Recurrent Laryngeal Nerve and thyroid surgeryMTD Lakshan
Recurrent Laryngeal Nerve is closely related to the thyroid gland and therefore at risk during thyroid surgery. In this presentation I discuss some important aspects of the recurrent nerve in relation to the thyroid surgery.
thyroidectomy-surgical seminare, prepared by Dr. Siddharth JINDAL, third year resident in dept. of general surgery at P.D.U. Government Medical College and Civil Hospital, Rajkot, Gujarat.
Recurrent Laryngeal Nerve and thyroid surgeryMTD Lakshan
Recurrent Laryngeal Nerve is closely related to the thyroid gland and therefore at risk during thyroid surgery. In this presentation I discuss some important aspects of the recurrent nerve in relation to the thyroid surgery.
thyroidectomy-surgical seminare, prepared by Dr. Siddharth JINDAL, third year resident in dept. of general surgery at P.D.U. Government Medical College and Civil Hospital, Rajkot, Gujarat.
laryngeal paralysis is a specific issue ENT have to deal with.
It is a sign of Disease and not a final diagnosis, should a patient present with the symptoms it is prudent to investigate and find cause of the paralysis
Mediastinoscopy & mediastinotomy indications & techniquesAbdulsalam Taha
The mediastinum is the central compartment of the chest. Its boundaries and compartments are well known.Although, it contains the most vital organs of the body; it is often a forgotten compartment. Involvement of mediastinal nodes has a dramatic prognostic and therapeutic impact in patients with non-small cell lung cancer. Cervical mediastinoscopy remains the most important technique for staging of the mediastinum.
The technique of extended mediastinoscopy and redo mediastinoscopy are described as well. Indications, technique and complications are discussed.
laryngeal paralysis is a specific issue ENT have to deal with.
It is a sign of Disease and not a final diagnosis, should a patient present with the symptoms it is prudent to investigate and find cause of the paralysis
Mediastinoscopy & mediastinotomy indications & techniquesAbdulsalam Taha
The mediastinum is the central compartment of the chest. Its boundaries and compartments are well known.Although, it contains the most vital organs of the body; it is often a forgotten compartment. Involvement of mediastinal nodes has a dramatic prognostic and therapeutic impact in patients with non-small cell lung cancer. Cervical mediastinoscopy remains the most important technique for staging of the mediastinum.
The technique of extended mediastinoscopy and redo mediastinoscopy are described as well. Indications, technique and complications are discussed.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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.
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
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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.
2. Introduction
2015 American Thyroid Association Guidelines
recommend “Visual identification of the recurrent
laryngeal [RLN] during dissection in all cases”
3. Surgical anatomy
Right RLN tracheoesophageal groove more horizontal
LRLN more vertically in the left tracheoesophageal
groove
4. Relationship of RLN and Berry’s ligament
fibrous structure that anchors the thyroid gland to the first three rings of the tracheal cartilage
5. Relationship of RLN and Inferior Thyroid
Artery
it may cross superficially or
deeply to the inferior
thyroid artery (ITA) or
between its branches
Unilateral or bilateral
absence of the ITA is not a
rare variation, and is
described in 3–6 % of
cases
6. Tubercle of Zuckerkandl
is the posterior and lateral projection of the thyroid gland.
described as “an arrow pointing to the recurrent laryngeal nerve
In patients with an identifiable tubercle of Zuckerkandl, the recurrent laryngeal nerve is located
medial to the tubercle in the vast majority of instances
7. Surgical anatomy
On both sides nerves
enter the larynx at the
cricothyroid articulation
beneath the fibers of the
inferior constrictor
muscles of the pharynx.
8. “non-recurrent” inferior laryngeal nerve
(0.6%), the right recurrent
laryngeal nerve passes directly
from the vagus in the neck
towards the larynx and does not
recur around subclavian artery.
Make it susceptible to injury
9. The “false” nonrecurrent nerve
enlarged anastomic branches between
the normal RLN and the cervical
sympathetic chain may mimic a
nonrecurrent laryngeal nerve (NRLN)
in up to 7.5 % of the cases
Another confounding condition is
represented by small branches
connecting an NRLN and the stellate
sympathetic ganglion
11. Approaches to RLN identification
lateral approach
• routine
• uncomplicated
• Theodor Kocher
Inferior approach
• revision
Superior
• least used
• consistent
12. lateral approach
identifies the RLN at the midpole of the thyroid lobe.
This approach is usually used and applicable to most cases
except those with a very large cervical or substernal goiter or
the presence of a fibrous scar due to previous surgery.
However, injury to the extralaryngeal branching of the RLN may
occur with this approach.
13. inferior approach
finds the RLN at the lower pole of the thyroid lobe around the
tracheoesophageal groove.
advantage is that extralaryngeal branching rarely occurs at this
level
disadvantage is that it involves the dissection of a long
segment, and it may be difficult to find the RLN because of
inferior thyroid artery bleeding.
14. Superior approach
identifies the RLN at the laryngeal entry point, which is above
the ligament of Berry
useful for large cervical or substernal goiters, where the nerve
cannot be found using a lateral or inferior approach.
The advantage of this approach is that the RLN entry point is
relatively constant
The disadvantage is that dissection around the ligament of
Berry is not easy because this region is fibrous and has a rich
vasculature.
16. Material and method
This study was conducted on 71 patients with thyroid cancer.
Duration : March 2010 and November 2014
Setting : Furan University Shanghai Cancer center.
