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It is also associated with the feeling of insertion cheap allegra 180mg otc, which is generally felt in the deep layers of the tissue generic allegra 180mg. Often generic allegra 180 mg free shipping, the De-Qi sensation radiates along the channel, especially when the distal points are needled. From the 1970s to 1980s, numerous studies on this phenomenon that generally occurs in 5% 10% of the patients, were carried out in China. Several methods of needle stimulation have been shown to evoke propagated sensations along the channels. Indeed, the efficacy of acupuncture treatment is considered to essentially depend on the sensation of De-Qi induced by the needle stimulation (lifting, thrusting, rotation, clockwise or counterclockwise, etc. However, the exact tissue setting that is related to these various kinds of feelings is difficult to judge from the morphological studies. Nevertheless, through studies employing the methods of morphology, myoelectricity of acupoint, separation of fine nerve tract, etc. Furthermore, Xiyan (Ex-36) and other acupoints at the articular capsules mainly comprise Ruffini corpuscles. Usually, acupoint stimulus to the nerves, vessels, tendon and periosteum, and muscles, mainly induces a feeling of numbness, soreness, sourness, and sourness as well as distend, respectively. The connective tissues are considered to be the main structure to accept a stimulus of the acupuncture. Furthermore, numerous mast cells are observed to regularly array around the micro-vessels, capillary, nerve endings, and nerve plexus at the acupoints. In addition, the activation of mast cells by the stimulus may also be related to the sensation and effect of acupuncture (Popov 2001). When manipulating the needles to obtain the De-Qi sensation, the acupunc- turist’s hand may experience the sensation of heaviness, tightness, non-smoothness, and stagnation. Histological observations show that the muscle spindles are the main receptive settings at the acupoints with thick muscles. The intrafusal fiber is observed to accept the impulse derived from the 61 Acupuncture Therapy of Neurological Diseases: A Neurobiological View Ȗ-efferent fiber of the spinal cord, contract, and subsequently release myoelectricity to induce contraction of the local muscles. When manipulating the needle, the afferent impulse of the acupuncture signal can stimulate the efferent sympathetic nerve on the vessels and activate the vascular smooth muscles. Thus, the micro-vessels at the local acupoints may be partially involved in the effect settings of the acupuncture. There has been evidence showing the relationship between the acupoints and blood vessels, as well as the autonomic nerve in the wall of the blood vessels. Huge et al (2000) showed that among the 361 acupoints of the entire body, 58 acupoints (16. All these facts indicate the somatic nerves’ connection with the plexus of the vegetative nerve around the vessels or the insertion into the vascular wall to form the anastomotic ramus or the converging point under the acupoints. They may be the key points or pathway linking the functional connections between the somatic and vegetative nerves. Furthermore, these facts may also explain the cause of the sensation of De-Qi concomitant with the effect of the vegetative nerve. Moreover, some investigators noticed the features of three-dimensional 62 2 Neuroanatomic Basis of Acupuncture Points construction of acupoints as well as the characters of the extracellular matrix of the acupoints (Yu et al. Taken together, an acupoint is very likely to be a complicated structure comprising nerve endings, receptors, vessels, connective tissues, and other tissue/cells with nerve signals being the cause of acupuncture sensation. The correlation between the meridian-points and viscera is also known as the body-surface connection with viscera (Cheng 1990), and refers to the bidirectional relationship between the meridian-points and viscera. In other words, the pathological or physiological change in the viscera can be reflected by the corresponding meridian and acupoints on the body surface, which in turn, stimulate certain meridian or acupoints that can adjust the physiological function or pathological change in the corresponding viscera (Li 2003). On comparing the correlation between the meridian-points and viscera with the relationship between the meridian-points and peripheral nerves, we can see that the meridian-points and viscera are closely correlated through the peripheral distribution of the nerves. The theory of correlation between the meridian- points and viscera may be adapted based on the current knowledge of the nervous system. First, the mutual internal and external meridians are observed to be closely related to their distribution in the peripheral nerves. These distributions correspond to the parlance of “Fu-organs following to Zang-organs and meridians of Fu-organs going along superficial and external”. One can observe the ulnar and medial antebrachial cutaneous nerve distributed along both the meridians. The branches of the medial antebrachial cutaneous nerve distributed along both the meridians, and many acupoints of the two meridians are observed to be related to the palmar interosseous nerve of the median nerve in the deep layer. On the head, both the facial and auriculotemporal nerves are distributed on the two meridians. Both the saphenous nerve and superficial peroneal nerves are distributed on the two meridians. In addition, Kidney Meridian of Foot-Shaoyin and Bladder Meridian of Foot-Taiyang are observed to be related to the internal and external meridian, respectively, comprising tibial-nerve distribution. Thus, diseases related to the internal meridian can be treated using both internal and external meridians. On the other hand, the “external” diseases can also be treated using external and internal meridians.

