#luppi x reader

[your-local-hollow-lover]

SFW AND NSFW head canons for luppi pls,we need more of him😔😔

We need more of him, indeed!

SFW

When you began introducing him to human things, two immediately caught his eye: makeup and skincare.

This guy would go crazy for makeup, especially purple glitter eyeshadow.

Don't even try to argue—why? Because sparkling like that makes him ✨stand out✨ on the battlefield.

The more attention he attracts, the more people witness his incredible abilities, acknowledging him as a force to be reckoned with.

On the flip side, skincare would be his relaxation haven.

He'd doze off while you pamper his skin with various products. Yes, you'd have to be the one who does it. He won't waste time putting creams on his face.

Obviously, you'd be the lucky one taking care of Luppi-sama 🙄

It's a privilege to thrive in his presence!

In truth, he just wants to spend time with you, but saying that out loud makes Luppi feel like he might spontaneously combust.

He takes you to see his fights like it's a football game 😩

Luppi thrives on the energy when he witnesses you shouting to cheer him on!

He starts showing off with a hint of cockiness. However, in the heat of the action, Luppi comes dangerously close to accidentally injuring you as a piece of his opponent hurtles in your direction.

And he sees this and immediately a bolt of unsettledness hits him.

Girl, he's like 😨

Rescues you in a heartbeat and then waits, allowing the sentiment to sink in.

Omg, he would care if you died!!!!

haha no, of course not! haha... no, right? Right???

This incident is the beginning of his spiral down the acknowledgment he has grown stupid, unwanted feelings for you.

Once he accepts it, horror strikes.

He claps a hand over his mouth and tiny droplets of sweat bead on his forehead. Honestly, he looks so dreadful you have to ask if he's alright.

NSFW

Now, he would be a bratty bottom™

But once you've dominated him well, he'll squirm and be all cute for you~♡

Totally has a mummy kink idk he looks like he likes that shit 😩🙏

This mtf is LOUD when he comes

He thinks he's so hot, he'd like mirror sex to look at himself 😭

Once he knows aftercare there's no way you'll end a session without giving him some cuddles

He'll act entitled about it tho. Like "Fine you can do that lovey-dovey thing you like to do. I'm ready." like it's such a drag for him

And when you're like, oh no I won't do it if you don't want to, as you motion to leave.

He'll cling to you 💀💀

Luppi's face is red as he says, "Is not that I don't want to, I- it doesn't bother me, so do it if you want."

Stop mocking him he's trying!

[my0vershareworld]

𝕪𝕠𝕦 𝕥𝕠𝕨𝕖𝕣

Pairing: Luppi Antenor x G/N human reader

Genre: Fluff, Headcanons, Romantic.

CW: None

Requested by anon: Heyyy,Can you do dating headcanons for Luppi with a reader that’s really taller then him maybe 6 foot? 😗

A/N: LUPPI REQUEST LES GO

he don't care too much about height since he's considered short in Hueco Mundo already.

but it just your height remind you of Grimmjow but he's fine with it since you are you and not him

he will keep mocking you with your height and keep telling you, you will walk into a wall while you're walking into the door.

he will call you these names

'pole light', 'giant', 'tower'

he call you these in a loving yet mocking way.

if you tell him to stop first time he would. for a day and a half

if you do it 2nd time he will not listen to you at all and only said 'Sorry!' in a sarcastic tone and keep doing it

but! if you did tell him to stop and tell him that he's hurting your feelings and that you don't like it he will completely stop. he won't ever call you any of those nicknames again.

he's afraid of losing you. so he will do anything to keep him with you.

[arrancarscenarios]

*gently rolls around on this blog*

ANYWAY I’M HOPING VERY MUCH that after I get things a little more under control on my RP blog, I can do some stuff here

because uh yanno........... thinkin about my babies uwu

I’m also thinking that even tho I’m not done with my Luppi x reader gory fic, I’d like to break another Arrancar

who should it be??

I’m torn between Ulquiorra and Halibel..........

they would both be so fun... but like, there really are endless options

(I REALLY want to write something gory and angsty for Szayel too, but I also wanna give some, eh, love to characters who don’t have nearly enough....... torture-y content. UWU-)

who would y’all like to see missing pieces and in mental anguish??? <3

in the meantime, if you wanna interact with Findorr or Wonderweiss in a more hands-on capacity (as well as literally TONS of other muses from different fandoms) you can head on over to @variantia to spend some time at my RP blog where I play them!! mwah

[biogenericpublishers]

Head and Neck Paragangliomas: a Narrative Review by Diego Duminy-Luppi in Open Access Journal of Biogeneric Science and Research

Abstract

Head and neck neoplasms arising in the paraganglion tissue, comprising carotid body, vagal and temporal bone paragangliomas, account for a small part of extraadrenal paragangliomas. They represent, however, a challenging diagnosis that is often made quite late, appearing in some of the most complex anatomical areas with regards to surgery. Morbidity is also high, with often permanent cranial nerves damage or audio-vestibular injury, both by the tumours themselves or as a consequence of late surgery. Therefore, it is important for physicians to be informed as much as possible on this subject. Throughout a vast and thorough assessment of the state-of-the-art advances, as well as some previously published remarkable takes on the matter, this narrative review aims to cover what is needed to know about the epidemiology, pathophysiology, clinical manifestations, diagnosis and treatment of this otorhinolaryngological condition.

Keywords: Head and neck paraganglioma; Paraganglioma; Carotid body tumour; Vagal paraganglioma; Temporal bone paraganglioma; Jugulotympanic paraganglioma; Tympanomastoid paraganglioma; Otorhinolaryngology; Head and neck surgery; Narrative review.

Introduction

Paragangliomas are traditionally poorly defined in literature, as the definition varies depending on the sources. Some more specific designations have recently been revised, such as non-chromaffin (parasympathetic) and metameric (sympathetic), and the term chemodectoma is no longer used [1]. The 2017 WHO classification of tumours of the endocrine organs defines ‘extra-adrenal paraganglioma’ as both functional (catecholamine secreting) and non-functional, sympathetic or parasympathetic-derived neoplasms arising in extra-adrenal paraganglion tissue. Tumours with the same characteristics originated inside the adrenal glands would be referred to as pheochromocytomas [2], although in clinical practice the term ‘paraganglioma’ generally refers to head and neck tumours with these characteristics [3].

