Written Flashcards

Question

Give the treatment of otosclerosis

Answer 1

The conductive component of otosclerosis can be corrected surgically in the form of Stapedectomy and insertion of a synthetic piston Amplification by Hearing Aid is an alternative.

Answer 2

Recurrent attacks of vertigo, hearing loss, tinnitus, nausea and vomiting usually preceded by aural fullness before the onset of vertigo. Confirm Diagnosis: At least 2 definitive episodes of vertigo of at least 20 minutes duration must have occurred to make the diagnosis. Attacks usually come in clusters

Answer 3

* PTA shows reversible low frequency hearing loss at the onset of the disease, later the condition progresses to high frequency loss. * Caloric test shows hypoactive labyrinth. The caloric test is done by introducing water into the ear canal on one side, both 7 degrees above and below the assumed body temperature. The water is stopped after 30 seconds, and nystagmus is observed, while the patient is distracted. * Electrocochleography (Ecog) is diagnostic.

Answer 4

o During the attack: Anti-vertigenous drugs. o In Between the attacks: * Conservative treatment: includes reassurance, a low salt diet and medications such as vasodilators , antihistaminic and diuretics. * Intratympanic injection of steroids * In case of progressive SNHL and vertigo: intratympanic gentamycin injection (Medical labyrinthectomy). * In resistant cases with intractable vertigo despite of medical, treatment entails surgery as endolymphatic sac decompression, labyrinthectomy or vestibular nerve section relying on hearing level.

Answer 5

o Wax causing deafness or difficulty in examining the drum. o Foreign body if not impacted or vegetable. o Fungal mass. o Caloric test. Contra-indications o T.M. perforation. o Vegetable foreign body or impacted foreign body. o Bacterial otitis externa. o Fistula between the middle and inner ears.

Answer 6

1- Trauma: A-Ruptured drum: the patient feels sudden severe pain with dizziness and deafness. Patient may feel fluid in the nasopharynx. B-Injury to external canal by: Nozzle of syringe, very hot fluid. 2- Infection: otitis externa. 3- Reflex Cough due to vagal stimulation. 4- Dizziness and vomiting if cold or hot water is used.

Answer 7

EAC causes of CHL: * Congenital: anomalies e.g., meatal atresia * Traumatic: foreign body * Inflammatory: infections and acute inflammatory swelling as in large furuncle, diffuse acute otitis externa and malignant otitis externa * Neoplastic: Benign and malignant tumors * Miscellaneous: impacted wax, the most common cause of conductive deafness. Tympanic membrane causes of CHL: *Perforation of tympanic membrane either traumatic or infective Middle ear causes of CHL: * Congenital: anomalies. * Traumatic: otitis barotrauma, hemotympanum and ossicular disruption * Inflammatory: All types of otitis media (AOM, CSOM).and Eustachian tube dysfunction leading to retracted tympanic membrane or otitis media with effusion (OME) *Neoplastic: Middle ear tumors. *Otosclerosis.

Answer 8

Bilateral choanal atresia It presents with acute respiratory distress immediately after birth as newborns are obligate nasal breathers. The classical picture is cycles of respiratory distress and cyanosis which are relieved by crying CT nose and protective nasal splint

Answer 9

Bilateral choanal atresia The goal is first directed towards securing the airway. o Oral airway is usually suitable to alleviate the distress as it temporarily bypasses the nasal obstruction. o Improvement using oral airway may aid the diagnosis of bilateral choanal atresia. Definitive treatment: surgical repair o Endoscopic nasal repair. o Trans-palatal approach can be used.

Answer 10

1- Traumatic: a) Surgical: - Endoscopic sinus surgery (ESS) b) Accidental: fracture base of anterior cranial fossa. 2- Inflammatory: syphilitic osteitis or osteomyelitis 3- Neoplastic: tumor eroding the roof of nose. 4- Congenital: defect in the cribriform plate. 5- Idiopathic

Answer 11

1- Biochemical analysis of discharge: - Clear, Colorless and contains no mucus. - Contains sugar more than 30 mg%. - Contains B2 transferrin, which is diagnostic. 2- CT with intrathecal metrizamide: to detect the site of leakage. 3- MRI 4- Endoscopic examination of nose after intra-thecal dye injection to locate the defect.

