This document discusses the management of chyle leaks after head and neck surgery. It begins with an overview of chyle, its formation and composition. It then describes the anatomy and course of the thoracic duct, which is vulnerable to injury during neck surgery and can result in chyle leakage. The pathophysiology of iatrogenic chyle leaks is explained. Diagnosis involves identifying milky fluid intraoperatively or from surgical drains. Treatment depends on drain output but may include reoperation to ligate the thoracic duct, use of flaps or sealsants, and restricting fatty foods to allow the leak to seal.
Chyle leakage occurs when the thoracic duct or lymphatic vessels are damaged, resulting in the leakage of milky fluid called chyle. It can lead to fluid and nutritional depletion if not properly managed. Treatment involves initially managing it conservatively with wound drainage, pressure dressings, and a low-fat diet. For higher output leaks, surgical exploration may be needed to locate and ligate the leak. Rarely, thoracoscopic ligation of the thoracic duct or percutaneous embolization of the duct may be required if conservative and surgical treatments are unsuccessful. Proper management is important to avoid serious complications like chylothorax.
Local flaps in head & neack reconstructionMd Roohia
A flap is a unit of tissue transferred from one site to another while maintaining its own blood supply. Flaps are classified based on their location as local or distant. Local flaps can be random, which rely on subdermal vessels, or axial, relying on named vessels. Flaps are also classified based on their composition, such as skin, muscle, or bone flaps. When planning local flaps, goals include color and thickness match, sensory preservation, and minimal secondary defects. Common local flap techniques include advancement, rotation, and transposition flaps to close facial defects. Complications can be prevented through proper planning to avoid tension and including a flap margin.
Mr. Sunil, a 72-year-old male, presented with a 3-month history of a left neck swelling. Further examinations revealed metastatic squamous cell carcinoma in the left neck lymph nodes. He was diagnosed with carcinoma of unknown primary (CUP) and underwent radical neck dissection, followed by chemotherapy and radiotherapy. CUP describes metastatic cancers where the primary site cannot be identified despite various examinations and evaluations. Treatment options for CUP include surgery, radiation therapy, chemotherapy, or concurrent chemoradiation depending on the lymph node involvement and other factors. Prognosis depends on the stage and presence of extracapsular extension, with 5-year survival rates ranging from 30% for upper cervical nodes to 5%
The document discusses different incision techniques for lip splitting surgeries. It describes various incisions used for lower and upper lip splitting, including the Roux-Trotter, McGregor, Robson, Bhatt, Hayter, Rassekh, Weber-Ferguson, and Altemir incisions. It emphasizes that incisions should follow relaxed skin tension lines to minimize scarring, protect important structures like nerves and vessels, and allow for adequate exposure while achieving good functional and cosmetic outcomes. The Hayter incision, which incorporates a chevron shape into the vermilion border, is highlighted as one of the best techniques.
This document discusses chylous fistulas, which occur when the thoracic duct is injured, resulting in a leak of chyle fluid. It covers the anatomy and pathophysiology of chylous fistulas, as well as their etiology, investigation, and management. Management involves both medical approaches like nutritional modifications using medium-chain triglyceride diets or total parenteral nutrition, as well as surgical interventions like thoracic duct ligation if medical management fails to reduce high chyle output. The goal of treatment is to reduce chyle production and replace fluid and nutrients to prevent complications like malnutrition.
Elevate the skin flaps superiorly to the level of the ramus of mandible. Identify and protect the external jugular vein.
Surgeon: Okay, elevating the skin flaps now. Carefully dissecting in the plane just deep to the platysma muscle. There's the external jugular vein, I'm protecting that as I elevate the flap. Almost to the level of the ramus now.
Total laryngectomy is a surgical procedure to remove the larynx that has been performed since the 1870s. Modern techniques have improved rehabilitative outcomes including voicing rehabilitation. Preparation includes nutritional assessment, speech and language review, and consultation with a previous laryngectomy patient. During surgery, the larynx is isolated and removed along with surrounding tissue, and the trachea is separated from the esophagus to form a tracheostomy stoma. Dividing the cricopharyngeus muscle is crucial for later voice rehabilitation. The pharynx is closed and a tracheostomy tube is placed overnight.
The document describes the pectoralis major island flap technique. It can be used for reconstruction of the pharynx, tongue, face, neck, and skullbase defects. The flap has a large arc of rotation from the clavicle to the xiphoid process. It provides a single stage transfer with a muscle carrier but does not match the color and texture of facial skin. The document outlines the surgical technique including flap design, elevation of the vascular pedicle, and closure of the donor site. Variations including osteomyocutaneous flaps with rib bone and use of the flap as a free tissue transfer are also discussed. Complications, risk factors, and modifications to the technique are summarized.
Chyle leakage occurs when the thoracic duct or lymphatic vessels are damaged, resulting in the leakage of milky fluid called chyle. It can lead to fluid and nutritional depletion if not properly managed. Treatment involves initially managing it conservatively with wound drainage, pressure dressings, and a low-fat diet. For higher output leaks, surgical exploration may be needed to locate and ligate the leak. Rarely, thoracoscopic ligation of the thoracic duct or percutaneous embolization of the duct may be required if conservative and surgical treatments are unsuccessful. Proper management is important to avoid serious complications like chylothorax.
Local flaps in head & neack reconstructionMd Roohia
A flap is a unit of tissue transferred from one site to another while maintaining its own blood supply. Flaps are classified based on their location as local or distant. Local flaps can be random, which rely on subdermal vessels, or axial, relying on named vessels. Flaps are also classified based on their composition, such as skin, muscle, or bone flaps. When planning local flaps, goals include color and thickness match, sensory preservation, and minimal secondary defects. Common local flap techniques include advancement, rotation, and transposition flaps to close facial defects. Complications can be prevented through proper planning to avoid tension and including a flap margin.
Mr. Sunil, a 72-year-old male, presented with a 3-month history of a left neck swelling. Further examinations revealed metastatic squamous cell carcinoma in the left neck lymph nodes. He was diagnosed with carcinoma of unknown primary (CUP) and underwent radical neck dissection, followed by chemotherapy and radiotherapy. CUP describes metastatic cancers where the primary site cannot be identified despite various examinations and evaluations. Treatment options for CUP include surgery, radiation therapy, chemotherapy, or concurrent chemoradiation depending on the lymph node involvement and other factors. Prognosis depends on the stage and presence of extracapsular extension, with 5-year survival rates ranging from 30% for upper cervical nodes to 5%
The document discusses different incision techniques for lip splitting surgeries. It describes various incisions used for lower and upper lip splitting, including the Roux-Trotter, McGregor, Robson, Bhatt, Hayter, Rassekh, Weber-Ferguson, and Altemir incisions. It emphasizes that incisions should follow relaxed skin tension lines to minimize scarring, protect important structures like nerves and vessels, and allow for adequate exposure while achieving good functional and cosmetic outcomes. The Hayter incision, which incorporates a chevron shape into the vermilion border, is highlighted as one of the best techniques.
This document discusses chylous fistulas, which occur when the thoracic duct is injured, resulting in a leak of chyle fluid. It covers the anatomy and pathophysiology of chylous fistulas, as well as their etiology, investigation, and management. Management involves both medical approaches like nutritional modifications using medium-chain triglyceride diets or total parenteral nutrition, as well as surgical interventions like thoracic duct ligation if medical management fails to reduce high chyle output. The goal of treatment is to reduce chyle production and replace fluid and nutrients to prevent complications like malnutrition.
