This powerpoint describes the types of maxillectomy & operative steps for total maxillectomy. It also enumerates various flaps used for reconstruction of maxillectomy defect.
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This powerpoint describes the types of maxillectomy & operative steps for total maxillectomy. It also enumerates various flaps used for reconstruction of maxillectomy defect.
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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.
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. Introduction
• It is a procedure to remove lymph nodes and surrounding
fibro fatty tissues from neck to eradicate metastasis to
cervical lymph nodes in cancer of aerodigestive tract.
• Status of the cervical lymph nodes is the single most
important prognostic factor in head and neck tumors.
• Cure rates drop into half when there is regional lymph node
involvement
3. Emil Theodor Kocher
Earned Nobel Prize in 1909 for
his work in thyroid and neck
surgery — the first ever
awarded to a surgeon.
4. 1906 – George Crile
described the classic radical
neck dissection (RND)
5. 1967 - Bocca and Pignataro
described the “functional
neck dissection” (FND)
6. Subgroups of lymph nodes
• Ia Submental
• Ib Submandibular
• IIa Upper jugular (Anterior to XI)
• IIb Upper jugular (Posterior to XI)
• III Middle jugular
• IVa Lower jugular (Clavicular)
• IVb Lower jugular (Sternal)
• Va Posterior triangle (XI)
• Vb Posterior triangle (Transverse
cervical)
• VI Central compartment
17. Level V
• Posterior triangle of neck
– Posterior border of SCM
– Clavicle
– Anterior border of trapezius
– Va Spinal accessory nodes
– Vb Transverse cervical artery
nodes
• Radiologic landmark
– Inferior border of Cricoid
– Supraclavicular nodes
18. Level VA & VB
Nasopharynx, oropharynx, posterior scalp/neck skin
19. Level VI
Anterior Compartment Structures
Boundaries
• Above by Hyoid bone
• Below by Suprasternal notch
• On either side by medial border
of Carotid sheath
Lymph Nodes
– Perithyroidal
– Pretracheal
– Precricoid Nodes (Delphian)
– Paratracheal nodes along
recurrent laryngeal nerves
20. Level VI
Thyroid gland, glottic and subglottic larynx, apex of
piriform sinus, cervical esophagus
21. Staging of the
neck
“N” classification – AJCC (1997)
Consistent for all mucosal sites except the nasopharynx
Thyroid and nasopharynx
have different staging based on tumor behavior and
prognosis
22. Staging
• Nx: Regional lymph nodes cannot be assessed.
• N0: No regional lymph node metastases.
• N1: Single ipsilateral lymph node, < 3 cm
23. Staging
• N2a: Single ipsilateral lymph node 3 to 6 cm
• N2b: Multiple ipsilateral lymph nodes < 6 cm
• N2c: Bilateral or contralateral nodes < 6cm
• N3: Metastases > 6 cm
32. Selective Neck dissection:
Any type of cervical lymphadenectomy with preservation of one
or more lymph node groups
Four subtype:
• Supraomohyoid neck dissection
• Postero-lateral neck dissection
• Lateral neck dissection
• Anterior neck dissection
33. Supraomohyoid neck dissection:
• Removal of lymph nodes in regions I –III
• The posterior limit is the cutaneous branches of the cervical
plexus and posterior border of SCM
• The inferior limit is the superior belly of the omohyoid where it
cross IJN
35. • Definition
– En bloc excision of lymph bearing tissues in Levels II-IV and additional
node groups – suboccipital and postauricular.
• Indications
-Cutaneous malignancies
-Melanoma
-Squamous cell carcinoma
-Merkel cell carcinoma
- Soft tissue sarcomas of the scalp and neck
36. • Definition
– En bloc removal of lymph structures in Level VI
Perithyroidal nodes
Pretracheal nodes
Precricoid nodes (Delphian)
Paratracheal nodes along recurrent nerves
– Limits of the dissection are the hyoid bone, suprasternal notch and carotid
sheaths
37. • Definition
– Removal of one or more
additional lymphatic groups and/or
non-lymphatic structures relatively
to a radical neck dissection.eg-level
VII, Retro-pharyngeal lymphnode,
hypoglosal nerve, carotid artery.
Indication
• Carotid artery invasion
–Other examples:
• Resection of the hypoglossal
nerve resection or digastric
muscle
• dissection of mediastinal nodes
and central compartment for
subglottic involvement, and
• removal of retropharyngeal
lymph nodes for tumors
originating in the pharyngeal
walls
38. Indication of RND
• 1. Significant operable neck disease (N2a,N2b,
N3) with tumour bulk near or directly involve
spinal accessory nerve and/or internal jugular
vein/SCM.
• 2.Extensive recurrent disease after previous
surgery or radiotherapy.
