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Katina Robertson, MD. Emory Family Medicine. AFP Journal Review. January 15, 2010 Issue. Articles Reviewed. Peripheral Nerve Entrapment and Injury in the Upper Extremity Vocal Cord Dysfunction Noninfectious Penile Lesions Outdoor Air Pollutants and Patient Health.

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afp journal review

Katina Robertson, MD

Emory Family Medicine

AFP Journal Review

January 15, 2010 Issue

articles reviewed
Articles Reviewed
  • Peripheral Nerve Entrapment and Injury in the Upper Extremity
  • Vocal Cord Dysfunction
  • Noninfectious Penile Lesions
  • Outdoor Air Pollutants and Patient Health
peripheral nerve injury
Peripheral Nerve injury
  • Peripheral Nerve Injury (PNI) in UE is common
  • Risk Factors
    • Superficial position
    • Long course through area at high risk of trauma
    • Narrow path through bony canal
pathophysiology
Pathophysiology
  • Three categories of nerve injury
    • Neurapraxia– least severe, focal damage of myelin fibers around axon. Limited course (days-wks)
    • Axonotmesis– more severe, axonal injury. Nerve regeneration possible but prolonged (months) and incomplete recovery
    • Neurotmesis– complete disruption of axon. Little chance of regeneration or clinical recovery
    • Mechanisms of nerve injury
      • Direct pressure
      • Repetitive microtrauma
      • Stretch- or compression- induced ischemia
differential diagnosis

SYMPTOMS OF UPPER EXTREMITY NERVE INJURIES

Differential Diagnosis
  • Consider PNI in pts with pain, weakness, parasthesias not related to known bone/soft tissue/vascular injury
shoulder arm
Shoulder & Arm

Axillary

Brachial Plexus

Long Thoracic

Spinal Accessory

Suprascapular

axillary nerve quadrilateral space syndrome
Axillary Nerve: Quadrilateral Space Syndrome
  • Mechanism
    • Shoulder dislocation
    • Upward pressure (e.g., from improper crutch use)
    • Repetitive overload activities (e.g., pitching a ball, swimming)
    • Arthroscopy or Rotator cuff repair
  • Symptoms
    • Arm fatigue w/ overhead activity or throwing
    • +/- associated paresthesias of lateral &posterior upper arm
  • Signs
    • Weak abduction
    • Weak external rotation
brachial plexus stinger
Brachial Plexus: Stinger
  • Mechanism
    • Collision sports (e.g. football)
  • Symptoms
    • Classic: acute onset paresthesias in upper arm
    • Paresthesias in circumferential pattern (not dermatomal)
    • Short duration: last seconds-minutes
    • Motor symptoms can develop at any point
  • Signs
    • Differentiate from C-spine injury (point tenderness, pain w/ neck motion, bilateral symptoms)immobilize
    • Motor weakness, can occur hrs-days after injury re-evaluate @ 24hrs, then every few days x 2wks
    • if recurrent stingers w/up the neck for underlying pathology predisposing to injury
  • Injury @ sporting event: All sxs resolve in 15 min + no C-spine injury may return to play, but repeat exam during event
long thoracic nerve
Long Thoracic Nerve
  • Mechanism
    • Blow to the shoulder
    • Chronic repetitive traction on nerve (e.g., tennis, swimming, baseball)
  • Symptoms
    • Diffuse shoulder or neck pain, worse with overhead motions
  • Signs
    • Winged scapula and weakness with forward elevation of arm
spinal accessory nerve
Spinal Accessory Nerve
  • Mechanism
    • Trapezius trauma
    • Shoulder dislocation
    • Iatrogenic (Radical neck dissection, carotid endarterectomy, and cervical node biopsy)
  • Symptoms
    • Generalized shoulder pain and weakness
  • Signs
    • Shoulder asymmetry
    • Shoulder sag, inability to shrug shoulder to ear
    • Weakness of forward arm elevation above horizontal plane
    • Chronic injury trapezius atrophy
suprascapular nerve
Suprascapular Nerve
  • Mechanism
    • repetitive overhead loading
    • Glenoid labrum tear +/- cyst formation at suprascapular notch
  • Symptoms
    • Motor weakness
  • Signs
    • Infraspinatus- weak external rotation of the arm
    • Supraspinatus- weak arm elevation, most @ 90 to 180 degrees
    • Differentiate from rotator cuff tear MRI
forearm elbow
Forearm & Elbow