Answer 12

A) Conservative: most traumatic cases heal spontaneously - Bed rest in semi-sitting position with the head-up. - Avoid coughing, straining, blowing of nose, nasal medications - Prophylactic antibiotics that cross blood brain barrier to prevent meningitis. B) Surgical: covering the defect by graft or flap Non traumatic cases usually need surgical repair

Answer 13

Atrophic stage: characterized by foul smelling purulent nasal discharge and crusting. Granulomatous stage: granulomatous nodules form in nasal mucosa usually starts at the mucocutaneous junction Cicatricial stage: stenosis of nares, distortion of upper lip, adhesions in the nose and pharynx -May extend to: Lacrimal sac > dacryoscleroma Pharynx > pharyngoscleroma Larynx > laryngoscleroma

Answer 14

Not required in uncomplicated cases - X ray sinus view shows sinus opacity or fluid level. - C.T. paranasal sinuses show the same finding and are more accurate. Required only in recurrent cases. - Culture & sensitivity of the discharge.

Answer 15

Medical: - Symptomatic treatment: bed rest, worm fluids, worm fomentations, steam inhalation, saline nasal irrigation, analgesics, antipyretics, decongestant nasal drops, antihistamines, and mucolytics. - Antibiotics are added if ABRS (acute bacterial rhinosinusitis) is suspected. Most guidelines recommend amoxicillin as first-line therapy. - Treat the predisposing factor e.g. diabetes. Surgical: - The aim of surgery is to drain the sinus and to restore aeration. Functional Endoscopic Sinus Surgery (FESS)

Answer 16

1. Orbital Edema: Upper eye lid edema, the lower eye lid is NOT affected. NO pain, chemosis, proptosis, affection of vision 2. Orbital Cellulitis: Eye pain, Chemosis, Proptosis and Limitation of eye movement. Diminution of vision that is reversible 3. Subperiosteal Abscess: Throbbing pain, Chemosis, Lateral Proptosis and Ophthalmoplegia. Diminution of vision is more marked and reversible. 4. Orbital Abscess: Throbbing severe pain, Chemosis, forward Proptosis and severe Ophthalmoplegia. Diminution of vision is Irreversible. 5. Cavernous Sinus Thrombosis: Inflammatory process extends through the draining veins into the cavernous sinus, causing thromboses.

Answer 17

1. C.T. paranasal sinus axial & coronal cuts with contrast 2. Visual acuity and fundus examination, documented by the ophthalmologist. -Hospitalization Medical: Massive broad-spectrum IV antibiotics -Nasal wash and decongestant nasal drops. -Daily monitoring of visual acuity. Surgical decompression: Indications for surgery: 1. Failure of any response to medical treatment for 48 hours. 2. Threat to vision, as documented by the ophthalmologist. 3. Formation of Subperiosteal or Orbital Abscess, as documented by the CT. Type of Surgery: * ESS: Complete ethmoidectomy, and abscess drainage.

Answer 18

* Invasive - Acute Invasive Fungal Sinusitis - Chronic Invasive Fungal Sinusitis - Chronic Invasive Granulomatous Fungal Sinusitis * Non-invasive - Allergic Fungal Sinusitis - Fungal Ball (Mycetoma)

Answer 19

Investigations of Nasal polyps CT scanning coronal cuts is the investigation of choice for assessing the extent of the disease. Treatment of Nasal polyps - All patients should have a trial of medical therapy first. - Medical treatment consists mainly of topical and systemic corticosteroids Surgical: - Surgical management is considered for patients who have failed to respond to maximal medical treatment and for those with complications. - Functional endoscopic sinus surgery aims to improve sinus ventilation and drainage as well as removing polyps.

Answer 20

Local causes: 1. Idiopathic: this is diagnosed after exclusion of the all possible scenarios. It is the most common, about 90%, from little’s area. 2. Trauma: Foreign bodies, nasal picking, accidental or surgical trauma. 3. Inflammations: Any acute or chronic rhinitis. 4. Neoplastic: Nasal or nasopharyngeal benign or malignant tumours. 5. Irritants (e.g., cigarette smoke) 6. Medications (e.g., topical corticosteroids) 7. Septal deviation or perforation. 8. Vascular malformation 9. Environmental factors: Humidity, dryness, allergens. Systemic causes: 1. Systemic hematologic, hepatic, renal, genetic, or cardiovascular diseases. 2. Long-term anticoagulation (aspirin, warfarin). 3. Hypertension. 4. Underlying coagulation disorder hemophilia, or thrombocytopenia.