Elevate the skin flaps superiorly to the level of the ramus of mandible. Identify and protect the external jugular vein.
Surgeon: Okay, elevating the skin flaps now. Carefully dissecting in the plane just deep to the platysma muscle. There's the external jugular vein, I'm protecting that as I elevate the flap. Almost to the level of the ramus now.
Total laryngectomy is a surgical procedure to remove the larynx that has been performed since the 1870s. Modern techniques have improved rehabilitative outcomes including voicing rehabilitation. Preparation includes nutritional assessment, speech and language review, and consultation with a previous laryngectomy patient. During surgery, the larynx is isolated and removed along with surrounding tissue, and the trachea is separated from the esophagus to form a tracheostomy stoma. Dividing the cricopharyngeus muscle is crucial for later voice rehabilitation. The pharynx is closed and a tracheostomy tube is placed overnight.
The document describes the pectoralis major island flap technique. It can be used for reconstruction of the pharynx, tongue, face, neck, and skullbase defects. The flap has a large arc of rotation from the clavicle to the xiphoid process. It provides a single stage transfer with a muscle carrier but does not match the color and texture of facial skin. The document outlines the surgical technique including flap design, elevation of the vascular pedicle, and closure of the donor site. Variations including osteomyocutaneous flaps with rib bone and use of the flap as a free tissue transfer are also discussed. Complications, risk factors, and modifications to the technique are summarized.
The document discusses various complications that can occur following head and neck surgery like neck dissection. It classifies complications as major/minor, early/late, local/systemic. It describes in detail immediate local complications like bleeding, shock, airway obstruction, increased intracranial pressure, and nerve injury and their management. Intermediate complications discussed include chylous fistula, seroma, wound infection, and flap failure. Late complications mentioned are recurrence, parotid gland hypertrophy, lymphedema, and hypertrophic scars. Prevention and management strategies are provided for many of the complications.
This document provides information about parotidectomy, which is the surgical removal of the parotid gland. It discusses the different types of parotidectomy including superficial and total parotidectomy. Superficial parotidectomy involves removing the superficial lobe of the parotid gland while preserving the facial nerve. The procedure is described in detail, including identifying landmarks to locate the facial nerve and carefully dissecting the gland superficial to the nerve. Complications involving the facial nerve are also addressed.
Maxillectomy and craniofacial resection Mamoon Ameen
all maxillectomy types in detail and maxillofacial resection ,indications ,contraindications ,preoperative asssessment and detail techniques and rehabilitations
Local and regional flaps in head and neck reconstructionSaleh Bakry
Local and regional flaps are used for head and neck reconstruction. There are several types of flaps classified by blood supply, location, configuration, tissue content, and transfer method. Local flaps use adjacent tissue while regional flaps are near but not adjacent. Free flaps completely detach tissue and reconnect blood vessels microsurgically. Examples of local and regional flaps discussed are advancement, rotation, and transposition flaps as well as pedicled and free myocutaneous flaps.
Recurrent Laryngeal Nerve and thyroid surgeryMTD Lakshan
This presentation discusses the recurrent laryngeal nerve (RLN) and its relevance to thyroid surgery. It covers the surgical anatomy of the RLN, including its origin, relationship to surrounding structures like the inferior thyroid artery, and anatomical variations. Risks of injury to the RLN during thyroid surgery are reviewed. The presentation emphasizes identifying the RLN to reduce risks of temporary or permanent paralysis, with identification allowing average permanent paralysis rates of 0.9% with localization only versus 0.1% with complete dissection. Factors like anatomical variations, branching patterns, scarring, and extent of disease must be considered during dissection to prevent mechanical, thermal, or severing injuries to the nerve.
managment of neck nodes with occult primaryBharti Devnani
This document discusses the management of neck nodes with an occult primary tumor. It defines this condition as biopsy-proven cancer of the neck that cannot be linked to a primary lesion after a full clinical and radiological workup. It notes the estimated incidence is 3-7% of head and neck cancers initially presenting with cervical lymph node metastases. Risk of lymph node metastases depends on factors like density of lymphatics in the potential primary site and histologic characteristics of the lesion. Diagnostic workup involves imaging, biopsies of suspicious areas, and examination under anesthesia. Treatment involves neck dissection, with options like radical, modified radical or selective dissection depending on the extent of disease. Post-surgery management considers disease
Micro vascular free flaps used in head and neck reconstruction /certified fi...Indian dental academy
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
This document discusses the surgical procedures for parotid gland surgery. It describes the indications for superficial parotidectomy including benign tumors, refractory sialolithiasis, and chronic sialadenitis. The key anatomical landmarks are identified. The surgical techniques including patient positioning, incision, identification of the facial nerve branches, and approaches for superficial and deep lobe parotidectomy are outlined. Potential complications such as facial palsy, Frey's syndrome, and sialocele are discussed along with their management.
This document describes various approaches to the infratemporal fossa (ITF) for tumors. It discusses anterior approaches like transoral, transantral, and transmaxillary which provide access to the anteromedial ITF. Lateral approaches like transzygomatic access the lateral ITF. Inferior approaches like transmandibular reach the ITF from below. The document outlines the pioneers who developed different ITF approaches and describes in detail the postauricular infratemporal fossa approach developed by Fisch, involving types A, B, and C. It discusses the advantages, disadvantages, and variations of different ITF approaches.
Surgical anatomy of neck and types of neck dissectionSanika Kulkarni
The document discusses the anatomy of the neck including fascial layers, muscles, triangles, contents, nerves, vessels and lymph nodes. It provides a detailed overview of the surgical anatomy and classifications of neck dissections. The classifications include the Academy's classification of radical, modified radical and selective neck dissections. It also discusses Medina and Spiro's classifications of neck dissections.
This document provides information on nose anatomy, blood supply, nerve supply, history of nose reconstruction, principles of aesthetic nasal reconstruction, approaches to reconstruction, aesthetic subunits of the nose, analysis of defects, goals of reconstruction, options for surface defect repair including skin grafts and local flaps, intranasal lining reconstruction using mucosal flaps, sources of nasal support grafts including cartilage, and skin grafting techniques for nasal cover reconstruction.
This document provides an overview of rhinoplasty procedures. It discusses the history and anatomy of rhinoplasty. It describes techniques for open and closed rhinoplasty approaches. It covers tip work including tip suturing and grafts. It also discusses nasal augmentation including graft materials and saddle nose repair. Deformities like deviated nose and underprojected tip are reviewed along with surgical correction methods. Key anatomical structures and surgical principles are emphasized.
A parotidectomy is the surgical removal of the parotid gland, the largest salivary gland, which is most often performed to remove benign or malignant tumors of the gland. There are several types of parotidectomy depending on the extent of gland removal, ranging from partial to total removal. The procedure involves raising skin flaps and carefully dissecting around the facial nerve branches to remove the tumor while preserving nerve function. Complications can include temporary or permanent facial nerve weakness, hematoma, seroma, salivary fistula, and Frey's syndrome.
This powerpoint describes the types of maxillectomy & operative steps for total maxillectomy. It also enumerates various flaps used for reconstruction of maxillectomy defect.
The document discusses the classification and techniques of neck dissection for cervical lymph node metastasis. It describes the different types of neck dissection including radical neck dissection (RND), modified radical neck dissection (MRND), and selective neck dissection (SND). It outlines the lymph node levels and boundaries involved in each procedure. Key factors in determining the appropriate procedure include the primary tumor site and extent of lymph node involvement.