Median

Radial

Ulnar

median nerve at the elbow pronator syndrome
Median Nerve at the elbow: Pronator Syndrome
  • Mechanism
    • pronator teres m. -- compress the median nerve
  • Symptoms
    • Forearm discomfort and aching w/activities requiring repetitive pronation (especially w/elbow extended)
    • +/- Paresthesias in the thumb and first two digits
  • Signs
    • Sensory loss over thenar eminence (not seen in carpal tunnel)
    • Negative Tinel
    • Negative Phalen
radial nerve at the elbow radial tunnel posterior interosseous nerve syndromes
Radial Nerve at the elbow: Radial Tunnel & Posterior Interosseous Nerve Syndromes
  • Mechanism
    • divides into a superficial branch (sensory only) and a deep branch (posterior interosseous nerve) at the lateral elbow– compression at any point
  • Symptoms
    • Pain that radiates from lateral elbow to forearm and wrist
    • Pain with wrist extension or grip (shaking hands, turning doorknob)
    • Generalized hand and forearm weakness
  • Signs
    • Differentiate from lateral epicondylitis (tennis elbow)
    • Both– pain with supination against resistance w/ elbow and wrist extended
    • Both– pain resisted extension of middle finger
    • **Maximal tenderness over anterior radial neck
    • If motor symptoms (weakness of digit & wrist extension)– likely post. interosseous
ulnar nerve at the elbow cubital tunnel syndrome
Ulnar Nerve at the elbow: Cubital Tunnel Syndrome
  • Mechanism
    • Very superficial– injury from acute contusion or chronic compression
  • Symptoms
    • Paresthesias of the fourth and fifth digits
    • elbow pain radiating to the hand (sxs may be worse w/ prolonged or repetitive elbow flexion)
  • Signs
    • Sensory loss
    • Motor: Weak digit abduction, weak thumb abduction, and weak thumb-index finger pinch
    • Late finding– decreased power grip
hand wrist
Hand & Wrist

Median

Radial

Ulnar

median nerve at the wrist carpal tunnel syndrome
Median Nerve at the wrist: Carpal Tunnel Syndrome
  • Mechanism
    • Repetitive fine movements– chronic compression
  • Symptoms
    • Paresthesias of thumb, 2nd & 3rd digits
    • +/- forearm pain
  • Signs
    • Hypalgesia (positive LR of 3.1)
    • Abnormality in a Katz hand diagram
    • Positive Tinel & Phalen signs
    • Late findings: weak thumb abduction, thenar atrophy
katz hand diagram
Katz Hand Diagram
  • classic carpal tunnel syndrome (CTS) for both hands; B. probable CTS, because of symptoms in palm; C. unlikely CTS
radial nerve at the wrist handcuff neuropathy
Radial Nerve at the wrist: Handcuff Neuropathy
  • Mechanism
    • Superficial branch of the radial nerve crosses the volar wrist-- vulnerable to compression by anything wound tightly around the wrist (e.g. handcuffs)
  • Symptoms
    • Numbness on dorsal hand (usually on radial side)
  • Signs
    • Decreased sensation to soft touch and pinprick over the dorsoradial hand, dorsal thumb, and index digit
    • Motor intact
ulnar nerve at the wrist cyclist s palsy
Ulnar Nerve at the wrist: Cyclist’s Palsy
  • Mechanism
    • Common in cyclists -- ulnar nerve compressed against handlebar during cycling
    • Activities involving prolonged pressure on the volar wrist (e.g., jackhammer use)
  • Symptoms
    • Paresthesias in the 4th and 5th digits
    • Weakness uncommon -- motor portion of nerve less superficial at wrist
  • Signs
    • Unless activity is prolonged or chronic-- results of the sensory examination are normal
    • Numbness resolves within hours after stopping the activity
diagnostic testing
Diagnostic Testing
  • Plain XR: fracture or cervical spondyloarthropathy
electrodiagnostic testing
Electrodiagnostic Testing
  • Nerve Conduction Studies– Evaluate motor and sensory nerves; Demyelination = slowing of conduction velocity
    • Helpful in confirming diagnosis in pts with atypical presentations
    • In pts with “classic” presentation, NCS do not change diagnosis or management, i.e. don’t bother
  • EMG– useful in conjunction with NCS to distinguish central vs peripheral neuropathies
peripheral nerve injury1
Peripheral Nerve Injury