• 3.Clinical sign of gross extranodal disease
39. Indication of MRND
– MRND Type I:
1. Clinically obvious neck
lymph nodes metastasis
and SAN not involved by
tumor
1. Intraoperative decision
just like preservation of
the facial nerve in parotid
surgery
• MRND Type II:
1. Rarely planned
2. Intra-operative decision for
tumor found adherent to SCM
but away from SAN & IJV
• MRND Type III:
– Depend on the autopsy
reports
1. Lymph nodes were in
the fibrofatty and do
not share the same
adventitia with blood
vessels
2. They are not found
within the aponeurosis
or glandular capsule of
the submandibular
“Functional neck
dissection”
40. • MRND Type III:
– For treatment of N0 neck nodes
– Indicated for N1 mobile nodes and not greater than 2.5 – 3.0 cm
• Contra-indicated in the presence of node fixation
• Result is difficult to interpret because of the use of radiation
therapy
41. • Selective/elective neck dissection:
– For treatment of N0 neck nodes
– For N+ nodes when combined with radiotherapy
• Adjuvant radiotherapy for patient with 2 – 4 positive
nodes or extra-capsular spread
– Upgrade intra-operatively following positive frozen section
42. Indication of SND
• SOH TYPE
• Is indicated for oral cancer.
• T1-T4 with clinical No neck
• .indicted for contra-lateral neck in midline
lession of the floor of the mouth or
ventral tongue.
• Other indication-extension of parotid
surgery, facial skin malignancy anterior to
the tragus
• In case antero-lateral part of the tongue
level I-IV also be considered.
ANTERIOR COMPARTMENT
• Selected Cases of Thyroid Carcinoma
• Parathyroid Carcinoma
• Subglottic Carcinoma
• CA of Cervical Oesophagus
LATERAL TYPE
N0 Neck in carcinomas of
• Oropharynx
• Hypopharynx
• Supraglottis
• Glottic Larynx
POSTERO-LATERAL TYPE
Cutaneous malignancies
• Melanoma
• SCC
• Merkell cell Carcinoma
- Soft tissue sarcomas of scalp and neck
43. • Indication and the type of ND, specially for N0, is controversial
• The following surgical outline was suggested:
– SCC oral cavity anterior to circumvalate papilla
• Supraomohyoid
– SCC Oropharynx, larynx and hypopharynx
• level I- IV or level II-V
– SCC with N+ nodes
• RND
– SCC with 2-4 positive nodes or extracapsular spread
• RND and adjuvant therapy
Shah Cancer July 1;109-113: 1990
45. Contra-indication
• 1.Untreatable primary tumour or unresectable neck
disease(i.e-encasement of brachial plexus, internal carotid
artery, prevertebral fascia.
• 2.Patient unfit for major surgery
• 3.Simaltaneous bilateral neck dissection
• 4. Distant metatases
46. PREOPERATIVE PREPARATION
1. Ensure all documentation, preoperative procedures,
and orders are complete.
2. Check the surgical consent form and others for
completeness.
3. Document allergies.
4. Document height and weight.
5. History and Physical.
6. Baseline vital signs.
7. Ensure results of all laboratory and diagnostic tests
are on the chart. Document and report any abnormal
results.Report special needs and concerns.
47. 1.Good exposure of the neck and primary disease.
2. Ensure viability of the skin flaps. Avoid acute angles
3. Protect carotid artery even in the cases of wound infection
4.Considered preoperative factor—previous radio or chemotherapy
.
5. When draping the surgical field the following ipsilateral landmarks
should be visible
6.Mastoid tip., Ear lobule, Body of the mandible, midline of the chin,
supra-sternal notch, clavicle and region of trapizius muscle
insertion
49. A p r o n I n c i s i o n
INCISION TYPES
Freeland and Rogers (1975) suggest
that the incisions that are most likely
to safeguard the blood supply to the
skin flaps are the superiorly based
apron like.
• incision from mastoid to mentum
designed by Latyschevsky and
Freund (1960) for combined neck
dissection with intraoral
procedures
• Apronlike incision described by
Freund (1967) to be used when a
neck dissection is performed in
conjunction with a laryngectomy
55. M a c F e e I n c i s i o n
• 1st limb begins over mastoid
process goes down to hyoid
bone then up again to the
point of chin.
• 2nd limb lies 2cm above the
clavicle.It start laterally at
ant border of tepezius and
and medially at the midline
60. Good Incision
• 1.Good exposure of the neck and
primary disease.
• 2. Ensure viability of the skin
flaps. Avoid acute angles
• 3. Protect carotid artery even in
the cases of wound infection.
• 4. Facilitate reconstruction
Example, if pectoral muscle is
used a lower limb should be near
the clavicle to enable flap
accommodation.
• 5. It should be cosmetically
acceptable.
61. 4 area of special attention
• Lower end of IJV
• Junction of lateral border of clavicle with lower edge of
trapezius
• Upper end of IJV
• Submandibular triangle
62. Critical steps in RND-lower neck
• Divide the lower end of the SCM muscle in the first area.
• Isolate and ligate the Internal jugular vein
• Look for and avoid damage to the thoracic duct and branches of the
jugular lymphatic duct in chaissaignac ‘s triangle
• Remove scalene nodes
• Devide and retract OM ms upwards.