Answer 21

Septal abscess, organization, and septal thickening. Treatment of Septal hematoma 1- Systemic antibiotics to prevent secondary infection. 2- Incision and evacuation: vertical incision on one side and horizontal on the other side to prevent septal perforation. 3- Anterior nasal packing to prevent recollection of the hematoma

Answer 22

Septal perforation, external deformity, cavernous sinus thrombosis. Treatment of Septal abscess 1- Systemic antibiotics. 2- Incision and evacuation: vertical incision on one side and horizontal on the other side to prevent septal perforation. 3- Anterior nasal packing to prevent recollection.

Answer 23

1- Atrophic rhinitis. 2- Nasal Granuloma. 3- Neglected foreign body. 4- Oroantral fistula. 5- Maxillary sinusitis especially of dental origin.

Answer 24

If there is diagnostic uncertainty, then allergy testing should be performed. These include skin prick test or measurement of specific IgE in the blood ( RAST test)

Answer 25

Allergen avoidance Oral antihistamines: This relieves the symptoms of running, sneezing, and nasal and eye itching. They have little effect on nasal blockage. Nasal irrigation with isotonic saline Intranasal corticosteroids: It is the first-line treatment of patients with mild to moderate persistent symptoms. The most commonly reported adverse effects are irritation, epistaxis, stinging, burning, and nasal dryness. Local nasal decongestants: Xylometazoline causes rapid decongestion, but prolonged use should be avoided. Systemic corticosteroids: Oral steroids may occasionally be useful in patients with chronic severe symptoms: Prednisolone 20–40mg/day is normally sufficient Leukotriene receptor antagonists Immunotherapy is a method of inducing tolerance to an allergen. It involves repeated exposure of the patient to the allergen, usually with a gradual increase in allergen dose. Surgical treatment: Surgery cannot cure allergy but can give relief of nasal blockage if other methods fail. - Reduction of submucosal tissue on the inferior turbinates that has developed

Answer 26

Symptoms: 1.Inspiratory stridor; starts soon after birth, improves on lying in the prone position. 2. Normal cry i.e. no hoarseness of voice. Signs: Laryngoscopy: usually shows the characteristic omega shaped epiglottis. The supraglottis collapses inwards during inspiration. Abnormally soft and flaccid cartilaginous framework. The ary-epiglottic folds are short and approximated ➔ narrow laryngeal inlet Is mainly conservative as it improves spontaneously.

Answer 27

* Routine laboratory tests to evaluate the patient’s medical condition * CT scan: To assess tumor extension and lymph nodes involvement. * Biopsy by direct laryngoscopy: To confirm the diagnosis. * Metastatic work-up: Chest x-ray, brain CT scan, bone scan & abdomen ultrasound. * PET CT may be required in the staging of more advanced cancers and for follow up of patients postoperatively or following chemotherapy or radiotherapy

Answer 28

Treatment of Early Cancer Larynx (depending on TNM staging). 1. Radiotherapy 2. Transoral laser microsurgery 3. Open surgery (partial laryngectomy or conservation laryngeal surgery). * The choice of treatment depends on tumor primary site, extension, and patient’s lifestyle and preference. Treatment of Advanced Cancer Larynx (depending on TNM staging) * The golden standard of treatment is total laryngectomy and concurrent chemoradiation therapy. * In lymph node metastases, the neck is treated by performing the appropriate type of neck dissection. * Radiation therapy alone is used if patients are medically unfit for surgery. Postoperative rehabilitation of voice after total laryngectomy: esophageal speech or artificial larynx or creating tracheoesophageal fistula Follow-up after treatment of cancer larynx is mandatory, every 3 months for the first year, every 4 months for the second year, every 6 months for the third to fifth year, then once a year after that.

Answer 29

- It present with Biphasic stridor - Almost always there is a history of prolonged ICU intubation, or manifestation of rhinoscleroma. - Congenital types may pass unnoticed if the stenosis grade is mild - Laryngoscopy show the stenosis grade - CT scan sagittal or coronal cuts shows the stenotic part length

Answer 30

- Tracheostomy if needed. - Laser excision in short, small stenosis. -excision of stenotic area with skin graft closure. - Resection of the stenotic area with end-to-end anastomoses.

