Uvulopalatopharyngoplasty is a surgical procedure or sleep surgery used to remove tissue and/or remodel tissue in the throat. This could be because of sleep issues. Tissues which may be removed include: The tonsils The adenoidsTissues which may be remodeled include: The uvula The soft palate The pharynx UPPP involves removal of the tonsils, the posterior surface of the soft palate, the uvula; the uvula is folded toward the soft palate and sutured together as demonstrated in the figures. In the US, UPPP is the most performed procedure for obstructive sleep apnea with 33,000 procedures performed per year; the surgery is more successful in patients who are not obese, there is a limited role in morbidly obese individuals. Standard UPPP procedure UPPP is administered to patients with obstructive sleep apnea in isolation, it is administered as a stand-alone procedure in the hope that the tissue which obstructs the patient's airway is localized in the back of the throat. The rationale is that, by removing the tissue, the patient's airway will be wider and breathing will become easier.
The Role of UPPP in the "Stanford Protocol" operation UPPP is offered to sleep apnea patients who opt for a more comprehensive surgical procedure known as the "Stanford Protocol", first attempted by Doctors Nelson Powell and Robert Riley of Stanford University. The Stanford Protocol consists of two phases; the first involves surgery of the soft tissue and the second involves skeletal surgeries. First, Phase 1 or soft tissue surgery is performed and after re-testing with a new sleep study, if there is residual sleep apnea Phase 2 surgery would consist of jaw surgery; the goal is to thereby treat sleep apnea. It has been found that obstructive sleep apnea involves multiple sites where tissue obstructs the airway; the Protocol successively addresses these multiple sites of obstruction. Note that genioglossus advancement can be performed either during Phase 1 or Phase 2 surgeries. Phase 2 involves maxillomandibular advancement, a surgery which moves the jaw top and bottom forward; the tongue muscle is anchored to the chin, translation of the mandible forward pulls the tongue forward as well.
If the procedure achieves the desired results, when the patient sleeps and the tongue relaxes, it will no longer be able to block the airway. Success is much better for Phase 2 than for Phase 1 - 90 percent benefit from the second phase, the success of the Stanford Protocol Operation therefore is due in large part to this second phase. There is debate among surgeons as to the role of Phase 1 surgery. In 2002, an Atlanta-based surgical team, led by Dr. Jeffrey Prinsell, published results which have approximated those of the Stanford team when UPPP was not included in their mix of surgeries; when UPPP has been administered in isolation, the results are variable. As explained above, sleep apnea is caused by multiple co-existing obstructions at various locations of the airway such as the nasal cavity, the base of the tongue; the contributing factors in the variability of success include the pre-surgical size of the tonsils, palate and tongue base. Patients who are morbidly obese are less to have success from this surgery.
Over one thousand people have undergone The Stanford Protocol operation and received follow-up sleep study testing. 60 to 70 percent of patients have been cured. In ninety percent of patients, a significant improvement can be expected. In the recent years, many surgeons have tried to address the multiple levels of obstruction by performing multiple procedures on the same surgical day, called the "multi-level approach". Typical surgeries in a multi-level approach may include: Nasal-level surgeries turbinoplasty, septorhinoplastySoft palate-level surgeries uvulectomy, uvulopalatopharyngoplasty, tonsillectomyHypopharyngeal-level surgeries hyoid suspension tongue suspension tongue base reduction genioglossus advancementThis approach improves postoperative results in well-selected patients. See Uvulopalatoplasty One of the risks is that by cutting the tissues, excess scar tissue can "tighten" the airway and make it smaller than it was before UPPP; some individuals who have undergone UPPP as a stand-alone procedure have written on internet forums that they experienced a worsening of their breathing following UPPP.