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Placement of prosthesis from incus otitis media and stapedial otosclerosis are to oval windows given in Table 15 allegra 120 mg overnight delivery. The tympanomeatal flap is put back Prognosis and the external auditory canal packed with gelfoam (Figs 15 120 mg allegra with mastercard. In 90 per cent of the cases order allegra 180 mg mastercard, the results are good, in 8 per cent no change occurs and in Complications Table 15. Injury to the chorda tympani and facial adhesive otitis media and stapedial nerve otosclerosis 2. Hence, only one Treatment ear should be operated upon at one time Surgery has no place in the treatment of pure because chances of sensorineural loss, cochlear otosclerosis. Advantages include a bloodless fenestra Other indications for flouride treatment are and reduced risk of subluxation of the foot- the following: plate but the disadvantages are a high cost 1. Fluoride therapy and cochlear otosclerosis without the involvement prescription of a hearing aid are the treatment of stapes can be suspected in any patient who for this condition. Benign lesions like haemangioma, papilloma, chondroma and fibroma may sometimes be seen. Malignant Tumours of the Auricle Squamous cell carcinoma and basal cell carcinoma are the two types of malignancies which usually involve the auricle. Surgical excision of the lesion is done and the local defect corrected by skin grafts. Basal Cell Carcinoma (Rodent Ulcer) This type usually presents initially as a raised pigmented plaque with a tendency to form Fig. Common sites involved are auditory canal and pinna Tumours of the Ear 95 outgrowths become large in size, they are removed using a drill and cutting burr. Osteoma Osteoma is a smooth, solitary, rounded, pedunculated tumour from the outer part of the bony meatus, usually from the region of tympanosquamous or the tympanomastoid suture. So, the adenoma could be of following types: the border of helix, meatal entrance and the i. Sebaceous adenoma The tumour arises from sebaceous glands and is usually seen as Benign Tumours of the External smooth, skin covered swelling in the outer Auditory Meatus part of the meatus. The lesion presents as a firm skin covered mass which may be sessile or pedunculated. Exostoses Treatment is wide local excision because Exostoses present as hemispherical smooth chances of its recurrence and turning malig- bony outgrowths from the canal wall. The exact cause is not known Malignant Tumours of the but it was thought that repeated swimming External Auditory Meatus in cold water could be an aetiological factor. Carcinoma Exostoses usually do not produce any symptoms unless these outgrowths obliterate The external auditory meatus is not a common the lumen of the canal. The disease When exostoses are small and symptom- is usually seen in cases having long-standing less, no treatment is needed but when these suppurative disease. The patient presents with 96 Textbook of Ear, Nose and Throat Diseases blood-stained discharge and pain in the ear and on examination, a malignant ulcer or a bleeding mass is seen in the canal. Wide surgical excision is done which may mean an extended radical mastoidec- tomy followed by postoperative radiotherapy. Adenocarcinoma The tumour may primarily arise from the glands of the external auditory canal and its differentiation from squamous cell carcinoma is difficult on clinical grounds. Depending upon the extent of involve- ment, surgery may be limited to radical mastoidectomy or even subtotal resection of the temporal bone may be needed to remove the disease. A tumour arising from this tissue The histopathological features include a is known as glomus tumour, chemodectoma or highly vascular tissue with sheets of eosino- nonchromaffin paraganglioma (Fig. These tumours are histologically benign but Clinical Features locally behave like malignant tumours (Fig. According to their location they are The tumour commonly occurs in elderly named as Glomus Jugulare, arising from the females. Depending upon the origin and jugular bulb, Glomus Vagale, arising from the spread of the tumour, symptoms may be vagus and Glomus tympanum, arising from aural, neurological, or combination of the two the promontory. Aural symptoms: The tumour presents in the Type A Tumour confined to the middle ear. Neurological symptoms: The tumour which infralabyrinthine part of the tempo- primarily arises from the jugular bulb ral bone. The thine part of the temporal bone and seventh and eighth cranial nerve involve- destruction of the petrous apex. Staging of Glomus Jugular Tumour Pain is not the usual feature unless infection is present. Hearing tests may show conductive or external auditory canal by the Siegle’s sensorineural loss.