Answer 31

(A) Peripheral causes Surgical trauma: Thyroidectomy (most common) and Radical neck dissection. Esophageal surgery, Cardiovascular surgery, Vagus injury at skull base. Neoplastic (important): * Thyroid malignancy. * Nasopharyngeal carcinoma * Hypo pharyngeal malignancy * Bronchogenic carcinoma * Esophageal carcinoma. * Malignant lymph nodes. * Pharyngeal pouch Non-surgical trauma: * Vagal schwannoma * Neck trauma e.g., strangulation, open injuries. * Cricothyroid joint dislocation. * Fracture skull base. Inflammatory: Infections herpes, influenza, and diphtheria. * Diabetes Mellitus * Malignant OE. * Apical pulmonary T.B. * Ascending polyneuritis. Idiopathic: most probably viral infection. Miscellaneous: Myasthenia gravis, rheumatoid arthritis, and SLE. (B) Central causes (Bulbar palsy)

Answer 32

Done if the cause is unknown (1) Radiology - CT from skull base to mid thorax. - According to suspicion: CT& MRI brain, barium swallow, or thyroid scan. (2) Endoscopy Panendoscopy: nasopharyngoscopy, laryngoscopy, hypopharyngoscopy, oesphagoscopy & bronchoscopy + biopsies. (3) Blood exam Especially blood sugar.

Answer 33

1- Most cases require no treatment: compensation or Spontaneous recovery occurs in 6 months 2- Treat the causes if possible. 3- Surgery is done if there are persistent symptoms after 6 months, it may be either: Injection of the paralyzed vocal cord either by synthetic material or fat to meet the healthy vocal cord * Thyroplasty: * Reinnervation of the RLN.

Answer 34

1- In cases of severe stridor: tracheostomy. 2- In established cases: laryngeal widening procedure 6-12 months later. Endoscopic arytenoidectomy, or posterior cordectomy, using CO2 laser, to provide space for respiration. This improves breathing but affects voice quality. 3- Reinnervation procedures are still under trials.

Answer 35

* Acute laryngitis which (the most common cause) * Voice abuse and misuse e.g. professional voice users * Benign vocal cords lesion e.g. nodules, cyst and polyps * Reinke's edema. * Vocal hemorrhage: sudden loss of voice after a yell * Gastroesophageal Reflux (GERD) * Specific inflammatory conditions * Intubation granuloma * Neoplastic lesions especially vocal cord carcinoma. * Neurological lesion as unilateral vocal cord paralysis. * Muscle tension dysphonia vocal cords are free from lesions and move normally, but aphonia occurs due to a psychological and neurological disorder.

Answer 36

1-Congenital: CONGENITAL LARYNGEAL WEB, LARYNGOMALACIA 2-Traumatic: FB, CORROSIVE or rough intubation. Physical trauma: radiotherapy and thermal injury. 3-Inflammatory: ACUTE NON-SPECIFIC LARYNGITIS in infants and children, ACUTE LARYNGOTRACHEORONCHITIS in children, laryngeal diphtheria or Chronic specific laryngitis (granuloma) 4-Neoplastic: RECCURENT MULTIPLE LARYNGEAL PAPILLOMATOSIS and laryngeal carcinoma 5-Miscellaneous: LARYNGEAL SPASM, LARYNGEAL EDEMA, Bilateral vocal cords paralysis 6-Tracheal causes

Answer 37

Congenital laryngeal web and laryngomalacia Foreign body and corrosives Inflammatory: Acute nonspecific laryngitis in infants and children, acute laryngotracheobronchitis in children Neoplastic: recurrent multiple laryngeal papillomatosis Others: Laryngeal spasm, laryngeal edema

Answer 38

◦ Upper airway (mechanical) obstruction ◦ Stridor (if severe) ◦ Obstructive SA (if severe) ◦ Lower airway (secretory) obstruction ◦ Chronic aspiration ◦ Depression of cough reflex ◦ Prolonged coma ◦ Severe chest injury ◦ Paralysis of the respiratory muscles

Answer 39

- Facilitate suction - Assist ventilation ◦Prophylactic: Before bloody major operation on the mouth, pharynx, larynx Value: To avoid blood inhalation during surgery If prolonged intubation is planned, to guard against occurrence of subglottic stenosis, and for better oral and pulmonary hygiene