In this review, we will focus on the epidemiology, pathophysiology and clinical manifestations, as well as the diagnosis and treatment of three specific and most frequent types of head and neck paragangliomas (HN-PGLs), consisting of carotid body paragangliomas (CBPs), vagal paragangliomas (VPs) and temporal bone paraganglioma (TBPs), which includes both tympanomastoid (TMPs) and tympanojugular paragangliomas (TJPs). All of them are parasympathetic-derived paragangliomas, with CBP arising from the carotid body at the carotid bifurcation, VP arising mainly (but not only) from the nodose ganglion or inferior ganglion of the vagus nerve. TBPs arise from Jacobson’s nerve (i.e. the tympanic branch of CN IX), Arnold’s nerve (the auricular branch of CN X) and intravagal paraganglia inferior to foramen jugulare [4]. The apparition near the jugular bulb describes TJPs whereas the apparition in the tympanic or mastoid canaliculi describe TMPs [5]. They are indolent slow-growing tumours, mostly non-secreting, in a complex anatomical area [6].

The description of temporal bone paragangliomas has been highly inconsistent, coming from the lack of consensus terminology. The distinction between tympanomastoid and tympanojugular paraganglioma is often unavailable, mentioning ‘jugulotympanic paraganglioma’ as a sole entity, leaving unclear to the reader if the first is simply dismissed or included in the latter. Others have adopted the terminology ‘middle ear paraganglioma’, without specifying up to which extent nearby paragangliomas outside of the middle ear are considered. It is however consistent that glomus tympanicum and glomus jugulare are now both included and referred to as jugulotympanic paraganglioma. We will therefore mention as temporal bone paraganglioma all tympanomastoid paragangliomas, tympanojugular or jugulotympanic paragangliomas, temporal paragangliomas and jugular foramen paragangliomas, specifying the subtype only when the information refers to that specific subtype exclusively. Finally, ‘Head and neck’ is commonly defined as the anatomical area delimitated inferiorly by the clavicle and superiorly by the cranial vertex, and so does this review [7].

Methods

Resource publications for this narrative review were identified and selected through searches of PubMed and MEDLINE, using ‘cervical paraganglioma’, ‘paraganglioma’, ‘head and neck paraganglioma’, ‘vagal paraganglioma’, ‘carotid body paraganglioma’, ‘carotid body tumor’, ‘glomus jugulare’, ‘temporal bone paraganglioma’, ‘jugular foramen paraganglioma’, ‘middle ear paraganglioma’, ‘glomus tympanicum’ and ‘jugulotympanic paraganglioma’ as search terms. Studies selected for this review include the most recent advances in research until November 2019, they were published in high-impact, peer-reviewed journals, and showed results based on satisfactory numbers of study participants, covering a relevant population.

Epidemiology

The incidence of head and neck paragangliomas in the general population ranges from 1/30.000 to 1/100.000 per year. CBPs account for approximately 60% and TBPs account for 30% of them, leaving approximately 10% to VPs. Laryngeal paragangliomas are extremely rare, with less than 100 cases reported in literature. The remaining ones (non-head and neck) are mostly found in the abdomen region [8-11]. Only 10% of paragangliomas do not occur in the adrenal paraganglia and are thus not pheochromocytomas. Of these, 97% arise in non-head and neck locations [12].

60% of HN-PGLs are sporadic, although the remaining 40% are familial inherited cases associated with succinate dehydrogenase subunits mutations [10]. These familial cases are more likely to be bilateral and multiple (10-25% for CBPs and 20-40% for VPs, 30% for TBPs). Only 5% of cervical paragangliomas are catecholamines producers. Malignant behaviour isn’t predictable by clinical manifestations nor histology, although familial cases are associated with higher rates of malignancy than sporadic ones [8-10] The pathologies most associated with paragangliomas are type 2B Multiple Endocrine Neoplasia (MEN), type 1 neurofibromatosis and Von Hippel-Lindau syndrome [8,9].

CBPs appear between the 5th and 6th decade of life, show approximately 2:1 (female:male) gender predilection and are rarely bilateral if sporadic (5%) [10] VPs usually appear during the 5th decade of life, also show 2:1 (female:male) gender predilection and have higher chances of being bilateral/multifocal or metastatic than CBPs [10].

TBPs also usually appear between the 5th and 6th decades of life and exhibit female gender predilection with a female:male ratio of 3:1 [10,12] Jugular paragangliomas have their peak incidence in the 6th decade, and some authors point at a higher female to male ratio, as high as 4:1 or 6:1 [10,13,14]. Bimodal distribution of cases in tympanic paraganglioma has been mentioned, with a first smaller peak around the 4th decade [15] Malignant TBP cases are lower than in other HN-PGLs, and often associated to SDHB mutations. These range from 2-5% and come from the presence of metastases, as proliferative index Ki67 is almost always very low, around 1-2% [5,13,16] Interestingly, the incidence of cervical paragangliomas is higher in people living above 1.000m over the sea level, as encountered in a single cohort study, postulating a potential role of chronic hypoxia as a risk factor for CP [17].

Pathophysiology

Cervical paragangliomas are a rare group of tumours, originated from the chromaffin cells of the extra-adrenal paraganglionic system (derived originally from the crista neuralis), following the autonomous system chain over the head and neck. They are slowly growing and invasive to nearby structures, and consist of highly vascularized structures, getting its blood supply mainly from external carotid artery branches [18].

To elucidate the aetiology, it’s mandatory to separate between the familial and the sporadic cases. As mentioned before, the familial cases are related to succinate dehydrogenase (SDH) mutations in 4 locus: 11q23 (SDHD gene causing PGL1), 11q13 (PGL2), 1q21 (SDHC gene causing PGL3) and 1p36.1p35 (SDHB gene causing PGL4 [19] The inheritance pattern is autosomal dominant, with incomplete penetrance [20] SDH plays a role in the tricarboxylic acid cycle and oxidative phosphorylation located in the mitochondrial complex II. The mutation in SDH produces similar effects as chronic hypoxia in paraganglionic cells [21]. Mutations in SDHD and SDHB increase intracellular concentrations of hypoxia molecular mediators (HIF) and stimulate angiogenic genes (VEGF) that translate into an increased hyperplasic proliferation, causing the neoplasia [19]. SDHD mutations are more common in multifocal paragangliomas, including non-functional ones, whereas SDHB mutations are more associated with malignant behaviours [22]. Finally, the SDHA subunit mutation hasn’t been related with paragangliomas nor other tumours, but with the autosomal recessive young encephalopathy [23].