The disease discount allegra 120mg, caused by Rickettsia akari generic allegra 180mg overnight delivery, a member of the spotted fever group of rickettsiae order 120mg allegra mastercard, is transmitted to humans from mice (Mus musculus) by a mite (Liponyssoides sanguineus). Incidence has been markedly reduced by changes in management of garbage in tenement housing, so that few cases have been diagnosed in recent years. Identification—Rubella is a mild febrile viral disease with a diffuse punctate and maculopapular rash. Clinically, this is usually indistinguish- able from febrile rash illness due to measles, dengue, parvovirus B19, human herpesvirus 6, Coxsackie virus, Echovirus, adenovirus or scarlet fever. Children usually present few or no constitutional symptoms, but adults may experience a 1–5 day prodrome of low grade fever, headache, malaise, mild coryza and conjunctivitis. Postauricular, occipital and poste- rior cervical lymphadenopathy is the most characteristic clinical feature and precedes the rash by 5–10 days. Leukopenia is common and throm- bocytopenia can occur, but hemorrhagic manifestations are rare. Arthral- gia and, less commonly, arthritis complicate a substantial proportion of infections, particularly among adult females. Encephalitis is a more common complication than generally appreciated, and occurs with a higher frequency in adults. Laboratory diagnosis of rubella is required, since clinical diagnosis is often inaccurate. An epidemiologically confirmed rubella case is a patient with suspected rubella with an epidemiological link to a laboratory- confirmed case. Rubella is important because of its ability to produce anomalies in the developing fetus. Congenital malforma- tions and fetal death may occur following inapparent maternal rubella. Fetuses infected early are at greatest risk of intrauterine death, sponta- neous abortion and congenital malformations of major organ systems. Occurrence—In the absence of generalized immunization rubella occurred worldwide at endemic levels with epidemics every 5–9 years. In countries where rubella vaccine has not been introduced, rubella remains endemic. By the end of 2002, 124 countries/territories (58% of the world total) were using rubella vaccine in their national immunization program with the highest levels in the Americas (94% of countries), Europe (84%) and the Western Pacific (59%). Period of communicability—For about 1 week before and at least 4 days after onset of rash; highly communicable. Infants born to immune mothers are ordinarily protected for 6–9 months, depending on the amount of maternal antibodies acquired transplacentally. Methods of control—Rubella control is needed primarily to pre- vent defects in the offspring of women who acquire the disease during pregnancy. Preventive measures: 1) Educate the general public on modes of transmission and stress the need for rubella immunization. Consequently, it is essential that childhood rubella vaccination programs achieve and maintain high levels of coverage (above 80%) on a long-term basis. A single dose of live, attenuated rubella virus vaccine elicits a significant antibody response in about 95%–100% of susceptible individuals aged 9 months or older. Following the introduction of large-scale rubella vacci- nation, coverage should be measured periodically by age and locality. If resources permit, longitudinal serological surveillance can be used to monitor the impact of the immunization program, especially through assessing ru- bella IgG antibody in serum samples from women attend- ing antenatal clinics. Rubella vaccine should be avoided in pregnancy be- cause of the theoretical, but never demonstrated, terato- genic risk. If pregnancy is being planned, then an interval of one month should be observed after rubella immunization. Rubella vaccine should not be given to anyone with an immunodeficiency or who receives immunosuppressive therapy. In case of infection with wild rubella virus early in preg- nancy, culturally appropriate counselling should be pro- vided. It is sometimes given in huge doses (20 ml) to a susceptible pregnant woman exposed to the disease who would not be in a position to consider abortion, but the value of this has not been established. Early reporting of sus- pected cases will permit early establishment of control measures. Such contacts should be tested serologically for suscep- tibility or early infection (IgM antibody) and advised accord- ingly. A limited number (5–10) of suspected cases (see definition earlier) should be investigated with laboratory tests periodi- cally during an outbreak to confirm that it is due to rubella. Identification—A bacterial disease commonly manifested by acute enterocolitis, with sudden onset of headache, abdominal pain, diarrhea, nausea and sometimes vomiting.