Study type : cohort study
17. The medial approach was performed
1. Revision cases with the presence of a fibrous scar due to previous
surgery
2. Multifocal thyroid cancer with local invasion (RLN, esophagus, and
carotid sheath) and lymph nodes metastasis
3. other cases in which it was difficult to find the RLN using the standard
approaches.
18. Surgical technique
A collar incision was used, and subplatysmal flaps were elevated.
The strap muscles were separated in the midline to expose the thyroid gland
the thyroid isthmus was clamped and transected at its attachment to the
opposite lobe. The lobe was separated internally from the trachea until half
of the lateral side of tracheal rings 2–4 was exposed from the thyroid lobe
Using the third tracheal ring as a landmark located 0.3 cm from the lateral
surface of the tracheal ring
the surgeon employed a careful blunt dissection to expose the RLN through
the layers of the fibers
19. • To avoid accidental bleeding of
the inferior thyroid artery caused
by injure, we try to identify the
RLN above the level of the artery.
In the author’s observation, this
level is about the third tracheal
ring.
• The location of the RLN in the
level of third tracheal ring is
relatively stable by its anatomical
characteristic, which is suitable
for both sides.
20. All patients then received a total thyroidectomy and central
lymph nodes dissection (with or without lateral lymph nodes
dissection)
A postoperative laryngoscopy was performed for all patients.
Patients were followed up every 6 months
for 12 to 62 months, with a median of 28 months.
21. Results
Age : 16 to 68 years
29 males and 42 females
in all of the cases, RLNs were successfully identified
Of the 71 patients, 22 were revision surgeries.
Among the remaining 49 patients, 81.6% (40 of 49) of the patients were T4
22. Complication rate
Number of case Complication
7 patients had clinical and biochemical
hypocalcaemia, which was corrected
using calcium supplementation.
2 cases showed unilateral vocal cord
paralysis one fully recovered after 6
months, while the other showed
lateral vocal paralysis and were
treated with a tracheotomy.
23. Discussion
In China, most thyroid procedures are performed by general surgeons even
though most of them are not well trained for thyroid cancer surgeries. Thus,
in our cancer center, reoperative thyroid procedures and those with severe
thyroid cancers are very common.
In revision cases , the lateral side of the thyroid was difficult to separate
because of scarring and the loss of normal tissue planes; thus, the RLN could
not be identify by regular approaches.
multifocal thyroid cancers with local invasion (RLN, esophagus, and carotid
sheath) and lymph nodes metastasis also difficult in terms of finding the RLN
with the three common approaches.
24. Thyroid surgeons should have a number of different techniques available if
identification of the RLN proves troublesome.
In this case series, we described a new backup approach for the
identification of the RLN. This work represents the largest series of patients
undergoing thyroid surgery using this method and provides valuable safety
data for surgeons wishing to use it as a backup method for RLN
identification in special cases.
25. Most patients in our study were in the late stages of thyroid
cancer, which makes it difficult to identify the RLN.
However, in all of the cases, the RLNs were successfully
identified by the medial approach. The data also confirm that
identifying the RLN with the medial approach does not increase
the risk of operative complications, including vocal paralysis,
hypocalcaemia, primary hemorrhage, or wound complications.
26. The patient size in this study seems to be small compared to
other studies on thyroid surgery.
However, the purpose of this study was to describe a backup of
the RLN identification approach for special cases, not routine
cases.
Especially in underdeveloped countries which, intraoperative
neuromonitoring of the RLN is expensive and not available in
most cases
Thyroid surgeries are the most frequently performed endocrine procedures worldwide.
One of the most serious complications of thyroid surgery is injury to the recurrent laryngeal nerve (RLN), which varies from 0.5% to 14.0%, depending on the
type of disease
the type of surgery
the extent of resection
and the surgical technique
Detailed and comprehensive knowledge of the RLNs’ anatomic relationships and variations is of paramount importance in order to avoid nerve injury during thyroidectomy.
The RLN was consistently noted on the medial aspect of this superficial fascia near to the thyroid
,” since the nerve is found between the tubercle of Zuckerkandl and the surface of the trachea
The most common site of injury to the RLN is near the BL, where the nerves penetrate into the larynx
The presence of a left-sided NRLN is extremely rare and is associated with a situs inversus totalis [19–21].
in presence of aberrant right subclavian artery, arising from the aorta after the left subclavian artery has given off,
in addition, attention needs to be paid to the possible existence of a non‐RLN, especially in the right side, and preoperative evaluation of an aberrant right subclavian artery with either a computed tomography scan or ultrasound is necessary.
Before concluding that it is a nonrecurrent ILN, one should follow it to identify whether it originates from the vagus nerve (VN) or from the cervical sympathetic system. ST, Sympathetic trunk
Therefore, division of the RLN, when present, usually occurs close to the ligament of Berry where it becomes particularly vulnerable
RLN branching is uncommon below the inferior thyroid artery but should always be suspected when a thin “main trunk” is identified.
At this stage, it is worth dissecting the nerve retrograde to make sure that the identified RLN is not the posterior branch of a very proximally bifurcated RLN.
in type 1 (arterial; 46.3 %), division occurs near inferior thyroid artery.
In type 2 (post- arterial; 31.5 %), division is found on post-arterial segment.
In type 3 (prelaryngeal; 11 %), division is located very close to laryngeal entry point.
In type 4 (prearterial; 11 %), bifurcation takes place before the nerve crossing the inferior thyroid artery.
Currently, there are three approaches used to identify the nerve
all three techniques is that the RLN is identified from the lateral side of the thyroid. Yet, in some special cases when the lateral side of the thyroid is difficult to divide, it is not possible to use any of the three techniques to identify the RLN.
which means that most of the patients in this study were in the late stage of thyroid cancer.