Macroscopic pathology of paragangliomas appears as well-circumscribed reddish-brown masses usually ranging from 2 to 6 centimetres at resection [6]. Rarely, the tumour can be pigmented [14] Jugular paragangliomas had an average size of 3.5 centimetres in a large retrospective study, whereas tympanic paragangliomas had considerably a smaller size with a mean of 0.7 centimetres [11].

Microscopic pathology shows a characteristic ‘Zellballen’ pattern composed by nests of neuroendocrine chief cells and peripheral glial-like sustentacular cells, surrounded by delicate vascular septae. Both types of cells are positive to immunochemistry staining with chromogranin, synaptophysin, neuron-specific enolase, CD56 and CD57 (chief cells) and S-100 (sustentacular cells). Antibodies against proteins encoded by recognised susceptibility genes (as previously mentioned) may also be used to establish an increased risk of germline mutations of these genes [24].

Clinical Manifestations

Clinical manifestations of head and neck paragangliomas are not so obvious, and whereas functional tumours are often suspected with the presentation of otherwise unexplained fluctuating or persistent specific symptoms such as headache, profuse sweating, palpitations, tachycardia, hypertension or anxiety, these only represent 1% of HN-PGLs, as even catecholamine secreting tumours often don’t reach high enough levels to produce symptoms [25,26] Most CBPs and VPs are thus non secreting at a clinically-significant level and grow on average at a rate of 0.83mm/year. Clinical manifestations mostly come from the compression or invasion of nearby structures, depending on the direction of the growth [6] TBPs also exhibit a similar slow growth, but often present in a symptomatic fashion. However, diagnosis is usually made after a considerable time, with patients waiting on average around 30 months before consultation [12,27].

The most common presentation of CBPs is that of an asymptomatic, pulsatile cervical mass, with a limited mobility in the cephalocaudal axis and good mobility in the lateral axis (classically referred to as Fontaine’s sign). In some cases, headache and syncope have also been reported as main complaints [28] Early detection through physical examination or self-detection may be challenging especially in obese patients. Bulging of the oropharyngeal wall is present in approximately 10% of tumours, originating hoarseness, dysphagia or foreign body sensation. Larger CBPs may cause vagal and hypoglossal palsy, and the compression of arteries may result in a noticeable bruit. Differential diagnosis of these masses includes carotid aneurysms and neurilemmomas [14].

VPs also present as painless cervical masses, and occasionally patients will show dysphagia and hoarseness. Oropharynx may be deviated following the occupation of parapharyngeal space. Cranial nerve (CN) dysfunction occurs more frequently than with CBPs, with preoperative weakness of CN X occurring in one third of patients [14,29]. In some cases, other CNs may be involved, such as CN IX, and although rare, the involvement of the sympathetic chain can cause Horner’s Syndrome. Also rare but of major importance, VPs may reach the skull base and extend intracranially (dumbbell-shaped tumour), or involve the jugular foramen and the atlas [6] Polymyalgia rheumatica is a described paraneoplastic syndrome associated with benign VP [30].

TBPs usually present as symptomatic tumours. Depending on their location and extension, symptoms may vary, as these appear based on the structure they alter by compression or erosion. Jugular paragangliomas will have higher rate of CN dysfunction, whereas tympanic paragangliomas will have significantly higher hearing symptoms. Both can however extend into the other’s anatomical area, ultimately behaving in a similar manner [11]. Most commonly reported symptoms are pulsatile tinnitus ranging from 60 to 80% of patients, and hearing loss, in 55 to 80% of patients [5,13-15,27] Conductive hearing loss is predominant, whereas neurosensorial hearing loss is less frequent and shows itself in extended tumours with vestibular involvement [13,27]. Aural fulness is also frequently reported, in up to 70% of patients [10,15] CN abnormalities are often present, in up to 40% of patients [5,16] These will show up in a clinical examination, or through a wide variety of symptoms such as dysphonia, dysphagia, dysarthria, tongue weakness, hoarseness and shoulder pain or weakness [12-15,31] Specifically, CN VII is affected in up to 39% of patients, CN IX and X in up to 40% of patients, and CN XI and XII in up to 30% of patients [5] Both Vernet syndrome (CN IX, X, XI abnormality) as well as Collet-Sicard syndrome (CN IX, X, XI, XII abnormality) have been described associated to TBPs, with the latter in up to 10% of jugular paragangliomas [13].

Some authors have considered the presence of a red, vascular middle-ear mass as pathognomonic of TBP, whereas others simply describe it as very common finding [5,14]. This mass can also be pulsatile [5,14,15] Other characteristic sings are Brown’s sign, described as a blanching of the lesion when pneumatic pressure is applied, revealing the vascular nature of the tumour, and the rising sun sign, presenting as an inferior semi-circular red-blue lesion behind the tympanic membrane [5,15] Rarer presentations may be vertigo (in up to 20%), otalgia (3%), otorrhagia (1.5-9.6%) and epistaxis (uncommon) [15,27]. Horner’s syndrome can also be seen [16].

CBPs’ malignancy rate is estimated between 5-10%. Pain, young age and rapid enlargement are the most predictive features. Although a retrospective cohort study reported a CBP with aggressive soft tissue invasion which affected the brachial plexus and cervical nerve roots, this is generally not accepted as a malignant CBP; malignancy requires the presence of regional or distant metastasis [11,29].

Metastatic CBP and VPs are rare but represent a challenging medical management. VPs are more like to become malignant and metastasize than CBPs [32] Described locations of metastatic CBP include peripheral lymph nodes or distant organs such as liver, bone, kidney, lungs, breast, pancreas, brain and thyroid gland [28,33]. Wang et al. mentioned what they believe to be the first case of CBP brain metastasis, with the particularity of having an endocrine activity [33]. The symptoms described were right limb weakness, dizziness, vomiting, hypertension and hyperglycaemia, resolving after the tumour extirpation. Needless to say, these are not the common rule. TBPs have even lower metastatic rates than CBPs, although some cases have been reported, especially in bone, lungs, lymph nodes and liver [5].

