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 AzizHospital1Dr. Naim Manhas
  2. 2. 2Dr. Naim Manhas
  3. 3. what is calculus/ lith/stoneCalculus:- / lithConcretion ofmaterial mainlycomposing ofmineral salts.Formation :-lithiasis3Dr. Naim Manhas
  4. 4. common sites:-Uro-genital system: kidney,ureter, bladderGall bladderSalivary gland submandibular glandparotid glandTonsillis palatinelingualNasal cavity4Dr. Naim Manhas
  5. 5. Effects on organsDisruption of normalflowDisrupting the functionof organ in questionLate effects ofobstruction on organs5Dr. Naim Manhas
  6. 6. etiologyExcessive levels of minerals• Usually increase levels of calciumslow flow rate• infection6Dr. Naim Manhas
  7. 7. Calculi in E.N.T. PracticeRhinolith :-Calculus present in nasalcavityActually exogenous foreignbody ,blood clot, or secretionis covered by slow depositionof calcium and magnessiumsalts over a period of time.Causes nasal obstruction ,unilateral prulent nasaldischarge,epistaxis,sinusitisor epiphora.7Dr. Naim Manhas
  8. 8. Calculi in E.N.T. PracticeTonsilliar lith :-Tonsilliar stone or tonsilliar calculiClusters of calicified material in thetonsillar crepts.Tonsilliar lith have been recordedweighing from 300 mg to 42 GComposed mostly of calcium, butmay contain other minerals likephosphorus , magnessium.May be asymptomaticOne of causes of Helitosis8Dr. Naim Manhas
  9. 9. case presentation30 years old saudilady presented toE.N.T. clinic with fileNo.494114 .History of swelling insubmandibularspace, since 6months increasing insize during meals.h/o pain was presentduring meals9Dr. Naim Manhas
  10. 10. presentationRecurrent swellingPain which isexcerbated witheatingStones in duct can bepalpatedImaging (C.T.) Scan isbest to detect calculiUltraSound has notproven useful10Dr. Naim Manhas
  11. 11. Radio-opague shadow in submandibular gland-11Dr. Naim Manhas
  12. 12. 12Dr. Naim Manhas
  13. 13. Incidence of salivary calculi13Dr. Naim Manhas
  14. 14. saliva & its compositionsaliva:- produced by clustered Acini cells andcontain electrolytes enzymes (e.g.ptylin andmaltase, carbohydrates, proteins, inorganicsalts and even some antimicrobial factors)Approx. 500-1500ml of saliva is produced dailyand transpored to oral cavity by ductalelements at an average of 1ml /mtObstruction :- causes stasis of salivary flow14Dr. Naim Manhas
  15. 15. saliva & its compositionsaliva• compositionAbundant• hydroxyapatite• Aggregates ofmineralizeddebrisFlow rate isdecreased• Formation ofnidus• Promotingcalculiformation15Dr. Naim Manhas
  16. 16. Submandibular glandcalculiHigh salivary mucin and highalkaline contentHigh concentration of calciumand phosphatePrimarly of calcium phosphateand hydroxyapatite16Dr. Naim Manhas
  17. 17. Approxaimately 74% of singlestone is found in the gland,and 26% in duct.74%26%1st Qtr17Dr. Naim Manhas
  18. 18. complications Persistant obstruction fromSialiolithasis leads to salivary stasiswhich predisposes gland to recurrentinfections and even abscessformation.18Dr. Naim Manhas
  19. 19. managementSURGICAL REMOVALCalculus impacted in duct:-After palpation and fixationof the calculi , duct isopened and calculiremoved. Duct is kept openas it heals by itself.Larger stone get embededin the hilum or body of thesubmandibular glandrequire surgical excision ofthe gland19Dr. Naim Manhas
  20. 20. submandibular glandspecimenExcisedsubmandibulargland withembedded stonein the hilum ofthe gland20Dr. Naim Manhas
  21. 21. Recent advances Endoscopic techniques ;- Allow an intraoral endoscopic examinationof the duct and extraction of salivarycalculi If stone is impacted in gland then surgicalremoval of gland is indicated21Dr. Naim Manhas
  22. 22. Penetrating neck injuriesPenetrating injuriescaused by gunshotsand sharp edgedweapons havedifferent approach formanagement.Gunshot wounds inthe neck are dividedin three zones ofneck.22Dr. Naim Manhas
  23. 23. Neck zonesZone -1Between suprasternalnotch to cricoidcartilage.Contains throacicoutlet structuresProximal commoncarotid ,vertebral andsubclavian arteries.Trachea, esophagus, thoracic duct, thymus23Dr. Naim Manhas
  24. 24. Neck zonesZone –IIBetween carotidcartilage and angle ofmandible.Internal and externalcaotid arteries, jugularveins, pharynx, larynx, esopahgus, recurrentlaryngeal nerve, spinalcord, trachea, thyroidand parathyroid.24Dr. Naim Manhas
  25. 25. Neck zonesZone –IIIBetween angle ofmandible and base ofskull.It has distalextracrainal carotidand vertbral arteriesand uppermostsegments of thejugular veins.25Dr. Naim Manhas
  26. 26. Penetrating Neck InjuryThe normal protocolregarding themanagement ofpenetrating neck injuriesdoes not apply in cases likethis.This egyptian manreported to E.R. withpentrating injury caused bysharp edged weapon inneck .After airway was securedby intubation patient wasshifted directly to O.R.26Dr. Naim Manhas
  27. 27. point to rememberTight facial compartments ofneck structures may limitexternal hemorrhage fromvascular compartment.These tight fascial boundariesmay increases risk of airwaycompromise , because the airwayis relatively mobile andcompressible by an expandinghematoma.27Dr. Naim Manhas
  28. 28. Penetrating Neck InjuryThe standard care isimmediate surgicalexploration who presentwith signs and symptomsof shock and continuoushemorrhage from theneck wounds.The specific injuries areconfirmed and treatedduring neck exploration28Dr. Naim Manhas
  29. 29. vital structures Because of numerous vital structures that arepresent in small area, the objective of surgicalexploration is to arrest hemorraghe yet maintaincerebral flow and preserve neurologic function. Jugular vein injury repair depends upon type ofinjury . Repair can be performed by simple lateralclosure, resection and reanastomosis orsaphenous vein graft reconstruction, particularlyInternal jugular vein.29Dr. Naim Manhas
  30. 30. vital structures Nerve injuries account for about 1-3%, vagus andrecurrent laryngeal nerve. Thoracic duct injuries :- difficult to diagnoseintially 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 tocontrol the bleeding30Dr. Naim Manhas
  31. 31. Don’t missLaryngo-trachealinjuries are alsocommon (10%) .Direct endoscopicexamination of Larynxand esophaus is done.After closing and airwayis secured by surgicaltracheostomy,endoscopic examination oflarynx and esophagus isdone . 31Dr. Naim Manhas
  32. 32. Before Decanulation. Esophageal injuries arethe third most common inpenetrating neck trauma(6%).Early diagnosis lessensprobability of delayedtreatment and missedinjury, which can bedevastating.After closure the airway issecured by tracheostomyand then endoscopicexamination is done .32Dr. Naim Manhas
  33. 33. prepration for dischargeOral feeding wasinitiated after bariumstudy which shows noevidence of leak.Decanulation wasdone after follow upendoscopy of larynxshow no evidence ofany pathology .33Dr. Naim Manhas
  34. 34. 34Dr. Naim Manhas

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