Answer 40

1-Anesthetic complications local or general. 2- Apnea: When operation is done under local anasthesia 3- Bleeding a-Primary: Anterior jugular vein injury, thyroid gland injury, innominate vein injury. b-Reactionary: Slipped ligature, from previously ligated vein c-Secondary: Due to infection (antibiotics & fresh blood). 4- Pneumothorax (most common) 5- Pneumomediastinum. 6- Crustation. 7- Delayed complications: a) Subglottic stenosis: due to cricoid injury. b) Tracheal stenosis: due to erosion by tube or infection. c) Difficult extubation. d) Tracheoesophageal fistula. e) Tracheocutaneous fistula. 8- Emphysema (surgical): Air accumulation under skin. 9- Embolism (air embolism) 10- Injury  Thyroid gland → Hemorrhage.  Apex of pleura → pneumothorax.  Cricoid cartilage → subglottic stenosis.  Posterior tracheal wall → Tracheoesophageal fistula.  Big vessels → Hemorrhage.  RLN → V.F paralysis. 11- Infection  Wound infection.  Chest infection. 12- Tube complications: a) Slipped tube: Due to low tracheostomy, wide stoma, short neck, or short tube. . c) Blocked tube by dried secretions.

Answer 41

NO ABSOLUTE CONTRAINDICATIONS, SINCE IT IS A LIFE SAVER

Answer 42

Symptoms: - Bilateral nasal obstruction: o Mouth breathing. o Speech hyponasality o Difficult suckling in infants o Snoring. - Bilateral nasal discharge. Signs: Nasal endoscopy shows the hypertrophied adenoid Treatment: adenoidectomy

Answer 43

-Obstructive Sleep Apnea. -Recurrent acute otitis media or otitis media with effusion -Adenoid facies due to habitual mouth opening and underdevelopment of middle 1/3 of face. * Pinched nostrils, Open dry mouth * Short elevated upper lip * Protruding central incisors. * High arched palate. * Receding mandible * Idiot expressionless look.

Answer 44

Caused by Group A beta-hemolytic streptococcus or viral infection Symptoms: - Fever, anorexia - Sore throat Signs: - Congested tonsils with possible follicles of pus -Tender large jugulodigastric lymph nodes Treatment: analgesic and antipyretics and antibiotics usually amoxicillin group

Answer 45

1-Suppuration: Peritonsillar abscess (Quinsy), Retropharyngeal abscess, Parapharyngeal Abscess 2-Immune complex disorders: Acute rheumatic fever and acute glomerulonephritis are due to immune complex formation following infection

Answer 46

- CT with contrast: hyperintense mass with forward bowing of posterior wall of maxilla, and widened sphenopalatine foramen. - MRI, MRA - Angiography: is diagnostic and used for preoperative embolization -Biopsy should be avoided as to avoid extensive bleeding since the tumor is very vascular. Treatment: Endoscopic excision after preoperative embolization is a treatment of choice. In recurrent or extensive cases, the tumor is excised using an external approach.

Answer 47

* Biopsy is mandatory * CT nasopharynx with contrast * MRI * Positron emission tomography (PET) Treatment: o Radiotherapy with or without Chemotherapy

Answer 48

Symptoms: General: High fever – headache – malaise. Local: * Marked sore throat. * Referred otalgia. * Bad odoured breath * Difficulty in mouth opening (Trismus). * Marked dysphagia with dribbling of saliva. Signs: General: High temperature. Local: * Enlarged tender jugulo-digastric lymph nodes. * Difficult oral exam due to trismus * Soft palate swelling above and lateral to inflamed tonsil. * Tonsil pushed downwards and medially. * Uvula edematous and pushed to other side.

Answer 49

-Antibiotics and analgesics in cellulitis stage. -After abscess formation: (hectic fever and pulsating pain): Incision and drainage (Intraoral -under local or general anesthesia). -Tonsillectomy in recurrent cases

Answer 50

Sudden rupture and inhalation of pus causing chest infections. Extension: * Laterally causing Parapharyngeal abscess. * Downwards leading to Laryngeal edema, stridor * Pyemia and Septicemia.

