Oral and Maxillofacial Surgery Review: A Study Guide

Library of Congress Cataloging-in-Publication Data

Oral and maxillofacial surgery review : a study guide / edited by Din

Lam, Daniel Laskin.

      p. ; cm.

  ISBN 978-0-86715-674-4 (softcover)

  I. Lam, Din, editor. II. Laskin, Daniel M., 1924- , editor.

  [DNLM: 1. Oral Surgical Procedures--methods. WU 600]

  RK529

  617.5’22--dc23

  2015002883

© 2015 Quintessence Publishing Co, Inc

Quintessence Publishing Co Inc

4350 Chandler Drive

Hanover Park, IL 60133

www.quintpub.com

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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Editor: Bryn Grisham

Design and production: Kaye Clemens

Cover design: Ted Pereda

Printed in the USA

Contents

Preface

Contributors

1 Medical Assessment
Alia Koch and Steven M. Roser

2 Anesthesia
Jason Jamali and Stuart Lieblich

3 Dentoalveolar Surgery
Esther S. Oh and George Blakey

4 Dental Implantology
Christopher Choi and Daniel Spagnoli

5 Orthognathic Surgery
David Alfi and Jaime Gateno

6 Trauma
Daniel E. Perez and Edward Ellis III

7 PathologyDin Lam and Eric R. Carlson

8 Maxillofacial Reconstruction
Din Lam and Andrew Salama

9 Orofacial Pain
David W. Lui and Daniel M. Laskin

10 The TMJ
David W. Lui and Daniel M. Laskin

11 Craniofacial Surgery
Jennifer Woerner and Ghali E. Ghali

12 Cosmetic Surgery
David E. Webb and Peter D. Waite

Index

Preface

When faced with a board or recertification examination, or just wanting to update your knowledge in oral and maxillofacial surgery, there is always the dilemma of where to begin and what and how much to study. This review book is designed to help you with this process. The format involves a detailed outline of the important items of didactic and clinical information in the 12 major areas of oral and maxillofacial surgery combined with numerous tables, summary charts, and useful mnemonics and surgical tips. Each chapter is also supplemented with many clinical photographs, diagrams, and photomicrographs, where appropriate.

The various chapters were each developed by two authors: (1) a young oral and maxillofacial surgeon who was board certified in recent years and is therefore very familiar with the process and the content, and (2) a more senior surgeon who has been a board examiner and/or involved in the recertification process and is therefore knowledgeable and experienced in the essential clinical aspects of the specialty.

To use this book as a review or study guide, it is suggested that you first read each chapter to determine what information is already familiar to you, what is new and needs to be learned, and what are the areas in which you desire more information from other sources such as the list of recommended reading at the end of each chapter. The last material should then be annotated where indicated in the various chapters. The book now becomes your study manual as well as a quick and easy way to review the material again just prior to the examination and a handy reference source during clinical practice.

We would like to express our deep appreciation and thanks to all of the contributing authors who gave so freely of their time and knowledge and who helped make this book a reality. Finally, we would like to thank Lisa Bywaters and Bryn Grisham of Quintessence Publishing for their expertise and guidance during the editorial process. Their concern for the success of this book was no less than ours.