Others have spoken of severe acid reflux. After surgery, complications may include these: Sleepiness and sleep apnea related to post-surgery medication Swelling and bleeding A sore throat and/or difficulty swallowing Drainage of secretions into the nose and a nasal quality to the voice. English language speech does not seem to be affected by this surgery. Narrowing of the airway in the nose and throat snoring and iatrogenically caused sleep apnea. Patients who have had the uvula removed will become unable to pronounce uvular consonants, found in French, German and others. Long term complications with pain, feeling sick and lesser sleep quality than before the LAUP. In 2008, Dr. Labra, et al. from Mexico, published a variation of UP3, by adding a uvulopalatal flap, in order to avoid such complications, with a good rate of success. WebMDHealth. Uvulopalatopharyngoplasty for snoring Retrieved August 26, 2005. Royal College of Surgeons Audit Symposium March 8th 2002 Retrieved April 22, 2006. University of Maryland Medical Center Patient Education - UPPP Retrieved April
Pharyngeal branch of vagus nerve
The pharyngeal branch of the vagus nerve, the principal motor nerve of the pharynx, arises from the upper part of the ganglion nodosum, consists principally of filaments from the cranial portion of the accessory nerve. It passes across the internal carotid artery to the upper border of the Constrictor pharyngis medius, where it divides into numerous filaments, which join with branches from the glossopharyngeal and external laryngeal to form the pharyngeal plexus. From the plexus, branches are distributed to the muscles and mucous membrane of the pharynx and the muscles of the soft palate, except the Tensor veli palatini, supplied by the nerve to tensor veli palatini, a branch of the nerve to medial pterygoid. A minute filament joins the hypoglossal nerve as it winds around the occipital artery. Pharyngeal nerve This article incorporates text in the public domain from page 911 of the 20th edition of Gray's Anatomy "10-7". Cranial Nerves. Yale School of Medicine. Archived from the original on 2016-03-03.
Cranialnerves at The Anatomy Lesson by Wesley Norman
Velopharyngeal insufficiency is a disorder of structure that causes a failure of the velum to close against the posterior pharyngeal wall during speech in order to close off the nose during oral speech production. This is important because speech requires sound and airflow to be directed into the oral cavity for the production of all speech sound with the exception of nasal sounds. If complete closure does not occur during speech, this can cause hypernasality and/or audible nasal emission during speech. In addition, there may be inadequate airflow to produce most consonants, making them sound weak or omitted; the terms "velopharyngeal insufficiency" "velopharyngeal incompetence, "velopharyngeal inadequacy" and "velopharyngeal dysfunction" have been used interchangeably, although they do not mean the same thing. "Velopharyngeal dysfunction" now refers to abnormality of the velopharyngeal valve, regardless of cause. Velopharyngeal insufficiency includes any structural defect of the velum or mechanical interference with closure.
Causes include a history of cleft palate, irregular adenoids, cervical spine anomalies, or oral/pharyngeal tumor removal. In contrast, "velopharyngeal incompetence" refers to a neurogenic cause of inadequate velopharyngeal closure. Causes may include traumatic brain injury, cerebral palsy, or neuromuscular disorders, it is important that the term "velopharyngeal insufficiency" is used if it is an anatomical defect and not a neurological problem. Velopharyngeal insufficiency can be diagnosed by a speech pathologist through a perceptual speech assessment. Speech characteristics of VPI include hypernasality and/or audible nasal emission of air during speech. Nasal emission can cause the consonants to be weak in intensity and pressure; the patient may develop compensatory productions for consonants, where the sounds are produced in the pharynx where there is adequate airflow. Nasometry is a method of measuring the acoustic correlates of resonance and velopharyngeal function through a computer-based instrument.
Nasometry testing gives the speech pathologist a nasalance score, the percentage of nasal sound of the total sound during speech. This score can be compared to normative values for the speech passage. Nasometry is useful in the evaluation of hypernasality because it provides objective measurements of the function of the velopharyngeal valve; as such, it is used for pre-and post-surgical comparisons and to determine speech outcomes as a result of certain surgical interventions. Nasopharyngoscopy is endoscopic technique in which the physician or speech pathologist passes a small scope through the patient's nose to the nasopharynx; the nasal cavity is numbed before the procedure, so there is minimal discomfort. Nasopharyngoscopy provides a view of the velum and pharyngeal walls during nasal breathing and during speech; the advantage of this technique over videofluoroscopy is that the examiner can see the size and cause of the velopharyngeal opening clearly and without harm to the patient. Small openings can be visualized.
This information is helpful in determining appropriate surgical or prosthetic management for the patient. The disadvantage of this technique is that the vertical level velar elevation is less obvious than with videofluoroscopy, although this is not a big concern. Multiview videofluoroscopy is a radiographic technique to view the length and movement of the velum and the posterior and lateral pharyngeal walls during speech; the advantage of this technique is. Disadvantages include the following: 1; this procedure requires radiation, a particular concern for children. 2. It is not well tolerated by some children because it requires injection of barium into the nasopharynx through a nasal catheter. 3. The resolution is not nearly as good as nasopharyngoscopy. 4. Small or unilateral openings can not be seen. 5. It only provides a two-dimensional view, therefore, multiple views are needed to see the entire velopharyngeal mechanism. Comparison between multiview videofluoroscopy and nasoendoscopy of velopharyngeal movements."/> A new approach in the diagnosis is magnetic resonance imaging, noninvasive.
