 72% (18 of 25), and 60% (24 of 40), respectively.
Conclusions.-The clinicopathologic outcome of ampullary carcinoma with a pT1b subclassification was worse than it was for T1a and approached the outcome for pT2.
- Pupillary Effects of High-dose Opioid Quantified with Infrared Pupillometry. [JOURNAL ARTICLE]
- Anesthesiology 2014 Jul 25.
The pupillary light reflex is a critical component of the neurologic examination, yet whether it is present, depressed, or absent is unknown in patients with significant opioid toxicity. Although opioids produce miosis by activating the pupillary sphincter muscle, these agents may induce significant hypercarbia and hypoxia, causing pupillary constriction to be overcome via sympathetic activation. The presence of either "pinpoint pupils" or sympathetically mediated pupillary dilation might prevent light reflex assessment. This study was designed to determine whether the light reflex remains quantifiable during opioid-induced hypercarbia and hypoxia.Ten volunteers were administered remifentanil with a gradually increasing infusion rate and intermittent boluses, until the increasing respiratory depression produced an oxyhemoglobin saturation of 85% or less with associated hypercarbia. Subjects' heart rate, blood pressure, respiration, and transcutaneous carbon dioxide level were continuously recorded. Arterial blood gases and pupillary measures were taken before opioid administration, at maximal desaturation, and 15 min after recovery.The opioid-induced oxygen desaturation (≤85%) was associated with significant hypercarbia and evidence of sympathetic activation. During maximal hypoxia and hypercarbia, the pupil displayed parasympathetic dominance (2.5 ± 0.2 mm diameter) with a robust quantifiable light reflex. The reflex amplitude was linearly related to pupil diameter.Opioid administration with significant accompanying hypercarbia and hypoxia results in pupil diameters of 2 to 3 mm and a reduced but quantifiable pupillary light reflex. The authors conclude that the pupillary examination and evaluation of the light reflex remain useful for neurologic assessment during opioid toxicity.
- Neuromodulation of perineally transposed antropylorus with pudendal nerve anastomosis following total anorectal reconstruction in humans. [JOURNAL ARTICLE]
- Neurogastroenterol Motil 2014 Jul 27.
We have reported perineal antropyloric segment transposition with its pudendal innervation as a replacement for anal sphincter. Our aim herein was to neuromodulate this segment by electrical stimulation.Eight patients with a permanent colostomy underwent perineal antropyloric segment transposition followed by neural anastomosis of its anterior vagus branch to pudendal nerve branch in the perineum. Perineal antropyloric graft was assessed for its functional integrity and electrophysiological effects. Nerve stimulation was done by surface stimulation technique, using a customized stimulation protocol for smooth muscle. Antral pressures were recorded on voluntary attempts and on nerve stimulation with simultaneous concentric needle electromyography of the perineal antropylorus.The antral segment showed slow spontaneous contractions (2-3/min) on digital examination, endoscopy, and electrophysiology. Stimulated antropyloric electromyography showed a latency of 2-5 s with a differential rise in amplitude (mean range 58.57-998.75 μV) according to the frequency of stimulation (range 10-150 Hz). An average latency of 10 s in relation to rise in the antral pressure was observed on pudendal nerve stimulation. Triggering of the intrinsic rhythm was observed in patients where it was initially absent. Voluntary attempts at contraction also showed a rise in perineally transposed antral pressure.Spontaneous rhythm, its generation after electrical stimulation, and response to voluntary contraction demonstrates the viability and functional reinnervation of the perineally transposed antropyloric segment. Rise in pressure on electrical stimulation shows evidence for its neuromodulation.
- [Anaesthetic management of Stiff Man syndrome.] [JOURNAL ARTICLE]
- Rev Esp Anestesiol Reanim 2014 Jul 21.
Stiff Man syndrome or stiff-person syndrome is a rare autoimmune disorder. It is characterized by increased axial muscular tone and limb musculature, and painful spasms triggered by stimulus. The case is presented of a 44-year-old man with stiff-person syndrome undergoing an injection of botulinum toxin in the urethral sphincter under sedation. Before induction, all the surgical team were ready in order to minimise the anaesthetic time. The patient was monitored by continuous ECG, SpO2 and non-invasive blood pressure. He was induced with fractional dose of propofol 150mg, fentanyl 50μg and midazolam 1mg. Despite careful titration, the patient had an O2 saturation level of 90%,which was resolved by manual ventilation. There was no muscle rigidity or spasm during the operation. Post-operative recovery was uneventful and the patient was discharged 2 days later. A review of other cases is presented. The anaesthetic concern in patients with stiff-person syndrome is the interaction between the anaesthetic agents, the preoperative medication, and the GABA system. For a safe anaesthetic management, total intravenous anaesthesia is recommended instead of inhalation anaesthetics, as well as the close monitoring of the respiratory function and the application of the electrical nerve stimulator when neuromuscular blockers are used.