Contributors

David Alfi, DDS, MD

Attending Oral and Maxillofacial Surgeon

Department of Oral and Maxillofacial Surgery

Houston Methodist Hospital

Houston, Texas

Assistant Professor of Clinical Surgery

Weill Cornell Medical College

Cornell University

New York, New York

George Blakey, DDS

Director of Oral and Maxillofacial Surgery Residency Program

Distinguished Associate Professor

Department of Oral and Maxillofacial Surgery

School of Dentistry

University of North Carolina

Chapel Hill, North Carolina

Eric R. Carlson, DMD, MD

Professor and Kelly L. Krahwinkel Chair

Department of Oral and Maxillofacial Surgery

Director of Oral and Maxillofacial Surgery Residency Program

University of Tennessee Graduate School of Medicine

Director of Oral/Head and Neck Oncologic Surgery Fellowship Program

Cancer Institute

University of Tennessee Medical Center

Knoxville, Tennessee

Christopher Choi, DDS, MD

Private Practice Limited to Oral and Maxillofacial Surgery

Rancho Cucamonga, California

Assistant Professor

Department of Oral and Maxillofacial Surgery

School of Dentistry

Loma Linda University

Loma Linda, California

Edward Ellis III, DDS, MS

Professor and Chair

Department of Oral and Maxillofacial Surgery

School of Dentistry

University of Texas Health Science Center at San Antonio

San Antonio, Texas

Jaime Gateno, DMD, MD

Chair, Department of Oral and Maxillofacial Surgery

Houston Methodist Hospital

Houston, Texas

Professor of Clinical Surgery

Weill Cornell Medical College

Cornell University

New York, New York

Ghali E. Ghali, DDS, MD

Professor and Chairman

The Jack W. Gamble Chair

Department of Oral and Maxillofacial Surgery

Louisiana State University Health Sciences Center—Shreveport

Shreveport, Louisiana

Jason Jamali, DDS, MD

Clinical Assistant Professor

Department of Oral and Maxillofacial Surgery

College of Dentistry

University of Illinois at Chicago

Chicago, Illinois

Alia Koch, DDS, MD

Assistant Professor

Department of Oral and Maxillofacial Surgery

College of Dental Medicine

Columbia University

New York, New York

Attending Oral and Maxillofacial Surgeon

New York Presbyterian Hospital

Columbia University Medical Center

New York, New York

Din Lam, DMD, MD

Adjunct Assistant Professor

Department of Oral and Maxillofacial Surgery

School of Dentistry

Virginia Commonwealth University

Richmond, Virginia

Daniel M. Laskin, DDS, MS

Professor and Chairman Emeritus

Department of Oral and Maxillofacial Surgery

School of Dentistry

Virginia Commonwealth University

Richmond, Virginia

Stuart Lieblich, DMD

Clinical Professor

Department of Oral and Maxillofacial Surgery

School of Dental Medicine

University of Connecticut

Farmington, Connecticut

Private Practice Limited to Oral and Maxillofacial Surgery

Avon, Connecticut

David W. Lui, DMD, MD

Assistant Professor

Department of Oral and Maxillofacial Surgery

School of Dentistry

Virginia Commonwealth University

Richmond, Virginia

Esther S. Oh, DDS, MD

Clinical Assistant Professor

Department of Oral and Maxillofacial Surgery

College of Dentistry

University of Florida

Gainesville, Florida

Daniel E. Perez, DDS

Associate Professor

Department of Oral and Maxillofacial Surgery

School of Dentistry

University of Texas Health Science Center at San Antonio

San Antonio, Texas

Steven M. Roser, DMD, MD

DeLos Hill Professor and Chief

Division of Oral and Maxillofacial Surgery

Department of Surgery

Emory University School of Medicine

Atlanta, Georgia

Andrew Salama, DMD, MD

Assistant Professor, Department of Oral and Maxillofacial Surgery

Director, Advanced Specialty Education Program in Oral and Maxillofacial Surgery

Henry M. Goldman School of Dental Medicine

Boston University

Boston, Massachusetts

Daniel Spagnoli, DDS, MS, PhD

Associate Professor and Chairman

Department of Oral and Maxillofacial Surgery

School of Dentistry

Louisiana State University Health Sciences Center—New Orleans

New Orleans, Louisiana

Peter D. Waite, DDS, MD, MPH

Professor and Chairman

Department of Oral and Maxillofacial Surgery

School of Dentistry

University of Alabama at Birmingham

Birmingham, Alabama

David E. Webb, Maj. USAF, DC

Attending Oral and Maxillofacial/Head and Neck Surgeon

Department of Oral and Maxillofacial Surgery

David Grant USAF Medical Center

Travis AFB, California

Jennifer Woerner, DMD, MD

Assistant Professor and Fellowship Director

Craniofacial and Cleft Surgery

Department of Oral and Maxillofacial Surgery

Louisiana State University Health Sciences Center—Shreveport

Shreveport, Louisiana

Chapter 1

Medical Assessment

Alia Koch and Steven M. Roser

Cardiovascular Disease

Acute Coronary Syndrome

Major blood vessels supplying the heart are damaged/diseased by cholesterol plaques, which cause the vessels to narrow. In turn, less blood reaches the myocardium, leading to an acute coronary syndrome.