A football player presents with upper arm paresthesias following a tackle. Which one of the following statements about a brachial plexus nerve injury (i.e., stinger) is correct?  (check one)

A. Paresthesias typically have a dermatomal pattern.

B. The athlete should not return to competition or activity for two weeks.

C. Bilateral symptoms make the diagnosis more likely.

D. Paresthesias typically have a circumferential pattern.

peripheral nerve injury2
Peripheral Nerve Injury

A patient works on an assembly line doing repetitive overhead work. He has weakness with external rotation of the right arm and when he raises his right arm above his shoulder. Which one of the following nerves is likely involved?  (check one)

A. Suprascapular nerve.

B. Posterior interosseus nerve.

C. Radial nerve.

D. Ulnar nerve.

peripheral nerve injury3
Peripheral Nerve Injury

Which of the following has/have been shown to provide short-term benefit for patients with carpal tunnel syndrome?  (check all that apply)

A. Nonsteroidal anti-inflammatory drugs.

B. Corticosteroid injection.

C. Vitamin B6.

D. Splinting.

vocal cord dysfunction1
Vocal Cord Dysfunction
  • Definition: inappropriate vocal cord motion produces partial airway obstructionsubjective respiratory distress
  • Normal-- person breathes  cords move away from midline during inspiration & slightly toward the midline during expiration
  • Dysfunction-- person breathes  cords move toward the midline during inspiration or expiration = obstruction
  • Other terms: paradoxical vocal cord dysfunction, paradoxicalvocal fold motion, factitious asthma
clinical presentation
Clinical Presentation
  • Women >men; Ages 20-40
  • Symptoms -- recurrent , subj. resp distress
    • Inspiratory stridor
    • Cough
    • Choking sensation
    • Throat tightness
  • 59% with VCD, previously Dx of asthma
  • Sxs usually mild, intermittent
  • Laryngospasm (subtype of VCD)
    • brief involuntary spasm of vocal cords producing aphonia and acute resp distress
    • common complication of anesthesia
  • Spasmodic Dysphonia
    • hoarseness and voice strain when the abnormal vocal cord motion occurs during speech

Vocal Cord Dysfunction

differential diagnosis1
Differential Diagnosis

Vocal Cord Dysfunction

precipitating factors
Precipitating Factors
  • Exercise: consider in pts with exercise-induced asthma not improved with bronchodilators
  • Psychosocial Conditions: stress disorder, anxiety, depression, and panic attack
  • Irritants: environmental/occupational ammonia, dust, smoke, soldering fumes, and cleaning chemicals
  • Rhinosinusitis
  • GERD
  • Medications:neuroleptics can cause transient VCD (considered focal dystonic reaction)

Vocal Cord Dysfunction

diagnosis
Diagnosis
  • PFT w/ a flow-volume loop = most common diagnostic test
    • expiratory loop = normal
    • inspiratory loop = flattened (c/w extrathoracic upper airway obstruction)
  • Flexible Laryngoscopy= diagnostic standard, direct visualization