MRI uses the property of nuclear magnetic resonance to image nuclei of atoms inside the body. MRI is non-radiographic and therefore can be repeated more in short periods of time. In addition, different studies show that the MRI is better as an imaging tool than videofluoroscopy for visualizing the anatomy of the velopharynx. There are some limitations of the MRI however. Unlike videofluoroscopy and nasopharyngoscopy, MRI does not show the movement of the velopharyngeal structures during speech. In addition, artifacts can be shown on the images when the patient moves while imaging or if the patient has orthodontic appliances. MRI is limited in children. MRI is much more expensive than videofluoroscopy or nasopharyngoscopy; because of these limits, MRI is not used for clinical diagnostic purposes. Speech therapy will not correct velopharyngeal insufficiency; the condition requires physical management. Speech therapy is appropriate to correct the compensatory articulation productions that develop as a result of velopharynge
Indigenous peoples of the Americas
The indigenous peoples of the Americas are the Pre-Columbian peoples of North and South America and their descendants. Although some indigenous peoples of the Americas were traditionally hunter-gatherers—and many in the Amazon basin, still are—many groups practiced aquaculture and agriculture; the impact of their agricultural endowment to the world is a testament to their time and work in reshaping and cultivating the flora indigenous to the Americas. Although some societies depended on agriculture, others practiced a mix of farming and gathering. In some regions the indigenous peoples created monumental architecture, large-scale organized cities, city-states, states and empires. Among these are the Aztec and Maya states that until the 16th century were among the most politically and advanced nations in the world, they had a vast knowledge of engineering, mathematics, writing, medicine and irrigation, mining and goldsmithing. Many parts of the Americas are still populated by indigenous peoples.
At least a thousand different indigenous languages are spoken in the Americas. Some, such as the Quechuan languages, Guaraní, Mayan languages and Nahuatl, count their speakers in millions. Many maintain aspects of indigenous cultural practices to varying degrees, including religion, social organization and subsistence practices. Like most cultures, over time, cultures specific to many indigenous peoples have evolved to incorporate traditional aspects but cater to modern needs; some indigenous peoples still live in relative isolation from Western culture and a few are still counted as uncontacted peoples. Indigenous peoples of the United States are known as Native Americans or American Indians and Alaska Natives. Application of the term "Indian" originated with Christopher Columbus, who, in his search for India, thought that he had arrived in the East Indies; those islands came to be known as the "West Indies", a name still used. This led to the blanket term "Indies" and "Indians" for the indigenous inhabitants, which implied some kind of racial or cultural unity among the indigenous peoples of the Americas.
This unifying concept, codified in law and politics, was not accepted by the myriad groups of indigenous peoples themselves, but has since been embraced or tolerated, by many over the last two centuries. Though the term "Indian" does not include the culturally and linguistically distinct indigenous peoples of the Arctic regions of the Americas—such as the Aleuts, Inuit or Yupik peoples, who entered the continent as a second more recent wave of migration several thousand years before and have much more recent genetic and cultural commonalities with the aboriginal peoples of the Asiatic Arctic Russian Far East—these groups are nonetheless considered "indigenous peoples of the Americas". Indigenous peoples are known in Canada as Aboriginal peoples, which includes not only First Nations and Arctic Inuit, but the minority population of First Nations-European mixed race Métis people who identify culturally and ethnically with indigenous peoplehood; this is contrasted, for instance, to the American Indian-European mixed race mestizos of Hispanic America who, with their larger population, identify as a new ethnic group distinct from both Europeans and Indigenous Americans, but still considering themselves a subset of the European-derived Hispanic or Brazilian peoplehood in culture and ethnicity.
The term Amerindian and its cognates find preferred use in scientific contexts and in Quebec, the Guianas and the English-speaking Caribbean. Indígenas or pueblos indígenas is a common term in Spanish-speaking countries and pueblos nativos or nativos may be heard, while aborigen is used in Argentina and pueblos originarios is common in Chile. In Brazil, indígenas or povos indígenas are common if formal-sounding designations, while índio is still the more often-heard term and aborígene and nativo being used in Amerindian-specific contexts; the Spanish and Portuguese equivalents to Indian could be used to mean any hunter-gatherer or full-blooded Indigenous person to continents other than Europe or Africa—for example, indios filipinos. The specifics of Paleo-Indian migration to and throughout the Americas, including the exact dates and routes traveled, are the subject of ongoing research and discussion. According to archaeological and genetic evidence and South America were the last continents in the world to gain human habitation.