Differential diagnosis of CBPs include lymph nodes, which may or may not contain metastatic disease, mainly from other neuroendocrine tumours such as neuroendocrine carcinomas, Merkel cell carcinoma and medullary thyroid carcinoma. For VPs, differential diagnosis can be established with schwannomas, vascular tumours and parotid gland salivary tumours. When investigating a possible TBP, clinicians should keep in mind that meningioma, middle ear adenoma and haemangioma can present in a similar manner and share part of neuroendocrine markers [10]. Also, an inflammatory polyp, an aberrant internal carotid artery, an anatomic variation of the jugular bulb, a CN VII neuroma, an osteoma, a cholesteatoma or a cholesterol granuloma can be misdiagnosed as a TBP [27].

HN-PGLs may be hard to distinguish from atypical carcinoids, although some characteristics may help differentiate both: atypical carcinoids usually appear during the 6th-7th decade, metastasize frequently and primarily affect male patients (3:1 M:F), although they have the same clinical manifestations and ultimately require histologic analysis [10].

Diagnosis

As mentioned before, although clinically non-secreting, HN-PGLs may secrete catecholamines, which justifies why biochemical tests such as plasma free metanephrines or urinary fractionated metanephrines are recommended as initial investigation for paragangliomas [34]. Imaging studies should be performed once a positive biochemical test occurs, and include both contrast enhanced CT or Magnetic Resonance Imaging [34]. MRI is preferred in HN-PGLs, with a sensitivity of 90-95% (higher than CT), and it helps differentiate HN-PGLs from other tumours (such as Schwannoma, neurofibroma, carotid artery aneurism), and provides excellent details on extension and vascularization [4,34,35]. CBPs and TBPs show a characteristic salt-and-pepper image in contrast in T1 MRI, distinguishing areas with subacute haemorrhage and slow blood flow (‘salt’) from serpent-shaped flow voids (‘pepper’). Gadolinium intensively enhances these lesions, and T2 shows mildly and heterogeneously hyperintense, well defined mass [4-6,15,35].

If the invasion of the skull base is suspected, contrast enhanced CT provides excellent spatial resolution. MRI can be, and usually is, complementary to CT [6]. CBPs appear as a hypervascular mass that spreads between the internal and the external carotid arteries. However, it is usually located at the same level or below the carotid bifurcation, not above. Digital subtraction angiography may be performed to evaluate internal carotid infiltration or preoperatively if embolization is considered. The image is classically described as a ‘lyre sign’, and CBPs show a slow and prolonged blush. VPs can also appear as CBPs but they usually present behind the internal carotid artery and push the vessels in an anteromedial direction [4,6,29,35] Another characteristic is that they may separate the jugular vein from the carotid sheath [29].

In TBPs, radiologic studies are also paramount in order to further classify the tumour and determine the most appropriate approach to treatment. High-resolution CT scan with contrast is both sensitive and specific, usually showing localized irregular bone destruction at the jugular foramen, with sometimes enlargement of the latter. This pattern is traditionally described as ‘moth-eaten’ [4,5]. TBPs are a soft tissue mass, enhanced by contrast [35]. The erosion of the jugular plate suggests that the tumour is a jugular paraganglioma [36]. MRI is preferred and complementary to CT in order to precisely determine intracranial involvement, especially in those tumours reaching outside of the middle-ear [5,15,35]. Furthermore, MRI differentiates more accurately tympanic paragangliomas from jugular paragangliomas [5,12]. Angiography is not always performed, but can be considered in case of suspected invasion of the internal carotid artery, or the anterior vertebral artery [5]. Tympanic paragangliomas may grow inside the tympanic cavity without destroying the ossicles, but being attached to them [4,15].

Ultrasound, if performed, shows solid hypoechoic lesions [35]. Biopsy of suspected PGLs is contraindicated because of the high risk of bleeding [37]. For metastatic cases, 18FDG PET-CT is preferred because of its higher sensitivity when compared to other techniques, especially in SDHB-related PPGLs [34].

Treatment

There is widespread consensus in the literature with regards to surgery as the only available option for treatment. There is no effective medical therapy.

Shamblin et al [38]. suggested a classification in 1971 based on CBP tumour size and carotid artery invasion to assess resection possibilities:

Shamblin 1: Less frequent group, containing small size (<4cm) and well localized tumours, without invasion of major vessels and easily resectable.

Shamblin 2: Nearly 50% of the cases, containing of mid-size (>4cm) tumours, adhered to or partially surrounding major vessels. They compress the internal and external carotid artery but can be removed through a cautious subadventitial dissection.

Shamblin 3: More than 25% of the cases, containing big size tumours, invading carotids and nearby structures. In order to be completely removed, partial or total resection of these structures is needed.

The reasons to resect a cervical paraganglioma include the following: [39]

Some HN-PGLs could eventually become malignant, although it’s not possible to know before or after the surgery.

There is no true consensus on an optimal follow-up strategy.

No cases of spontaneous regression, even correcting hypoxemia, have been published.

The risk of vascular injury in experienced surgical teams intervening a Shamblin 1 tumour is minimal.

All tumours can become symptomatic.

The basic surgical technique consists of an incision over the anterior edge of sternocleidomastoid muscle. The deep anterior fascia is dissected in order to expose the common carotid artery, which is important for an early vascular control. The dissection plane then extends anteriorly until the carotid bifurcation. This way the subadventitial plane or ‘white line’ as described by Gordon-Taylor can be identified, which allows a fine separation of the tumour and the artery due to a relatively avascular plane [39,40].