Vocal Cord Dysfunction

treatment
Treatment

Vocal Cord Dysfunction

vocal cord dysfunction2
Vocal Cord Dysfunction

Which of the following is/are common triggers of vocal cord dysfunction?  (check all that apply)

A. Gastroesophageal reflux disease.

B. Airborne irritants.

C. Anticholinergics.

D. Exercise.

vocal cord dysfunction3
Vocal Cord Dysfunction

Which of the following is/are the most valuable diagnostic tests for confirming vocal cord dysfunction?  (check all that apply)

A. Methacholine challenge test.

B. Flexible laryngoscopy.

C. Pulmonary function testing with a flow-volume loop.

D. Arterial blood gases.

vocal cord dysfunction4
Vocal Cord Dysfunction

Which of the following symptoms is/are often present in patients with vocal cord dysfunction?

(check all that apply)

A. Cough.

B. Inspiratory stridor.

C. Choking sensation.

D. Throat tightness.

noninfectious penile lesions
Noninfectious Penile Lesions

Inflammatory Papulosquamous

Neoplastics

anatomy
Anatomy

Noninfectious Penile Lesions

psoriasis
Psoriasis
  • Epidemiology
    • bimodal peaks at 16-22 yo & 57-60 yo
    • Prevalence 1-2%, up to 40% have GU involvement
  • Symptoms
    • red or salmon-colored, papulosquamous, circinate plaques, w/ white or silvery scales
    • Pruritis
    • Exacerbated by-- stress, excess etoh &tobacco use, acute infections (strep), medications(e.g., beta blockers, lithium)

Noninfectious Penile Lesions

psoriasis1
Psoriasis
  • Treatment
    • 1st line options for localized disease
      • mild to mod strength topical corticosteroids (CS)—qDay
      • Vitamin D3 analogues– qDay or BID
    • Prevent skin atrophy–
      • use <50 mg ultrapotent or <100 mg potent topical CS over long-term
      • dose ultrapotent daily x 2wks then q weekend
    • Lesions may recur when CS discontinued
    • If long-term therapy required, tacrolimus (Protopic) or pimecrolimus (Elidel) may decrease risk of atrophy
    • Refractory cases– dermatology referral
  • Diagnosis
    • Clinical systemic signs (nail pitting, arthritis, other skin)
    • If atypical– punch or shave biopsy

Noninfectious Penile Lesions

lichen sclerosus balanitis xerotica obliterans
Lichen Sclerosus(balanitisxeroticaobliterans)
  • Epidemiology
    • All ages; ave age 42yo
    • Prevalence..? 1 in 300
    • 4-6% assoc w/ squamous cell carcinoma (SCC)
  • Signs/Symptoms
    • hypopigmented lesion
    • texture like crinkled paper/cellophane.
    • glans penis and prepuce involv
    • Bullae, erosions, or atrophy
    • phimosis, painful erections, obstructive voiding, itching, pain, and bleeding
    • DDX: carcinoma in situ, leukoplakia, and scleroderma

Noninfectious Penile Lesions

lichen sclerosus balanitis xerotica obliterans1
Lichen Sclerosus(balanitisxeroticaobliterans)
  • Treatment
    • Goal: decr symptoms & prevent malignant transformation
    • mod to ultrapotent fluorinated topical CS
    • Surgery if persistent dz or h/o SCC
      • Circumcision if limited to glans and prepuce
      • Severe cases– reconstructive surgery
    • Systemic agents (e.g. retinoids) for severe refractory cases
    • Long term f/u to monitor for malignant transformation

