Presentation 2013

Dr. Naim Manhas 1

case presentation

Dr. M. Naim Manhas m.s.,m.b.b.s.

E.N.T. Specialist King Abdul Aziz Hospital

Dr. Naim Manhas 2

Sialorrhea Injection Site Identification - 3D Medical Animation - YouTube.flv

Dr. Naim Manhas 3

what is calculus/ lith/stoneCalculus:- / lithConcretion of material mainly composing of mineral salts.Formation :- lithiasis

Dr. Naim Manhas 4

common sites:-

Uro-genital system: kidney,ureter, bladderGall bladderSalivary gland submandibular gland parotid gland

Tonsillis palatine

lingual

Nasal cavity

p

Dr. Naim Manhas 5

Effects on organs

Disruption of normal flow

Disrupting the function of organ in question

Late effects of obstruction on organs

Dr. Naim Manhas 6

etiology

Excessive levels of minerals• Usually increase levels of

calcium

slow flow rate

• infection

Dr. Naim Manhas 7

Calculi in E.N.T. Practice

Rhinolith :-Calculus present in nasal cavity

Actually exogenous foreign body ,blood clot, or secretion is covered by slow deposition of calcium and magnessium salts over a period of time.

Causes nasal obstruction , unilateral prulent nasal discharge,epistaxis,sinusitis or epiphora.

Dr. Naim Manhas 8

Calculi in E.N.T. Practice

Tonsilliar lith :-Tonsilliar stone or tonsilliar calculi

Clusters of calicified material in the tonsillar crepts.

Tonsilliar lith have been recorded weighing from 300 mg to 42 G

Composed mostly of calcium, but may contain other minerals like phosphorus , magnessium.

May be asymptomatic

One of causes of Helitosis

Dr. Naim Manhas 9

case presentation

30 years old saudi lady presented to E.N.T. clinic with file No.494114 . History of swelling in submandibular space, since 6 months increasing in size during meals.h/o pain was present during meals

Dr. Naim Manhas 10

presentation

Recurrent swellingPain which is excerbated with eatingStones in duct can be palpatedImaging (C.T.) Scan is best to detect calculiUltraSound has not proven useful

Dr. Naim Manhas 11

Radio-opague shadow in submandibular gland-

Dr. Naim Manhas 12

Dr. Naim Manhas 13

Incidence of salivary calculi

• Submandibular gland80 to

90%• Reported in • Parotid gland10 to

20%

Dr. Naim Manhas 14

saliva & its composition

saliva:- produced by clustered Acini cells and contain electrolytes enzymes (e.g.ptylin and maltase, carbohydrates, proteins, inorganic salts and even some antimicrobial factors)

Approx. 500-1500ml of saliva is produced daily and transpored to oral cavity by ductal elements at an average of 1ml /mt

Obstruction :- causes stasis of salivary flow

Dr. Naim Manhas 15

saliva & its composition

saliva•composition

Abundant •hydroxyapatite•Aggregates of mineralized

debris

Flow rate is decreased •Formation of nidus•Promoting calculi

formation

Dr. Naim Manhas 16

Submandibular gland calculi

High salivary mucin and high alkaline content

High concentration of calcium and phosphate

Primarly of calcium phosphate and hydroxyapatite

Dr. Naim Manhas 17

Approxaimately 74% of single stone is found in the gland, and 26% in duct.

74%

26%

Dr. Naim Manhas 18

complications

Persistant obstruction from Sialiolithasis leads to salivary stasis which predisposes gland to recurrent infections and even abscess formation.

Dr. Naim Manhas 19

managementSURGICAL REMOVAL

Calculus impacted in duct:-

After palpation and fixation of the calculi , duct is opened and calculi removed. Duct is kept open as it heals by itself.

Larger stone get embeded in the hilum or body of the submandibular gland require surgical excision of the gland

Dr. Naim Manhas 20

submandibular gland specimen

Excised submandibular gland with embedded stone in the hilum of the gland

Dr. Naim Manhas 21

Recent advances

Endoscopic techniques ;- Allow an intraoral endoscopic

examination of the duct and extraction of salivary calculi

If stone is impacted in gland then surgical removal of gland is indicated

Dr. Naim Manhas 22

Penetrating neck injuries

Penetrating injuries caused by gunshots and sharp edged weapons have different approach for management.

Gunshot wounds in the neck are divided in three zones of neck.

Dr. Naim Manhas 23

Neck zones

Zone -1Between suprasternal notch to cricoid cartilage. Contains throacic outlet structuresProximal common carotid ,vertebral and subclavian arteries.Trachea, esophagus, thoracic duct, thymus

Dr. Naim Manhas 24

Neck zones

Zone –IIBetween carotid cartilage and angle of mandible.

Internal and external caotid arteries, jugular veins, pharynx, larynx, esopahgus, recurrent laryngeal nerve, spinal cord, trachea, thyroid and parathyroid.

Dr. Naim Manhas 25

Neck zones

Zone –IIIBetween angle of mandible and base of skull.It has distal extracrainal carotid and vertbral arteries and uppermost segments of the jugular veins.

Dr. Naim Manhas 26

Penetrating Neck Injury

The normal protocol regarding the management of penetrating neck injuries does not apply in cases like this.

This egyptian man reported to E.R. with pentrating injury caused by sharp edged weapon in neck .

After airway was secured by intubation patient was shifted directly to O.R.

Dr. Naim Manhas 27

point to remember

Tight facial compartments of neck structures may limit external hemorrhage from vascular compartment.These tight fascial boundaries may increases risk of airway compromise , because the airway is relatively mobile and compressible by an expanding hematoma.

Dr. Naim Manhas 28

Penetrating Neck InjuryThe standard care is immediate surgical exploration who present with signs and symptoms of shock and continuous hemorrhage from the neck wounds.The specific injuries are confirmed and treated during neck exploration

Dr. Naim Manhas 29

vital structures Because of numerous vital structures that

are present in small area, the objective of surgical exploration is to arrest hemorraghe yet maintain cerebral flow and preserve neurologic function.

Jugular vein injury repair depends upon type of injury . Repair can be performed by simple lateral closure, resection and reanastomosis or saphenous vein graft reconstruction, particularly Internal jugular vein.

Dr. Naim Manhas 30

vital structures Nerve injuries account for about 1-3%, vagus

and recurrent laryngeal nerve.

Thoracic duct injuries :- difficult to diagnose intially but later on presents as chylous leak

Needs reexploration and ligation of throacic duct

Thyroid injuries :- can cause extensive bleeding. Extensive injury require an ipsilateral lobectomy to control the bleeding

Dr. Naim Manhas 31

Don’t miss Laryngo-tracheal injuries are also common (10%) .

Direct endoscopic examination of Larynx and esophaus is done.

After closing and airway is secured by surgical tracheostomy,endoscopic examination of larynx and esophagus is done .

Dr. Naim Manhas 32

Before Decanulation. Esophageal injuries are the third most common in penetrating neck trauma (6%).

Early diagnosis lessens probability of delayed treatment and missed injury, which can be devastating.

After closure the airway is secured by tracheostomy and then endoscopic examination is done .

Dr. Naim Manhas 33

prepration for discharge

Oral feeding was initiated after barium study which shows no evidence of leak.

Decanulation was done after follow up endoscopy of larynx show no evidence of any pathology .

Dr. Naim Manhas 34

your presence is appreciated

Thank you