Mandibular swing approach a step by step approach

Mandibular Swing

Mandibular swing approach for Parapharyngeal mass lesions Video clipping

Mandibular swing approach for parapharyngeal mass lesions An E Atlas

Orbital disorders

Orbital Disorders

Coablation tonsillectomy

Introduction:
Tonsillectomy is a commonly performed surgical procedure these days. With the advent of latest surgical equipments and innovations the risks involved in the surgical procedure has been considerably reduced. One such emerging technological innovation is the introduction of coablation technology which is currently being used to perform tonsillectomy.

Emerging technology – Current expectations:

Technological innovations in any surgical procedure should focus on the following parameters:

Bloodless surgical field
Reduction in the surgical time
Reduced post operative pain
Improved healing rates
Affordability
Safety

Coablation:
This is also known as “Controlled ablation” / “Cold ablation”. This technology uses bipolar high frequency electrical energy to exite the electrolytes in a conductive medium. This excitation creates a plasma field which is higly focussed. The ions present in the plasma field are highly energized and this energy is sufficient to break organic molecular bonds found in the living tissue. This energy dissolves soft tissue at relatively low temperatures, while preserving the integrity of surrounding tissue. Sodium chloride solution is commonly used as a conducting medium in coablation surgical procedures.

Advantages of coablation:

It operates at relatively cool temperatures (40 – 70 degrees centigrade)
Its cutting effect is very precise with very minimal effect on the surrounding tissue
The plasma field which is generated by this equipment is about 100 – 150 microns thick. This is the reason for its precision

Plasma field:
This is the technology involved in coablation surgical procedures. Plasma field is defined as a collection of charged particles (equal amounts of positive and negative ions). Plasma field resembles gas physically in some respects, but show significant differences as well. Plasma field is a good conductor of electricity and is affected by the presence of magnetic field, where as it is not so with gases.

Crudely put plasma is a state of matter in which many electrons are free and unbound and move independently. Coablation technology utilizes this phenomenon by generating an electrical field between two small electrodes. This electrical field when made to pass through a medium like normal saline which conducts it rather well, the sodium and chloride molecules become energized and separate from the solution. These sodium and chloride ions are responsible for the formation of plama field.

The wand used in coablation surgical procedures has channels for suction and irrigation. Normal saline should flow through irrigation channel and central suction should be connected to the suction channel.

Tympanic neurectomy Golding wood's operation

This procedure is performed to decrease salivary flow by interrupting parasympathetic fibers of Jacobson's nerve. It was first performed by Golding Wood hence goes by the term “Golding Wood operation”.

Indication:

1. In excessive drooling caused by neurological disorders
2. Frey syndrome following parotid surgery
3. Recurrent inflammation of parotid gland if conventional medical management fails

Procedure:

Can be performed both under local / General anesthesia.

Postero superior tympanomeatal flap is created and carried down up to the level of annulus. The incision should be fashioned in such a way that if need arises it can be extended anteriorly along the inferior canal wall to about 5 o clock position. This extension of incision helps in the evaluation of the inferior most portion of the nerve as it enters through the floor of hypotympanum.

The annulus is dissected off its groove and is pushed forwards to 5 o clock position anteriorly and superiorly up to the short process of malleus. After elevation of the tympanic membrane the jacobson's nerve is identified at the promontory as it crosses from inferior to superior direction. This nerve may be completely exposed or partially covered by bone. The hypotympanic portion of this nerve is searched for its antero inferior branch which should be sought and avulsed. This nerve identified at the promontory should be cleared off its bony covering if present and avulsed completely.

Eventhough majority of parasympathetic nerve supply to the parotid is via the tympanic nerve, it has been demonstrated that chorda tympani nerve also carries a few parasympathetic fibers.

The decision to avulse chorda tympanic nerve along with Jacobson's nerve is highly controversial as it can lead to troublesome xerostomia.

Complications:

1. Residual perforation of ear drum
2. Damage to middle ear structures
3. Rarely troublesome xerostomia
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   

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Centripetal endoscopic sinus surgery

Introduction:

Endoscopic sinus surgery has its own attendent complications. Intraoperative complications include bleeding, CSF leak, and periorbital damage. There are also short term complications which include infections, synechiae formation and lateralization of middle turbinate. Intraoperative complications can largely be avoided by scrupulously following meticulous surgical technique and precise anatomical knowledge.

Centripetal FESS technique:

Vertical incision is made in the nasal mucosa close to the anterior margin of the uncinate process. If the uncinate process is not clearly visible due to the presence of polypoidal changes the incision can be sited close to the posterior margin of agger nasi. The medial wall of the orbit is identified at the earliest and the dissection proceeds in the postero superior direction to the floor of the anterior cranial fossa (roof of the ethmoid) which should be identified in all cases. Dissection always proceeds in a direction parallel to the lamina papyracea. The bulla ethmoidalis is sectioned away from its attachment to the lamina papyracea using a scissors. It should be sectioned in a plane parallel to lamina papyracea. This dissection proceeds till the anterior wall of sphenoid sinus is reached. If need be the anterior wall of sphenoid sinus can be opened. The surgical plane formed by the junction of lamina papyracea as it joins the lateral wall of sphenoid sinus. If this plane is adhered to then damage to vital structures can be avoided.