Answer 51

Caused by: Dental or periodontal infections (70%), Penetrating injuries of the floor of mouth and Mandibular fractures. * Usually young patient with poor dentition or diabetics. * Unilateral neck pain and swelling that soon becomes bilateral. * Increasing edema and brawny induration of floor of mouth thrusting of tongue against the palate with resultant respiratory embarrassment. * Increasing fever, neck rigidity, trismus, and odynophagia. * Some patients progress rapidly from onset of symptoms to respiratory obstruction in 24 hours.

Answer 52

1. Intensive I.V. antibiotic therapy. 2. Early airway maintenance; tracheostomy must be ready. 3. Rapid surgical intervention: Horizontal submental incision just above hyoid bone.

Answer 53

1. Acute Follicular Tonsillitis: Caused by beta-hemolytic streptococci - Bilateral, Yellowish, Limited to the tonsils, Loose, No bleeding upon removal 2. Diphtheriae: Caused by Corynebacterium Diphtheriae - Unilateral, Exceeds tonsil, Dirty greyish, Bleeding upon removal and reform rapidly, Severe toxemia and tachycardia disproportionate to fever 3. Vincent's Angina - Caused by spirochetes and fusiform bacilli, Unilateral - Gingivitis & pharyngeal ulceration with deep punched out edges, covered by a dirty grayish pseudomembrane that extends beyond tonsils. 4. Infectious Mononucleosis: Caused by EBV Oropharyngeal ulcerations with greyish-white pseudomembrane, and Generalized lymphadenopathy + splenomegaly

Answer 54

Symptoms: -Severe pain in mouth, tongue, pharynx -Severe dysphagia & regurgitation -Stridor due to laryngeal edema Signs: -White sloughs, edema -Skin burns -Shock & dehydration Complications: * Shock, dehydration, electrolyte imbalance. * Esophageal perforation. * Esophageal stricture. * Tracheo-esophageal fistula. * Stridor. * Chest infection. Treatment: 1-Milk & egg white. 2-Management of shock & electrolyte imbalance 3-Tracheostomy if severe obstruction 4-Parentral antibiotics 5-Cortisone to decrease edema & fibrosis 6-Rubber naso-gastric tube is inserted in 1st few days to facilitate feeding & maintain the lumen

Answer 55

Clinical picture: 1- Dysphagia reappears 2-3 weeks. 2- Dehydration & starvation. 3- Regurgitation & chest infection. Investigations: * Plain X ray neck & chest. * Barium swallow: irregular narrow segment. * Esophagoscopy Treatment: A) Permeable stricture: Regular dilatation via rigid Esophagoscopy. B) Impermeable stricture (non dilatable) 1-Temporary gastrostomy 2-Resection of stricture & free jejunal loop re-anastomosis, or colon bypass. 3-Esophagogastrostomy or jejunostomy 4-Stents

Answer 56

A. Causes in the lumen: Foreign body. B. Causes in the wall: 1. Congenital diseases: Congenital atresia or stenosis 2. Inflammatory: Acute ulcerations, chron’s disease, 3. Traumatic: Foreign body 4. Ingestion of corrosives. 5. Persistent vomiting 6. Reflux esophagitis 7. Plummer Vinson syndrome. 8. Neoplastic: benign and malignant tumors 9. Neurological: Paralytic: paralysis of the pharyngeal and esophageal muscles. 10. Pharyngeal pouch 11. Achalasia of the cardia 12. Diffuse esophageal spasm C. Pressure on the esophagus from outside In the cervical region (upper 1/3): -Malignant thyroid tumor -Huge multinodular goiter. -Enlarged cervical lymph nodes e.g. metastasis /lymphoma. In the thorax (middle 1/3) -Mediastinal tumors. -Pericardial effusion. -Enlarged left atrium. -Bronchogenic carcinoma. -Aneurysm of the aorta. In the abdomen (lower 1/3) -Enlarged left lobe of liver -Para-esophageal hiatus hernia

Answer 57

Indications: 1- Marked tonsillar hypertrophy causing obstructive sleep apnea 2- Recurrent acute tonsillitis (7 times in one year, 5 times in two successive years or 3 times in three successive years) 3- Recurrent Peritonsillar abscess (Quinsy) 4- Suspected tumour, 5- Troublesome tonsillolith Contraindications: 1- Bleeding tendency because of systemic disease 2- Current or recent infection 3- Uncontrolled systemic disease (hypertension, diabetes)