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?
Posts
123 comments:
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).
:)
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.
Your blog keeps getting better and better! Your older articles are not as good as newer ones you have a lot more creativity and originality now keep it up!
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Switching a service located outside of the United States it not hard to do. In fact it is quite easy since there are many quality services to choose from. The most difficult thing that you will need to do is find the one that best suits your needs.
And finally, in the first article in this series I mentioned being honest with yourself, because one of the biggest lies I have found that a tremendous number of Bettors are guilty of is denying to themselves how many times their Base Bank has been busted! If you too are guilty of this, please remember that until you face up to the truth with the determination to do something about it, you can't expect to turn the situation round in your favour.
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.
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 changes that are going to be made to the Wire Act are quite simple. First and foremost the internet will be added to the list of wire communications that are prohibited. Of course the internet was not around in 1961 so it was not included in the first draft. In addition, penalties for breaking the Wire Act will increase from a maximum of two years in prison to five.
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!
If you’re like me when you first saw the term “arbitrage sports betting” you just said, “huh?” You may even be reading this article because you were wondering. It is a relatively little method that can actually allow you to make money no matter who wins or loses. Kind of like heads I win, tails I win!
Finally, to insure that you do indeed have the best betting odds that you can get, it is crucial as a bettor to shop the money line and the odds. Any reputable sports book online would offer the best line for your wagers without coercion. However, once you have found the best deal, it is important to verify and scrutinize the odds based on the past performance of the particular teams involved you can make appropriate judgments that can be indicative of the weaknesses and strengths of the respective sporting teams. You should also do research on the sports players, injury lists, and the teams if possible.
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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:
- 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.
- The more adventurous group analyses the matches and odds on offer, and then makes selections based on their own gut feeling about how the matches will turn out, making sure that the odds match their concept of a "value" bet.
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We came across an article on ESPN.com written by Bill Finley entitled "2005 was a lousy year for horse racing." In his article Mr. Finley cites 9 reasons why 2005 was such a bad year for horse racing in America. Although we agree with several of his observations, number 8 on his list, "U.S. Pari-Mutuel Handle Falls", should have been dealt with more objectively.
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In the United States, races can occur on flat surfaces of either dirt or grass, generally for thoroughbred racing. Other tracks offer quarter horse racing]] and harness racing. The best events in US horse racing have been Kentucky Derby, which, together with the Preakness Stakes and the Belmont Stakes, form the Triple Crown for three-year-olds. However, in recent years the Breeders' Cup races, held at the end of the year, have been challenging the Triple Crown events, held early in.
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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Horse racing is one of the world's oldest sports. It is followed world wide with ardor and passion. The aspect of betting, adds a flavor to the races and people are turned into millionaires over night. Money flows in and out of hands in this sport making it exciting and thrilling at most times.
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.
Finally, realize that all the various bookmakers have their own rules and policies regarding how they settle bets done through arbitrage sports betting when they have such irregular results. As with the advice on pricing, be sure to check the rules of the individual bookmakers before you place your bets.
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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The second half was a completely different story; the French team started on fire, producing great opportunities. The first came at minute 52 when Lisandro made a 25-yard shot that tested Madrid’s goalkeeper, Iker Casillas. Casillas was clearly starting to feel the pressure produced by the French team. [url=http://www.pulsebet.com]himno real madrid[/url] Close to the end of the first half, Real Madrid seemed to lack ideas and, though they tried to score, the Whites were unable to disturb the local team.
A few short minutes after the opening of the game, in minute 5, the Meringues opened the score. A foul gave a free kick to Esteban Granero, who crossed a pass that was headed by Sergio Ramos, putting the scoreboard at 1-0. [url=http://www.pulsebet.com]ronaldo goals[/url] With the win, Real Madrid joins Barcelona at the top of the standings with 12 points. There is no doubt that this will be a very competitive season in La Liga.
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Minutes later, however, the Argentine Nicolas Young suffered a twist in his right knee, forcing him to retire from the game with seconds left in the first half. With the injury, the half ended at 2-0. [url=http://www.pulsebet.com]karim benzema[/url] Barcelona had other opportunities and some penalty appeals, but in the end the game finished 4-1 with a victory for Barca.
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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Everyone who is involved in any kind of gaming, gambling, or betting as heard the stories of legendary people who have supposedly created the next foolproof betting system and have used the system themselves to help them to avoid losing and get higher profits over the long haul. The fact is that there is not a system in existence that can guarantee you that you will definitely be successful and never lose.
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With this movement the United States has taken a different approach to online gambling. Whereas other countries are working with these services to regulate them, the United States is attempting to prohibit them once and for all. By doing this they are missing out on the ability to tax internet gambling instead of getting rid of it entirely. Conservative estimates have shown that taxing these services could make the government in upwards of $6 billion a year.
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.
- The more adventurous group analyses the matches and odds on offer, and then makes selections based on their own gut feeling about how the matches will turn out, making sure that the odds match their concept of a "value" bet.
Luck plays a major role in your winnings through a game of online bingo. Nevertheless, there are certain winning strategies in play at a game of online bingo. Hence, the result of your game depends on these strategies to quite an extent. Employ such winning strategies to enjoy and win good prize amounts at a game of online bingo.
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