If surgery is not contemplated in the frontal outflow tract then the superior portion of the uncinate process is left undisturbed.

This centripetal technique of ethmoidectomy begins at the periphery and progresses towards the centre.

Advantages of centripetal resection:

1. It provides wide exposure
2. It provides excellent hemostasis
3. This provides adequate lateral margins
4. Since the plane is dissection proceeds along the floor of anterior cranial fossa keeping medial to the medial wall of orbit, the surgeon need not bother about the variations in the ethmoidal lamella.

Could oxygen consumption by bacteria in the middle ear cavity be the cause for negative pressure in patients with otitis media?

Negative middle ear pressure is commonly seen in patients with otitis media. This space is invariably occupied by secretions causing middle ear effusion.

Probable causes of negative middle ear pressure in these patients:

1. Eustachean tube dysfunction: Hydrops ex vacuuo theroy proposed by Politzer about 100 years ago is still valid. This theory suggests that vacuum in the middle ear cavity is replaced by fluid. This is caused by transudation of fluid from the middle ear mucosa into the middle ear cavity.
2. Sniffing
3. Failure of clearance of effusion by the eustachean tube
4. Toyenbee's phenomenon: Stuffed nose causes Negative pressure in the middle ear cavity
5. Oxygen consumption by middle ear bacteria

Chemosensory elements of nasal cavity

It is common knowledge that nasal cavity is capable of olfaction. The primary sense of olfaction is really primitive phylogenetically

and is perceived by the first cranial nerve i.e. olfactory nerve.

Introduction:

It is common knowledge that nasal cavity is capable of olfaction. The primary sense of olfaction is really primitive phylogenetically and is perceived by

the first cranial nerve i.e. olfactory nerve. In humans this sensation plays a vital role in:

1. Determining the flavours of food and beverages

2. In maintaining the nutrition of the individual

3. Plays a vital role in safety of the individual

Olfactory dysfunction could be an early pointer for a number of neurological disorders which include:

1. Alzheimer’s disease

2. Parkinsonism

3. Multiple sclerosis

4. Frontal Meningiomas

5. Nasopharyngeal carcinoma

Types of nasal chemosensory elements:

There are 4 different types of chemosensory elements present in the nasal cavity of humans. These include:

1. Nervous terminalis also known as terminal nerve system. It is also arbitrarily christened as cranial nerve zero as this nerve was

identified after all the cranial nerves have been named.

2. Main olfactory nerve i.e. olfactory nerve

3. Vomeronasal or accessory olfactory system

4. Trigeminal sensory system

The first cranial nerve (olfactory nerve) mediates the classic sense of olfaction and perception of flavour. This nerve innervates the

olfactory epithelium present in the roof of the nasal cavity and the corresponding portion of nasal septum.

The Free nerve endings of fifth cranial nerve innervate the whole of the nasal cavity including the olfactory area. These nerve endings

are sensitive to irritation, burning, cooling and tickling sensations. These nerves also initiate nasal reflexes like increased secretions from nasal mucosal glands, halting the

inhalation of potentially noxic substances which could harm the nasal and tracheal air ways. Most odorants in high concentrations stimulate these nerve endings.

It has been suggested that free nerve endings of trigeminal nerve may interact with olfactory nerves. The role played by this interaction is still being studied.

Cranial nerve 0 has been described in almost all vertebrates including humans. It is composed of loose plexus of nerve fibres within the nasal cavity.

These nerve fibres can be identified by the presence of ganglia at nodal points. These nerve endings demonstrate high levels of gonadotropin releasing hormone.

Olfactory dysfunction could be an early pointer for a number of neurological disorders which include:

1. Alzheimer’s disease

2. Parkinsonism

3. Multiple sclerosis

4. Frontal Meningiomas

5. Nasopharyngeal carcinoma

Types of nasal chemosensory elements:

There are 4 different types of chemosensory elements present in the nasal cavity of humans. These include:

1. Nervous terminalis also known as terminal nerve system. It is also arbitrarily christened as cranial nerve zero as this nerve was identified after all the

cranial nerves have been named.

2. Main olfactory nerve i.e. olfactory nerve

3. Vomeronasal or accessory olfactory system

4. Trigeminal sensory system

The first cranial nerve (olfactory nerve) mediates the classic sense of olfaction and perception of flavour. This nerve innervates the

olfactory epithelium present in the roof of the nasal cavity and the corresponding portion of nasal septum.

The Free nerve endings of fifth cranial nerve innervate the whole of the nasal cavity including the olfactory area. These nerve endings

are sensitive to irritation, burning, cooling and tickling sensations. These nerves also initiate nasal reflexes like increased secretions from nasal mucosal glands, halting

the inhalation of potentially noxic substances which could harm the nasal and tracheal air ways. Most odorants in high concentrations stimulate these nerve endings.

