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Presentation 2013

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Presentation 2013

  1. 1. case presentation  Dr. M. Naim Manhas  m.s.,m.b.b.s.  E.N.T. Specialist  King Abdul Aziz Hospital 1Dr. Naim Manhas
  2. 2. 2Dr. Naim Manhas
  3. 3. what is calculus/ lith/stone Calculus:- / lith Concretion of material mainly composing of mineral salts. Formation :- lithiasis 3Dr. Naim Manhas
  4. 4. common sites:- Uro-genital system: kidney,ureter, bladder Gall bladder Salivary gland submandibular gland parotid gland Tonsillis palatine lingual Nasal cavity 4Dr. Naim Manhas
  5. 5. Effects on organs  Disruption of normal flow Disrupting the function of organ in question Late effects of obstruction on organs 5Dr. Naim Manhas
  6. 6. etiology Excessive levels of minerals • Usually increase levels of calcium slow flow rate • infection 6Dr. Naim Manhas
  7. 7. Calculi in E.N.T. Practice Rhinolith :- Calculus present in nasal cavity Actually exogenous foreign body ,blood clot, or secretion is covered by slow deposition of calcium and magnessium salts over a period of time. Causes nasal obstruction , unilateral prulent nasal discharge,epistaxis,sinusitis or epiphora. 7Dr. Naim Manhas
  8. 8. Calculi in E.N.T. Practice Tonsilliar lith :- Tonsilliar stone or tonsilliar calculi Clusters of calicified material in the tonsillar crepts. Tonsilliar lith have been recorded weighing from 300 mg to 42 G Composed mostly of calcium, but may contain other minerals like phosphorus , magnessium. May be asymptomatic One of causes of Helitosis 8Dr. Naim Manhas
  9. 9. case presentation 30 years old saudi lady presented to E.N.T. clinic with file No.494114 . History of swelling in submandibular space, since 6 months increasing in size during meals. h/o pain was present during meals 9Dr. Naim Manhas
  10. 10. presentation Recurrent swelling Pain which is excerbated with eating Stones in duct can be palpated Imaging (C.T.) Scan is best to detect calculi UltraSound has not proven useful 10Dr. Naim Manhas
  11. 11. Radio-opague shadow in submandibular gland- 11Dr. Naim Manhas
  12. 12. 12Dr. Naim Manhas
  13. 13. Incidence of salivary calculi 13Dr. Naim Manhas
  14. 14. saliva & its composition saliva:- produced by clustered Acini cells and contain electrolytes enzymes (e.g.ptylin and maltase, carbohydrates, proteins, inorganic salts and even some antimicrobial factors) Approx. 500-1500ml of saliva is produced daily and transpored to oral cavity by ductal elements at an average of 1ml /mt Obstruction :- causes stasis of salivary flow 14Dr. Naim Manhas
  15. 15. saliva & its composition saliva • composition Abundant • hydroxyapatite • Aggregates of mineralized debris Flow rate is decreased • Formation of nidus • Promoting calculi formation 15Dr. Naim Manhas
  16. 16. Submandibular gland calculi High salivary mucin and high alkaline content High concentration of calcium and phosphate Primarly of calcium phosphate and hydroxyapatite 16Dr. Naim Manhas
  17. 17. Approxaimately 74% of single stone is found in the gland, and 26% in duct. 74% 26% 1st Qtr 17Dr. Naim Manhas
  18. 18. complications  Persistant obstruction from Sialiolithasis leads to salivary stasis which predisposes gland to recurrent infections and even abscess formation. 18Dr. Naim Manhas
  19. 19. management SURGICAL REMOVAL Calculus impacted in duct:- After palpation and fixation of the calculi , duct is opened and calculi removed. Duct is kept open as it heals by itself. Larger stone get embeded in the hilum or body of the submandibular gland require surgical excision of the gland 19Dr. Naim Manhas
  20. 20. submandibular gland specimen Excised submandibular gland with embedded stone in the hilum of the gland 20Dr. Naim Manhas
  21. 21. Recent advances  Endoscopic techniques ;-  Allow an intraoral endoscopic examination of the duct and extraction of salivary calculi  If stone is impacted in gland then surgical removal of gland is indicated 21Dr. Naim Manhas
  22. 22. Penetrating neck injuries Penetrating injuries caused by gunshots and sharp edged weapons have different approach for management. Gunshot wounds in the neck are divided in three zones of neck. 22Dr. Naim Manhas
  23. 23. Neck zones Zone -1 Between suprasternal notch to cricoid cartilage. Contains throacic outlet structures Proximal common carotid ,vertebral and subclavian arteries. Trachea, esophagus, t horacic duct, thymus 23Dr. Naim Manhas
  24. 24. Neck zones Zone –II Between carotid cartilage and angle of mandible. Internal and external caotid arteries, jugular veins, pharynx, larynx, es opahgus, recurrent laryngeal nerve, spinal cord, trachea, thyroid and parathyroid. 24Dr. Naim Manhas
  25. 25. Neck zones Zone –III Between angle of mandible and base of skull. It has distal extracrainal carotid and vertbral arteries and uppermost segments of the jugular veins. 25Dr. Naim Manhas
  26. 26. Penetrating Neck Injury The normal protocol regarding the management of penetrating neck injuries does not apply in cases like this. This egyptian man reported to E.R. with pentrating injury caused by sharp edged weapon in neck . After airway was secured by intubation patient was shifted directly to O.R. 26Dr. Naim Manhas
  27. 27. point to remember Tight facial compartments of neck structures may limit external hemorrhage from vascular compartment. These tight fascial boundaries may increases risk of airway compromise , because the airway is relatively mobile and compressible by an expanding hematoma. 27Dr. Naim Manhas
  28. 28. Penetrating Neck Injury The standard care is immediate surgical exploration who present with signs and symptoms of shock and continuous hemorrhage from the neck wounds. The specific injuries are confirmed and treated during neck exploration 28Dr. Naim Manhas
  29. 29. vital structures  Because of numerous vital structures that are present in small area, the objective of surgical exploration is to arrest hemorraghe yet maintain cerebral flow and preserve neurologic function.  Jugular vein injury repair depends upon type of injury . Repair can be performed by simple lateral closure, resection and reanastomosis or saphenous vein graft reconstruction, particularly Internal jugular vein. 29Dr. Naim Manhas
  30. 30. vital structures  Nerve injuries account for about 1-3%, vagus and recurrent laryngeal nerve.  Thoracic duct injuries :- difficult to diagnose intially but later on presents as chylous leak  Needs reexploration and ligation of throacic duct  Thyroid injuries :- can cause extensive bleeding. Extensive injury require an ipsilateral lobectomy to control the bleeding 30Dr. Naim Manhas
  31. 31. Don’t miss Laryngo-tracheal injuries are also common (10%) . Direct endoscopic examination of Larynx and esophaus is done. After closing and airway is secured by surgical tracheostomy,endoscop ic examination of larynx and esophagus is done . 31Dr. Naim Manhas
  32. 32. Before Decanulation . Esophageal injuries are the third most common in penetrating neck trauma (6%). Early diagnosis lessens probability of delayed treatment and missed injury, which can be devastating. After closure the airway is secured by tracheostomy and then endoscopic examination is done . 32Dr. Naim Manhas
  33. 33. prepration for discharge Oral feeding was initiated after barium study which shows no evidence of leak. Decanulation was done after follow up endoscopy of larynx show no evidence of any pathology . 33Dr. Naim Manhas
  34. 34. 34Dr. Naim Manhas

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