The risk of an arterial injury during the resection increases with tumour size, but without a significative increase of brain ischaemic events. Adjacent CN lesions are one of the major risks during surgery, mainly accessory spinal nerve (XI), vagus nerve (X) and hypoglossal nerve (XII). Again, the risk increases with tumour size, but locating, isolating and carefully dissecting these structures prior to tumour resection decreases the risk. In vast tumours, where surgical resection could entail bigger morbidity, or in suboptimal basal patients, either because of age or because of concomitant pathologies, radiotherapy is indicated, with 45Gy in 25 fractions showing good results in/at stopping tumour progression at 5 and 10 years of follow-up (only 4 to 6% recurrence at 5 and 10 years respectively), but sometimes leaving an asymptomatic residual mass [39,41,42]. Regarding potential complications of radiotherapy, histologic examination has shown that chief cells are minimally affected by irradiation, although the distinctive vascular structure of the tumour is replaced by fibrous connective tissue, raising awareness over the appearance of malignant tumours such as fibrosarcoma [43-45]. 15% of patients who underwent radiotherapy suffered at least one complication, which include inflammation of the external auditory canal and middle ear, skin loss with bone exposure, osteoradionecrosis, cranial nerve neuropathies (specially hearing and taste loss, in <3%) and direct injury to brain tissue, among others. Additionally, it is worth mentioning that if radiotherapy fails, surgery will be more difficult [40,42,45-47] For CBPs, 14% of <5cm tumours extirpation entail CN disfunction as compared to 67% of >5cm tumours [12].

Another alternative worth mentioning is embolization, a technique consisting in introducing a catheter (generally through a percutaneous approach to the femoral vessels with Seldinger technique) to deploy coils in tumour’s vascularisation that will form a clot and interrupt blood flow, reducing blood loss and facilitating tumour resection. The procedure is usually undergone 48h before surgery to avoid intraoperatory inflammatory phenomena. There have been some controversial discussions regarding its efficacy, since it also entails some risks (distal embolization, necrosis, cerebral or ocular infarcts, etc.), so there is no real general consensus over the existing evidence [48].

For VPs, the same management options are generally considered. However, surgery isn’t supported by high levels of evidence, especially when compared to small CBPs, because an intervention almost always (93%) implies complete resection of the vague nerve which causes serious side effects such as unilateral vocal fold paralysis, pharyngeal plexus deficit, pharynx numbness and soft palate dysfunction, resulting in dysphagia and dysphonia among others, often worse than the tumour itself would cause. The typical approach is lateral, transcervical and preauricular, sometimes superiorly extended. Damage to other CNs is also possible, with numbers ranging from 21% to 39%. When compared to Radiotherapy (RT) and Stereotactic Radiosurgery (SRS), results are similar to surgery but with less damage to CN, postulating the option of an observation ± RT ± SRS as a reasonable alternative to surgery in selected patients [12]. A recent study has shown that immediate selective laryngeal reinnervation using the phrenic nerve and the ansa cervicalis as donor nerves after VP excision improves both dysphagia and dysphonia. [49] However, further evidence is needed to define management algorithms for VPs.

Regarding TBPs, the modified Fisch and Mattox classification is used to divide them based on their extension, which at the same time determines the optimal surgical approach (presented between brackets). Tympanomastoid paragangliomas, on the one hand, can be classified as class A, if they are confined to middle ear, and then further subdivided into A1 if the tumour margins are clearly visible on otoscopic examination (transcanal approach) or into A2 if margins are not visible on otoscopy (retroauricular-transcanal approach, glove finger flap technique). An emerging new technique, consisting of transcanal endoscopic minimally invasive surgery, has demonstrated feasibility and promising results among this class [50-52]. They can also be classified as class B if they are confined to the tympanomastoid cavity without bone destruction in the temporal infralabyrinthine compartment, and then further subdivided into B1 if they extend to the hypotympanum alone (canal wall up mastoidectomy with posterior tympanotomy), into B2 if they extend to the hypotympanum and the mastoid (canal wall up mastoidectomy with posterior tympanotomy and subfacial recess tympanotomy) or into B3 if they erode the carotid canal (subtotal petrosectomy with middle ear obliteration).(27) Major postoperative complications such as CN deficits are usually not expected, but minor complications such as postoperative conductive hearing loss may occur [53].

Tympanojugular paragangliomas, on the other hand, can be classified as class C if they extend beyond the tympanomastoid cavity, destroying bone of the infralabyrinthine and apical compartment of the temporal bone and involving the carotid canal, with further subdivisions C1-C4 depending on the degree of invasion (C1, tumours with limited involvement of the vertical portion of the carotid canal; C2, tumours invading the vertical portion of the carotid canal; C3, tumours with invasion of the horizontal portion of the carotid canal; C4, tumours reaching the anterior foramen lacerum). They can also be classified as class D if they extend intracranially (De1, tumours up to 2 cm dural displacement; De2, tumours with more than 2 cm dural displacement; Di1, tumours up to 2 cm intradural extension; Di2, tumours with more than 2 cm intradural extension; Di3, tumours with inoperable intradural extension) or as class V if they involve the vertebral artery (Ve, tumours involving its extradural portion; Vi, tumours involving its intradural portion) [5]. They are usually resected via an infratemporal approach, but C1, C2, De1, De2, Di1 and Di2 may demand a variant of the juxtacondylar approach [54] Because these tumours are adherent and occasionally CN IX-XII are involved, higher rates of CN deficits are anticipated for the postoperative outcome, and thus possibly requiring further surgical procedures attempting to correct them.(55,56) Di1 and Di2 tumours should be generally resected in a two-stage multidisciplinary procedure involving neurosurgeons, whereas in Di3 tumours palliative radiotherapy is advocated. Although some inconsistencies regarding Fisch classification and follow-up intervals among different studies must be taken into account, long-term success rate following surgical therapy of tympanojugular paragangliomas is 72-95% [54].

Conclusion

Paragangliomas are functional or non-functional, sympathetic or parasympathetic-derived neoplasms arising in extra-adrenal paraganglion tissue. Amongst these, HN-PGLs are mainly composed by CBPs, VPs, and TBPs. Some genetic associations have been described. Clinical manifestations are diverse although some signs and symptoms strongly suggest the diagnosis. Biochemical screening is the first complementary step when investigating a possible HN-PGL, followed, if positive, by the best available imaging technique, which usually narrows down the differential diagnosis. Surgical intervention, with or without previous embolization, is the best and only approved therapeutic option for CBPs and TBPs, whereas for VPs further evidence is needed to determine whether surgery with reinnervation or a combination of RT and SRS is the best therapeutic management strategy. For some tympanomastoid paragangliomas, endoscopic surgery is emerging with promising results.