During the Wisconsin glaciation, 50–17,000 years ago, falling sea levels allowed people to move across the land bridge of Beringia that joined Siberia to northwest North America. Alaska was a glacial refugium; the Laurentide Ice Sheet covered most of North America, blocking nomadic inhabitants and confining them to Alaska for thousands of years. Indigenous genetic studies suggest that the first inhabitants of the Americas share a single ancestral population, one that developed in isolation, conjectured to be Beringia; the isolat
Eritrea the State of Eritrea, is a country in the Horn of Africa, with its capital at Asmara. It is bordered by Sudan in the west, Ethiopia in the south, Djibouti in the southeast; the northeastern and eastern parts of Eritrea have an extensive coastline along the Red Sea. The nation has a total area of 117,600 km2, includes the Dahlak Archipelago and several of the Hanish Islands, its toponym Eritrea is based on the Greek name for the Red Sea, first adopted for Italian Eritrea in 1890. Eritrea is a multi-ethnic country, with nine recognized ethnic groups in its population of around 5 million. Most residents speak languages from the Afroasiatic family, either of the Ethiopian Semitic languages or Cushitic branches. Among these communities, the Tigrinyas make up about 55% of the population, with the Tigre people constituting around 30% of inhabitants. In addition, there are a number of Nilo-Saharan-speaking Nilotic ethnic minorities. Most people in the territory adhere to Islam; the Kingdom of Aksum, covering much of modern-day Eritrea and northern Ethiopia, was established during the first or second centuries AD.
It adopted Christianity around the middle of the fourth century. In medieval times much of Eritrea fell under the Medri Bahri kingdom, with a smaller region being part of Hamasien; the creation of modern-day Eritrea is a result of the incorporation of independent, distinct kingdoms and sultanates resulting in the formation of Italian Eritrea. After the defeat of the Italian colonial army in 1942, Eritrea was administered by the British Military Administration until 1952. Following the UN General Assembly decision, in 1952, Eritrea would govern itself with a local Eritrean parliament but for foreign affairs and defense it would enter into a federal status with Ethiopia for a period of 10 years. However, in 1962 the government of Ethiopia annulled the Eritrean parliament and formally annexed Eritrea, but the Eritreans that argued for complete Eritrean independence since the ouster of the Italians in 1941, anticipated what was coming and in 1960 organized the Eritrean Liberation Front in opposition.
In 1991, after 30 years of continuous armed struggle for independence, the Eritrean liberation fighters entered the capital city, Asmara, in victory. Eritrea is a one-party state in which national legislative elections have never been held since independence. According to Human Rights Watch, the Eritrean government's human rights record is among the worst in the world; the Eritrean government has dismissed these allegations as politically motivated. The compulsory military service requires long, indefinite conscription periods, which some Eritreans leave the country to avoid; because all local media is state-owned, Eritrea was ranked as having the second-least press freedom in the global Press Freedom Index, behind only North Korea. The sovereign state of Eritrea is a member of the African Union, the United Nations, the Intergovernmental Authority on Development, is an observer in the Arab League alongside Brazil, Venezuela and Turkey; the name Eritrea is derived from the ancient Greek name for the Red Sea.
It was first formally adopted with the formation of Italian Eritrea. The name persisted over the course of subsequent British and Ethiopian occupation, was reaffirmed by the 1993 independence referendum and 1997 constitution. At Buya in Eritrea, one of the oldest hominids representing a possible link between Homo erectus and an archaic Homo sapiens was found by Italian scientists. Dated to over 1 million years old, it is the oldest skeletal find of its kind and provides a link between hominids and the earliest anatomically modern humans, it is believed that the section of the Danakil Depression in Eritrea was a major player in terms of human evolution, may contain other traces of evolution from Homo erectus hominids to anatomically modern humans. During the last interglacial period, the Red Sea coast of Eritrea was occupied by early anatomically modern humans, it is believed that the area was on the route out of Africa that some scholars suggest was used by early humans to colonize the rest of the Old World.
In 1999, the Eritrean Research Project Team composed of Eritrean, American and French scientists discovered a Paleolithic site with stone and obsidian tools dated to over 125,000 years old near the Bay of Zula south of Massawa, along the Red Sea littoral. The tools are believed to have been used by early humans to harvest marine resources such as clams and oysters. According to linguists, the first Afroasiatic-speaking populations arrived in the region during the ensuing Neolithic era from the family's proposed urheimat in the Nile Valley. Other scholars propose that the Afroasiatic family developed in situ in the Horn, with its speakers subsequently dispersing from there. Together with Djibouti, northern Somalia, the Red Sea coast of Sudan, Eritrea is considered the most location of the land which the ancient Egyptians called Punt, first mentioned in the 25th century BC; the ancient Puntites had close relations with Ancient Egypt during the rule of Pharaoh Sahure and Queen Hatshepsut. This is confirmed by genetic studies of mummified baboons.