• Symptoms: Dull substernal pain and pain radiating to left arm and jaw; associated with diaphoresis, dyspnea

• Diagnosis: electrocardiogram (ECG), cardiac enzymes

– ST segment elevation myocardial infarction (STEMI)

∘ Treatment: Immediate reperfusion (angioplasty or thrombolytic therapy) within 12 hours of onset of chest pain

– Non-ST segment elevation myocardial infarction (NSTEMI)

∘ Treatment: Medical therapy (aspirin, beta blockade, angiotensin-converting enzyme [ACE] inhibitor)

– Unstable angina

∘ Treatment: Medical therapy (same as NSTEMI)

Congestive Heart Failure

• Systolic heart failure: Reduced ejection fraction (< 40%), S3 murmur, dilated left ventricle

• Diastolic heart failure: Preserved ejection fraction (> 50%), S4 murmur, left ventricle hypertrophy

• Symptoms: Chest pain, shortness of breath, orthopnea, extremity swelling, jugular vein distention

• Diagnosis

– Echocardiogram: Evaluate heart motion, ejection fraction

– ECG: Evaluate changes in ECG, heart strain

– Stress test: Evaluate coronary artery disease

– Brain natriuretic peptide: Normal value rules out acute heart failure

– Chest radiograph: Evaluate heart size, fluid in the intrathoracic cavity

Classification of congestive heart failure (CHF)

Valvular Disease

Arrythmias

CHADS₂ scoring table

Stroke risk assessment in atrial fibrillation to determine necessity of anticoagulation or antiplatelet treatment.

Stroke risk assessment

Heart block (Fig 1-1)

Hypertension

• Primary hypertension: No identifiable cause

• Secondary hypertension: Identifiable cause, some listed below

– Renal artery stenosis

– Diabetic nephropathy

– Thyroid disease

– Cocaine use

– Pheochromocytoma

– Obstructive sleep apnea

• Diagnosis: At least two elevated BP readings on at least two different occasions

– Prehypertension: Systolic blood pressure (SBP) from 120 to 130 mm Hg, diastolic blood pressure (DBP) from 80 to 89 mm Hg

– Stage 1: SBP from 140 to 159 mm Hg, DBP from 90 to 99 mm Hg

– Stage 2: SBP ≥ 160 mm Hg, DBP ≥ 100 mm Hg

• Etiology: Obesity, familial, smoking, diabetes, kidney disease, Cushing syndrome, catecholamines, obstructive sleep apnea

• Treatment: Diet, weight reduction, aerobic activity, sodium restriction, medications

Medications

Hypertensive emergencies

Infective Endocarditis (IE)

Duke criteria for diagnosis

• Definite IE: 2 major; 1 major and 3 minor; 5 minor

• Possible IE: 1 major and 1 minor; 3 minor

Treatment

• Native valve endocarditis: Vancomycin and gentamicin

• Prosthetic valve endocarditis: Vancomycin, rifampin, and gentamicin

• Culture positive: Treat organism

Surgical Management of Patients on Cardiovascular Medications

Preoperative treatment decision algorithm

MET, metabolic equivalent of task.

Respiratory Disease

Normal Lung Volumes (Figs 1-2 and 1-3)

Common abbreviations

• Residual volume (RV): Air left after maximal expiration

• Tidal volume (TV): Entering air during normal inspiration

• Expiratory reserve volume (ERV): Air that can still be expired after normal expiration

• Functional residual capacity (FRC): RV + ERV

Abbreviations associated with pulmonary function tests (PFTs)

• Forced expiratory volume in 1 second (FEV1): Air that can be expired in 1 second

• Forced vital capacity (FVC): Maximum volume of air that can be forcefully exhaled

• Total lung capacity (TLC): FVC + RV

Common types of pulmonary disease

Obstructive versus restrictive lung disease

Chronic Respiratory Diseases

Asthma

• Definition: Chronic obstructive reversible disorder of airway hyper-reactivity causing dyspnea, cough, wheezing, and chest tightness

• Diagnosis: Diagnosed by showing reversible obstructive lung disease with normal diffusing capacity