More information regarding this Article visit: OAJBGSR

https://biogenericpublishers.com/pdf/JBGSR.MS.ID.00178.pdf https://biogenericpublishers.com/jbgsr-ms-id-00178-text/

[your-local-hollow-lover]

Maybe relationship headcanons for Luppi and Nelliel with the reader?

Luppi:

He's self-centered and a bit shallow, so he'd love a significant other who praises him, compliments him, and constantly asserts he's fantastic.

However, this man isn't used to human compliments, so he might act like he knows he's pretty when you tell him, but his heart always skips a beat!

Absolute whore for attention (might die without, seriously, don't push your luck)

Luppi would force you to live with him, tbh. If you're human, prepare to be abducted indefinitely to Hueco Mundo.

Loves pdh (gradatory) he'll def be the one who puts a dog collar on your neck and walks around with you.

However, he's melting in your arms when you're alone. He can't help but enjoy your scent so much, to fall asleep on top of you and fantasize about you staying with him forever.

Luppi's best quality as a partner is he's perceptive of your feelings, even if you try to hide them, while his worst is that he's enough of a cunt to ignore if you're not feeling okay if he's pissed with you.

Nell:

She can be a bit suffocating, but give her time to get used to the fact you're not leaving.

Nelliel, unlike the other Espada, enjoys the life she's got in Hueco Mundo, and she lives enjoying her every day in her way, which she's grateful you understand. "Why," you might be asking. Well, because she wants to share that with you!

Nell takes you to all the cool places she's found in Hueco Mundo, taking tea with Pesche and Dondochakka and fishing in the sand! Escaping danger when you happen to bump into someone looking for a fight.

Nelliel carries herself with such elegant parsimony that watching her fight became one of your favorite activities! More so because it's rare that she agrees to jump into a fight.

Nell's best quality as a partner is that she's considerate, while her worst is that she might be Incomprehensive.

[my0vershareworld]

Masterlist (updated 10/11/2023)

list of Genre: Fluff🧡, Angst💛, crack🖤, Yandere💗 Headcanons💚, Familia💙, Platonic💜, Romantic🤎, one shot🤍, story ❣, Female reader💕, Male reader 💞, Gender neutral reader 💓

Sosuke Aizen

I am the one who make you (Fake)🧡💚💙💓

My tool 💛💙❣💓

a child.. 🧡💚🤎💕

brand new powerful species 💚💕

Espada

Nnoitra Gilga

Grumpy x Sunshine 🧡💚🤎💓

Nnoitra Gilga relationship headcanons 🧡💚🤎💓

Holidays together? 🧡💚🤎💓

Aaroniero Arruruerie

You stole my heart but I'll let you keep it 🧡🤎🤍💓

Sitting on Aaroniero's lap 🧡💚🤎💓

Ulquiorra Cifer

This is fine 🧡💚🤎💓

the perfect Fraccion 💚💜💓

Szayelaporro Granz

Sitting on Szayelaporro's lap 🧡💚🤎💓

a smartie like me fit perfectly with you 🧡💚🤎💓

love day you say? 🧡💚🤎💓

what are you doing, human? 🧡💚🤎💓

but there is only one bed! 🧡💚🤎💓

will you be the last piece to make me the perfect being? 🧡🤎🤍💓

I'll make you fall for me, my dear 🧡💚🤎💓

General hcs 💚

sakura mochi 🧡💚🤎💓

the day you kept me warm 🧡💚🤎💓

so this is love..how fun! 🧡🤍💓

Grimmjow Jaggerjaques

what an annoyance (lovingly) 🧡💚💙💓

Nelliel Tu Odelschwacnk

the friendliest friend! 🧡💚💜💓

General hcs 💚

Tier Harribel

Dating the dangerous shark 🧡💚🤎💓

my dear.. 🧡💚🤎💓

Coyote Starrk

burden 💛🤎🤍💓

protective reader 🧡💚🤎💓

Arrancars

Yylfordt Granz

Ice Skating with Yylfordt 🧡💜💓

Date? Me? 🧡💚🤎💓

you're trying every tricks huh? 🧡💚💜💓

Tesla Lindocruz

I will always be with you 🧡💚🤎💓

Luppi Antenor

you tower 🧡💚🤎💓

Roka Paramia

...me? your friend?.. 🧡(little)💛💚💜💓

a friend..? 🧡💚💜💓

Roka general hcs 💚

Quincies

Jugram Haschwalth

the important 🧡💚🤎💞

Giselle Gewelle

my living zombie friend! 🧡💚💜💓

my blissful lovergirl! 🧡💚🤎💕

Äs Nödt

the shyness of yours.. 🧡💚🤎💓

is that supposed to be scary? 🧡💚🖤💓

Askin Nakk Le Vaar

silly funky man 💚🖤

Cang Du

the memories will always haunt him 🧡💚🤎💓

Bambietta Basterbine

unseen love 🧡💛🤎🤍💕

Gremmy Thoumeaux

dusk til dawn 🧡💚🤎💓

Yandere Gremmy 💗💚🤎💓

Quilge Opie

vampire Yandere with stockholm syndrome reader 💗💚🤎💓

Visored

Shinji Hirako

lemme help you with your anxiety, babe! 🧡💚🤎💓

would a kiss work for making up to you? 🧡💚🤎💓

I can teach ya how ta' be like me! 💚💓

Lisa Yadomaru

well aren't you a lucky one? 🧡💚💜💓

Multi-Character

friend? friend! (Coyote Starrk x reader, Lilynette Gingerbuck x GN!Human reader) 🧡💚💜💓