Noninfectious Penile Lesions

angiokeratomas
Angiokeratomas
  • Epidemiology
    • Age >40yo; white males
    • Prevalence <1%
  • Signs/Symptoms
    • well-circumscribed, red or blue papules, 1 to 6 mm
    • Clinical diagnosis
      • Usuglans penis; also involv scrotum, groin, thighs, abdominal wall
      • Involv of penile shaft, suprapubic area, and sacrum a/wFabry disease– referral needed
    • rare intermittent bleeding, pain, or pruritus
    • Tx options: (if symptomatic) surgery, cryoablation, electrocautery, and laser ablation

Noninfectious Penile Lesions

lichen nitidus
Lichen Nitidus
  • Epidemiology: uncommon
  • Signs/Symptoms
    • Discrete, slightly elevated, hypopigmented papules, approx 1 mm
    • Can involve upper limbs &abdomen
    • Diff from pearly papulesring-like distribution on coronal sulcus
    • Tx options: for cosmesis-- corticosteroids, vitamin A analogues, cyclosporine (Sandimmune), itraconazole (Sporanox), and phototherapy

Noninfectious Penile Lesions

lichen planus
Lichen Planus
  • Epidemiology: uncommon but ¼ affected have GU lesions
  • Signs/Symptoms
    • raised, violaceous, flat-topped, polygonal papules
    • Fine white streaks (Wickham striae), on surface
    • Pts c/o pruritus and soreness
    • Biopsy ulcerated/indurated lesions to r/o SCC
    • Tx options: variable response
      • Potent CS daily vsUltrapotent CS qWknd
      • If refractory and isolated to prepuce-- circumcision

Noninfectious Penile Lesions

zoon balanitis
Zoon Balanitis
  • Epidemiology:
    • Men ; usu Ages 50-62 yo
  • Signs/Symptoms
    • Patches
      • bright red or brown,
      • shiny with red specks /spots
      • sharply demarcated
      • occur on glans penis, inner prepuce, or coronal sulcus
    • Lesions – tend to bleed +/- erode
    • Mimic carcinoma in situ-- biopsy

Noninfectious Penile Lesions

carcinoma in situ
Carcinoma in Situ
  • Pre-malignant, restricted to skin
  • Epidemiology:
    • uncircumcised men >60 yo
    • Progress to SCC in 5-30% pts
  • Etiology:
    • Primarily HPV
    • Other factors: smegma, trauma
  • Signs/Symptoms
    • 2-35 mm; involvglans penis, urethral meatus, frenulum, coronal sulcus, and prepuce
    • Lesions= raised, beefy red, velvety, irreg shaped plaques, may ulcerate
    • Velvety plaques of glans = erythroplasia of Queyrat
    • Keratotic plaques on shaft, scrotum, or perineum = Bowen disease
    • approx 50% have pruritus and pain

Noninfectious Penile Lesions

carcinoma in situ1
Carcinoma in Situ
  • Dx: shave biopsy adequate
  • Treatment
    • Prepuce only-- circumcision
    • Other-- Mohs micrographic surgery
    • ? Radiation for non-surgical candidates
    • ? Imiquimod (Aldara)
    • fluorouracil, curettage, local excision, laser ablation a/w significant recurrence

Noninfectious Penile Lesions

invasive squamous cell carcinoma
Invasive Squamous Cell Carcinoma
  • Epidemiology:
    • Rare; 2-3 cases/100,000 men
    • Peak Incidence men >70 yo
    • SCC 95% of penile cancers
  • Risk Factors
    • HPV
    • Lichen sclerosus
    • Smegma
    • Smoking
    • Older age
    • Poor hygeine
    • Foreskin
    • phimosis
  • Signs/symptoms
    • Early stage: painless lump/ ulcer
    • Progress to thickened skin & wart-like growth
    • sometimes a/w foul discharge

Noninfectious Penile Lesions

invasive squamous cell carcinoma1
Invasive Squamous Cell Carcinoma
  • Signs/symptoms (Cont’d)
    • Exophytic or fungating SCC--large, irreg shape
    • Exophytic lesions -- can cause phimosis (mass not visible until prepuce retracted)
    • Endophytic SCC -- ulcerative and infiltrating lesions