This document discusses penetrating neck trauma. It begins by outlining the anatomy of the neck and dividing it into three zones. It then discusses the mechanisms of injury, signs indicating injury to structures like blood vessels, and considerations for resuscitation and investigation. Hard signs that require emergency surgery include uncontrolled bleeding or shock. Soft signs may allow for further investigation with imaging or endoscopy before deciding on exploration. Surgical management depends on the injured zone, and may involve sternotomy, collar incisions, or mandible resection.
This document discusses the forehead flap procedure. It provides background on the history and anatomy of the forehead flap, which is based on the superficial temporal artery and its branches. The forehead flap can be used to reconstruct large defects in the nose, eyelids, cheeks, mouth, chin, and tongue. The technique involves outlining the flap based on the eyebrows and behind the ear. A tunnel is constructed to pass the flap to the defect site, either directly through the cheek or deep to the zygomatic arch. The donor site is closed primarily while the flap is monitored, with a second surgery needed to divide and close the bridge of the flap. Complications are rare given the rich blood supply but include infection, nerve injury, and
This document discusses the history and anatomy of neck dissections for head and neck cancer. It traces developments from the late 19th century of increasingly conservative neck dissections to preserve important structures. It describes the levels and boundaries of lymph node groups involved in the neck dissection staging system, including levels I-V. Key structures like the hypoglossal nerve and spinal accessory nerve are discussed in relation to the lymph node groups.
This document discusses laryngeal transplantation, including:
1. Pioneering attempts at laryngeal transplantation in the 1960s-1980s faced technical limitations and ethical concerns.
2. Advances in microsurgery, immunosuppression, and organ preservation have made laryngeal transplantation a possibility once deemed too risky.
3. The first reported successful human laryngeal transplantation was in 1998, where the patient regained voice function and swallowing abilities over time despite facing some complications.
1. Chylothorax is defined as a collection of chyle in the pleural cavity resulting from a leak in the lymphatic vessels, usually from the thoracic duct which transports lymph from the body.
2. The thoracic duct anatomy is described, beginning near the kidneys and ascending through the diaphragm before crossing left and terminating near the subclavian vein. Damage to different parts of the duct can cause right or left-sided chylothorax.
3. Causes of chylothorax include traumatic injury, malignancy compressing vessels, and spontaneous/idiopathic cases. Diagnosis involves fluid analysis showing chylomicrons.
A chylothorax is an abnormal accumulation of chyle, a type of lipid-rich lymph, in the space surrounding the lung. The lymphatics of the digestive system normally returns lipids absorbed from the small bowel via the thoracic duct, which ascends behind the esophagus to drain into the left brachiocephalic vein. If normal thoracic duct drainage is disrupted, either due to obstruction or rupture, chyle can leak and accumulate within the negative-pressured pleural space. In people on a normal diet, this fluid collection can sometimes be identified by its turbid, milky white appearance, since chyle contains emulsified triglycerides.
Chylothorax is a rare but serious condition, as it signals leakage of the thoracic duct or one of its tributaries. There are many treatments, both surgical and conservative.[1] About 2–3% of all fluid collections surrounding the lungs (pleural effusions) are chylothoraces.[2] It is important to distinguish a chylothorax from a pseudochylothorax (a pleural effusion that happens to be high in cholesterol), which has a similar appearance visually but is caused by more chronic inflammatory processes and requires a different treatment
The document discusses various complications that can occur following head and neck surgery like neck dissection. It classifies complications as major/minor, early/late, local/systemic. It describes in detail immediate local complications like bleeding, shock, airway obstruction, increased intracranial pressure, and nerve injury and their management. Intermediate complications discussed include chylous fistula, seroma, wound infection, and flap failure. Late complications mentioned are recurrence, parotid gland hypertrophy, lymphedema, and hypertrophic scars. Prevention and management strategies are provided for many of the complications.
This document provides information about parotidectomy, which is the surgical removal of the parotid gland. It discusses the different types of parotidectomy including superficial and total parotidectomy. Superficial parotidectomy involves removing the superficial lobe of the parotid gland while preserving the facial nerve. The procedure is described in detail, including identifying landmarks to locate the facial nerve and carefully dissecting the gland superficial to the nerve. Complications involving the facial nerve are also addressed.
Maxillectomy and craniofacial resection Mamoon Ameen
all maxillectomy types in detail and maxillofacial resection ,indications ,contraindications ,preoperative asssessment and detail techniques and rehabilitations
Local and regional flaps in head and neck reconstructionSaleh Bakry
Local and regional flaps are used for head and neck reconstruction. There are several types of flaps classified by blood supply, location, configuration, tissue content, and transfer method. Local flaps use adjacent tissue while regional flaps are near but not adjacent. Free flaps completely detach tissue and reconnect blood vessels microsurgically. Examples of local and regional flaps discussed are advancement, rotation, and transposition flaps as well as pedicled and free myocutaneous flaps.
Recurrent Laryngeal Nerve and thyroid surgeryMTD Lakshan
This presentation discusses the recurrent laryngeal nerve (RLN) and its relevance to thyroid surgery. It covers the surgical anatomy of the RLN, including its origin, relationship to surrounding structures like the inferior thyroid artery, and anatomical variations. Risks of injury to the RLN during thyroid surgery are reviewed. The presentation emphasizes identifying the RLN to reduce risks of temporary or permanent paralysis, with identification allowing average permanent paralysis rates of 0.9% with localization only versus 0.1% with complete dissection. Factors like anatomical variations, branching patterns, scarring, and extent of disease must be considered during dissection to prevent mechanical, thermal, or severing injuries to the nerve.
managment of neck nodes with occult primaryBharti Devnani
This document discusses the management of neck nodes with an occult primary tumor. It defines this condition as biopsy-proven cancer of the neck that cannot be linked to a primary lesion after a full clinical and radiological workup. It notes the estimated incidence is 3-7% of head and neck cancers initially presenting with cervical lymph node metastases. Risk of lymph node metastases depends on factors like density of lymphatics in the potential primary site and histologic characteristics of the lesion. Diagnostic workup involves imaging, biopsies of suspicious areas, and examination under anesthesia. Treatment involves neck dissection, with options like radical, modified radical or selective dissection depending on the extent of disease. Post-surgery management considers disease
Micro vascular free flaps used in head and neck reconstruction /certified fi...Indian dental academy
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
This document discusses the surgical procedures for parotid gland surgery. It describes the indications for superficial parotidectomy including benign tumors, refractory sialolithiasis, and chronic sialadenitis. The key anatomical landmarks are identified. The surgical techniques including patient positioning, incision, identification of the facial nerve branches, and approaches for superficial and deep lobe parotidectomy are outlined. Potential complications such as facial palsy, Frey's syndrome, and sialocele are discussed along with their management.
This document describes various approaches to the infratemporal fossa (ITF) for tumors. It discusses anterior approaches like transoral, transantral, and transmaxillary which provide access to the anteromedial ITF. Lateral approaches like transzygomatic access the lateral ITF. Inferior approaches like transmandibular reach the ITF from below. The document outlines the pioneers who developed different ITF approaches and describes in detail the postauricular infratemporal fossa approach developed by Fisch, involving types A, B, and C. It discusses the advantages, disadvantages, and variations of different ITF approaches.