Chaotic (Fraccion's in a reality show)💚🖤

more..SIBLING?! (the granz brothers x GN!Human reader) 🧡💚💙💓

..what a sweet Shinigami.. (the espadas x GN!Shingami reader) 🧡💚🤎💓

I fucking hate you (espada meeting someone like Bellatrix Lestrange) 💚

I AM NOT SHARING! (the Granz brothers x M!human reader) 🧡💚🤎💞

love..., LOVE!, love! (As Nodt, Gerard Valkyrie, Giselle Gewelle x GN!Human reader) 🧡💚🤎💓

perfection (espada x GN!Arrancar reader) 🧡💚🤎💓

GET OFF OF ME (Szayelaporro Granz, Nnoitra Gilga, Coyote Starrk, Grimmjow Jaegerjaquez X GN!Human reader) 🖤💚💜💓

what the fuck is this creature.. (Espadas with a genderfluid child made by Szayelaporro) 💚🖤

you're related to who? (Espadas with an S/O who's related to one of the Espada) 🧡💚🤎💓

go! girlboss go! (Espadas (Excluding Barragan and Yammy) x Girlboss reader) 🧡💚🤎💕

you should put your phone away sometimes (Espadas (excluding Barragan and Yammy) x GN!Human reader rizzing them up) 🧡🖤💚💓

what are you trying to achieve here? (Fracciones (excluding Lilynette) x GN!Human reader rizzing them up) 🧡🖤💚💓

cuddles (Espada (excluding Yammy and Barragan) x GN!Human reader) 🧡💚🤎💓

highschool year (espadas (excluding Barragaan and Yammy) in high school year +BONUS Yylfordt and Luppi)🖤💚

happy valentine, here's your love (Cang Du, Bazz-B, Jugram, Gremmy x GN!Human reader on valentine day) 🧡💚🤎💓

Amoral individual (Espadas (excluding Yammy and Barragan) meeting someone like Tiffany Valentine)

[my0vershareworld]

𝕝𝕠𝕧𝕖𝕣, 𝕝𝕠𝕧𝕖𝕣, 𝕒𝕞 𝕀 𝕥𝕙𝕖 𝕡𝕣𝕖𝕥𝕥𝕚𝕖𝕤𝕥 𝕓𝕠𝕪 𝕚𝕟 𝕥𝕙𝕖 𝕨𝕠𝕣𝕝𝕕?

Pairing ; Luppi Antenor x GN!Human reader

Genre ; Fluff , Headcanons

CW ; fucking asshole luppi.

Requested by anon ; I NEED MORE LUPPI DATING HEADCANONS👹👹👹👹(please🙏🏻🙏🏻)

he hates that he's dating a human - but it also makes it fun for him too ! because you got a lot of stuff he can fuck around and find out with whether is food , electronics and a buncha other stuff !

he bugs you a lot when he's free , going through the garganta right into your house whenever he pleases

he likes to pokes you everywhere and also likes to play with your hair . . that also includes him pulling your hair especially if you . . well ignore him because it can get irritating with how much he tends to bug and annoy you

he also likes to lay his head on your lap and loves to have you feed him food . . and he also sometimes likes to steal your food

sometimes he appears in the middle of the night just because he's free and if you're asleep he'll just stare at you while you sleep until you either wake up or he have to go or he just got bored

he likes to boast about himself about how powerful and strong he is especially after he was put as the sexta espada

he also got a lot of gossips from hueco mundo at times and tends to talks about it a lot to you and in return he'll also listens to you gossip about your co-worker , enemies , boss , whatever ya have goin' ! after all Luppi LOVE gossiping !

he sometimes flop onto you and just lay on you and not getting up , he doesn't care whether he's heavy or not because he don't think he is ! oh , c'mon ! he got this small waist and body ! he's as light as a feather !

he also love praises especially coming from you - after all he LOVES validation and attention . telling him he's pretty , cute , strong and anything that could count as compliments ! and oh he'll be in heaven and start smothering you with kisses and starts to be annoying again teasing you with how much you seemed to love him

he loves you too though - he won't deny that - despite that you're a human , who gives a fuck ? you're still his lover ! and he loves you more than anything

[my0vershareworld]

𝕌𝕨𝕒𝕙!⁓ 𝕪𝕠𝕦'𝕣𝕖 𝕟𝕠 𝕗𝕦𝕟!

Pairing ; Luppi Antenor x F!Arrancar reader

Genre ; silly!! I think , Headcanons , Romantic

CW ; yapperoni luppi

Requested by anon ; This sounds funny 😭 but Luppi x dark arrancar woman like she’s a baddie but manipulative or she doesn’t let what he says slide and stands up for herself yk?

he's a yapper , a huge talker , he is also extremely straightforward and always says what he thinks before thinking it through , and that is his issue that he won't even try to fix it whether he knows it or not . but it does seems like you don't enjoy fun and whimsy at all !

he makes multiple rude remarks to either straight up mocks you or making fun of you jokingly or not , but you don't seems to be taking any of it well ! you're BORING ! you don't cry or whines when he do it ! instead you get mad and . . boringly enough you stood up for yourself - that isn't what he wanted ! ! he just wants you to start whining and crying about how rude he is - he hates how weak he feels when you do that . . but not like he really cares though , he'll just keeps doing it anyways ! there's zero points in standing up for yourself if you don't give him a punch to his face . . but still doesn't matter , he don't care

the manipulation also kind of works on him ? in a weird way ? especially if you put affections and love on the line , he craves for those from you so it's his weakness and he won't refuse - but at the same time it makes him irritated - he felt like something was off - almost like you were treating him like a weakling . but he doesn't understand manipulation and you were his lover , so again , he did not care

you don't let the things he said go past you nor do you like it - you were still boring for that ! but he still loves you , just wish you'll get more emotional instead of angry when he makes fun of you ! to him you know no fun and whimsy

he even complains at times about how you have no idea what is fun , just straight up saying it to your face of how boring you acts when you don't let the things he yap about slides

he also calls your rants to him as 'ears numbingly long rant session'

[your-local-hollow-lover]

Requests are officially

☽ O P E N ☾

[arrancarscenarios]

'XD There probably won’t be any smut in this fic, but there’ll be plenty of caretaking!' (Quoted) Well that's good at least. ^^ btw; could you possibly post a list of the asks/requests that are left in your in box? I wanna know what to look forward to. XD Only if you want to tho! And only if you have time! Ty either way! ^^

Definitely~ I mean I love gore but I also love cute fluffy caretaking! Hurt/comfort is like my favorite genre. XD

Of course, no problem! Most of the stuff is drafted but the matchup requests I keep in my inbox.

SO THAT SAID, here’s the stuff I currently have in my inbox and drafts!

