Friday, March 31, 2006

Q17: I have a voice like Louis Armstrong


A 40-yr old non-smoker presents with hoarseness of voice for the past 2 months. He has a history of total thyroidectomy for thyroid cancer 2 years ago and intubation was difficult.

Q1: Describe the lesion.

Q2: What is the most likely diagnosis?

Q3: What is the theory behind the pathogenesis of this lesion? Posted by Picasa

123 comments:

Jo said...

Mr Yap.. I was kinda poring over this question.. and wondering what was it .. whether it was just a vocal polyp or nodule or some kinda a single papilloma...Then, I was wondering why you mentioned thyroidectomy where the pt was intubated..
then I googled! :)
I hope I'm right!
:)

Q1 : There is a pale white pedunculated mass sitting on the posterior 1/3 or the left vocal cord.It looks like it is a two-lipped structure that ft the vocal process of the opposide side.

Q2 : intubational granuloma

Q3 : Contact ulcers occur when the thin mucosa overlying the firm cartilage of the vocal process is crushed repetitively against the opposite side, causing a breakdown of the mucosa. An ulcer forms, accompanied by granulation tissue formation. An object such as an endotracheal tube may cause the injury leading to granulomas, or granulomas may result secondary to chronic irritation (eg, persistent gastroesophageal reflux injury).

:)

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Thank you CC & Jo.

Good tries both of you, and would you give you full marks in an undergrad exam. The key to answering such questions is to pay attention to the clues in the opening statement, which both of you have done. Appearances may be deceiving without the information that is intentionally given.

Q1: It's hard to commit to 'pedunculated' when you don't see the stalk, nor can you move the mass. Also, it's impossible to measure the size without a reference ruler present. It would have been sufficient to say 'an irregular white mass arising from the posterior 1/3rd of the left vocal cord.' And, if you took a look around and didn't concentrate on the mass alone, you might have (with sufficient knowledge) noticed the interarytenoid bar/edema.

Q2: The answer, we can deduce from history and examination - is an Intubation Granuloma, secondary to a traumatic intubation and acid reflux (LPR/GERD).

Q3: Theory of pathogenesis is - trauma + acid --> ulcer --> perichondritis + infection --> granulation tissue

The term 'granuloma' here is a bit of a misnomer, since it is not a granulomatous disease but a hypergranulation response. Also the fact that it is pale white indicates that it is a 'mature' granuloma - with a predominance of collagen rather than fibroblasts. An early granuloma would be redder/pinkish - containing more fibroblasts and new vessels.

Overall - well done on a challenging case. Excision of this mass revealed exactly that - granulation tissue.

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Following the philosophy of pyramiding, what happens in this system is that you place a bet and if you come out a winner you re-invest the winnings on the next wager. So in horse racing, for example, you simply let it ride. Also, unlike the other betting systems, the Parlay System offers a lower amount of risk of all bettors for because they only need be concerned with a win, place or show selection or a combination thereof.
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The important thing to note here is that neither of the above approaches is "systemised", although those in the first group believe that they are limiting losses while increasing their winning chances. But what the majority in that first group generally do not take proper account of is how the Bookies have fixed the odds to ensure that they, the Bookies, will come out on top in the long run. What this means is that if you only bet on "favourites" you will eventually lose all your money, although it is true that you will enjoy a much longer period of betting before you kiss your last buck goodbye!

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Overall, the majority of people feel that the United States is missing the boat on this matter. Instead of simply regulating the industry like the rest of the countries in the world, they are trying to get rid of it altogether. This may have some benefits, but for the most part there is a chance that it could end up back firing. It will be interesting to see what the Senate decides to do in the upcoming months.

So, having established that using a good Selection System is an absolute must if you want to make money from sports betting, how does the average Bettor actually go about making his/her betting selections? My research shows me that, in the main (ignoring the extremes), there are generally two approaches taken:

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Will Barbaro be the next Triple Crown winner? He has the breeding and the talent, but as of this writing twenty horses have won the first two legs of the Triple Crown only to fail at Belmont. Twenty five more have won two of the three races, but maybe this year...

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On paper, Barbaro is the horse to beat, and after his decisive win at the Kentucky Derby, he appears capable of beating all comers. But this is horse racing and no matter how it looks on paper we still have to run the race.

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Yes, horse racing does have its problems and challenges, but it also has a lot going for it. It's the only sport offering legalized wagering in the majority of the United States and across most of the world. Why it's even legal to bet on horse racing in China where basic human rights are hard to come by.
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What makes this event so difficult to win? Several factors have to be considered. First there's the age of the horses. Triple Crown races are limited to 3 year olds, juveniles, all of whom officially have their birthday on January 1st of each year. By the first Saturday in May (the running of the Kentucky Derby), though most of the contestants will have actually reached their third birthday, they won't realize their full growth and potential until their fourth or fifth years.

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Now that Ah Day has passed on the Preakness, eight other horses will be looking to spoil Barbaro's bid for the second leg of the Triple Crown. Two are returning from their Derby bids and six more that skipped the Run for the Roses.

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Still, there are tons of bettors looking through rose colored glasses for the holy grail of betting systems that will let them make money without risking any. Well, there is a way to do that and it is called work! Gambling is called gambling for a reason, it’s risky. Let’s take a look at some sports betting systems.
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The most commonly occurring reason I have found for people consistently losing money at sports betting is that they have no "game plan". The most essential elements of a good game plan for betting purposes are a valid, proven Selection System and a proper Staking Plan. The Staking Plan alone won't cut it; first and foremost you must employ a worthwhile Selection System.

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If you are a novice gambler you probably haven’t heard the term but professional bettors who earn their livelihood from sports betting use the method all the time taking advantage of the variance in odds from the opinions of the diverse number of bookmakers. Even though it sounds as if it is a no risk situation that may not always be the case and there some issues that can cause you to lose.
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So, having established that using a good Selection System is an absolute must if you want to make money from sports betting, how does the average Bettor actually go about making his/her betting selections? My research shows me that, in the main (ignoring the extremes), there are generally two approaches taken:

- The more conservative group looks at the "Short Odds" calls, and plays safe by selecting only those matches where they themselves feel very confident about the outcome.

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