• Exam will show expiratory wheezing during acute exacerbations, with a prolonged expiratory phase

• Severe attacks will have pulsus paradoxus, accessory muscle use, and silent chest

Medications for treatment of asthma

Chronic Obstructive Pulmonary Disease (COPD)

• Definition: Nonreversible chronic airway restriction

• Symptoms: Worsening dyspnea, increasing cough and change in sputum, hyperinflation, prolonged expiration, wheezing

• Chronic bronchitis: Chronic productive cough for 3 months in 2 consecutive years; “blue bloater”

• Emphysema: Enlargement of airways and wall destruction distal to bronchioles; “pink puffer;” pursed-lip breathing

• Diagnosis:

– PFTs to evaluate FEV1, FEV1/FVC, and postbronchodilator values

– Arterial blood gas (ABG) analysis will show hypercarbia, hypoxemia

– Evaluate for alpha 1 antitrypsin deficiency in emphysema patients

– Chest radiograph

Classification of COPD

Acute Pulmonary Diseases

Acute respiratory distress syndrome (ARDS)

• Definition: Acute, hypoxemic respiratory failure associated with bilateral lung infiltrates

• Etiology: Pneumonia, aspiration, trauma, acute pancreatitis, inhalational injury, reperfusion injury

• Symptoms: Rapid onset of dyspnea, tachypnea, diffuse lung crackles

• Diagnosis: Bilateral infiltrates on chest radiograph, ratio of PaO₂ to FiO₂ < 200

• Treatment

– Treat underlying cause

– Use mechanical ventilation with low tidal volumes of 6 cc/kg

– Positive end-expiratory pressure (PEEP)

– Conservative fluid management

Pulmonary embolus (PE)

• Risk factors: Prior PE, pregnancy, malignancy, obesity, immobility, stroke, tobacco use, recent surgery, trauma

• Symptoms: Dyspnea, hemoptysis, fever, cough, tachypnea, tachycardia

• Diagnosis

– Modified Wells criteria (see table below)

– D-dimer test: Only helpful to exclude PE in low-risk patients (Wells score ≤ 4)

– Computed tomography angiography (CTA): Multidetector-row CTA (MDCTA) is standard pulmonary angiography when CTA is not available

– ECG: New right heart strain; nonspecific anterior T wave inversions; sinus tachycardia; large S wave in lead I, a large Q wave in lead III, and an inverted T wave in lead III (S1Q3T3)

– ABG analysis: Respiratory alkalosis with increased alveolar arterial gradient

– V/Q scan: Ventilation without perfusion suggests PE

• Treatment

– Heparin as bridge to coumadin to maintain INR of 2 to 3 for at least 3 to 6 months

– Inferior vena cava filter if anticoagulation is contraindicated

– Direct thrombin inhibitors for patients with heparin-induced thrombocytopenia (HIT)

– Thrombolysis for massive PE

– Thrombectomy

Modified Wells criteria

To determine likelihood of PE.

• ≤ 4 = Unlikely PE

• > 4 = Likely PE

Contraindications to anticoagulation

Renal Disease

Acute Renal Failure

• Increase in serum creatinine ≥ 0.3 mg/dL over baseline

• Urine output less than 0.5 cc/kg/hour for more than 6 to 12 hours

Prerenal

• Etiology: Volume depletion, severe liver disease, severe CHF

• Diagnosis: Fractional excretion of sodium (FENa) < 1%; ratio of blood urea nitrogen (BUN) to creatinine, 10–15:1; high urinary osmolarity

• Treatment: Fluids (rapid improvement with fluids)

Renal

• Etiology: Tubular injury, acute tubular necrosis, interstitial disease, glomerular disorder

• Diagnosis: FENa >1%; BUN-to-creatinine ratio, 10–15:1; muddy brown casts

• Treatment: Remove underlying agent, treat underlying cause

Postrenal

• Etiology: Urinary tract obstruction

• Diagnosis: FENa < 1%, oliguria/anuria

• Treatment: Remove obstruction

Need for emergent dialysis

Chronic Renal Failure (CRF)

• Permanent loss of renal function for at least 3 months

• Etiology: Hypertension, diabetes, renal artery stenosis, polycystic kidney disease