3 matchup requests

(NSFW) Charlotte x female reader where she’s body worshipping and taking care of him

(NSFW) Luppi blowjob and body worship headcanons

(NSFW) most to least rating -- which of ‘my group’ (Charlotte, D-Roy, Findorr, Grimmjow, Luppi, Szayel, Tesla, and Yylfordt) would enjoy having a female S/O who’s very horny all the time

(NSFW) scenario -- giving Yylfordt a sensual, gentle spanking

scenario -- Szayel caught applying makeup

NSFW headcanons for Charlotte and Findorr

NSFW headcanons for Luppi

headcanons -- having a female human S/O who goes through a traumatic event that makes her ill because of the stress and eventually loses her voice (Charlotte, D-Roy, Findorr, Grimmjow, Luppi, Szayel, Tesla, and Yylfordt)

(NSFW) reactions -- accidentally walking in on their S/O masturbating (Charlotte, Luppi, and Yylfordt)

(probably NSFW) reactions -- they remove their S/O’s blanket to see their S/O sleeping soundly with no clothes or just underwear (Aaroniero, Baraggan, Grimmjow, Halibel, Nnoitra, Starrk, Szayel, Ulquiorra, Yammy, and Zommari)

(NSFW) headcanons for turn-ons (Charlotte and Luppi)

reaction -- Ulquiorra reacting to his S/O joining a fight in order  to protect him

[arrancarscenarios]

Veeeeery tiny preview of my gory Luppi x reader fic under the cut? Just a couple paragraphs and there’s not much good description here, but it’s something to set the scene and make y’all want more >:D

So when the door opens, you’re not expecting the horrific scene you get to take in.

A young man is tossed onto the floor with a sickening crack, thrown by the Arrancar who opened the door. This one has shocking blue hair and eyes to match, his shirt is open, and his clothes from the waist down – not that he’s wearing much on his upper half in the first place – are covered with blood. That’s to say nothing of his left arm, which is so bloody you would think he’s injured too if not for the fact that he doesn’t seem to be in any pain.

What’s his name again? Grimmjow, you think? He’s always sort of unnerved you.

“Hey.” His voice is sharp and cuts over the sounds of the other Arrancar who’s writhing in pain on the ground. “Got a patient for you.”

You’re almost frozen until his words snap you out of it, and then immediately you run over to kneel by the hurt Arrancar. “W-what?! What happened?!”

The look Grimmjow gives you implies that he thinks you’re a complete idiot. “I broke him. Now fix him so I can break him again.”

[arrancarscenarios]

YET ANOTHER!! Preview of my gory Luppi x reader fic under the cut!!! <3

As always, people sensitive to gore and such please tread cautiously. And those of you who are into it (like yours truly~), enjoy. :D

He doesn’t say anything, so you pull his outfit open to try and get a better look. There aren’t any wounds like the cuts on his hip or the missing arm. There is, however, a mess of plum splotches. There are more bruises here, a cluster of several so close together that they’re all blossoming into each other like an oil painting.

That shouldn’t keep him from breathing properly, should it? So… add in something internal going on in his chest.

“Hurts!” is all he can say. He lets out what sounds like a strangled cough, and when he does, blood splatters up from it, staining his lips and dribbling down his chin. Flecks of it land on his chest and on any parts of his shirt that weren’t already covered. You have to hope that he isn’t too attached to this particular outfit.

Tears form in your eyes as you double your efforts in trying to get these wounds to stop bleeding. This isn’t fair. He doesn’t deserve to be in so much pain, so much that he can’t even form sentences. Why did Grimmjow just drop this man in your lap without a thought? Why isn’t the bleeding slowing down? Where the fuck is Szayel to help you?!

Just as your anxiety starts to bubble up and threaten to boil over, the door opens again. Looking over, you see it’s the one person you were praying was going to show up soon.

“Here’s a tip, my dear,” Szayel sighs as he breezes into the room. “The louder you scream, the faster I will realize you need help. You’re very lucky Verona heard you and came running to alert me.”

“Szayel! I-I just… Grimmjow came and… said he broke…” Ouch. Now you’re not even forming coherent sentences.

Szayel pushes up the remains of his mask. “Broke Luppi, yes. I can see that. Lumina, Verona! Take (Name) and get them a glass of water. (Name), you go sit down and take deep breaths.”

He pulls on a pair of gloves as two small, round heads poke into the doorway. “I’ll take it from here.”

[arrancarscenarios]

Here’s another preview of the Luppi x reader gore fic, under the cut!!

This preview is a bit longer, with some nice gross juicy stuff. ;D

Tread lightly if you’re sensitive to gore, please!!! <3

Those who aren’t... enjoy. ;)

When you use a scalpel to cut Luppi’s bloody sleeve at the shoulder so you can see the wound, the blade clangs to the floor in an instant as your hands fly to cover your mouth.

His arm’s been cut off.

Everything up to the elbow is gone, and that’s where all this blood is coming from. The wound itself looks shoddy, jagged, like the weapon of whoever did it wasn’t sharp enough and they had to keep hacking away. There are bits of muscle and nerves still hanging off the stump, you think, at least from what you can see through the blood. It’s the most disgusting thing you’ve ever seen.

“OH, MY GOD!”

You can’t help it. The scream that escapes you can probably be heard through the entirety of the palace, and you can’t bring yourself to care. How are you supposed to hold that back? There’s no way. You can’t just bite back your visceral reaction to seeing another living being missing a limb.

You can just imagine everyone else’s reactions. Chuckling, making jokes at your expense, claiming “poor little weak thing, we knew they couldn’t handle us.” The other Arrancars are almost certainly amused at hearing your terrified screeching.

The world around you goes dim for a moment, and it’s only by some miracle that you grasp onto the edge of the table. You wobble and retch a few times, and you think maybe you’re going to pass out. Whatever Luppi did to Grimmjow, it can’t have been enough to warrant something like this.

After a moment, you somehow scrounge up the strength to remain conscious – if only for the fact that if you don’t, it could very well mean Luppi’s death. You lean against the table for a moment to steady and mentally prepare yourself.

“Okay, right,” you mumble to yourself. “That’s one… one wound… missing arm… o-okay… um…”

Might be smart to keep him from bleeding out while you try to take stock of everything else.