It has been suggested that free nerve endings of trigeminal nerve may interact with olfactory nerves. The role played by this interaction is still being studied.

Cranial nerve 0 has been described in almost all vertebrates including humans. It is composed of loose plexus of nerve fibres within the nasal cavity.

These nerve fibres can be identified by the presence of ganglia at nodal points. These nerve endings demonstrate high levels of gonadotropin releasing hormone.

These nerves have been postulated to play a vital role in reproduction. Secretion of gonadotropin releasing hormone in these nerve endings are partly regulated by oestrogen levels.

These nerves have been postulated to play a vital role in reproduction. Secretion of gonadotropin releasing hormone in these nerve endings are partly

regulated by oestrogen levels.

Define “Parenteral fluid therapy”. Enumerate their main components and their role. Also enumerate the complications of this therapy

The major objective of parenteral fluid therapy is to provide pareneterally water that could replace physiological losses. Water loss from the body can be via urine / sweat /insensible means. Water losses from the body roughly parallels energy metabolism and is not related to body mass index.

Basic rules of parenteral fluid therapy include:

1. Never be generous with fluid administration
2. The source and amount of usual water out put from the body should be known
3. Amount of nutrients and electrolytes administered parenterally should be accurately known
4. The aim of fluid therapy should be clear
5. The same substance should not be given and removed at the same time
6. Commonly preferred parenteral fluid is isotonic solution
7. Kidney does'nt manufacture water / electrolytes
8. For short term fluid replacement water, glucose, sodium chloride, and phosphate alone needs to be given. Divalent ions like calcium and magnesium need not be replaced.
9. There are two types of parenteral fluids i.e crystalloids and colloids
10. Composition of various intravenous fluids should be accurately known

Main components of parenteral fluids:

1. Water
2. Electrolytes like sodium and chloride
3. Calcium ions
4. Magnesium ions
5. Bicarbonate
6. Phosphate

Types of parenteral fluids:

1. Isotonic
2. Hypertonic
3. Hypotonic

Classification of parenteral fluids:

1. Volume expanders
2. Blood / blood based products
3. Blood substitutes
4. Medications

Volume expanders:

There are two types of volume expanders i.e. Crystalloids and colloids. Crystalloids are aqueous solutions of mineral salts and other water soluble molecules.

Colloids contain large insoluble molecules. Gelatine is one classic example of such insoluble molecule.

Buffer solutions: These solutions are used to correct acidosis / alkalosis. Intravenous sodium bicarbonate is one such example of buffer solution. Commonly used buffer solution is Ringer lactate.

Parenteral nutrition: This helps in feeding a person bypassing the usual process of eating and digestion.

Intravenous route can be used to administer drugs.

Complications of fluid therapy:

1. Infection
2. Phlebitis
3. Extravasation to subcutaneous tissues
4. Fluid overload
5. Hypothermia
6. Electrolyte imbalance
7. Embolism 

Tracheostomy versus endotracheal intubation

Endotracheal intubation versus Tracheostomy a comparison

Tracheostomy	Endotracheal intubation
Reduced need for sedation	Patient needs to be sedated
Not so easy	Easier & Quicker
Virtually no damage to glottis	Danger of damage to glottis
Reduction of dead space	Dead space reduction not appreciable
Tolerated well for long periods	Patients dont tolerate ET tubes for long periods
Weaning easy	Weaning not so easy after prolonged intubation
Requires skill	Skill can be easily learnt by practice
Bleeding & wound infections common	Virtually no bleeding
Humidification of inspired air a must	Humidification of inspired air is not a must
Scar formation +	No scar formation
Low risk of improper placement of tube	Risk of improper tube placement is rather high

Fractures involving nasal septum

Introduction:

Fractures of nasal septum occurs commonly in combination with fractures of nasal bones. Prompt identification of trauma involving nasal septum will help in preventing cosmetic defects in later life. Early reduction of fractures involving nasal bones and septum will go a long way in preventing cosmetic defects involving the nose.

Types of nasal septal fractures:

Nasal septal fractures have been classified into three types. This classification helps in deciding the optimal management modality.

Type I septal fracture:

In this type the fracture line is limited to either cartilage / bony component of nasal septum, The most important feature is that the fracture line does not cross the osseous cartilagenous junction.

Image showing Type I fracture of nasal septum

Type II septal fracture:

In this type the fracture line involves both bony and cartilagenous portions of nasal septum with the fracture line crossing the osseo cartilagenous junction.

Figure showing Type II fracture of nasal septum

Type III septal fracture:

This type of fracture is characterised by multiple fracture lines involving bony or cartilagenous portions of the nasal septum.

Image showing Type III septal fracture

Classification of septal fracture is not complete without assessing whether the septum is dislocated from the nasal spine or not. If the nasal septum is not displaced from the nasal spine then the fracture is classified under the subcategory A and if it is displaced from the nasal spine then it is subclassified under the category B.


If the nasal septum is dislocated from the nasal spine then it should be repositioned and the fracture reduced at the earliest. Before manipulating the nasal septum the nasal bone fracture should be reduced.