• Diagnosis: Glomerular filtration rate (GFR) < 15 mL/minute, albuminuria > 30 mg/day

• Treatment: Management of hypertension with ACE inhibitors and angiotensin receptor blockers, low density lipoproteins < 100 mg/dL

• Predictor of disease progression: Proteinuria

Severity of chronic renal disease based on GFR

Severity of chronic renal disease based on albuminuria

Complications of CRF

Urinalysis interpretation

Nephrotic Disease

• Symptoms: Peripheral edema, hypoalbuminemia, hyperlipidemia, increased proteinuria

• Diagnosis: Urinalysis shows oval fat bodies, proteinuria, and 24-hour urine protein > 3.5 g/day

Primary nephrotic syndrome

Direct damage to glomeruli causing massive proteinuria.

Secondary nephrotic syndrome

Damage of glomeruli secondary to systemic disease.

Nephritic Disease

Inflammatory disorder in the glomeruli.

• Glomerulonephritis: RBCs in urine with or without cellular casts and varying degrees of proteinuria

• Symptoms: Hypertension, edema, oliguria, hematuria

• Diagnosis: Red blood cell (RBC) casts in urine, renal biopsy

• Types of glomerulonephritis

– Immune complex: Decreased complement levels

– Pauci immune: Normal complement levels

Immune complex glomerulonephritis

Pauci immune glomerulonephritis

Nephrotic Versus Nephritic Disease

Acid-Base Disorders

Arterial Blood Gas (ABG) Versus Venous Blood Gas (VBG)

• ABG: The gold standard to evaluate acid-base disorders

– Invasive procedure

– Serial examinations necessary

– Risk of hematoma and nerve injury

• VBG

– Easier to obtain and less injury to patients

– Data (pH, bicarbonate [HCO₃], lactate, and base excess) are similar to those found in ABG

– Partial pressure of carbon dioxide (PaCO₂) is also well correlated except in patients with severe shock or when PaCO₂ > 45 mm Hg

Quick Guide to ABG Interpretation

Step one: Identify primary disorder

• Evaluate pH and PaCO₂:

– If change in same direction → metabolic disorder

– If change in different direction → respiratory disorder

Step two: Check for compensation if disorder has a primary origin

• Metabolic disorder: Calculate the expected PaCO₂

• Respiratory disorder: Calculate the expected pH

• If the actual value is different from the calculated value (pH or PaCO₂), expect an additional acid-base disorder

Step three: Calculate the anion gap if metabolic acidosis or mixed disorder is detected

• Anion gap (AG): Na – (Cl + HCO₃) ≤ 12

• If AG < 12, acidosis is due to loss of bicarbonate (ie, diarrhea)

• If AG > 12, acidosis is due to increase of nonvolatile acids (ie, lactic acidosis)

• AG can be influenced by an abnormal albumin level

Acid-Base Disorders

Sodium Disorders

• Normal sodium concentration in the body is 135 to 145 mEq/L

• To determine the cause of sodium disorder, measure

– Plasma osmolality (290 mOsm/kg H₂O)

∘ (2 × Plasma Na+) + Glucose/18

– Extracellular volume

∘ Clinical examination (eg, peripheral edema, orthostatic hypotension, and skin turgor)

∘ Not the most reliable method but is readily available

∘ Invasive monitoring (cardiac filling pressures and cardiac output)

Potassium Disorders

• Normal potassium level is between 3.5 mEq/L and 5 mEq/L

• Work-up should include:

– Urine potassium and chloride level

– Serum magnesium level

– ABG as needed

Gastrointestinal Disease

Irritable Bowel Syndrome

Hepatitis

Hepatitis B serology

Gastroesophageal Reflux Disease

• Etiology: Lower esophageal sphincter relaxation

• Symptoms: Retrosternal burning, regurgitation, excessive salivation, bitter test, throat fullness, halitosis

• Diagnosis: Treat empirically; if no success, upper endoscopy with biopsy, esophageal pH monitoring

• Treatment: Elevate head of bed, stop tobacco and alcohol use, dietary modification, antacids, histamine blockers, proton pump inhibitors