Surgical anatomy of neck and types of neck dissectionSanika Kulkarni
The document discusses the anatomy of the neck including fascial layers, muscles, triangles, contents, nerves, vessels and lymph nodes. It provides a detailed overview of the surgical anatomy and classifications of neck dissections. The classifications include the Academy's classification of radical, modified radical and selective neck dissections. It also discusses Medina and Spiro's classifications of neck dissections.
This document provides information on nose anatomy, blood supply, nerve supply, history of nose reconstruction, principles of aesthetic nasal reconstruction, approaches to reconstruction, aesthetic subunits of the nose, analysis of defects, goals of reconstruction, options for surface defect repair including skin grafts and local flaps, intranasal lining reconstruction using mucosal flaps, sources of nasal support grafts including cartilage, and skin grafting techniques for nasal cover reconstruction.
This document provides an overview of rhinoplasty procedures. It discusses the history and anatomy of rhinoplasty. It describes techniques for open and closed rhinoplasty approaches. It covers tip work including tip suturing and grafts. It also discusses nasal augmentation including graft materials and saddle nose repair. Deformities like deviated nose and underprojected tip are reviewed along with surgical correction methods. Key anatomical structures and surgical principles are emphasized.
A parotidectomy is the surgical removal of the parotid gland, the largest salivary gland, which is most often performed to remove benign or malignant tumors of the gland. There are several types of parotidectomy depending on the extent of gland removal, ranging from partial to total removal. The procedure involves raising skin flaps and carefully dissecting around the facial nerve branches to remove the tumor while preserving nerve function. Complications can include temporary or permanent facial nerve weakness, hematoma, seroma, salivary fistula, and Frey's syndrome.
This powerpoint describes the types of maxillectomy & operative steps for total maxillectomy. It also enumerates various flaps used for reconstruction of maxillectomy defect.
The document discusses the classification and techniques of neck dissection for cervical lymph node metastasis. It describes the different types of neck dissection including radical neck dissection (RND), modified radical neck dissection (MRND), and selective neck dissection (SND). It outlines the lymph node levels and boundaries involved in each procedure. Key factors in determining the appropriate procedure include the primary tumor site and extent of lymph node involvement.
This document discusses penetrating neck trauma. It begins by outlining the anatomy of the neck and dividing it into three zones. It then discusses the mechanisms of injury, signs indicating injury to structures like blood vessels, and considerations for resuscitation and investigation. Hard signs that require emergency surgery include uncontrolled bleeding or shock. Soft signs may allow for further investigation with imaging or endoscopy before deciding on exploration. Surgical management depends on the injured zone, and may involve sternotomy, collar incisions, or mandible resection.
This document discusses the forehead flap procedure. It provides background on the history and anatomy of the forehead flap, which is based on the superficial temporal artery and its branches. The forehead flap can be used to reconstruct large defects in the nose, eyelids, cheeks, mouth, chin, and tongue. The technique involves outlining the flap based on the eyebrows and behind the ear. A tunnel is constructed to pass the flap to the defect site, either directly through the cheek or deep to the zygomatic arch. The donor site is closed primarily while the flap is monitored, with a second surgery needed to divide and close the bridge of the flap. Complications are rare given the rich blood supply but include infection, nerve injury, and
This document discusses the history and anatomy of neck dissections for head and neck cancer. It traces developments from the late 19th century of increasingly conservative neck dissections to preserve important structures. It describes the levels and boundaries of lymph node groups involved in the neck dissection staging system, including levels I-V. Key structures like the hypoglossal nerve and spinal accessory nerve are discussed in relation to the lymph node groups.
This document discusses laryngeal transplantation, including:
1. Pioneering attempts at laryngeal transplantation in the 1960s-1980s faced technical limitations and ethical concerns.
2. Advances in microsurgery, immunosuppression, and organ preservation have made laryngeal transplantation a possibility once deemed too risky.
3. The first reported successful human laryngeal transplantation was in 1998, where the patient regained voice function and swallowing abilities over time despite facing some complications.
1. Chylothorax is defined as a collection of chyle in the pleural cavity resulting from a leak in the lymphatic vessels, usually from the thoracic duct which transports lymph from the body.
2. The thoracic duct anatomy is described, beginning near the kidneys and ascending through the diaphragm before crossing left and terminating near the subclavian vein. Damage to different parts of the duct can cause right or left-sided chylothorax.
3. Causes of chylothorax include traumatic injury, malignancy compressing vessels, and spontaneous/idiopathic cases. Diagnosis involves fluid analysis showing chylomicrons.
A chylothorax is an abnormal accumulation of chyle, a type of lipid-rich lymph, in the space surrounding the lung. The lymphatics of the digestive system normally returns lipids absorbed from the small bowel via the thoracic duct, which ascends behind the esophagus to drain into the left brachiocephalic vein. If normal thoracic duct drainage is disrupted, either due to obstruction or rupture, chyle can leak and accumulate within the negative-pressured pleural space. In people on a normal diet, this fluid collection can sometimes be identified by its turbid, milky white appearance, since chyle contains emulsified triglycerides.
Chylothorax is a rare but serious condition, as it signals leakage of the thoracic duct or one of its tributaries. There are many treatments, both surgical and conservative.[1] About 2–3% of all fluid collections surrounding the lungs (pleural effusions) are chylothoraces.[2] It is important to distinguish a chylothorax from a pseudochylothorax (a pleural effusion that happens to be high in cholesterol), which has a similar appearance visually but is caused by more chronic inflammatory processes and requires a different treatment
The spleen filters blood, removes old red blood cells and platelets, stores blood, and plays an important role in the immune system. It lies in the left upper abdomen between the stomach and diaphragm. The spleen receives blood from the splenic artery and drains into the splenic vein. Trauma is the most common cause of splenic injury, ranging from superficial tears to complete rupture. Symptoms of a ruptured spleen include abdominal pain and tenderness. Treatment involves resuscitation followed by splenectomy or splenic preservation depending on the severity of injury. Enlargement of the spleen (splenomegaly) can result from various blood disorders and infections but often does not require splenic removal.
The spleen lies in the left hypochondrium between the stomach and diaphragm. It filters blood and removes old red blood cells, produces antibodies, and stores a small blood volume. The spleen can be injured by direct or indirect trauma, with grades ranging from superficial bruising to complete rupture. Symptoms of rupture include abdominal pain and tenderness along with hypotension. Treatment involves resuscitation followed by splenectomy in adults or splenic preservation techniques in children. The spleen can also enlarge in conditions like infections, increasing the risk of injury.
The spleen filters blood, removes old red blood cells and platelets, stores blood, and plays an important role in the immune system. It lies in the left upper abdomen. The spleen can be damaged by trauma, which ranges from superficial bruising to complete rupture. Rupture presents with shock, abdominal pain, and swelling. Treatment is splenectomy for adults but splenic preservation is attempted for children. The spleen can also enlarge in diseases like portal hypertension, leading to a condition called hypersplenism with low blood counts.
The document provides an overview of the gastrointestinal system, including:
- It describes the anatomy and functions of the GI tract from mouth to anus, as well as related organs like the liver and pancreas.
- It lists 100 key facts about the structure and function of different parts of the GI system, including the mouth, esophagus, stomach, and liver.
- It explains that understanding the basic science of the normal GI system is important for learning about GI diseases.