• Mobilize the fat pad overlying prevertebral fascia
• Identify and preserve brachial plexus
• Identify and preseve the phrenic nerve
• Deal with 2nd area
63. Critical steps in RND-upper neck
• Divide the upper end of SCM in 3rd area
• Retract the post belly of digastric muscle upward
• Identify and ligate IJV
• Identify and preserve hypoglossal n.
64. 1st area-lower end IJV
• Lower end of IJV is approached 1st by continuing dissection along upper boder of
clavicle from trapezius to suprasternal notch
• Supra clavicular n and vessel divided
• IJV lies between sternal and clavicular head of SCM .Divide ms fibre reveal vein
• Carotid sheath opened , IJV exposed few cm ligate with 3 suture( vicry 0-0) and
transfixed at lower end taking care vagus n.
• Left side dissection thoracic duct passes medial to IJV then post finally curve
around it and enter the jn of IJV and subclavian v.
• Rt side similar but smaller duct ( accessory duct) encouter
• Once IJV tied dissection extends laterally upward towards chaissaignac triangle(
b/w scalenus ant attach to tubercle of c6 , subclavian Ar base)
• Remove scalene nodes .
• Main jugular lymph duct that terminate on left side with thoracic duct risk if
damage . Found source and transfixed
65. 2nd area – Jn of Clavicle and Ant. border of Trapezius
• Begin dissection at lower end of trapezius.
• The fatty tissue in supraclavicular region are divided.
• While the fat is retracted upwards, the inferior belly of omohyoid muscle is
encountered.
• It is either cut or ligated and then it can be retracted upwards.
• Deeper to omohyoid, transverse cervical artery and vein found , run laterally
across floor of post triangle is ligated which may be a source of bleeding during
dissection of posterior triangle.
• Dissection continued till prevertebral fascia—Phrenic nerve and brachial plexus
protectrd.
• Phrenic n. descends from lateral to medial through the neck over the ant
scalenus ms and brachial plexus emerges from between medial and ant scalenus
ms.
• Supraclavicular dissection is continued to ant border of trepizius and dissection
continue in upward direction to dissect post triangle.
66. Dissection of posterior triangle
• Following the ant border of trapezius but dissecting on the prevertebral fascia
the post triangle is cleared. Prevertebral fascia left intact.
• Acessory n. is identified before dissection of post. triangle . Nerve run in the
floor of post triangle.
• Methods of identification of acessory n.
It exists the lat border of SCM at Jn of upper 1/3 and lower 2/3 and
then has sinuos course before arriving at lower ant border of trepizius
to supply this ms.
At the exist from sternomastoid , 1cm above Erb’s point where nerve
winds around the ms on its way to supply the parotid fascia.
Dissect up ant border of trapizius in post triangle until nerve is
encounter ( confused with with branches of B. plexus.
Drow line lat from laryngeal prominence through post triangle, n
crosses that line as it run from erb’s point to the lower post corner of
post triangle.
67. Dissection of posterior triangle
• Attempt to preserve shoulder ( preserve C3 , C4 n) even if acessory n
divided.
• Dissection continue up to mastoid tip
• SCM ms at upper end divided under tension by pulling down
• The level of transection is at angle of jaw include lower pole of parotid.
68. 3rd Area-Upper end of IJV
• Using langenbech retractor under post belly of digatric ms (resident’s
friends), upper end of IJV identified
• Its position may be located by palpating transverse process of C2
• Vein is mobilise using lehey forcep , nonabsorbable suture 2 above and 1
below to point of division along with transfixing suture.
• Before tying any ligature ,vagus and hypoglossal n identified and preserved
• Vagus n run along ICA and CCA. Hypoglossal n run across carotid
bifurcation.
• Remember- all branches of IJV arise from antero-medial surface ligated
69. 4th area- submandibular triangle
• Dissection begin in the midline
• Fat is divided in submental area , display ant belly of DG ms.
• Ant. Part of submandibular gland is then idintified and dissected to the
post border of mylohyoid
• Upper border of submandibular gland freed by dividing and tying the
vessel including the facial artery
• Mylohyoid ms retracted in forward direction to reveal the submandibular
duct. At this point lingual n. is is pulled down in a curve.
• Lingual gives small but const branch to SM ganglion, divided
• SM duct is tied and divided , taking hypoglossal n in direct vision
• Specimen is removed following transfixion and division of facial artery as
it winds over post border of DG ms at post-inf border boder of SM gland.
70. summary
Subplatismal flap elevation with external
jugular vein and greater auricular nerve
overlying the SCM
Transecting the sternal head of
the SCM
80. Posterior flap fully elevated to the
trapezius muscle
The XIn is located 1-2cm behind
the greater auricular nerve
81.
82. Posterior flap fully elevated to the
trapezius muscle
The XIn is located 1-2cm behind
the greater auricular nerve
83.
84.
85.
86. Clossure
• The neck is irrigated with water
• 2 suction drain(12 fz) is inserted.drai should never cross
carotid sheath.
• Anaesthetist ask to perform a valsalva manoeuvre to check
chylous leak and bleeding.
• The neck is closed in layers with continuous vicryl to platysma
and sutures/staples to skin
• The drain is maintained on continuous suction e.g. low
pressure wall suction, until the drainage volume is <50ml
/24hrs