• Complications: Barrett esophagus, adenocarcinoma, upper gastrointestinal bleeding, cough, asthma

End Stage Liver Disease (ESLD)

• Etiology: Chronic hepatocellular injury leads to fibrosis of liver

• Symptoms: Fatigue, anorexia, impotence, melena, spider nevi, gynecomastia, jaundice, testicular atrophy, coarse hand tremor, caput medusae, spider telangiectasia, Dupuytren contractures

• Diagnosis: Liver function tests, liver biopsy; monitor disease with Child-Turcotte-Pugh score or model for end stage liver disease (MELD) score

• Treatment: Avoid alcohol and medications metabolized by the liver, treat underlying disease process, screen for hepatocellular carcinoma, monitor for complications

• Complications: Esophageal varices, ascites, increase in bleeding risk, portal hypertension, hepatic encephalopathy

Child-Turcotte-Pugh score

• 5 to 6 points: Class A, 90% 3-year survival rate

• 7 to 9 points: Class B, 50% to 60% 3-year survival rate

• > 9 points: Class C, 30% 3-year survival rate

Hematologic Disease

Anemia

Hypoproliferative (low reticular cell count)

Hyperproliferative (high reticular cell count)

Sickle Cell Disease

Homozygous defect in gene for beta-globulin that produces hemoglobin S.

• Triggers: Dehydration, acidosis, hypoxia

• Diagnosis: Target cells, sickle cells, Howell Jolly bodies, hemoglobin S on smear

• Symptoms: Acute chest pain, stroke, autosplenectomy

• Treatment: Folate, hydroxyurea, aggressive hydration, analgesia, oxygen, transfuse for major surgery (9 to 10 g hemoglobin)

Bleeding Disorders

Disseminated Intravascular Coagulation (DIC)

Consumptive coagulopathy associated with serious illness.

• Symptoms: Thrombocytopenia, excessive bleeding or clotting

• Diagnosis: Decreased fibrinogen, platelets; increased prothrombin time (PT)/ partial thromboplastin time (PTT), d-dimer test; schistocytes present

• Treatment: Treat underlying cause; platelets and cryoprecipitate for bleeding, low-dose heparin for clotting

Hypercoagulable State

• Risk factors: Prior embolus, pregnancy, surgery, tobacco use, prolonged immobilization, hospitalization, malignancy

• Diagnosis: History and physical examination, complete blood count, PTT

• Treatment: Postoperative patients should be treated for 3 months at an INR of 2 to 3, all others for 3 to 6 months

• Exceptions

– Active cancer: Treat for duration of disease

– Mechanical heart valves: INR goal is 3 to 4

Specific thrombophilic disorders

Anticoagulation medications

Endocrine Disease

Diabetes Mellitus (DM)

Diagnosis

• Random glucose > 200 mg/dL

• Fasting glucose > 126 mg/dL

• Two-hour glucose > 200 mg/dL (75 gm)

• Hemoglobin A1c (HbA1c) > 6.5

Insulin types

Oral hypoglycemics

Goals of treatment

• BP < 130/85 mm Hg

• Low-density lipoprotein < 100 mg/dL, total glycerides < 150 mg/dL, high-density lipoprotein > 40 mg/dL

• Smoking cessation

• Glycemic control for HbA1c < 7

Monitoring glycemic control in DM

• HbA1c >10 is poor control

• HbA1c between 8.5 and 10 is fair control

• HbA1c between 7 and 8.5 is good control

• Fasting glucose < 130 mg/dL

• Peak postprandial glucose < 180 mg/dL

Diabetic Ketoacidosis

An insulin deficiency and glucagon excess that causes severe hyperglycemia and ketogenesis. Severe hyperglycemia causes an osmotic diuresis leading to dehydration and volume depletion.