The umbilical cord forms between 5-12 weeks of gestation and is usually 50-60cm long. It contains vessels embedded in Wharton's jelly and transfers nutrients and metabolites between the fetus and placenta. Abnormal cord lengths or structures can impact fetal development. Umbilical cord anomalies seen on ultrasound include cysts, tumors, hematomas, and variations in coiling that may cause growth issues. Other fetal anomalies like omphalocele involve abdominal organs protruding in the umbilical cord. The urachus is a remnant of early development that can rarely cause infections if patent.
The umbilical cord forms between 5-12 weeks of gestation and is usually 50-60cm long. It contains vessels embedded in Wharton's jelly and transfers nutrients and water between the fetus and placenta. Abnormal cord lengths or structures can impact fetal development. Umbilical cord anomalies seen on ultrasound include cysts, tumors, hematomas, and variations in coiling that may cause growth issues. Other fetal anomalies like omphalocele involve abdominal organs protruding in the umbilical cord. The urachus is a remnant of early development that can rarely cause infections if patent.
Chylothorax occurs when chyle, or lymph fluid containing fatty acids, leaks into the pleural space surrounding the lungs. It is uncommon in dogs and cats and usually secondary to other conditions like trauma, cancer, or heart disease. Diagnosis involves identifying milky white fluid in the chest that contains high levels of triglycerides. Treatment aims to drain the fluid and reduce lymph flow through dietary changes, medications, or duct ligation surgery, but prognosis is generally poor.
Pregnancy causes many physiological changes in a woman's body to support the growth of the fetus. These include changes to the breasts, skin, genitals, weight gain and water retention, hematological and cardiovascular systems, metabolism, and more. The document discusses these changes in detail to provide an overview of the normal adaptations a woman's body undergoes during pregnancy.
This document discusses key anatomical, physiological, and pharmacological differences between pediatric and adult patients that are important for pediatric anesthesia. Specifically, it notes that pediatric patients have higher risks during anesthesia due to immature organ systems and differences in how pharmacologic agents affect them. The respiratory, circulatory and thermoregulatory systems are less developed in pediatric patients compared to adults. Understanding these developmental differences is essential for safe anesthetic management of pediatric patients.
Breast cancer with anatomy physiology and staging .pptxDoctorDeath3
The document provides details about the anatomy of the breast. It describes how the breast is composed of ductal and lobular structures that produce and carry milk. It notes the blood, nerve and lymphatic supply of the breast and how these systems are involved in the physiology of lactation. The document also discusses common breast pathologies like invasive ductal carcinoma and outlines investigations and treatments for breast cancer.
A pleural effusion is a collection of fluid in the pleural space between the lungs and chest wall. It can be caused by conditions that increase hydrostatic pressure or decrease oncotic pressure, allowing fluid to accumulate. Diagnosis is typically made initially through chest x-ray or ultrasound imaging. Treatment depends on the underlying cause but may involve thoracentesis to drain fluid if it is causing breathing difficulties or pleurodesis to fuse the lung layers together to prevent further effusions.
Postpartum hemorrhage (PPH) is excessive bleeding after childbirth, defined as blood loss over 500 ml for vaginal births or 1000 ml for C-sections. The main causes of PPH are uterine atony (failure of the uterus to contract), retained placenta, and trauma to the genital tract. Management involves bimanual uterine massage, uterotonic drugs, vaginal packing, balloon tamponade, and in severe cases surgical interventions like B-Lynch sutures or hysterectomy.
Breast - Anatomy and Phsiology with Congenital anomalies - Dr. Vijayandra.pptxJhansi897032
This document provides an overview of the anatomy, physiology, and congenital anomalies of the breast. It begins with the embryological development of the breast from mammary ridges. The anatomy sections describe the structure, blood supply, lymphatic drainage and microscopic anatomy. Physiology sections cover development during puberty, the menstrual cycle, pregnancy, lactation and involution. The document concludes with descriptions of common congenital anomalies such as accessory nipples, hypoplasia, amastia and Poland's syndrome.
The document provides an overview of the anatomy, physiology, and pathologies of the small intestine. It discusses the following key points:
- The small intestine is responsible for digestion and absorption. It starts at the pylorus and ends at the ileocecal valve, measuring around 7 meters long.
- Common pathologies include small bowel obstruction, which can be diagnosed using imaging like CT scans, and ileus, which results in impaired motility.
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This document provides tips for using a PowerPoint presentation on the anatomy and physiology of the spleen. Some key points:
- Slides can be freely downloaded, edited and modified. Many slides are blank except for the title to facilitate active learning sessions.
- The presentation encourages showing blank slides first to elicit what students already know before presenting content.
- It can be used for self-study as well as active learning sessions involving multiple revisions of topics.
- Notes provide information on the bibliography used.
The rest of the document consists of a detailed PowerPoint presentation on the anatomy and physiology of the spleen.
New born baby and adjustment to extra uterineraveen mayi
This document summarizes the physiological adjustments that newborn babies undergo after birth as they transition from intrauterine to extrauterine life. It discusses changes in major body systems including respiratory, circulatory, thermoregulation, gastrointestinal, renal, integumentary, musculoskeletal, and neurological systems. The summary focuses on how newborns must quickly establish independent breathing and circulation after losing placental support, as well as how their immature organs such as the liver and kidneys impact fluid balance, temperature regulation and other functions in the first days of life.
New born baby and adjustment to extra uterineraveen mayi
The document summarizes the physiological adjustments that newborn babies undergo after birth as they transition from fetal to extra-uterine life. It discusses changes in major body systems like respiratory, circulatory, thermoregulation and others. The most critical changes are in establishing independent breathing and circulation as the placenta is no longer providing oxygen and removing carbon dioxide. Other key adjustments include thermoregulation, fluid and electrolyte balance, and development of digestive and renal functions.
Similar to Management of Chyle leakage after head and neck surgery - DIKIOHS DUHS (20)
This document outlines the principles of Advanced Trauma Life Support (ATLS) for treating trauma patients. It describes the primary and secondary surveys which involve assessing and stabilizing the ABCDEs (airway, breathing, circulation, disability, exposure). The primary survey focuses on life-threatening injuries through rapid evaluation of airway/breathing, circulation, disability, and exposure. The secondary survey involves a full physical exam and history to identify all injuries and guide further care. The goal of ATLS is to prevent avoidable deaths through systematic initial management within the critical golden hour after trauma.
This document discusses osteomyelitis of the jaws, including predisposing factors, pathogenesis, classification, clinical presentation, radiographic features, and management. It notes that osteomyelitis typically occurs due to spread of an odontogenic infection or trauma. Predisposing factors include age, immunosuppression, drugs, local factors like osteoporosis, and malnutrition. Management involves both medical approaches like antibiotics and surgical approaches like incision and drainage, debridement, and sequestrectomy. The document also discusses a recent study finding that pentoxifylline and tocopherol used as an adjunct for more than 3 months can help increase bone density and decrease inflammation in osteomyelitis.
1) Determining when a patient can safely be discharged after sedation or anesthesia is challenging and should involve objective criteria like standardized scales.
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3) Discharge criteria also considers bleeding control, nausea/vomiting prevention, review of postoperative instructions, and follow up care for special populations like diabetics and those with sleep apnea.
Platelet Rich Fibrin (PRF) is a platelet concentrate containing growth factors that promotes wound healing. It is prepared from centrifuging the patient's own blood without anticoagulants. PRF forms a fibrin clot that traps platelets, cytokines and cells to slowly release growth factors. It can be used as a membrane or graft material to enhance tissue regeneration due to its angiogenic and immunomodulatory properties. PRF preparation is simple, inexpensive, and avoids risks associated with other graft materials or membranes.
This document describes a new clinical classification system for temporomandibular joint ankylosis (TMJA) based on condylar structure (C), dentofacial deformity (D), and skeletal age (A). 95 patients were classified into 8 groups. Different treatment strategies are outlined for each group, focusing on condyle preservation, deformity management, and growth monitoring. Strategies include condyle-preserving arthroplasty, joint reconstruction, distraction osteogenesis, and orthognathic surgery. Close follow-up is important for growing patients to monitor joint function and facial development.
This document discusses concepts of rigid fixation in facial fractures. It defines rigid fixation as fixation strong enough to prevent movement across a fracture during functional use of the skeletal structure. It describes different types of bone healing and pathways for fracture healing. It also discusses concepts of load-bearing versus load-sharing fixation, different rigid fixation techniques including plates, screws, and wires, and materials used for rigid fixation.
Radiotherapy is used in the management of oral cancer for curative and palliative purposes. It can be delivered as primary treatment combined with chemotherapy for organ preservation or after surgery as adjuvant treatment. Newer radiotherapy techniques like IMRT allow higher doses to be delivered to tumors while reducing damage to nearby organs. Side effects depend on treatment dose and area irradiated, and may include mucositis, xerostomia, skin changes, osteoradionecrosis and rare complications like carotid rupture. Ongoing research aims to reduce toxicity through altered fractionation schedules and novel delivery methods.
This document discusses osteoradionecrosis of the jaws, providing definitions, epidemiology, staging systems, clinical and radiological findings, risk factors, diagnosis, and radiation techniques. It defines ORN as exposed irradiated bone that fails to heal over 3 months without evidence of tumor. Risk factors include high radiation dose, oral cavity primary site, and tooth extractions after radiation. Diagnosis requires previous irradiation, no recurrent tumor, mucosal breakdown exposing bone for over 3 months. Later radiation techniques like IMRT may reduce risks by more precisely targeting tumors and minimizing dose to surrounding tissues.
This document discusses current concepts in chemotherapy for head and neck cancer. It begins by introducing head and neck squamous cell carcinoma (HNSCC) as the sixth most common cancer worldwide. It then reviews epidemiology and risk factors for HNSCC before defining different types of chemotherapy. The bulk of the document discusses evidence and standards of care for systemic therapy in previously untreated locally advanced HNSCC as well as recurrent/metastatic HNSCC. It covers the role of induction, concurrent, adjuvant and definitive chemotherapy combined with surgery or radiation. Overall survival benefits have been shown with platinum-based chemotherapy regimens and cetuximab combined with radiation or chemotherapy.
This document provides an overview of medication-related osteonecrosis of the jaw (MRONJ), including descriptions of antiresorptive and antiangiogenic medications, diagnostic criteria, theories of pathophysiology, risk estimates, and management strategies. It discusses bisphosphonates, denosumab, tyrosine kinase inhibitors, diagnostic criteria requiring exposed bone for over 8 weeks, and proposed mechanisms including inhibition of bone remodeling, inflammation, angiogenesis, and immune dysfunction. Risk factors include medication type/duration, dentoalveolar surgery, oral disease, anatomy, and systemic factors. Management involves preventive dental treatment and is based on clinical staging from asymptomatic exposed bone to extensive necrosis.
TRALI is a clinical diagnosis of acute lung injury following blood transfusion. It is caused by antibodies (often from multiparous female donors) that activate neutrophils and cause them to accumulate in the lungs, resulting in pulmonary edema. It requires two "hits" - initial patient risk factors like surgery or sepsis prime the lungs, then transfusion antibodies provide the second hit. Management is supportive care with oxygen and ventilation. Risk can be reduced by using fresher blood products, restricting transfusions in ventilated patients, and screening high risk donors.
This document discusses the use of cyanoacrylate adhesives in oral applications. It provides an overview of the mechanism of cyanoacrylate adhesives, their advantages over sutures for wound closure including faster hemostasis, less inflammation and pain, and ease of use. Several studies are cited showing cyanoacrylate adhesives resulted in less shrinkage of grafts, inflammation and patient discomfort compared to sutures for intraoral wound closure. The document concludes cyanoacrylate adhesives are useful alternatives to sutures for oral procedures due to their hemostatic, bacteriostatic and painless properties.
This document discusses proper chair positioning for dental treatments and tooth extractions. It recommends that the operator maintain a neutral spine, parallel thighs and forearms, and stable tripod stance to reduce strain and fatigue. For maxillary extractions, the operator stands in front and to the right of the patient, who is tipped back 30 degrees. For mandibular extractions on the left, the operator also stands in front, while on the right the operator stands behind the patient. Proper hand positioning to support the jaw is also described.
- Alveolar osteitis, commonly known as dry socket, is a painful inflammation of the jaw bone at the site of a recent tooth extraction characterized by pain and bad breath. It results from premature breakdown of the blood clot in the extraction socket.
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Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
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The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
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Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
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Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
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Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
2. Chyle
◦ Chyle is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids. It is formed
in the small intestine during digestion of fatty foods, and taken up by lymph vessels specifically
known as lacteals. The lipids in the chyle are colloidally suspended in chylomicrons.
◦ Chyle is typically white or light pink in color while an effusion is often clear or amber
◦ During digestion of a meal containing long-chain fats, chyle has a typical milky white
appearance because of the presence of chylomicrons. The rate of formation of chyle
depends on several factors such as the state of nutrient absorption, portal venous
pressure, and the rate of lymphatic uptake.
3.
4. Introduction
◦ Chyle leak due to thoracic duct injury during head and neck surgery is rare but a serious complication
occurs in ,
◦ 0.5 -1.4% in thyroidectomies
◦ 2-8% in neck disections
◦ The variable anatomy and fragile composition of the thoracic duct render it prone to inadvertent injury.
◦ The majority of CL transpires with surgery of the left neck; however, up to 25% of CL occur with right neck
surgery.
◦ Early identification and appropriate management of a CL are imperative for optimal surgical outcome.
5. Anatomy and physiology of thoracic
duct
◦ The thoracic duct forms during the 8th week of gestation as two distinct vessels anterior to the aorta, connecting the superior
jugular lymph sacs to the inferior cisterna chyli.
◦ These vessels develop into the embryonic right and left thoracic ducts and share a number of anastomoses.As the fetus
matures, the embryonic thoracic ducts fuse partially to form two distinct lymphatic divisions within the body.
◦ The adult thoracic duct is the product of the fusion of the lower 2/3 of the embryonic right duct, the upper 1/3 of the left duct,
and their numerous interconnections.
◦
◦ The thoracic duct is the largest lymphatic vessel that drains up to 75% of the body’s lymph from the entire left body and the
right side of the body below the diaphragm.
◦ The adult right lymphatic duct receives lymph from the right thorax, arm, head and neck region.
◦ Variations in the course of the thoracic duct are common and may occur as either a persistence of embryonic structures or
failure of normal developmental progression.
6.
7. Course of thoracic duct
◦ The thoracic duct originates from the cisterna chyli, a dilated sac at the level of the 2nd lumbar vertebra that
receives lymph from intestinal and lumbar lymphatics as well as intercostal lymphatics and periaortic lymph
nodes.
◦ When the cisterna chyli is congenitally absent, the thoracic duct originates from a haphazard coalescence of
lymphatic channels instead.
◦ Within the abdomen,the thoracic duct ascends along the anterior surface of the lumbar vertebra,between
the aorta and azygous vein, to enter the thorax via the aortic hiatus in the posterior mediastinum.
◦ Within the thorax, the thoracic duct veers leftward as it continues to ascend, passing posterior to the aortic
arch, and enters the root of the left neck lateral to the esophagus.
8.
9. ◦ At the root of the neck, the thoracic duct is bordered anteriorly by the left common carotid
artery, Vagus nerve, and IJV, medially by the esophagus, laterally by the omohyoid muscle,and
posteriorly by the vertebra.
◦ T he thoracic duct generally courses 3–5cm superior to the clavicle.
◦ however it has been reportedly found as high as the level of the superior cornu of the thyroid
cartilage.
◦ the thoracic duct turns inferiorly and anteriorly, passing over the subclavian artery to terminate
with 1cm of the confluence of the internal jugular and subclavian vein.
Within this 1cm region the thoracic duct may terminate into the venous circulation at a number of
sites:
The most common site is the IJV (46%), followed by the confluence of the IJV and subclavian vein
(32%) and the subclavian vein
10. ◦ Less commonly, the thoracic duct may terminate in the brachiocephalicvein,external jugular vein,or
vertebral vein.
◦ The thoracic duct generally empties into the venous system as a single duct (76%).
◦ Near its termination, the thoracic duct receives additional lymphatics from subsidiary lymphatic
trunks of the left neck (jugular, subclavian, and bronchomediastinal trunks).
◦ The typical length of the adult thoracic duct is 36–45cm with an average diameterof 5mm.
◦ The diameter of the thoracic duct decreases from the abdomen to the thorax and then increases
again in the cervical region,reaching up to 1cm in diameter as it empties into the venous system.
◦ Additionally, rises in intra-abdominal or intrathoracic pressure may further distend the thoracic duct
through propagation of hydrostatic forces.
11. Functions of thoracic duct
◦ The thoracic duct is the primary structure that returns lymph from the left body and the right body below the
diaphragm to the venous circulation. This includes chyle derived from intestinal lacteals.
◦ The thoracic duct serves a crucial role in the maintenance of fluid balance and return of lymph and chyle to the
systemic circulation.
◦ Chyle is composed of lymphatic fluid and chylomicrons from the gastrointestinal system.
◦ Its lymphatic fluid contains protein, white blood cells, electrolytes, fat-soluble vitamins, trace elements,and
glucose absorbed from the interstitial fluid, to be returned to the systemic circulation.
◦ Chylomicrons consist of esterified monoglycerides and fatty acids combined with cholesterol and proteins.
12. ◦ These are formed from the break down products of long-chain fatty acids by bile salts and absorbed into the
lymphatic system through special lymphaticvessels in the villous region of the intestines known as lacteals.
◦ Conversely, the smaller short and medium-chain fatty acids are more water soluble and are absorbed via the
intestinal mucosa directly into the hepatic portal vein, thus bypassing the lymphatic system.
◦ Chyle is propagated within the thoracic duct primarily by the muscular action of breathing and further
facilitated by the duct’s smooth muscles and internal valves, which prevent retrograde flow.
◦ Factors that modulate chyle flow include :
diet, intestinal function, physical activity, respiration rate, and changes in intra-abdominal and intrathoracic
pressure.
13. Pathophysiology of Iatrogenic Head and
Neck Chyle Leak:
1. Iatrogenic Chylous Fistula in Head and NeckSurgery:
◦ Due to its proximity to the IJV and thin vessel wall, the thoracic duct is particularly susceptible to
inadvertent injury during dissection low in the neck.
◦ Prior irradiation and the presence of metastatic lesions at the confluence of the IJV and subclavian vein
make for a more challenging surgical dissection and significantly greater risk of iatrogenic CL.
2. Chyle Leak Sequelae:
The impact of acute large volume CL includes the loss of protein, fat, and fat-soluble vitamins, trace
elements, and lymphocytes in quantities that result in hypovolemia, electrolyte imbalances (hyponatremia,
hypochloremia, and hypoproteinemia), malnutrition, and immunosuppression.
14. ◦ Wound healing complications can result from the disruption of the normal biochemical milieu,
manifesting as delayed wound healing, infection, or wound breakdown with fistula formation.
◦ Within the wound bed, extravasated chyle provokes an intense inflammatory reaction, prompting the
release of proinflammatory cytokines and tissue proteases that interfere with the healing process.
◦ The pressure of accumulated chyle beneath skin flaps may decrease tissue perfusion, resulting in flap
necrosis.
◦ Systemic metabolic and immunologic derangements associated with CL may further compromise healing.
◦ Acervical CL can spread from the root of the neck into the mediastinum. With sufficient hydrostatic
pressure, the collection of chyle may penetrate the pleural, forming a chylothorax,
which presents clinically with shortness of breath, tachypnea, and chest pain.
15. Diagnosis Cl:
◦ Chyle leaks may be identified intraoperatively or postoperatively.
◦ Due to the potential significant morbidity associated with a CL, leaks identified at the time of surgery should
be repaired immediately.
◦ Ingeneral,the supra clavicular region should be examined carefully at the conclusion of a head and neck
procedure, particularly if the case involves dissection low in the neck.
◦ If creamy or milky fluid is noted, the thoracic duct should be identified and ligated.
◦ Given the variable course and collapsibility of the thoracic duct and patient fasting in preparation for surgery,
identification of the thoracic duct may prove to be difficult. Magnification with surgical loupes or an operative
microscope can assist with visualization.
16. ◦ Maneuvers that increase intrathoracic or intra-abdominal pressure may facilitate the identification of
a CL as well.
◦ Trendelenburg positioning and Valsalva maneuver while the anesthesiologist applies positive
pressure to raise intrathoracic pressure or manual abdominal compression.
◦ Out put alone should not dictatetr treatment choices.Treatment effectiveness can often be gauged
by how much drain output changes in response to particular interventions.
17. Treatment Options for Chyle Leaks
1. Intraoperative Chyle Leak:
◦ When a CL is identified during surgery, the thoracic duct may be ligated with surgical clips or oversewn
with non absorbable suture.
◦ Additionally, locoregional flaps may be incorporated for additional coverage of the surgical bed.
◦ a rotational pectoralis major flap can provide sufficient tissue bulk and coverage to reliably address a CL .
◦ Additional topical agents can be applied to the wound bed at the time of surgery.
18. 2. Postoperative Chyle Leak:
◦ Following surgery, management of a CL depends on drain output, patient comorbidities, available
institutional expertise, and surgeon preference.
◦ Chyle leaks may be broadly categorized as low output (<500mL/day) or high output (>500mL/day) based
drain out put to assist with treatment decision making.
◦ low output CL can be treated effectively with conservative management.
◦ while high output fistulas will often respond unsatisfactorily to conservative management alone and
surgical intervention.
◦ Treatment effectiveness can often be gauged by how much drain output changes in response to particular
interventions.
19. Conservative Measures
1.Activity:
◦ Because chyle flow is propelled by physical activity, patients with suspected CL should be restricted to
bedrest.
◦ The head of bed should be elevated(30–40∘) and stool softeners provided to reduce intrathoracic and
intraabdominal pressure with bowel movement.