In 2010, a study was conducted on baboon mummies that were brought from Punt to Egypt as gifts by the ancient Egyptians. The scientists from the Egyptian Museum and the University of California used oxygen isotope analysis to examine hairs from two baboon mummies, preserved in the British Museum. One of the baboons had distorted isotopic data, so t
Tobacco smoking is the practice of smoking tobacco and inhaling tobacco smoke. The practice is believed to have begun as early as 5000 -- 3000 BC in South America. Tobacco was introduced to Eurasia in the late 17th century by European colonists, where it followed common trade routes; the practice encountered criticism from its first import into the Western world onwards but embedded itself in certain strata of a number of societies before becoming widespread upon the introduction of automated cigarette-rolling apparatus. German scientists identified a link between smoking and lung cancer in the late 1920s, leading to the first anti-smoking campaign in modern history, albeit one truncated by the collapse of Nazi Germany at the end of World War II. In 1950, British researchers demonstrated a clear relationship between cancer. Evidence continued to mount in the 1980s. Rates of consumption declined. However, they continue to climb in the developing world. Smoking is the most common method of consuming tobacco, tobacco is the most common substance smoked.
The agricultural product is mixed with additives and combusted. The resulting smoke is inhaled and the active substances absorbed through the alveoli in the lungs or the oral mucosa. Combustion was traditionally enhanced by addition of potassium or nitrates. Many substances in cigarette smoke trigger chemical reactions in nerve endings, which heighten heart rate and reaction time, among other things. Dopamine and endorphins are released, which are associated with pleasure; as of 2008 to 2010, tobacco is used by about 49% of men and 11% of women aged 15 or older in fourteen low-income and middle-income countries, with about 80% of this usage in the form of smoking. The gender gap tends to be less pronounced in lower age groups. Many smokers begin during early adulthood. During the early stages, a combination of perceived pleasure acting as positive reinforcement and desire to respond to social peer pressure may offset the unpleasant symptoms of initial use, which include nausea and coughing. After an individual has smoked for some years, the avoidance of withdrawal symptoms and negative reinforcement become the key motivations to continue.
A study of first smoking experiences of seventh-grade students found out that the most common factor leading students to smoke is cigarette advertisements. Smoking by parents and friends encourages students to smoke. Smoking's history dates back to as early as 5000–3000 BC, when the agricultural product began to be cultivated in Mesoamerica and South America; the practice worked its way into shamanistic rituals. Many ancient civilizations – such as the Babylonians, the Indians, the Chinese – burnt incense during religious rituals. Smoking in the Americas had its origins in the incense-burning ceremonies of shamans but was adopted for pleasure or as a social tool; the smoking of tobacco and various hallucinogenic drugs was used to achieve trances and to come into contact with the spirit world. To stimulate respiration, tobacco smoke enemas were used. Eastern North American tribes would carry large amounts of tobacco in pouches as a accepted trade item and would smoke it in ceremonial pipes, either in sacred ceremonies or to seal bargains.
Adults as well as children enjoyed the practice. It was believed that tobacco was a gift from the Creator and that the exhaled tobacco smoke was capable of carrying one's thoughts and prayers to heaven. Apart from smoking, tobacco had a number of uses as medicine; as a pain killer it was used for earache and toothache and as a poultice. Smoking was said by the desert Indians to be a cure for colds if the tobacco was mixed with the leaves of the small Desert sage, Salvia dorrii, or the root of Indian balsam or cough root, Leptotaenia multifida, the addition of, thought to be good for asthma and tuberculosis. In 1612, six years after the settlement of Jamestown, John Rolfe was credited as the first settler to raise tobacco as a cash crop; the demand grew as tobacco, referred to as "brown gold", revived the Virginia joint stock company from its failed gold expeditions. In order to meet demands from the Old World, tobacco was grown in succession depleting the soil; this became a motivator to settle west into the unknown continent, an expansion of tobacco production.
Indentured servitude became the primary labor force up until Bacon's Rebellion, from which the focus turned to slavery. This trend abated following the American Revolution as slavery became regarded as unprofitable. However, the practice was revived in 1794 with the invention of the cotton gin. Frenchman Jean Nicot introduced tobacco to France in 1560, tobacco spread to England; the first report of a smoking Englishman is of a sailor in Bristol in 1556, seen "emitting smoke from his nostrils". Like tea and opium, tobacco was just one of many intoxicants, used as a form of medicine. Tobacco was introduced around 1600 by French merchants in what today is modern-day Gambia and Senegal. At the same time, caravans from Morocco brought tobacco to the