Noninfectious Penile Lesions

invasive squamous cell carcinoma2
Invasive Squamous Cell Carcinoma
  • Diagnosis: confirmed w/ biopsy (excision vs incision based on size)
  • Treatment
    • low-grade/low-stage tumors: organ-sparing techniques, (e.g. Mohs micrographic surgery)
    • Prepuce only: circumcision
    • Higher-stage tumors (i.e., T2 to T4): Penile amputation is standard treatment
    • Partial penectomy, laser therapy, radiation, and brachytherapy have been attempted as alternatives to radical penectomy

Noninfectious Penile Lesions

noninfectious penile lesions1
Noninfectious Penile Lesions

A patient presents with red plaques on his penis. He also reports a history of silvery scales on his elbows that were diagnosed as psoriasis. Which one of the following statements about this patient’s treatment is correct?  (check one)

A. A minimum daily dosage of 50 g of ultrapotent topical corticosteroids is recommended.

B. First-line treatment includes oral corticosteroids.

C. Tacrolimus (Protopic) is inappropriate for long-term use.

D. Vitamin D3 analogues should be reserved for refractory cases.

E. Weekend dosing of topical corticosteroids reduces the risk of atrophy.

noninfectious penile lesions2
Noninfectious Penile Lesions

A 40-year-old man presents with hypopigmented penile lesions, phimosis, painful erections, and erosions that itch and bleed. The lesions are limited to the glans penis and prepuce. Which one of the following statements about this patient’s condition is correct?   (check one)

A. Topical corticosteroids aggravate the lesions.

B. Lichen sclerosus is usually self-limiting.

C. Timely treatment may prevent malignant transformation.

D. Circumcision is contraindicated.

noninfectious penile lesions3
Noninfectious Penile Lesions

Which of the following penile lesions has/have potential for malignant transformation?  (check all that apply)

A. Zoon balanitis.

B. Lichen sclerosis.

C. Angiokeratomas.

D. Erythroplasia of Queyrat.

air pollutants
Air pollutants
  • Federal Clean Air Act– requires EPA to set National Ambient Air Quality Standards (NAAQS) for certain pollutants
  • Six Major Pollutants
    • ozone, particulate matter (PM), carbon monoxide, nitrogen oxides, sulfur dioxide, and lead

Outdoor Air Pollutants

air pollutants1
Air pollutants
  • Does your local area meet EPA standards? Go to http://airnow.gov

Outdoor Air Pollutants

air pollutants2
Air pollutants
  • AQI = information about local air quality, potential health effects, and actions to take to protect when air pollutants reach unhealthy levels

Outdoor Air Pollutants

air pollutants3
Air pollutants

Outdoor Air Pollutants

air pollutants patient health
Air Pollutants & Patient Health

Which one of the following major air pollutants, or “criteria” pollutants, is thought to be the most widespread and serious threat to health in the United States?  (check one)

A. Carbon monoxide.

B. Particulate matter.

C. Nitrogen oxides.

D. Sulfur dioxide

air pollutants patient health1
Air Pollutants & Patient Health

Which one of the following statements most accurately reflects the health advice of the U.S. Environmental Protection Agency to the general population when the Air Quality Index is 130 for ozone?  (check one)

A. Everyone should reduce prolonged outdoor exertion.

B. No specific health advice is given.

C. Persons with asthma should avoid all outdoor exertion.

D. Persons with chronic obstructive pulmonary disease should reduce prolonged outdoor exertion.

E. Older adults should avoid prolonged outdoor exertion.

air pollutants patient health2
Air Pollutants & Patient Health

Which of the following actions is/are recommended to reduce exposure to air pollution?  (check all that apply)

A. Opening windows on sunny days to reduce indoor ozone levels.

B. Increasing physical activity.

C. Using air conditioning in recirculation mode.

D. Adjusting exercise schedules to avoid times of day when air pollution levels are highest.