2.Diet:
◦ Dietary management plays a crucial role in the nonsurgical management of a CL.
◦ With potential high volume fluid shift with protein and electrolytes loss, patients with CL need to be
monitored for dehydration and malnutrition.
◦ Fluid balance and electrolytes should be checked daily and albumin weekly .
◦ Intravenous fluids should be administered to achieve euvolemia and electrolytes replenished as needed.
◦ All patients with suspected CL should be transitioned to a nonfat diet, low-fat diet, or medium-chain fatty
acid (MCFA) diet.
20. ◦ In general, a MCFA diet with protein, metabolic mineral mixture, and multivitamin supplementation is
preferable to a nonfat diet
◦ Because short-and medium-chain fatty acids are largely water soluble and absorbed via the portal
venous circulation rather than the gastrointestinal lymphatics, this special diet bypasses the
gastrointestinal lymphatic system, resulting in decreased chyle flow at the CL site, allowing the thoracic
duct injury to heal faster.
◦ Despite this, a MCFA diet does not stop chyle production entirely.
◦ Orlistat, a pancreatic lipase inhibitor, interferes with lipid metabolism in the duodenum and prevents lipid
absorption and may be given as an adjunct to decrease chyle production.
◦ Alternatively, patients can be made NPO if the drain output is low and suspected duration of CL is short.
NPO is rarely implemented today, as alternative superior dietary options are available that do not
contribute to ongoing hypovolemia and malnutrition.
21. ◦ Patients with persistent or high output CL will likely require total parental nutrition (TPN), which bypasses
the lymphatic system completely.
◦ While more effective than a MCFA diet at reducing chyle production, the use of TPN must be carefully
weighed against its need for central venous access, potential complication of increase infection risk, and
metabolic disturbances and high cost.
3. Wound Care:
◦ The use of pressure dressings remains controversial.
◦ Some recommend its use to expedite closure of a CL,while others are concerned with its potential
compromise of skin flap perfusion.
◦ Suction drainage, placed at the time of surgery, is invaluable in the evacuation of extravasated chyle and
monitoring of drain output to assess both severity of the CL and treatment effectiveness.
22. ◦ While helpful in evacuating high output CL, however, some advocate for the timely removal of
suction drainage once its output has diminished sufficiently, to avoid the possibility that the drain
suction may prohibit the complete resolution of a CL.
◦ Negative wound pressure therapy, or vacuum-assisted closure, with placement of an air-tight seal
over the wound and application of negative pressure to the entire wound bed to remove fluid and
shrink wound size has had promising results.
◦ negative wound pressure therapy requires exposure of the wound bed.
23. 4. Somatostatin and Octreotide:
◦ Somatostatin is a neuroendocrine hormone .
◦ Somatostatin decreases chyle production via reduction of gastric, pancreatic, and intestinal secretions.
◦ It constricts smooth muscles in splanchnic and lymphatic vessels to decrease lymph production and lymph
flow respectively.
◦ broad applications for use in therapy for acromegaly, intractable diarrhea, hyperinsulinism, severe
gastrointestinal bleeding, pancreatitis, metastatic carcinoids, and tumors secreting vasoactive intestinal
peptides.
◦ Somatostatin’s major drawback is its short half-life, which requires continuous intravenous infusion.
24. ◦ This problem of short half life was solved with the development of octreotide, somatostatin’s long-acting
analog, which permitted administration with long-lasting subcutaneous injections.
◦ Octreotide has gained considerable popularity in the management of CL, first in thoracic surgery and more
recently with head and neck surgery.
◦ Octreotide is a cost-effective therapy for iatrogenic CL that significantly decreases morbidity, length of stay,
and need for surgical intervention.
◦ Octreotide dosage ranged from 100 ug subcutaneous every 8 to12 hour, 200 ug subcutaneous every 8hours.
◦ Time from initiation of octreotide therapy to CL cessation ranged from 1 to 15 days, s, and total octreotide
treatment duration varied widely from 3 to 24 days.
◦ In general, octreotide was administered an additional 1-2 days after CL cessation to ensure complete
resolution.
25. ◦ study, low output leaks (<500mL/day)stopped after 2–4 days of octreotide and these patients were given
a total of 5 days of octreotide;
high outputleaks(>500mL/day) resolved after 5 days of octreotide and these pt was treated for a total of 7
days.
Side effects of octeoride therapy :
◦ The most commonly associated side effects of octreotide are nausea, abdominal discomfort, and diarrhea.
Rare but serious complications include hypoglycemia and cholecystitis secondary to cholestasis.
◦ Inless than1% of patients, anaphylactic shock,gastrointestinal bleeding, and pulmonary embolism have
been described.
◦ Octreotide should be prescribed with caution in patients with preexisting cardiovascular and hepatic
disease.
◦ Most adverse effects are dose and duration dependent.
26. 4. Topical Agents
◦ Sclerosing agents such as OK-432 or tetracycline administered at the time of surgery or postoperatively
through drainage tubing or percutaneous injection can generate fibrosis to seal a CL.
◦ sclerosing agents should be used with care, as it could potentially injure surrounding structures in the
wound bed. Phrenic nerve paralysis after doxycycline sclerotherapy for CL has been reported.
◦ Cyanoacrylate adhesives, fibrin glue, and polyglactin (Vicryl) mesh have been placed at the time of surgery,
with success, for controlling visible CL.
27. .5. Surgical Exploration:
◦ Surgical reexploration should be considered only after conservative measures have either been exhausted
or deemed ineffective.
◦ Suggested criteria for reexploration range from outputs of >500mL/day to >1000mL/day output for 5
days.
◦ surgical intervention should be decided upon within first 4-5 days of a CL, when prompt response to
medical management is absent.
◦ At the time of reexploration, local inflammation from extravasated chyle can make thoracic duct
identification difficult.
◦ Trendelenberg positioning and maneuvers that raise intrathoracic and intra-abdominal pressure can
facilitate identification of the site of the CL.
28. ◦ Having the patient ingest a fatty diet before surgery can stimulate chyle production and aid in CL
localization .
◦ when identified, the leaking thoracic duct can be ligated, covered with a muscleflap, or treated with
any number of sclerosing agents, adhesive agents, or mesh.
29. 6. Distant Management:
◦ In certain instances, when there is a persistent CL after surgical reexploration or when reexploration may not
be ideal because of distorted anatomy or tenuous in the case of a microvascular free flap,
◦ the head and neck surgeon may seek the assistance of his interventional radiology or thoracic-foregut
colleagues for distant management of a thoracic duct leak.
◦ Percutaneous trans abdominal cannulation of the thoracic duct at the cisterna chyli with lymphography and
selective distal embolization with coils or tissue adhesive is a safe and minimally invasive technique for the
treatment of CL that do not respond to conservative management, with a reported success rate of 45–70%.
◦ Given the relative low morbidity and reasonable success rate, this may be a viable alternative to surgical
exploration, if one’s facility has the appropriate equipment and personnel.
30. ◦ The major draw back to this method is that it can be time-consumingand often require multiple
attempts.
◦ For patients with failed surgical ligation, thoracoscopic ligation can be an effective salvage
procedure that addresses the thoracic duct proximally.
◦ Exposure and ligation of the thoracic duct are performed through a right sided thoracoscopic
approach, through which the thoracic duct is ligated at the supradiaphragmatic hiatus between the
aorta and azygous vein.