• Symptoms: Abdominal pain, nausea, vomiting, Kussmaul respirations, ketone breath, anion gap metabolic acidosis, marked dehydration, tachycardia, polydipsia, polyuria, weakness, altered consciousness

• Diagnosis: Serum glucose > 250 mg/dL, metabolic acidosis (pH > 7.3 and serum bicarbonate < 15 mEq/L), increased anion gap, ketonuria, ketonemia; check chemistry panel for hyperkalemia and hyponatremia

• Treatment:

– IV insulin dose at 0.1 units/kg, then start drip at 0.1 units/kg/hour (check potassium prior to starting insulin); drip should run with normal saline replacement

– Once anion gap has closed and acidosis is resolved, start to decrease the insulin and switch to subcutaneous insulin

– Add dextrose to IV fluids when glucose is below 250 mg/dL

– Manage sodium, potassium, and magnesium levels very closely

Thyroid Disorders

Adrenal Disorders (Fig 1-4)

Complications: Adrenal crisis—shock, nausea, vomiting, confusion, fever; can be fatal

Addison disease (primary adrenal insufficiency)

• Etiology: Autoimmune adrenalitis, malignancy, infection

• Symptoms: Hyperpigmentation of the oral mucosa, dehydration, hypotension, fatigue, anorexia, nausea, vomiting, diarrhea, abdominal pain, salt craving, hyponatremia, hyperkalemia

• Diagnosis: Check chemistry panel for electrolyte abnormalities, low cortisol, high adrenocorticotropic hormone (ACTH)

• Treatment: Mineralocorticoid and glucocorticoid replacement

Cushing syndrome

• Etiology: Exogenous steroids, pituitary adenoma, ectopic ACTH, adrenal hyperplasia

• Symptoms: Moon facies, “buffalo hump,” hypertension, truncal obesity, depression, striae, diabetes, osteopenia, hypokalemia, metabolic acidosis

• Diagnosis: Check chemistry panel for acidosis and abnormalities of electrolytes; conduct dexamethasone suppression test or 24-hour urine free cortisol level

• Treatment: For Cushing syndrome, adenoma resection; if ectopic ACTH release, treat underlying neoplasm

Pituitary Disorders

Hormones released from pituitary gland include: ACTH, thyroid-stimulating hormone (TSH), luteinizing hormone/follicle stimulating hormone (LH/FSH), growth hormone (GH), prolactin.

Hypopituitarism

• Etiology: Invasive disease, infiltrative disease, infarction, head trauma, iatrogenic infection

• Symptoms: Depends on the hormone deficiency; GH, LH/FSH, TSH, ACTH, antidiuretic hormone

• Diagnosis: Blood test for specific hormones suspected in hypopituitarism

• Treatment: Treat the underlying cause and correct hormone deficiencies with appropriate oral/nasal hormonal medications

Hyperpituitarism

• Etiology: Adenoma, prolactinoma

• Symptoms: Headache, vision changes, additional symptoms specific to hormone released from pituitary gland

– Prolactinoma has additional symptoms: Galactorrhea, amenorrhea, impotence

• Diagnosis: MRI, visual field testing for bitemporal hemianopsia (other defects may occur with larger lesions)

• Treatment: Surgical removal of adenoma, dopamine agonists for prolactinomas

Hypercalcemia

• Symptoms

– “Moans” (stupor, depression, psychosis)

– “Groans” (nausea, vomiting, constipation)

– “Stones” (kidney stones, nephrogenic diabetes insipidus)

– “Bones” (arthritis, fractures)

– Other symptoms: Weakness, hypertonia, bradycardia

• Etiology: Malignancy (parathyroid hormone-related protein [PTHrP], local osteolysis), granulomatous disorders, Paget disease

• Diagnosis: Check parathyroid hormone, ionized calcium

• Treatment: Normal saline infusion for urinary excretion

– If calcium is still elevated after normal saline infusion, consider diuretics to inhibit calcium reabsorption and bisphosphonates or calcitonin when hypercalcemia is secondary to malignancy

– Glucocorticoids may be used to treat hypercalcemia in patients with multiple myeloma

Hypocalcemia

• Symptoms: Neuromuscular excitability (seizures, tetany), Chvostek sign, Trousseau sign, prolonged QT interval

• Etiology: Hypoparathyroidism, parathyroid hormone resistance, vitamin D deficiency

• Diagnosis: Check ionized calcium, parathyroid hormone values, renal function

• Treatment: Intravenous calcium drip acutely, oral calcium (calcitriol, if needed) chronically

Autoimmune Disease

Sarcoidosis

• Definition: