Ayurveda and Liver care

WHAT ROLE DOES THE LIVER PLAY IN THE BODY?

Often called the engine of the body, the liver plays an important role in digesting, metabolising and manufacturing essential compounds. For example, the liver is responsible for converting clear plasma to blood. The liver's job is to scan and identify toxins in the plasma and store them so they do not enter the blood. This maintains the purity of the blood by keeping impurities, known in Ayurveda as ama, from mixing with it.

The liver also produces bile to break down and digest fatty acids; It produces blood-clotting factors and creates protective elements that keep blood clots from blocking the circulatory system. It converts sugars into glycogen and stores it for use by the muscles in the form of glucose energy; It synthesizes proteins and cholesterol. The liver also stores valuable trace elements such as iron, copper and vitamins A, D and B12.

HEALTH PROBLEMS RESULTING FROM AN UNHEALTHY LIVER

In Ayurvedic terms, the liver is the seat of Pitta dosha, so Pitta-based problems of skin infection can be a direct result of liver imbalance.

To understand what can go wrong, let's examine the minority functions of the liver.

The liver is composed of five digestive fires (known in Ayurveda as Bhuta Agnis) that correspond to the five Ayurvedic elements of earth, fire, water, air and space.

Each specializes in digesting a particular element in the food. To effectively transform the clear part of plasma to blood tissue, these five digestive fires must be in balance. If their 'flame' burns too high, or too low, or burns unevenly, then the plasma will not be properly converted into blood tissue, and toxins will enter the blood.

All of these functions are governed by one of the sub-doshas of Pitta called Ranjaka Pitta. When Ranjaka Pitta goes out of balance it can affect the blood and skin and result in inflammatory problems such as skin breakouts, acne, cold sores, and skin diseases such as psoriasis.

Toxins building up in the liver can also result in allergies, high cholesterol, hypoglycemia, constipation, digestive problems and fatigue.

If the imbalance lasts for a long time, serious diseases of the liver can develop, including hepatitis, cirrhosis, jaundice and cancer.

WHAT MAHARISHI AYURVEDA OFFERS FOR LIVER HEALTH

Maharishi Ayurveda offers two main products that take care of the liver:

Liver Care (MA579) and Liver Care Syrup (MA936) Their ingredients are very similar and the syrup is faster acting. Both are designed to balance and support all the functions of the liver.

They help the cleansing function of the liver and clear the channels for toxins to flow out, and support the first stage of digestion and metabolism, which breaks down food in the stomach and small intestine.

Bitter and astringent tastes are particularly supportive to liver function. The two Liver Care formulas include several very bitter herbs including Wormwood, Bhumiamla (Phyllanthus), Neem bark, Gulancha Tinospora, Katuki (Picrorrhiza) and Wild Indigo (Tephrosia).

Research has shown that Bhumiamla is a powerful help in maintaining resistance to the Hepatitis B virus, Gulancha Tinospora has produced excellent results in maintaining freedom from jaundice, and Katuki has been found to support the liver on a daily basis and to maintain resistance to infectious viruses .

DIETARY ADVICE FOR KEEPING THE LIVER IN BALANCE?

First, avoid toxins in your food. Eat organic, freshly cooked foods. Foods that contain preservatives and chemicals, or that are processed or leftover, will make your liver have to work overtime to filter out the toxins. Occasionally this will tax the health of your liver.

Minimise intake of alcohol (well-proven as the cause of cirrhosis of the liver). This is especially important for people of Pitta constitution. Stay away from cigarette smoke and air pollution and exposure to commercial household cleansers and other toxic substances. These are all taxing to the liver. In general, drink lots of pure water to flush out toxins.

One of the best ways to prevent liver imbalance is to keep Pitta dosha in balance. Eat a Pitta-pacifying diet in summer, rewarding cooling foods with as sweet, bitter and astringent tastes, such as sweet, juicy fruits, summer squashes, cooked greens, sweet milk products, lassi, and grains.

Avoid sour or fermented foods such as vinegar, pungent foods such as chillies, and salty foods. If you have a lot of Pitta in your basic constitution, then favor this diet all year round. Start the day with a stewed apple or pear, to set the metabolism and cleanse the liver. Just eating a sweet, juicy pear every day can go a long way to soothing Pitta dosha and cleansing the liver.

LIFESTYLE TIPS FOR HELPING THE LIVER

Be careful not to skip or delay meals, especially if you are trying to balance Pitta or have a sharp appetite.

In the evening, retire early, well before 10:00, as you want to be sleeping before the Pitta time of evening starts (from 10:00 pm to 2:00 am). If you are awake during this time, you'll only increase Pitta dosha and prevent the liver from performing its necessary cleaning and resting functions during the night.

Also, lack of sleep has been shown to throw off metabolism of glucose, resulting in weight gain. It also has been linked to an increase in anger. Both of these symptoms point to a liver imbalance caused by lack of sleep.

Avoid situations that cause conflict or anger. Avoid pressure situations during work. Exercise Transcendental Meditation regularly to reduce mental toxins , and to prevent the stress and strain of daily life from taking its toll on your liver. Negative emotions create powerful hormones that flood your liver with toxins.

IN SUMMARY If you take care of your liver, you will enjoy more energy, clearer skin and stronger immunity throughout the year. For an all-year-round cleaning product to support liver function you can also use Maharishi Ayurveda Triphala with Rose twice a day.

SALIVARY GLAND PATHOLOGIES

SALIVARY GLAND PATHOLOGIES

Author:

Dr. Altaf H Malik

Dept. of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

Co authors: 

Dr. Ajaz A Shah

Associate Professor and Head,

Dept. of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

Dr. Suhail Latoo

Lecturer

Department of Oral Pathology and Microbiology,

Govt. Dental College, Srinagar.

Dr. Manzoor Ahmad Malik

J & K Health Services, SDH Banipora

Dr. Rubeena Tabasum

Resident

C.D Hospital, Srinagar.

Dr. Shazia Qadir

Dept. of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

Introduction

            The salivary glands, major and minor, comprise a complex anatomic and physiologic organ system producing enzyme, lubrication, mixing agent and immune factors. The salivary glands respond to physical (food and drink) and emotional (flight, exhilaration and exhaustion) stimuli. They may fall prey to a host of pathologic conditions, including infection, calculus, immune disorders, hypertrophy and atrophy, systemic diseases and neoplasms, both benign and malignant.

            The diseases of salivary glands may be divided into

  1. Developmental anomalies
  2. Infections                       acute

                                    chronic

                                    systemic

  1. Neoplasms                                   benign

                                                malignant

  1. Auto-immune
  2. Miscellaneous      necrotising sialometaplasia

                                    cystic fibrosis

                                    mucocele and ranula

Developmental anomalies

Aberrant salivary gland

            An aberrant (ectopic) salivary gland tissue that develops at a site where it is not normally found. This condition is reported as an single anomaly or in combination with other facial anomalies. They are most frequently reported in the cervical region near the parotid gland or the body of the mandible. The latter is found posterior to the 1st molar and often has a communication with a major salivary gland. Most aberrant salivary glands in the neck occur in the upper portion in the  area of the branchial cleft and bronchial cleft cysts.

Aplasia and hypoplasia

            Total aplasia of the major salivary glands, though rare, may occur in combination with other congenital anomalies like cleft palate. The major symptom is severe xerostomia. Hypoplasia of parotid glands has been reported in patients with Melkerson-Rosenthal syndrome, which presents as a classical triad of orofacial granulomas, facial paralysis and fissure tongue.

Accessory glands

            This is a common condition, found in more than half the people. It is usually found superior and anterior to the normal Stensson’s duct orifice.

Diverticuli

            These are small pouches or outpocketings of the ductal system of one of the major salivary glands, and these lead to repeated episodes of acute parotitis.

Infections of the salivary glands

            Sialadenitis, infection of salivary gland tissue is a relatively common tissue. It may be classified as

(I)              Bacterial and viral

a)     Mumps (viral parotitis)

b)     Bacterial parotitis (sialadenitis)          i.  Acute

ii. chronic

                                    c)   Recurrent parotitis of childhood

(II)          Obstructive sialadenitis

a)     Sialolithiasis

b)     Mucous plugs

c)     Stricture – stenosis

d)     Foreign body

(III)      Systemic granulomatous diseases

a)     Tuberculosis

b)     Actinomycosis

c)     Fungal infection

d)     Uveoparotid fever

Acute bacterial parotitis

Acute bacterial parotitis is a disease of the elderly, malnourished, dehydrated, post-operative and chronically ill patient. Dehydration secondary to acute illness or debilitation result in diminished salivary flow and retrograde infection of Stensson’s duct. Antisialogogues, diuretics, antihistamines and tranquillisers also can be the causes. Clinically, the  condition is characterised by the sudden onset of firm, erythematous swelling of parotid region and exquisite pain and tenderness. Body temperature rises and purulent discharge may emanate from Stensson’s duct. If untreated, it leads to a markedly toxic and life-threatening situation.

            The treatment of bacterial parotitis includes hydration, antimicrobial therapy (semisynthetic penicillins are found to be adequate), and drainage if necessary. Drainage is accomplished by the surgical exposure of the gland and penetration of capsule by blunt probing using a small Kelly clamp.

Chronic bacterial parotitis

            This may be secondary to an episode of acute parotitis, and is characterised by unilateral or bilateral swelling of the parotid and by a course of intermittent exacerbations and remissions. Parotidectomy is considered to be the definitive therapy.

Viral parotitis (mumps)

            Mumps is an acute communicable disease, occurring in epidemics and transmitted by infected salivary secretions and urine. It usually occurs in a child or in an adult who has previously escaped earlier infection. Mumps is characterised by a rapid, painful swelling of one / both parotids 15 – 18 days after initial exposure. Prodromal phase of 1 – 2 days of fever, headache etc. precedes the swelling. Complications include pancreatitis, orchitis and meningitis (due to viremia). Mumps resolves spontaneously in 5 –10 days. Symptomatic treatment for fever and pain are necessary. 

Submandibular sialadenitis

            This is less common than parotid infection, and is mostly due to stones and strictures. The clinical importance is that it may be confused with submandibular space infections of odontogenic origin.

Sialolithiasis

            Sialoliths are calcified and organic matter that develop in the parenchyma or ducts of the major or minor salivary glands.  Biochemically, they appear laminated with layers of organic material covered with concentric shells of calcified matter.  The crystalline structure is chiefly hydroxyapatite and contains octacalcium phosphate.

            The aetiology of a sialolith is varied.  Inflammation, local irritants, antisialogogues etc. are thought to play a significant role.

            Stones are a common etiologic factor for sialadenitis.  Mucous plugs, strictures etc. produce a similar clinical picture.

            About 80 – 90 % occur in the submandibular gland or duct for the following reasons.

  • Wharton’s duct contains sharp curves likely to trap mucin plugs or cellular debris
  • Calcium levels are high in submandibular saliva
  • Dependent position of the gland

5 – 15 % of sialoliths occur in parotid gland and 2 – 5 % in sublingual and minor salivary glands.

Clinically, the most common symptom of sialolithiasis is painful intermittent swelling in the area of a major salivary gland, which worsens during eating and resolves after meals.  The pain migrates from the backup of saliva behind the stone or plug.

Sialoliths of Stenson’s or Wharton’s duct will be palpable if present in the peripheral portion of the duct.  The common site of calculus is buccal mucosa and it presents as an asymptomatic well circumscribed, freely movable draining swelling.

Diagnosis:       

  1. Ordinary radiography
  2. Sialography
  3. CT scan

Treatment:

            Acute infections secondary to stasis should be treated with antibiotics.  Stones in the distal portion of duct can often be removed manually.  Deeper stones require surgery.  Lithotripsy has been described as a non-invasive method of disintegrating sialoliths.

Miscellaneous infections of salivary glands

Tuberculosis

            Salivary glands may be primarily involved in tuberculosis, or the disease may infect periglandular lymph nodes.  The parotid is most commonly affected.  The clinical picture is of a firm, non-tender swelling, resembling a tumour.  Draining fistulae may be present.  Diagnostic investigation of chronic salivary gland enlargement should include chest radiograph, skin test and acid fast staining of drainage and culture.

Sarcoidosis (Heerfodt’s disease)

            This is a chronic, systemic, granulomatous inflammation involving salivary glands in 60 % of cases.  Uveoparotid fever occurs in 10 % of cases which present a triad of findings – facial palsy, parotid enlargement and uveitis.

            Treatment is symptomatic care and long term corticosteroid therapy.

Actinomycosis

            Actinomycosis israelii is a commonplace member of oral flora and may invade the salivary glands.  Sialadenitis occurs in as high as 10 percent of cases of orofacial actinomycosis.  Long term high dose penicillin therapy is the treatment of choice.

Diagnosis of salivary gland infections

            A detailed history and physical examination are useful in the diagnosis of salivary gland infections. The patient who reports acute swelling of a salivary gland at meal time may be diagnosed as having an acute ductal obstruction.  Children should be questioned carefully for exposure to epidemic mumps in recent pasts.

            Careful inspection of oral cavity is mandatory to differentiate between a salivary gland swelling and a space infection of dental origin.  Physical examination must include gentle palpation of all major salivary glands and bimanual intraoral and extraoral palpation of ducts.

            Diagnostic roentgenology may be useful.  Indications for plain films or sialography are

a)     detection of strictures, calculi, foreign bodies

b)     detection of large parenchymal abscesses

c)     estimation of severity of parenchymal damage or residual function

Tumours of salivary glands

            Tumours of salivary glands constitute a heterogenous group of lesions of great morphologic variations, and this presents difficulties in having a general classification.

Benign tumours

Pleomorphic adenoma (mixed tumour)

            This is the most common of all salivary gland tumours, constituting over 50 % of all the cases of tumours and about 90 % of all benign salivary gland tumours.  It is characterised by a morphologic and histologic complexity marked by the presence of a variety of cell types.

            Numerous theories have been advanced to explain the histogenesis of this tumour, and the current arguments centre around the myoepithelial cell and a reserve cell in the intercalated duct. It is said that the myoepithelial cell is responsible for the morphologic diversity of the tumour, while the intercalated duct reserve cells can differentiate into ductal cells and myoepithelial cells, which can undergo mesenchymal metaplasia to give rise to more different types of cells.

Clinical features:

            The parotid is the most common site of pleomorphic adenoma (90 %). It may occur, however, in any gland and is more common in women and in patients in 4th to 6th decades. The history  is that of a small, painless, quiescent nodule which slowly increases in size. It is usually an irregular nodular lesion which is firm in consistency. Pain is not a common symptom. Among the minor glands, the palatal glands are frequently affected. It may cause difficulties in breathing, talking and mastication.

Histology:

            The tumour is always encapsulated. The diverse histologic pattern is characteristic. Some areas present cuboidal cells arranged in duct-like pattern with an eosinophilic coagulum. In other areas, the tumour cells may assume a stellate, polyhedral or spindle shape. Some may even show chondroid or osseous character.

Treatment:

            The accepted treatment is surgical excision. The tumour and the involved lobe are removed. Intra-oral lesions may be treated more conservatively by extracapsular excision. Malignant transformation may occur in a long-standing untreated tumour or in a recurrent one.

Monomorphic adenoma

            WHO classification of monomorphic adenomas subdivides them into

1)      adenolymphoma (Warthin’s tumour)

2)     oxyphilic adenoma

3)     others, which includes tubular, alveolar (trabecular), basal cell and clear cell adenomas.

Adenolymphoma (Warthin’s tumour)

            This unusual type of tumour is found almost exclusively in the parotid gland. This exhibits a definite predilection for men and for age groups of 4th, 5th and 6th decades.

            The tumour is generally superficial, lying just beneath the parotid capsule or protruding through it. It usually does not grow more than 3 –4 cm in diameter . it is painless, firm to palpation and is clinically indistinguishable from other benign lesions.

            Histologically, the tumour consists of two components – epithelial and lymphoid tissue. It is essential an adenoma exhibiting cyst formation, with papillary projections into the cystic spaces and a lymphoid matrix showing germinal centres.

            The currently accepted theory of histogenesis is that the tumour arises in salivary gland tissue entrapped in paraparotid or intraparotid lymph nodes during embyogenesis.

            The treatment is surgical excision of the tumour.

Oxyphilic adenoma (oncocytoma / acidophilic adenoma)

            This is a rare tumour usually occurring in the parotid gland . it is more common in women and in elderly persons. It does not grow to great size and is clinically not different from other benign tumours

            Microscopically, the tumour is characterised by large cells with an eosinophilic cytoplasm and a distinct cell membrane, and which tends to be arranged in narrow rows or cords. These tumour cells resemble the apparently normal cells called ‘oncocytes’, which are usually seen in a great number of locations in the body.

            The treatment of choice is surgical excision. The tumour does not tend to recur and malignant transformation is uncommon.

Basal cell adenoma

            This tumour occurs usually in major salivary glands and a majority of patients are over 60 years of age. It presents as a painless slow-growing lesions. Histologically, it has a well-defined connective tissue capsule, and the cells are isomorphic and basaloid in appearance with basaloid round to oval nuclei. The cells bear similarity to the secretory cells of intercalated duct. The basal cell adenoma is treated by excision.

Canalicular adenoma

            This occurs in intra-oral accessory salivary glands, mainly in the upper lip. Patients are usually over 60 years of age. It presents as a slow-growing, painless, non-fixed nodule of the lip. Histologic presentation is of cords of epithelial cells, arranged in a double row. The canalicular adenoma is treated by simple excision.

Myoepithelioma

            It occurs in adults and the parotid gland is the commonest site of occurrence. The commonest intra-oral site is the palate. The tumour is composed of spindle-shaped or plasmacytoid cells or a combination of the two, set in a myxomatous background. Definitive diagnosis lies in ultrastructural identification of myoepithelial calls. The lesion is treated by excision.

Ductal papillomas

            Papillomas arising from excretory ducts of salivary glands present in three forms.

1)      Simple ductal papilloma – an exophytic lesion with a papillary surface and a pedunculated        base.

2)     Inverted ductal papilloma – presents as a nodule of the oral mucosa.

3)     Sialadenoma papilliferum – exophytic growth of hard palate.

All types are treated by excision.

Benign lymphoepithelial lesion

            This common lesion exhibits both inflammatory and neoplastic character. The lesion is manifested essentially as a unilateral or bilateral engagement of the parotid and / or submandibular glands with mild discomfort, occasional pain and xerostomia.

            It is considered to be an auto-immune disease in which the salivary gland tissue becomes antigenic. There is often a diffuse, poorly outlined enlargement of the gland rather than the formation of a discrete nodule. Histologically, there is an orderly lymphocytic infiltration of gland tissue, destroying or replacing the acini.

            The condition has been treated by both surgical excision and radiation. But the latter is not used now in view of the possibility of radiation induced malignancy.

Relation to Mikulicz’s disease

            The disease originally  described by Mikulicz in 1988 was characterised by a symmetric or bilateral chronic, painless enlargement of the lacrimal and salivary glands. Mikulicz’s patient manifested a benign course without  lymphatic involvement. Some later workers noticed that certain cases diagnosed as  Mikulicz’s disease often ran a rapidly fatal course. These were later proved to be malignant lymphomas.

            It is now believed that Mikulicz’s disease and the benign lymphoepithelial lesion are identical in nature.

Malignant tumours

Malignant pleomorphic adenoma

This term includes those histologically benign tumours which are shown to have metastases resembling the primary lesion, as well as those which clinically resemble benign pleomorphic adenoma but exhibits cytologically malignant changes. There is considerable debate as to whether they arise from an earlier benign lesion or they represent a malignant lesion from the onset.

There is no obvious clinical difference between benign and malignant pleomorphic adenomas, except an occasional fixity to deeper structures and increased incidences of surface ulceration, pain and regional lymph node enlargement in malignant cases. Frequent metastases to lungs, bones, viscera and brain are seen.

Histologically, the malignant component may overgrow the benign one or may stay localised in discrete locations. Nuclear changes, invasion of connective tissue, focal necrosis etc. are the features used to determine malignancy.

The treatment is essentially surgical, and recurrent lesions are managed by combined surgery and radiotherapy.

Adenoid cystic carcinoma

            This is a form of adenoid carcinoma, which frequently affect intra-oral accessory salivary glands, parotid and submaxillary glands. Clinical manifestations include local pain, facial paralysis (in case of parotid involvement), fixity to deeper structures, local invasion and surface ulceration. Histologically, the tumour is composed of small, deeply staining uniform cells resembling basal cells, arranged in duct-like pattern, the central portion of which contain a mucoid material. spread of tumour cells along the perineural spaces or sheaths is a common feature.

            The treatment is chiefly surgical, but it is often coupled with radiation. This tumour usually metastasises only late in its course and hence long-term follow-up is mandatory.

Acinic cell carcinoma

            This lesion is peculiar in that the cells show acinar cell differentiation instead of the duct-like pattern seen in other tumours. It closely resembles pleomorphic adenoma in gross appearance. It is reported occurring chiefly in the parotid. Acinic cell carcinoma is composed of cells of varying degrees of differentiation. Well-differentiated cells resemble normal acinar cells. Lymphoid elements are also commonly seen.

            The treatment is essentially surgical. The recurrence rate is 8 – 59%, which occurs many years after surgery. Long-term follow-up is necessary.

Mucoepidermoid carcinoma

            This is an unusual type of salivary gland tumour, described as a separate entity in 1945 by Stewart, Foote and Becker. Majority of cases occurred in parotid. Other gland also may be affected. This tumour has a low-grade malignant variety and a high-grade malignant type. The former appears as a slowly enlarging painless mass. Because of the tendency to develop cystic areas, intra-oral lesions resemble mucocoele. The tumour of high-grade malignancy grows rapidly and produce pain and facial nerve paralysis.

            The mucoepidermoid carcinoma is not encapsulated; it infiltrates into the surrounding tissue and show metastases. Histologically, this is a pleomorphic tumour composed of mucous-secreting cells, epidermoid-type cells and intermediate cells.

The treatment is surgical. Recent data has shown favourable response to radiation therapy. Low-grade malignant type can be managed by surgery alone.

Clear cell carcinoma

            This is a relatively recently recognised lesion, characterised by the presence of peculiar ‘clear cells’ which are thought to arise from intercalated duct cells or myoepithelial cells. This lesion is also found mainly in major glands, especially parotid. Clear cell carcinoma tends to occur in elderly adults and in females. Clinical presentation is not different from other tumours. Histology shows clusters of clear cells surrounded by a thin septum of fibrous connective tissue. The lesion is treated by surgery. It usually shows a relatively favourable prognosis.

Epidermoid (squamous cell) carcinoma

            This tumour involves a grave prognosis, since it exhibits infiltrative properties, metastasises readily and recurs readily. It may arise in any salivary gland. It seems to be of ductal origin, since the ducts undergo squamous metaplasia with ease. A combination therapy of surgery and radiotherapy is indicated.

Salivary gland involvement in rheumatic disease

            A salivary gland swelling, especially of the parotid, can be a manifestation of auto-immune disease. The distinct subsets of auto-immune salivary gland disease are

1)      allergic sialadenitis,

2)     Sjögren’s syndrome / myoepithelial sialadenitis and

3)     Epithelial cell sialadenitis / granulomatous sialadenitis.

Allergic sialadenitis

            This is an acute, but rare, condition. Deposition of antigen-antibody complexes within the parenchyma results in glandular swelling. Removal of allergen is curative. The allergens include certain foods and drugs such as phenyl butazone and nitrofurantoin.

Myoepithelial sialadenitis (Sjögren’s syndrome)

            This is a condition originally described as  a triad consisting of keratoconjunctivitis sicca, xerostomia and rheumatoid arthritis. Some patients present only with dry eyes and dry mouth (primary Sjögren’s syndrome /sicca complex) while others develop other collagen vascular diseases like SLE, polyarteritis nodosa, scleroderma and rheumatoid arthritis (secondary Sjögren’s syndrome).

            The disease occurs predominantly in women over 40 years of age. The clinical diagnosis requires a combination of two of the classical triad. Dryness of eyes and mouth cause grittiness and pain in eyes, and pain and burning sensation of oral mucosa. Oral candidiasis, rampant caries and fissured tongue are common. Patients often have bilateral parotid involvement. Other glands also may be affected.

Mikulicz’s disease is thought to be synonymous with the salivary component of Sjögren’s syndrome. The lesion may have extra-glandular manifestations like lymphomas.

            Histologically, intense lymphocytic infiltration of salivary glands and proliferation of ductal epithelium are seen. Antiductal antibodies may be present in the serum of the patients. Other factors like the rheumatoid factor and antinuclear antibodies are also common. ESR may rise to 80%.

Sialography may be of diagnostic value in Sjögren’s syndrome. It shows a typical ‘cherry-blossom’ (branchless fruit-laden tree) appearance.

There is no satisfactory treatment to Sjögren’s syndrome. The patients are treated symptomatically with artificial tears and salivary substitutes.

Miscellaneous diseases

Cystic fibrosis

            This condition is transmitted as an autosomal recessive trait and is the most common lethal genetic syndrome among white children. The children suffer from chronic pulmonary disease, pancreatic insufficiency and elevated concentration of electrolytes in sweat.

            Though mucous-secreting glands are more pathologically involved, parotid saliva is also slightly affected. The elevation of calcium and protein levels in the glands results in the turbidity of secreted fluid owing to the formation of calcium-protein complexes.

Necrotising sialometaplasia

            Necrotising sialometaplasia is a benign inflammatory reaction of salivary gland tissue, which both histologically and clinically mimics malignancy. The most likely cause is local ischaemia, the cause of which is not known though alcohol and tobacco abuse have been implicated by some workers.

            The condition occurs more commonly in men. Most patients are in 4th and 5th decades. Most cases occur in palate, but other intra-oral sites have also been noticed. The lesion generally presents as an ulcer. Pain is not common. Swelling may present in some cases.

            Necrotising sialometaplasia is histologically characterised by ulcerated mucosa, pseudoepitheliomatous hyperplasia of the mucosal epithelium, acinar necrosis and squamous metaplasia of salivary glands.

            The lesion is essentially self-limiting and heals by secondary intention.

Mucous retention phenomenon (mucocoele)

            This is generally conceded to be of traumatic origin, and is a common lesion. It may be caused by traumatic severance of a salivary duct, or a chronic partial obstruction of a salivary duct. Thus mucocoeles may be classified into extravasation type and retention type. The former is more common.

            The condition occurs more commonly in lower lip. The lesion may lie fairly deep in the tissue or be exceptionally superficial. The superficial lesion is a raised, circumscribed vesicle with a bluish, transparent cast and is less than 10 mm in diameter. The deeper lesion is also a swelling, but the colour and surface appearance are of normal mucosa. The contents usually consists of thick, mucinous material.

            Histology shows elevation of mucosa, thinning of epithelium, wall made of a lining of compressed fibrous connective tissue and a lumen filled with an eosinophilic coagulum, containing variable cells.

            The treatment is excision of the lesion along with the removal o f the associated salivary gland acini.

Ranula

            This is a form of mucocoele which specifically occurs in the floor of the mouth in association with Wharton’s duct or sublingual ducts. The aetiology and pathology are essentially the same as for mucocoele of other glands.

            The lesion develops as a slowly enlarging painless mass on one side of the floor of the mouth. Since the lesion is deep-seated, overlying mucosa is normal in appearance. If it is superficial, the mucosa will have a translucent bluish colour. Treatment is to unroof the lesion to drain the contents.

Imaging in salivary gland diseases

            Multiple imaging techniques may be used in the diagnostic evaluation of salivary gland. These range from plain radiographic examination to the most complex magnetic resonance imaging (MRI).

Plain radiography

            Plain radiography still serves an important function in the examination of the salivary glands. It is indicated to identify any radio-opaque sialoliths, phleboliths or dystrophic calcification present in the gland or duct.

            For evaluation of parotid gland, PA view, true lateral and lateral oblique views with the chin extended and mouth open, should be performed. For evaluation of submandibular gland, the lateral view radiograph should be taken with index finger pressing the tongue down. In addition, an intra-oral occlusal view may be helpful.

            About 80% of salivary calculi can be visualised with plain radiography. They appear as focal calcific densites, most commonly associated with submandibular gland.

Nuclear medicine (radionuclide imaging)

            The findings of nuclear medicine techniques are less specific than sialography, CT or MRI. But this may be useful as an adjunct to these techniques.

            Intravenous injection of 10 mCi of Tc-99m pertechnate is performed with gamma camera images obtained every 2 minutes. Abnormalities may be defined as increased, decreased or absent uptake of radionuclide. Increased uptake is seen in sialadenitis and granulomatous diseases and in oncocytoma and Warthin’s tumour. Decreased uptake is seen in ageing, viral infections and most tumours.

Ultrasonography

            This provides a non-invasive means for examination of the salivary glands, with the exception of the deep lobe of parotid. The differentiation between cystic and solid compartments can easily be made. Fluid-filled structures with no tissue interfaces, such as an abscess or cyst, appear echo-free on ultrasound studies. Solid structures, such as heterogeneous tumour, appear filled with multiple echoes and various shades of grey.

            High frequency transducers in the order of 7.5 MHz are used. Sequential images in transverse and longitudinal planes are performed. Ultrasonography may be used in the evaluation of all types of pathology within the salivary glands. In  the case of inflammatory lesions, the chronicity of the process determines the sonographic pattern.

Sialography

            Sialography is the direct radiographic demonstration of the salivary gland and duct system by injection of radio-opaque contrast material into the ductal orifice. The three main indications for the performance of sialography are

(i)                sudden acute swelling of a gland possibly secondary to ductal obstruction by a stone or stricture,

(ii)              progressive glandular enlargement or symptoms suggesting recurrent inflammation,

(iii)            palpable salivary gland masses.

Technique:

            Prior to canulation of the duct, conventional radiographic examination is indicated to determine the radiographic view. No premedication or local anaesthesia is required for sialography. After placement of cannula in the duct, an oily contrast material such as ethiodol is introduced by either hydrostatic pressure or gentle intermittent manual injection. Contrast injection is performed under fluoroscopic guidance. The gland should be visualised during ductal filling, acinar filling, evacuation and post-evacuation stages.

Findings:

            In chronic inflammatory sialadenitis, focal dilatation of peripheral ducts and globular or sacular collections of contrast are noted in an irregular pattern throughout the gland. Delayed contrast evacuation is noted.

            In auto-immune diseases, punctate or globular collections of contrast material is homogeneously seen throughout the gland, and these do not disappear during evacuation. Sjögren’s syndrome is characterised by a ‘cherry-blossom’ (branchless fruit-laden tree) appearance.

            In evaluation of calculi, plain radiography is superior to sialography since most calculi are radio-opaque, and the contrast may obscure it. Granulomatous diseases and lymphoma has a similar sialographic appearance. The findings have a progressive nature depending on the course of the disease. Sialography may also be used to evaluate lacerations or haematoma formations.

            Sialography is contra-indicated in cases of

(i)                acute infection and

(ii)              history of allergy to the contrast medium.

Computed tomography (CT)

            The primary indications of CT evaluation include masses or generalised enlargements of one or more glands, acute inflammatory processes or abscesses. This technique is helpful in diagnosis, treatment planning and in evaluating response to the treatment.

            Routine CT may be performed with or without intravenous contrast administration. The CT has a 10-fold advantage over conventional radiographs in the detection of calcifications within the glands. Acute and chronic inflammation, benign and malignant tumours and cysts can be visualised. In the case of malignant tumours, infiltration to surrounding tissues may be seen. Also, facial nerve and other associated structures may be visualised, and this aid in treatment planning.

Magnetic resonance imaging (MRI)

            The indications for CT and MRI overlap. MRI is the examination of choice for the evaluation of neoplastic lesions. The advantages of MRI include increased soft tissue contrast at the margins of the tumour. The major disadvantages include the high cost, limited availability of facilities and increased technical complexity.

            MRI examination of salivary glands uses a superconducting magnet with a field-strength of 1.5 T. Routine examination includes slice thickenings of 5 mm or less. The MR appearance of pleomorphic adenoma and Warthin’s tumour is inhomogeneous with low signal intensity compared to the normal gland. In Warthin’s tumour, cystic components are encountered. Fibrosis or calcifications appear as areas of low signal or signal void. Malignant tumours show a lower intensity signal than that of benign tumours. Haemorrhagic spots appear as high intensity images.

            The use of MRI in salivary gland disease is limited because many diseases show similar patterns. The contra-indications to MRI include pacemakers, ferromagnetic valvular clips and implanted neurostimulation devices.

Surgical Management of Salivary Gland Diseases

With the possible exception of surgical management of retention cysts like mucoceles and ranulas, transoral sialolithotomy is the most frequent operation performed on salivary system. This is a simple operation often but overlooked by the medical practitioner untrained in oral surgery in favour of enucleation of the gland. If the stone is favourably located, its removal through the mouth preserves the gland and hence its function.

The submandibular gland can be enucleated without harmful sequelae if the operation is properly accomplished. In most patients with normal salivary secretion in the remaining glands its removal is of no consequence.

            However parotid gland is of greater concern. Danger to the facial nerve is always present although careful surgery permits removal of this gland with only transient weakness in most instances.

            Removal of either gland will result in a significant facial deformity. However these factors are most significant if operation is necessary but contraindicate such procedures when conservative methods would suffice.

            Tumours involving the parotid, submandibular, sublingual or minor salivary glands located in the cheek, lips palate may also warrant their removal in certain instances. Such procedures have been discussed in detail below. 

Submandibular sialoliths

Submandibular gland lithiasis is the most common disorder of submandibular gland and most frequent location being extra glandular. Despite the fact that these calculi are large they are rarely painful since lumen of Wharton’s duct is larger and more expandable than the Stenson’s duct. Usual symptoms are pain and sudden gland enlargement during eating. Usually there is return of function in most patients after removal of sialolithiasis.

Those located in the anterior part of the duct

Usually stones located anterior to the second mandibular molar are best removed under local anaesthesia. Those lying anterior to a line joining mesial surfaces of second molars are designated as anterior calculi.

            Preoperative assessment of anterior calculi depends on history, clinical examination and plain radiographs. Usually a preoperative sialogram is not indicated because of the possibility of the stone being propelled into a more posterior part of the duct by the force of the injection.

Procedure

            A suture is passed around the duct posterior to the stone to prevent its posterior dislodgement during manipulation after passing one suture into the floor of the mouth to test the tissues up for easy passage of the circumductal suture. Duct can be easily located by bisecting the angle formed by the sublingual plica and the line attachment of the tongue.

            The circumductal suture is then secured to a haemostat and placed over the adjacent teeth resulting in kinking of the duct. A second suture is then placed between the submandibular duct papilla and frenum. Gentle traction applied to these sutures will make tissues at surgical site taut thereby allowing mucosa to be cut easily.

            Incision is made along the line of the duct over the stone. Scalpel should not be plunged deeply but should only divide the mucous membrane and enter just into the underlying tissues. The duct is then uncovered by both blunt and sharp dissection with a fine pointed scissors through the loose connective tissue always being aware of sublingual veins lingually. It is then mobilised. Frequently at this stage the calculus is visible through the duct wall and by a longitudinal incision, it is released. If it is adherent to the duct wall, then it is slowly released with a small curette without further damaging the duct.

            A few interrupted sutures at the floor of the mouth then close wound. Ductal incision is not sutured to prevent formation of a stricture.

Those located in the posterior part of the duct-

These are best removed under general anaesthesia, as few patients will tolerate retraction required under local anaesthesia.

An obstruction sufficient to cause symptoms can occur in any one of the two ways: – stone may increase to such a size that only a minimal amount of saliva can be secreted or an infection may set in.

If the stone is not visible on a central occlusal film, then it is not feasible to remove it by the method used for anteriorly placed stones and it must be treated as a posteriorly placed stone or an intraglandular stone. Majority of the posterior stones can be viewed in a posterior oblique occlusal film. This is supplemented with an oblique lateral jaw film so that its position relative to the mandible can also be assessed. However the best means of locating its position and status of the gland is by sialography. If it depicts a ” sausage string appearance” in the sialogram a good chance of recovery exists. When the intraglandular ducts are irregular, grossly dilated and cavitated then removal of the gland is the best choice.

Procedure

Best done under general anaesthesia. Tongue is retracted sideways. A lacrimal probe is inserted via the ductal orifice and elevated to assist in locating the duct and then mucosa is excised in the premolar region. Duct is identified and drawn forwards using a suture passed around it. Duct is then followed posteriorly and lingual nerve identified where it crosses beneath the duct. Once lingual nerve is identified then initial incision is enlarged, lingual nerve is mobilised laterally and retraction sutures passed to expose the surgical site.

            An assistant then pushes the lower pole of the gland upwards so that the upper pole is brought into view. A suture is then passed over posterior margin of mylohyoid to retract it forward. If the stone is visible, it is delivered via a longitudinal incision. If not duct is opened at most likely location and explored until recovered. Wound is then irrigated; retraction sutures removed and incised duct left open, mucosal tissues are then closed with interrupted sutures.

Those located in intraglandular position of the submandibular duct-

Here the entire gland is removed. If the stone is a chance finding and is small, asymptomatic and sialographically normal, it can be left in place and observed for any changes in its location or function of the gland. Any change for the worse indicates the need for gland excision.

Procedure

A two-inch long convex incision is made parallel to skin crease, approximately 1.5-2cm below the inferior border of mandible.

            Incision deepened down through superficial cervical fascia, reflected inferiorly, anterior facial vein identified and divided between ligatures. An upper flap of connective tissue is then raised close to the gland surface thus protecting any branches of facial nerve raised along with the flap.

            The facial artery is found by dissecting and then retracting the lower pole of the gland upwards and forwards. The posterior belly of digastric is identified and it along with the stylohyoid is retracted down and back. The facial artery is seen passing behind the muscle towards the gland. It is clamped and divided, then ligated.

            Then the anterior aspect of the lower pole of the gland is reflected upwards and backwards. Through finger dissection and keeping close to the gland, a covering of loose connective tissue is maintained over the hypoglossal nerve that lies medial to the gland.

            The gland is then pulled downwards, exposing the V-shaped fold of connective tissue containing the lingual nerve and submandibular duct. These two structures are then dissected out with care. At this stage one should be able to clearly delineate three basic structures medial to the gland namely lingual nerve superiorly, duct centrally and hypoglossal nerve inferiorly.

Now only the duct and deep part of the gland still remain attached. The posterior border of the mylohyoid is retracted and a branch of the sublingual artery ligated. Then the submandibular duct is clamped, divided and double ligated so that only a short stump remains.

Tissues are then closed in layer, a drain inserted if necessary and a pressure dressing applied.

Parotid sialoliths

  • Stensen’s duct is the location of 6-10% of salivary calculi. Of these 40% are opaque. They are seen at 4 basic locations: –
  • Impacted in the papilla
  • In the sub mucous part of the duct
  • Intraglandularly
  • In the extra glandular part of duct external to the buccinator.

 

Those in the papilla and submucous part of the duct

Calculi in this location can be released by slitting the papilla. One blade of a pair of fine sharp pointed scissors is inserted a portion of the way into the duct and a small cut is made backward from the orifice. Usually the calculus pops out as soon as the blade of scissors is removed, if not then gentle pressure on the gland will force out the calculus along with a quantity of saliva. The wound heals rapidly.

Those located extraglandularly external to the buccinator –

Calculi located in this region can be approached via an incision in theintra-oral aspect of the cheek. Injection of a local anaesthetic with a vasoconstrictor will reduce bleeding and also raise the mucous membrane off the surface of buccinator to aid in soft tissue dissection. A traction suture is placed anterior to the papilla, a U-incision is made through the mucosa, and the triangle containing the papilla and the duct is then raised off the buccinator. Upper and lower flaps are mobilised and stay sutures placed to hold them out of the way. Dissection is proceeded until the point where the duct pierces the buccinator is reached. The superior and inferior margins of buccinator dehiscence are identified and traction sutures placed at each margins and retracted to enlarge the dehiscence. Then duct is traced laterally and retracted medially into the mouth with a suture. With this approach calculi in a large portion of Stenson’s duct can be removed easily even well outside the masseter musculature. Once calculi are located, adhesions to tissues around are divided; longitudinal incision made over the duct and stone removed. The duct is not sutured but tissues around are closed with absorbable sutures.

Those located in the intraglandular portion of the duct-

Stones located intraglandularly cannot be reached by an intraoral approach. A parotidectomy type incision is recommended. Skin and subcutaneous tissues are raised from deep fascia covering the gland until its anterior border is uncovered. Then deep fascia is incised horizontally over the supposed portion of the duct. Duct at this point lies on a line joining the angle of mouth and ala of nose. The buccal branch of facial nerve usually lies on its surface and transverse facial vessels usually lie about 1cm higher than the duct.

Once duct is identified, it is then traced back into the gland. Branches of facial nerve tend to cross immediately superficial to the duct and must be preserved. When the section containing the calculi is reached it is incise longitudinally in the usual way and delivered after passing necessary sutures in front and behind the stone around the duct to prevent slippage. Capsule of the gland is closed with continuous fine plain catgut and skin incision is closed in layers with a vacuum drainage.

Tumours of salivary glands

Salivary gland neoplasms are uncommon and account for less than 3% of all tumours of head and neck region. Of these tumours about 75-85% occur on parotid, 10-20% in minor salivary glands, most commonly in palate (58%), tongue (10%) and upper lip (9%).

Sublingual gland has the highest ratio of malignant to benign neoplasms. In fact 80% of parotid, 65% of submandibular, 50% of minor salivary and 20% of sublingual gland tumours are benign.

The only curative treatment of salivary gland tumours is surgical extirpation. Resection of parotid gland tumours is complicated by the presence of facial nerve within the gland. With the exception of Warthin’s tumours, enucleation of parotid tumours is not advised. Mixed tumours are often poorly encapsulated and malignant tumours often invade surrounding glandular tissue, hence adequate margins of normal salivary tissue must be resected to reduce the chances of local recurrence.

Total resection of submandibular gland is the preferred treatment for all submandibular neoplasms. Minor salivary gland neoplasms of palate or mucosa frequently involve periosteum or bone and hence portions of these must be included along with the surgical excision.

Parotidectomy with the preservation of facial nerve

This operation is also called superficial or conservative parotidectomy. Superficial parotidectomy is used to describe the removal of the gland superficial to facial nerve. But both superficial and deep parts can be removed as necessary with preservation of facial nerve.

After adequate preparation of surgical site, a solution of 1 in 200,000 parts adrenaline in saline is injected under the skin over the parotid anterior to external ear and close against external auditory meatus. Not more than 10ml is injected.

Incision starts within the hairline above and anterior to the auricle and is taken down and back to free margins of tragus, follows it and under its cover is carried in a gentle curve over the mastoid to join a convenient skin crease passing down and forwards into the neck behind the mandible.

Incision in the neck crease is deepened first, dividing the platysma until the deep fascia is reached. The great auricular nerve is then identified as it crosses the posterior border of sternomastoid to lie in the wound about 1cm below and 1cm in front of the lobe of the ear, immediately below the deep fascia, branching over the gland surface. The nerve with the branches is tucked under the lower edge of the wound to keep it moist.

Once deep fascia is identified the rest of the wound is deepened to this level and skin reflected forwards from it. Often one or more facial branches will be identifiable through translucent deep fascia as they emerge from anterior border of the gland. They are uncovered by opening the fascia, each branch is identified, labelled by under running it with black silk and ends of it are clamped in mosquito artery forceps.

The main trunk of the facial nerve lie further deeper down in the angle between bony external auditory canal and anterior surface of mastoid process. It is found by separating lower pole of gland from anterior border of sternomastoid and from mastoid process and cartilaginous part of external auditory meatus. Parotid is retracted forwards as dissection proceeds and the nerve is identified as it emerges in the angle between tympanic bone and anterior border of the mastoid process and just superior to the upper border of the posterior belly of the digastric. The stylomastoid branch of posterior auricular artery passes superficial to the nerve to enter the stylomastoid foramen and rough instrumentation can tear this small vessel causing haemorrhage.

Since the facial nerve and its branches are invested by loose connective tissue and lie in tunnels within the parotid, they are freed by introducing the tip of the blades of a curved mosquito artery forceps and opening it after which a short length of the gland substance mat be cut through with scissors to expose the gland.

The nerve trunk travels laterally within the parotid, passing around posterior border of mandible and just below the neck of the condyle before it splits into an upper temporofacial and cervicofascial division. Generally it is better to follow the lower division first and trace the cervical or at least marginal mandibular branch anteriorly to a point in front of the parotid, hence the lower pole is mobilised after which progressing upwards branch by branch, further mobilisation is achieved. Those branches that pass into the tumour must be divided and the point at which they emerge identified and divided and both ends are tagged for subsequent repair.

Interconnecting branches joining two peripheral branches vertically should be conserved if possible. In general nerve passes superficial to retromandibular vein; careful mobilisation of both nerve and vein with division and ligation of the latter is needed. Tiny veins are sealed by diathermy.

For pleomorphic adenomas a margin of about half a cm of apparently normal tissue should be removed around palpable mass as the tumour is lobulated and some of these lobules may be left behind if dissection passes too closely. Low-grade mucoepidermoid tumours or acinic cell tumours should be removed with a somewhat greater and more uniform margin.

Once tumour is removed, the wound is flushed liberally with saline and haemostasis checked. Branches of facial nerve may be repaired with grafts if necessary from great auricular nerve. A vacuum drain is then passed out through the skin below the ear; wound is closed in layers and light pressure dressing applied.

Total parotidectomy

            This is indicated when: –

  • A slow growing mass not clinically malignant is present in deeper parts
  • When a small neoplasm is recognised clinically as malignant and to secure necessary margin, removal of whole gland is planned. 
  • Large tumour in deep part of parotid gland presenting as a swelling of the soft palate (often dumb-bell in shape with isthmus lying in the gap between styloid process and back of mandible).

Procedure

A skin flap is raised in usual way, but incision in the neck skin crease is continued as far forward as the first molar region. Facial nerve is dissected out; periosteum is then divided at lower border of angle of mandible and masseter elevated from bone. A vertical cut similar to that used for vertical sub sigmoid osteotomy is made just behind the mandibular foramen, medial pterygoid is then freed from posterior fragment, which is then displaced forwards, lateral to anterior fragment. This opens up the interval between the styloid process and mandible.

Lower pole is then mobilised and digastric and sytlohyoid followed back to their origins, divided and turned forwards. External carotid emerging above the muscles is identified and divided and ligated.

At this stage mouth is uncovered and entered. A solution of adrenaline 1:200,000 in saline is injected into soft palate over swelling and a vertical incision, circumscribing any previous biopsy scar is made. Edges are undermined leaving a thin layer of muscle and connective tissue over the tumour. Mass is freed working through both wounds. Great care is exercised above and particularly behind the lesion for fear of damaging the internal jugular vein or internal carotid artery, both of which lie deep to styloid process.

Following removal, wound is irrigated; oral tissues are closed with chromic catgut. The mandibular fragments are then wired together. Preauricular wound is closed in layers and drainage established.

Parotidomandibulectomy

This is indicated when there is invasion of mandible by a malignant neoplasm.

Procedure: –

After preparation of surgical site, a skin flap is raised as for excision of a benign neoplasm of the deep part of parotid. Gland is then mobilised posteriorly and inferiorly and main trunk of facial nerve identified. As many branches are dissected out as possible, sometimes sacrifice of the whole nerve may be necessary.

Next the TMJ capsule is opened, and condyle mobilised. Masseter is separated from the zygomatic arch and mandible is divided in the third molar region. Parotid and mandibular ramus are tilted up and forward and separated from the styloid process and its attachment muscles. Then further elevation of the ramus is possible after which the origin of the medial pterygoid muscle from the tuberosity is palpated and separated. Before this is done the external carotid is identified where it emerges from behind the stylohyoid and enters the deep part of the gland. It is first ligated and transected to prevent troublesome haemorrhage from maxillary artery as the medial pterygoid is sectioned.

Strong downward traction will now permit separation of the insertion of temporalis into the coronoid and lateral pterygoid to the condyle. As hemostasis is completed the maxillary artery is sought and ligated. Facial nerve is repaired using great auricular nerve as graft. A bone graft can then be placed unless a postoperative course of radiotherapy is to be employed. Where a bone graft does not replace ramus, patient will be left with a deep depression in front of the ear, but this can be covered by a suitable hairstyle. There will be a tendency for the mandible to swing towards the affected side and hence early training is needed to overcome this problem.

If condyle is invaded, then articular fossa and eminentia can also be removed. Styloid process and muscles can also be excised to increase the margins, but should be done after resection of the main mass.

Temporoparotidectomy

Small-scale resection of external auditory canal may be included with excision of pinna and overlying skin of parotid when these structures are involved. The mastoid process can also be detached without much difficulty, thus exploring facial trunk to make suturing and nerve grafting easy.

Extension of a parotid neoplasm back into bone is therefore amenable to excision of parotid gland, mandibular ramus and TMJ together with temporal bone. However the operation carries high risk for the need to section dense bone and separate it from internal carotid artery, internal jugular vein and sigmoid, superior and inferior petrosal sinuses. Adequate cover needs to be provided for the dura as the wound is closed. The hypoglossal nerve is mobilised and anatomised to the peripheral branches of facial nerve at the end of the operation.

Parotidectomy in continuing with neck dissection

A radial neck dissection should be performed where cervical lymph nodes are involved or where there is a mass at lower pole of parotid due to an aggressive tumour of much size that invasion of upper cervical nodes cannot be excluded. Consideration should be given to pre-operative radiation of the neck to a dose of 400-500 rads.

Extracapsular excision of submandibular salivary gland

There is a great incidence of recurrence for the submandibular gland than for the parotid after excision of slow growing neoplasm like pleomorphic adenomas.

The gland is removed together with its investing fascia, which is separated from the anterior and posterior bellies of digastric and stylohyoid muscle. The hypoglossal nerve is identified and preserved. The facial artery is identified where it emerges from under the cover of the stylohyoid and again on the lateral surface of the mandible. Marginal mandibular nerve is isolated and preserved and then fascia divided at the lower border of the mandible. Gland is freed off the mylohyoid muscle anteriorly and the angular tract of fascia posteriorly.

If the lingual nerve is involved in the tumour mass then it is sectioned in front of and behind the gland and cut ends sutured. If a greater margin of tissue than the immediate capsule is needed laterally then the periosteum of the mandible is divided at the lower border and stripped up from the submandibular fossa. The duct is divided close behind the papilla and the wound closed in layers with drainage in usual way.

Radical excision of neoplasms of submandibular/sublingual gland

Excision of frankly malignant invasive neoplasms of submandibular or sublingual salivary gland will include the tongue on that side, floor of the mouth and mandible together with a radical neck dissection of palpable nodes if present.

Excision of palatal pleomorphic adenomas

Small palatal pleomorphic adenomas cause only pressure resorption of palate and rarely invade bone. The incision is deepened to bone and specimen reflected off the hard palate with the periosteum. The neoplasm frequently sits over the greater palatine foramen and the periosteum is freed here until the lesion can be drawn down and neurovascular bundle is clamped, sectioned and coagulated with diathermy before it is sectioned. Interrupted silk sutures are then placed and tied together to retain a pack soaked in Whitehead’s varnish.

When full thickness of the soft palate has to be removed for adequate tumour clearance then the defect is repaired by an “island flap” described by Worthington (1974).

Excision of palatal mucoepidermoid carcinoma

            Low-grade mucoepidermoid carcinomas may be treated by excision of a full thickness disc of palate, including palatal and alveolar bone. Nasal and oral mucous membranes are then sewn together around the defect and stabilised with a gutta-percha obturator. Surgical repair of such defects should be undertaken only at least after 5 years due to the possibility of a recurrence.

Excision of palatal adenoid cystic carcinoma

            Danger with these neoplasms is that the surgical margin may be inadequate and spread can occur along perineural tissues of palatine nerves into skull base. Hence a combination of surgery and radiotherapy is the best.

            Surgical excision should include a hemimaxillectomy including orbital floor, which is the minimum. Where soft palate and pterygoid region is involved, “Crockelt’s extended maxillectomy approach” is essential to remove adequate excision under direct vision.

Neoplasms of cheek and lips

Slow growing lumps can be removed with a margin of normal adjacent tissue, using scissors to effect dissection. A biopsy is mandatory if there is any doubt in the mind of the operator. Clinically aggressive neoplasms can be biopsied since adequate treatment may involve radiotherapy and full thickness excision and repair.

Strictures

            Strictures can result from resolutions of the ulcerations of the duct lining that occurred secondary to the presence of sialoliths. Sometimes the ulcerations will result in the discharge of stone into the mouth forming a fistula. But if fistula closes a stricture will result. If transverse incisions are put on the duct, strictures can develop. Those close to the papilla can be treated by papillotomy. Those posterior in the duct can be treated by implanting the divided end of the duct into the floor of the mouth i.e., sialodochoplasty, but those close to the submandibular gland will require gland excision.

Dilation

            Strictures of parotid duct can be managed by dilation with probes. This is done slowly and the procedure may have to be repeated two or three times at 2 weeks intervals, but dilation may be effective for a long period of time.

Papillotomy

            A fine probe is passed into the duct to mark the lumen. With a probe or a thread serving as a guide a fine pointed scissors is passed into the duct and papilla is laid open. Cut is continued posteriorly until the dilated portion of duct proximal to the strictures is reached. Using a 5.0 chromic suture, cut edge of the duct lining is sewn to the mucosa of the mouth. Resultant opening remains somewhat wide for a month or so, then narrows to a acceptable degree.

Sialodochoplasty

            Here the duct is completely divided and implanted into the floor of the mouth. Two sutures are made one beneath the papilla and other behind surgical area putting tension on the mucous membrane. A incision is made over the duct and region of stricture is identified. A suture is placed around the duct and then a longitudinal incision is made in the duct behind the stricture. Posterior end of the slit is sewn to the posterior part of the wound edge with a 5.0 chromic suture. Further sutures are placed so that either side of slit may be sewn to either side of the incision in floor of the mouth. Then a suture is passed down through the under side of the duct just beneath the anterior end of slit, duct is then transacted to the anterior longitudinal portion of

Funny Bible Quotes

Can you find funny Bible quotes in the Bible? Even though it is not a book for jokes or humor, you can still find some funny phrases and stories inside the Bible. They are some of the most entertaining Christian funny quotes you can find.

So why it is so? Does God want to tell us it is good and encouraged to have fun and enjoy ourselves? Does you want to tell us he is not that serious and strict that some of us may think? You can think anyway you like, but the fact is we can find many funny quotes in the Bible.

Here are some of the funniest parts you can find…

1. Funny Bible Quote:

Proverbs 21:19 (New Living Translation)
“It is better to live alone in the desert than with a crabby, complaining wife.”

2. Funny Christian Quote:

Proverbs 31:6 (New International Version)
“As a dog returns to its vomit, so a fool repeats his folly.”

3. Funny Bible Quote:

One time, Jesus was asked to leave town to for kill all the pigs… Matthew 8:28-34 (New International Version)

“When he arrived at the other side in the region of the Gadarenes, two demon-possessed men coming from the tombs met him. They were so violent that no one could pass that way. “What do you want with us, Son of God?” they shouted. “Have you come here to torture us before the appointed time?”

Some distance from them a large herd of pigs was feeding. The demons begged Jesus, “If you drive us out, send us into the herd of pigs.” He said to them, “Go!” So they came out and went into the pigs, and the whole herd rushed down the steep bank into the lake and died in the water. “

4. Funny Bible Quote:

Proverbs 29:20 (New Living Translation)
“There is more hope for a fool than for someone who speaks without thinking.”

Did you enjoy the funny quotes above taken from the Bible? Then you can find even more amusing quotes and funny stories here.

Organic Baby Food – Do Not Buy ANY Brands Until You Read This!

The nasty components of some Organic Baby Foods that food manufacturer’s don’t want you to know!

Most Organic Baby Foods are fantastic, made by ethical, sustainable & considerate companies.

Others are large corporations simply aiming to get a piece of the “Organic pie” – although they may still scrape under the regulations and call themselves “Organic baby food” some of them are no good for your baby and not much better than the non organic varieties.

Read through the below tips to help you tell the good brands from the bad!

Is it certified organic?

Many brands put the word ‘organic’ somewhere on their label without any regulation or being truly organic. Only trust brands which have a say “certified organic” & have a logo somewhere on their label. In the USA the main certifier logo is the USDA but there are many others Packaging – What is it made of?

  • Is it plastic? If so, make sure it is BPA Free.
  • NEVER heat anything made from plastic (even if it says microwave safe!) as heat causes all sorts of dangerous toxins to leach out of all plastics and into the food. (Especially in the microwave)
  • If you need to heat this item, empty the contents into a glass, ceramic or stainless steel container.
  • Is it recyclable? Try always to buy food in packaging that can be recycled – and remember to recycle it! every little jar counts!
  • How much packaging is used? Don’t support companies that don’t care about our environment and who use multiple levels of packaging. For example, a jar, inside a cardboard box then wrapped in plastic. Instead choose to support a company who uses only 1 level of packaging.

Filler ingredients – what other ingredients are in this item?

Baby food really should be only 1 ingredient – the food you are feeding your baby! (And maybe a little breast milk to make a runnier consistency for newbies)

However, when you buy any premade, packaged foods (organic or not), some other ingredients are needed such as preservatives to maintain quality and thickeners/stabilizers to ensure a good consistency.

The percentage of the main ingredient will determine how good this food is and how ethical the company supplying it is.

Do not buy any baby foods that do not have the main ingredient at the first thing in the ingredient list, or that have lots of other ingredients as well as the main one.

For example, green bean puree ingredients should read: green beans, water. And maybe a little citric acid (lemon juice) or vitamin c.

The bottom line is the less ingredients – the better, more pure and closer to nature this food will be!

Preservation method – Fresh or frozen?

Frozen foods are ALWAYS best. They contain fewer (if any) preservatives as the freezing is the preservation method. They are also more nutritious as they have been frozen quickly after harvest or preparation, thus locking in the goodness.

Room temperature foods in pouches or jars are not very fresh or nutritious. They either have preservatives in them (organic baby foods will have natural preservatives). Or if there are “no preservatives”, the food has been heat treated to kill bacteria and seal the jar or pouch which raises a few issues;

  • The chemicals in the packaging can leach into the food during the heating process.
  • Heating foods also kills vitamins and minerals and nutrition levels! So your food may be “safe”, has no bacteria and has a long shelf life – but all the goodness of eating fresh, organic baby food is killed! And nutrition levels keep dropping the longer it has been sitting on the shelf.

The bottom line – buy frozen organic baby food or make your own from the freshest local produce you can find.

Additives like DHA etc

Many baby foods and formulas now contain extra additives – which may sound like they are good for you – but think twice before believing the marketing hype!

Anything which says “fortified”, “enriched”, “supplemented” or “added nutrition” etc should be treated with caution, things such as DHA or ARA (a synthetic version of Omega 3 fatty acid), Iron, Vitamin C, or anything similar are needed in a diet of a child, but if you are breastfeeding (which the AAP recommends until the age of 12 months) then your baby should be getting all of these things from you.

And if you are feeding your baby a wide variety of organic fruits and vegetables, they will be getting much of their iron and vitamin needs from those foods.

If your baby is formula fed, they may be missing out on some essential fatty acids which is why many baby formula brands are fortified with DHA & ARA.

However – the jury is still out on the safety of these additives in their synthetic version in food. So – in my opinion – until the jury is in, I am avoiding them. For more info read this article http://pediatrics.about.com/cs/nutrition/a/dha_ara.htm

The company as a whole

While this may not affect the actual quality of the food, I like to access the company who provides each product to decide whether I want to support them with my money. I look at things like –

Are they are large or small company?

I prefer to support smaller companies as they tend to be more ethical, sustainable and local and I feel good knowing I am supporting a family.

Are they a local or international company?

I prefer to support companies who are from my own country – thus creating jobs for my own community.

What other products do they sell?

Do they sell only certified organic and other healthy products? Or are they a big company who makes non organic baby food and has decided to make an organic version of it?

I tend not to support this kind of company because in my opinion they probably started making organic baby food for the money and market share and not because they truly believe in it.

What kind of marketing do they use?

Does this company make sugary or salty “junk” foods as well and still tell the consumers they are healthy?

Breakfast foods are the worst kind of foods for this – many, many cereals and breakfast items are marketed as “healthy” but common sense and a quick look at the ingredients for sugar & salt levels will tell you otherwise.

I prefer not to support a company who misleads their consumers in this way.

Dog Poisoning Symptoms – a Look at Common Symptoms of Dog Poisoning

If your dog has been poisoned, you need to seek treatment quickly.  There are a few symptoms of dog poisoning that you should be aware of.  These signs mainly depend on the amount of toxin that your dog ingested and his weight.  Before we discuss these dog poisoning symptoms, let’s take a look at some of the common ways your dog can get poisoned.

Causes

Dogs usually eat or drink toxin materials.  Antifreeze that leaks from your car tastes sweet to animals, so they will readily lick it.  Your dog can also eat a mushroom that pops up after a rainy night.  Toxins can also be delivered in the form of insect stings or hazardous fumes.  In some cases, dogs absorb the materials through their skin.

Skin

Speaking of skin, the development of a rash is one of the first symptoms of dog poisoning.  The rash occurs when toxins enter through the skin and are absorbed in the bloodstream.  However, sometimes a rash can form because of dermatitis or another skin condition.

Blood

One of the more serious dog poisoning symptoms is the appearance of blood.  Some toxins are dangerous enough to cause internal bleeding.  You may notice blood in your dog’s stool, vomit, or from the nose.  One of the common substances that causes this sign is rat poison.  So, always be careful when using this around your home.

Brain

Some substances affect your dog’s brain.  This can lead to loss of coordination which you can easily notice when your dog moves around.  Damage to the brain can also cause seizures or tremors.  Another severe sign that the brain has been affected is the loss of consciousness.  Sometimes, dogs can remain conscious but appear to be in their own world.  Death usually follows if the dog slips into a coma.

Appetite

One of the final symptoms of dog poisoning is the loss of appetite.  If poisoned, your dog’s mouth or tongue may become swollen.  This will make it more difficult for him to eat.  However, a dog can lose his appetite due to many other diseases.

Obstalces Are Just Opportunities In Disguise

What is an obstacle? Dictionary.com says its, "something that obstructs or hinders progress". That's certainly one way to see it, but I believe there is much more to obstacles than being obstacles to progress. Certainly there are situations in which obstacles are problems, obstructions, impediments to our progress both personal and professional. But I believe that with the right ATTITUDE, obstacles can become Opportunties. Let me explain …

We all face trouble in our lives, "Momma said there'd be days like these". No matter our background, financial situation, education or election, we all encounter hard times and have tough things to deal with. Certainly there are steps we can take to avoid some of life's pitfalls and set ourselves up for success as best we can, but there's still no cure for cancer and disease, financial trouble relationship stress can affect all of us.

There's no question that it is impossible to avoid all of life's challenges and problems. You will face obstacles in your life. No matter how rich, successful, or connected you are, there will always be hard times and obstacles to face. That's a definite; Like death and taxes. What has yet to be determined however, is how you will handle those obstacles.

Depending on the problems you face, there may appear to be several options for handling a particular situation. In truth, while a particular situation may be complex and have many issues involved, I believe we can handle things in one of 4 basic ways based on what I call the 4 basic life perspectives.

The Four Life Perspectives
Read the following descriptions to see which one best describes you:

1) The Worrying Willy – You often find yourself anxious and worried about life and the problems you face. You get concerned about the state of your bank account, the future health of your spouse, the safety of your home or if you'll keep your job, while, some of your concerns are based on legitimate issues, you also recognize that some of The things you worry about are not worth your attention, and yet you can not seem to stop yourself.

2) The Optically-Challenged Optimist – While fewer in numbers than the other categories, those of us who fit into this category, are still easily recognizable because of their enthusiasm and vocal optimism on every issue these people can sometimes get a bad rap from those Around them who become irritated or annoyed by their appearance immunity to life's problems. Life could be totally rosy for these people were it not for the fact that, due to their blind optimism, they fail to recognize problems before they become serious and often become very reactive in how they deal with obstacles.

3) The Negative Nancy – The Negative Nancy is the antithesis of the Optically Challenged Optimist. Negative Nancies also often very vocal, can find something to complain about in any situation. These people have a unique ability to find the worst in people and situations. They are also determined to focus on the negative no matter how much positivity might also be present in a situation.

4) The Positive Realist – The positive realist, as I call it, is someone who can look at the positive without losing sight of the facts. Unlike the Optically-Challenged Optimist, the Positive Realist will not fail to pay bills, or get into trouble due to a failure to address the facts.

Similarly, these people do not let the weight of the world's problems beat them up because they know that we can not make things better by feeling defeated. The positive realist addresses the realities of their world but rather than feeling hopeless or disillusioned, they use their positive energy to try to make things better.

Odds are good that you find bits of yourself in each of these descriptions. The descriptions above are charicatures of people. There are few REAL people who would exemplify all of the characteristics of one of these categories. And while I do not for a minute suggest that we should all the theike, we SHOULD all try to become POSITIVE REALISTS.

When you start to feel like negativity or worry is starting to creep into your thinking, I urge you take immediate action. A touch of negativity is normal. The problem is that a touch of negativity can quickly become a pattern of negativity. It can grow into frequent or even constant negative thinking.

When this happens it can be very difficult to turn ourselves around. We get into a funk and find it tough to get pumped up again.

So, the next time you feel negativity start to creep into your thinking, make a conscious effort to try to see the positive. When it looks like there is nothing to be happy about, make a list of all of the things you have to be thankful for. The change will not happen right away, but over time, you'll become a more positive, and happy person.

Every Obstacle is an Opportunity in Disguise
This is a life-lesson that I teach in all of my presentations. While we can not avoid the problems that we face in life, what we CAN do is use a positive attitude to transform the obstacles we face into opportunities.

If you look hard enough, with a positive outlook, I really believe that you can turn any obstacle you face in your life into an opportunity. This is a lesson I've learned over years of facing obstacles in my own life.

From the first day of my life I've been dealing with obstacles. Born with a congenital heart defect, my life nearly ended before it began. Less than 24hrs after I was born I was put on a medical helicopter and transported to the Isaac Walton Killam Children's Hospital for emergency open-heart surgery.

Deemed a very risky procedure at that time, doctors were quick to warn my parents that the valve surgery that I would go may well kill me. However, without it, I would certainly not survive. So we went ahead …

I was very fortunate. The surgeons did an amazing job. Within a few months I was able to go home with my parents for this first time. Unfortunately, my journey was far from over. A year later, almost to the day, I had more problems and doctors decided that I needed another surgery.

Again, the surgery went well but the doctors were quick to warn my parents that I was far from being out of the woods. They warned my parents that I would never be a normal kid. I would always have to take medication. I would have to see my cardiologist at least twice a year, and I would quite likely not be able to do much of what "normal" kids could. The doctors were partly right …

There were doctors appointments and from the time I can first remember, I've had to take medication. But I persisted my condition, I was able to do things that the doctors never thought I could.

Both of parents were physical education teachers and they encouraged me to be as active as I could be. I played soccer, basketball and baseball. I ran track and cross country. Despite my continued heart problems, I was able to live an active and mostly normal life.
I say "mostly normal" because despite being able to effectively deal with most of my health issues, there was one issue that I had to face each and every day. I was small. Not just a little short. Not just a bit smaller than the other kids in my class. I was SHORT. I was always the smallest kid in my class and by grade three or four I was usually shorter than the kids in grade below mine too. Even now, I stand at just 4'11 ".

Because I was small, I had to CONVINCE the other kids to let me play football in the school yard. I had to work twice as hard as my teams on my basketball teams just to keep up. My size put me at a disadvantage in many ways.

As a kid, being different in any way is hard. Being short was particularly hard because the difference was so immediately visible. I was teased relentlessly. "Shorty", "Short-stuff", "Small-Fry" and "Pip Squeek" were just a few of the hundreds of names that I was called.

At first, the names upset me a lot. I felt left out and alone like I was somehow less a person than my friends. But with the help of encouraging parents, a few good friends and supportive teachers, I was able to build my self-confidence so that when the names came, they had less and less effect on me.

During those early years of my life, I hated the fact that I was teased and I was not too fond of the people who did it either! But now, twenty plus years later, I can see that being small has been a great opportunity in my life. Being small has been an opportunity because dealing with the adversity I faced has made me a stronger person and helped me to deal with the other problems I've had to face along the way.

Things get more complicated
In 1991 I faced one of the largest obstacles of my life. I went to the congenital heart disease clinic for my regularly scheduled check-up and Dr. Nantin, my cardiologist, came to me with what was then life-altering news. My heart condition was growing increasingly more complicated. Now in addition the valve problems that I had had since birth, I had developed a condition called atrial fibrulation. The top two chambers of my heart, the atria, were no longer beating. As a result my heart function was deteriorating.

Dr. Nantin came in and told me at just twelve years old that I had to stop any activity that would put undo strain on my heart. Because my heart was now working harder just to supply my body with blood when at rest, putting extra demand on my heart, by doing things like running, climbing stairs or lifting weights, I was putting myself at high risk for cardiac arrest.

My world ended in that moment. For a thirteen year old, finding out that you can not do what you love to do is the end of the world. Dr. Nantin might as well have told me that I was not allowed to eat anymore, sports was so much the center of my world. It was the way I expressed myself. It was the source of my self-esteem, it was the way I socialized with friends, it was the way I defined who I was. Without sports, what was left?

After a period of feeling sorry for myself, I came to the realization that I had a choice. I could sit and sulk, or I could find something ELSE to do with my life.

Now do not misunderstand, this did not happen overnight. It did not happen in a week or even two. In fact, it was probably several months to a year before I began to seek out other avenues of self-fulfillment. For a long time, I simply rebelled against the doctors and continued to play sports even though I was not supposed to. My parents had taken me out of all organized team events, but they could not stop me from sneaking pick-up games of basketball with my brothers and friends, or playing football in the backyard when they were not watching.

I continued to "rebel" in that way until a fateful day in the winter of 1993 when I got a wake-up call as to exactly how serious my condition had become.

I was living with my family in Indiana. My parents were taking their masters degrees at the University of Indiana and the whole family, Mom, Dad, my three brothers and I, were living in a three bedroom apartment in the family residency on campus.

On a cool fall day Dad and I had been out running errands and came home to find the habit slow elevators in our building both occupied. We decided to take the stairs to our apartment on the seventh floor …

As we walked I could feel my breathing becoming more worked and my heart beating harder and faster. This was not completely unusual but I knew that something was not right. I should have told my Dad how I was feeling and stopped to catch my breath. But we were at the sixth floor at this point, just one more to go and we'd be home anyway.

As we reached the top of the stairs, my heart was pounding so hard I could feel it in my throat and in my head. We were on level ground now though, not climbing anymore, so I figured it would slow down. It did not … I remember seeing the door to the apartment and my Mom opening the door …

The next thing I remembered was the paramedic kneeling beside me putting an oxygen mask on my face. I'd late learn that I had gone unconscious as Dad and I had reached the door. The paramedics put me on a stretcher and bought me by ambulance to the university hospital.

After a lot of investigation, the exact cause of the incident was not decided. The doctors suggested that what likely happened was that my body was asking my heart for more blood than it could pump with its reduced function. Since the body was not getting the oxygenated blood it needed, I passed out. A simple explanation, but it did not make me feel any better.

That "cardiac incident" as the doctors called it, was a real wake-up call to me. Until that moment I'd been able to forget, or ignore my heart condition because, with the exception of my size, there were no immediately obvious signs of it. Day to day, I was not affected by it at all. Now in an instant, that had changed.

Over the next several years my condition ever so slowly declined. So slowly in fact, that I hardly noticed it was happening. Unlike a heart attack or a car accident, heart disease often doesnt change your life in an instant. Certainly in my case, it took years for me to decline to my absolute worst.

Fortunately for me, by the time I reached my lowest point, I was mentally ready for it. I've had years of training in how to find the positive in the most negative of situations, and I used that positive perspective on life to help me survive.

So what do you do when you face hardship and struggle? Do you dwell on the negative? Some do. Some people will find themselves in a negative situation and with a negative perspective on life, they immediately have a negative reaction.

The people will react in a number of negative ways, none of which help them deal effectively with the sitatution. Some people find themselves facing an obstacle in their life and start to play the "poor me" game. They come down with a severe case of "victimitis".

For someone suffering from "victimitis" everything that "happens to them" is a crime. Whether it's being stuck in traffic or finding out the item they want on the menu is sold out, the person suffering from victimism takes it personally. They will feel like whatever is happening to them is because someone out there, has it in for them.

I use the phrase, "happens to them" because that's is how someone with victimitis feels. The feel as thought they have no control over their lives. They have no ownership over what happens. Things just come at them, the world HAPPENS TO THEM and they are forced to deal with it.

If you are ever going to live the life you want, you can not allow yourself to suffer from victimitis. You have to take some responsibility for your life and realize that life does not happen to us. Life Happens. It's up to us to make life into what we want it to be.

So the next time you're faced with a problem in your life, stop. Take a step back and evaluate if there's any way that this seemingly negative situation could hold un-seen benefits. I promise you that if you can stay positive, eventually you will come to find there is an opportunity waiting to be sorted.

Information You Want to Know about Virgin Coconut Oil

Virgin coconut oil is very popular nowadays. A lot of interested people will surely have a lot of questions. Below is a list of the most frequently asked questions about virgin coconut oil and the answers.

Is virgin coconut oil safe?

Virgin Coconut oil is not a medicine but a food. It doesn’t have any side effect. But individuals differ and some may experience unfavorable reactions. The most common is loose bowel movement or diarrhea. This is because the lauric acid component of coconut oil which is antibacterial, antiviral, and anti-protozoal works to eliminate the bad bacteria from your system.

To prevent this, it is suggested not to start with the recommended daily intake of 3-4 tbsp. Break it into smaller doses over the course of the day. You may also choose to reduce your intake. Some people may be allergic to it, though this is very unlikely.

Why does virgin coconut oil cost so much?

Virgin coconut oil is expensive because its production is laborious and exhaustive. It is necessary to be meticulous to ensure the best quality. Only healthy coconuts are used and the unhealthy ones are removed. After harvesting, the meat is processed as soon as possible to prevent spoilage. Since they are made with fresh coconuts, it doesn’t require further refining. Its natural antioxidant properties make it very stable oils.

How is it different from coconut oil?

In purchasing virgin coconut oil, you may come across a brand that is not labeled as virgin. This type of coconut oil is known as the RBD coconut oil and in some ways different from virgin coconut oil. The RBD tag means that that it has undergone refining, bleaching and deodorizing. The oil is extracted from copra not coconut. Unlike virgin coconut oil which retains the distinct taste and aroma of fresh coconuts, coconut oil is tasteless and odourless. Its color is yellowish, has a thick texture, and melts at around 76° F. It retains the Medium Chain Fatty Acid component of the fresh coconut though it may contain some residues. Some RBD oils are hydrogenated, meaning it is artificially pressed into the molecules to create oil with a higher melting point. The trans fatty acids which are present in hydrogenated oils are highly toxic.

Coconut oil is previously perceived as unhealthy. Why is it suddenly recommended for use today?

The perception that coconut oil is bad for the health has been has been proven wrong by various scientific studies done by scientists and experts. Old research that says coconut oil is bad sees it as full of saturated fats which raise cholesterol levels. But a lot of these studies were done on hydrogenated oil and fail to see that coconut oil comes from a plant source and is therefore not the same from those found in animal sources. Recent findings show that coconut oil is high in lauric acid (also present in human breast milk) which is very beneficial in attacking viruses, bacteria, and other pathogens. Its antimicrobial properties can be used to fight various diseases which include even the fatal HIV that causes Aids.

To guarantee quality, does virgin coconut oil require refrigeration?

Virgin coconut oil doesn’t need to be refrigerated. It contains natural antioxidants which give it a long shelf life. In countries of colder climates, virgin coconut oil may solidify at room temperature. Never put it in a microwave to liquefy. Putting it in a pan of warm water will cause it to return to its solid state. Keep it out of direct sunlight.

Is there a specific amount of coconut milk that I should take in a day?

According to researchers, the most favourable amount for adults is 3 to 4 tablespoons per day.  Use it three times a day during meal time. It is equivalent to the amount of medium chain fatty acids a nursing child would consume in one day from mother’s milk.  To avoid diarrhea, it is best not to consume the recommended dosage at first especially if you are used to a low fat diet. Gradually increase your intake until your body get use to it.

If I heat virgin coconut oil, will it turn into hydrogenated oil?

It is absolutely safe to heat virgin coconut oil and can therefore be use for cooking. Heating coconut oil is different from hydrogenation. The latter is an industrial process where hydrogen molecules are introduced into the oil to make it solid at room temperature.  Hydrogenation chemically alters the oil and creates the toxic trans fatty acids.

If I heat virgin coconut oil, will its essential properties be destroyed?

No, the medium chain fatty acid of coconut oil is not destroyed even if heated to a high temperature. The beneficial nutrients are retained and not harmed.  The fact that coconuts are grown in areas with very hot weather explains why. God naturally designed coconut to adapt to warm climates. Also, unlike other seed oils like olive oil, coconut oil doesn’t turn into a trans fat which are toxic when heated. This makes coconut oil one of the safest oils to use for cooking.

Will eating fresh coconut meat give me the same benefits that I will get from virgin coconut oil?

Fresh coconut contains coconut oil, but it also includes fiber, protein and natural sugar.  Coconut oil doesn’t have protein. Since coconuts contain sugar, it is also not recommended for someone trying to limit sugar intake.  To get the equivalent amount of virgin coconut oil, you would have to eat more coconut by weight. Fresh coconuts also do not have a long shelf life so its quality may be not as superior as that of virgin coconut oil.

Can pregnant women take virgin coconut oil?

Virgin coconut oil is safe for anyone as it is not a medicine but a food. In coconut producing countries, it is normal for pregnant women to eat coconuts. Virgin coconut oil contains lauric acid (also present in breast milk) so it is beneficial for lactating women. But caution should be exercised as some first-users may experience allergic reaction. Let your body get used to virgin coconut oil first.

From: http://www.thevirgincoconutoil.com/articleitem.php?articleid=161&pageid=228

Use These 4 Steps And You’ll Be Networking Like a Rockstar

You understand that networking is critical to your success, but are you networking with forethought and an excellent strategy in place, or are you just “winging it?”

Almost all of us are squarely in the category of winging it but there are some simple and swift changes you can make that will put even your most crucial networking tasks on autopilot.

Outsource the research:

This is the first step, hire a Virtual Assistant with networking skills who can find and hook you up with potential JV partners, affiliates, guest interviews, guest blogging, podcasts, and any or all of the other marketing options at your disposal.

With a list of requirements at hand, your VA can spend an hour or two on Google and bring back a list of hundreds of folks you can then reach out to. What would a list of 100-or even 10-new JV partners do for your business growth and networking goals? And just think of how much time your VA will save you with your networking activities.

Automate the initial connection:

Create a script or email template to use when you first reach out to potential partners. Your VA can send this in an email or make a call on your behalf, but having the script in position will accomplish two benefits:

1. The method will be much faster than if you have to think about what to say.

2. You can tweak the script as you go to get better results. Simply like you split test your emails, you can test your outreach process as well.

Automate the follow-up:

At the risk of sounding like a broken record, create an email or phone script to help speed up the process. You or your VA (or your email autoresponder series) can send out several emails to follow up on that initial connection.

Automate your scheduling:

Using a service such as Acuity Scheduling or Calendy, you can certainly set up your calendar with your preferred times for interviews, training calls,seminars on the web, webinars and so on. Offer your JV partners a link to

schedule a time with you, and the meetings will automatically appear on your calendar. No more countless back and forth to go over potential meeting times, simply a single click, and your partner can choose the time that works for both of you.

Here is a hint though: make certain to use your calendar appointments diligently, because if you don’t you run the risk of someone scheduling time with you when you already have another commitment.

Will it take a little bit of work to get these systems in place? Sure. But once you do, you’ll find that attracting and working with JV partners, guest experts and others is much easier and more streamlined. Not only that, the time you save from your networking skills and networking opportunities, you’ll be able to focus on creating new programs and services. Or maybe just spend more time with the kids a bit. Don’t you think you deserve some time off?

Medical Equipment As Modern Technology

During olden times, hospitals and doctors depended on traditional knowledge, passed down from person to person, to diagnose, monitor and treat people suffering from diseases and health conditions. The knowledge that was used during those times was considered to be fact, but it always lacked accurate results. Besides lacking results, these processes were slow, taking a long time to provide treatments to patients. The incapacity of traditional medical practices to provide fast and accurate results has further led to complications and made matters even worse. As time progressed, advancements were made in medical equipments, allowing for better, quicker, and more efficient treatments.

Medical equipments, from the time they were discovered have been able to save thousands of lives every year. They are a crucial part of medical operations and healthcare and have been used extensively from hospitals to clinics, all around the world. These medical apparatus and devices are very crucial in the diagnosis, monitoring or treatment of medical conditions. Without them, the detection and treatment of a certain medical conditions are compromised.

In recent years, there had been major advancements made in medical equipment. The discovery of modern computers has helped a lot in the technological advancements that were done in these modern medical devices. These technological breakthroughs cover a wide array of medical field and treatment including cardiology, neurology, gynecology and reproductive health among others.

One of the recent and most essential advancements made in medical devices is the portable ultrasound machine. With the aid of a smart phone available with ultrasound probe knowledge via USB, this device enables patient data to be sent from remote locales to experts through the phone. In turn, these specialists can further analyze the data that was sent and send back a diagnosis in the quickest time possible.

Prostate cancer, a condition common among many older men can now be treated with the help of an original method of treating growths on the prostate. This method makes use of microwave pulses that are super focused to dissolve the abnormal growth in the prostate area. The newly-discovered gamma cameras have become one of the most helpful tools for the diagnosis of breast cancer. The Brest-specific gamma imaging or BIGS can provide a lot of help in detecting cancer cases, which often go undetected. Another important advancement made is the idea of using microwave in treating certain forms of cancer. This technology involves the use of a skinny needle which is inserted into a tumor that has been found to be cancerous. The needle gives off hot microwaves, causing cancer cells to die after a while. Surgeries will soon be conducted even without the physical presence of a doctor with the introduction of robotic surgeries. These robotic surgeons will be outfitted with an artificial intelligence (AI) program, including 3D ultrasound imaging, enabling these robots to conduct simple surgical by itself.

Drink Water On An Empty Stomach!

It is popular in Japan toady to drink water immediately after waking up every morning. Furthermore, scientific tests have proven it’s value. For old and serious diseases as well as modern illnesses the water treatment had been found successful by a Japanese medical society as a 100% cure for the following diseases:

Headache, body ache, heart system, arthritis, fast heart beat, epilepsy, excess fatness, bronchitis, asthma, TB, meningitis, kidney and urine disease, vomiting, gastritis, diarrhea, piles, diabetes, constipation, all eye diseases, womb, cancer and menstrual disorders, ear nose and throat diseases.

Method Of Treatment

1. As you wake up in the morning before brushing your teeth, drink 4*160ml glasses of water.

2. Brush and clean the mouth but do not eat or drink anything for 45 minutes.

3. After 45 minutes you may eat and drink as normal.

4. After 15 minutes of breakfast, lunch or dinner do not eat or drink anything for 2 hours.

5. Those who are old or sick and are unable to drink 4 glasses of water at the beginning may commence by taking little water and gradually increase it to 4 glasses per day.

6. The above method will result in quick weight loss, cure the diseases mentioned and can enjoy a healthy lifestyle.

This treatment has no side effects, however at the commencement of treatment you may have to urinate a few times.

The Chinese and Japanese drink hot tea with their meals, not cold water. Maybe it’s time we adopt their drinking habit while eating!!

For those who like to drink cold water , this article is applicable to you. It is nice to have a cup of cold drink after a meal. However, the cold water will solidify the oily stuff that you have just consumed. It Will slow down the digestion. Once the “sludge” reacts with the acid, it will break down and be absorbed by the intestine faster than the solid food should. It will line the intestine. Very soon this will turn into fats which leads to obesity and cancer. It is best to drink hot soup or warm water after a meal.

The more we know, the better the chance we could survive. Drink water, stay healthy and active.

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Top 5 Pec Exercises To Make Superman Look Like A Weakling

Many individuals – Weightlifters and Bodybuilders most especially – consider the chest or pectorals among the most important muscles to develop for all round strength and obvious aesthetics. This is why fitness enthusiasts are always searching for the best Pec exercises to strengthen their chest. But, before we go about presenting the best exercises for your pectorals, let us first take a look at how your chest muscles work so that you will know better how to target them for growth.

Anatomy and Functions of the Pectorals

Your chest muscles are composed of the pectoralis major and the pectoralis minor. The pectoralis major is located on the front part of your rib cage and originates from the breastbone in the centre. The fibres of this muscle group fan out across your chest, a structure that allows your humerus to move in a variety of planes across your body. The pectoralis minor can be found underneath the pectoralis major and originates from your middle ribs.

The primary function of your pectoralis major is to move the humerus across your chest, as demonstrated in the flye movement. The pectoralis minor, on the other hand, is used to move the shoulders forward as when you shrug your shoulders forward. Now that you know more about the anatomy and functions of your chest muscles, you are ready to learn about the five best Pec Exercises you can take advantage of.

1. Barbell Bench Press

This is considered as the king of all Pec Exercises and has been the standard for strength building for many years. In fact, even if we limit this list to the top three chest exercises, the barbell bench press would still be in it. Set up for the exercise by lying down on a bench with a 45-lb barbell. Make sure that the soles of your feet are comfortably flat on the floor. Be sure as well that when you remove the barbell from the rack, it will be positioned directly above your chest so that you don’t have to pull it over.

If you are doing a medium-grip bench press, then you’ll have to make sure that your elbows are neither flared out nor tucked in. Instead, they should be positioned about 45 degrees from your body. Once the barbell is unracked, lower it slowly until it touches your nipples. Be very careful not to bounce the weight on your chest. When you raise the weight back up, do it slowly and then hold the position for a few seconds when your elbows are completely straight before lowering it down to your chest again.

There are several variations of the bench press that you can try, among them the wide-grip, narrow-grip, and incline bench presses. You may also want to do board, floor, or pin presses. Among these variations, the incline bench press is considered very effective in targeting the upper pectorals (pectoralis major). While performing bench presses, remember to keep your butt, upper back, and head in contact with the bench at all times.

2. Dumbbell Bench Press

This is considered as one of the core pec exercises and is a very good way of ensuring that you do not have any strength imbalance between the opposing sides of your body. The dumbbell bench press is also advisable because it promotes the natural functions of your pectoral muscles by focusing on moving the weights towards the centre of your body.

The necessary first step is to find a bench that allows you to sit and lie comfortably with both feet touching the floor. Once you’ve found the ideal bench, grab a dumbbell in each hand and then stand about six inches in front of the bench. Slowly move into a sitting position on the bench while letting the flat side of each dumbbell rest on your thighs. Now, lie back slowly and make sure that your butt, upper back, and head touch the bench all throughout the exercise.

Position the dumbbells at shoulder height, just slightly touching your shoulders and then push up until your elbows are straight. Lower the weights slowly back to shoulder height to complete a rep. You can choose to do a flat, incline, or decline dumbbell bench press.

3. Push-ups

No matter how many bench presses you perform, you really can’t do away with the ever-reliable push-ups. This is one of the most effective pec exercises for developing explosive chest, shoulders, and triceps power. To set up for this exercise, you should decide whether to do the push-ups on your knuckles or your palms. Lie on the floor with your body in a straight line, with only your hands and toes actually touching the floor. Female beginners may start by doing push-ups on their knees and then move up to doing push-ups on their toes as their strength increases.

Position your hands about 2-3 inches outside shoulder width. Position a large hardcover book or weight plates on either side of your hands. Make sure that the books or plates are at least an inch thick. You may increase the height of these objects as you get better at this exercise.

Lower your body as near to the ground as possible without actually touching your chin, chest, abdomen, or legs to the floor. Push yourself up off the floor with a force that is intended to propel your body up into the air. The movement should end with your arms straight and hands on top of the books or weight plates. You may then “walk” your hands back to the starting position before lowering yourself for another rep, or immediately drop into the beginning of another rep.

4. Chest Dips

This exercise is similar to a decline bench press, except for the fact that decline presses work more for strengthening the triceps than the pectorals. It is best to skip this exercise if you have a bad shoulder or at least just limit yourself to shallow dipping. Set up for chest dips by grabbing a weighted belt and dumbbells and then finding a dip station.

Start the dips with you arms almost fully extended. Lean slightly forward so that tension is built more on the pectorals rather than your triceps. Dip down slowly until your arms are parallel to the floor. Pause for about half a second at the bottom of the movement and be careful not to bounce. Squeeze your pecs and push yourself back to starting position. Be careful not to lock your elbows at any time during the exercise.

5. Dumbbell Flyes

This may not be as important as the other pec exercises on this list, but it is the perfect complement to the four exercises discussed above. Some people even claim that this is the key to muscle growth and flexibility. To set up, you need to assume a position identical to that of a flat bench press, with one dumbbell in each hand.

Start the exercise by holding the weights straight overhead. Lower the weights slowly to your sides until your arms are parallel to the floor. Pause for about half a second and then bring the dumbbells immediately back up without bending your elbows. Make sure that the entire flye motion is controlled by your chest muscles rather than your triceps.

Instead of performing dumbbell flyes at the end of each chest workout, it is best to do this a day or two after your workouts. It serves as an excellent recovery exercise because it allows you to stimulate your sore muscles with free weights that are considerably lighter than what you used in your workouts. This exercise is also a good way of increasing blood flow to all areas of your chest.

The Eyes Don’t Lie – Reading People By Eye Movements

Your eyes will position themselves according to the thoughts that are in your head. By watching your eyes other people can often tell what you are thinking and if you are lying.

Professional poker players know that your eyes can be a dead giveaway. Most professional players are very good at reading body language and are keen at reading them. They also tend to wear sunglasses, ball-caps and other accessories on their faces to hide their eyes.

The behavior of the eyes is fairly predictable, someone will make eye contact with you and during the conversation they take a moment to think. For this brief moment while they access information in their brain, and their eyes will move to a predictable position. Here are what the different positions mean:

– Eyes in the Upper Right (1st person upper-left) – When someone moves their eyes up and right it means that they are accessing the visual part of their memory. In this person’s head they are visualizing objects, colors, movements, and other visual information that pertains to your conversation. If you want to see someone do this a good question to ask them is, “what color is your car?”

– Eyes to the Middle Right (1st person left) – Moving the eyes directly to the right is a sign that they are accessing the auditory part of their memory. The person could be remembering a song, the sound of a voice, or a particular noise. If you ask someone to think about the sound of their alarm clock they should look to the right.

– Eyes Down and Right (1st person down-left) – Someone that is talking to themselves or thinking about what they are about to say next will look down and to the right. Ask someone how a conversation went and they will look down and to the right.

– Eyes Up and Left (1st person up-right) – Looking up and to the left allows someone to access the visual part of their imagination. This person is constructing a picture in their head. If you ask someone to imagine a green sky with red clouds they should look up and to the left.

– Eyes to the Middle Left (1st person right) – A person looking directly to the left is constructing sounds in their head. They may be imagining what an unheard voice sounds like, or putting together a new melody. Ask someone to image the sound of a car horn underwater and they will likely look to the left.

– Eyes Down and Left (1st person down-right) – When thinking about their feelings someone will look down and left. Often when people say “I feel…” They will glance down and left, and you can know they are actually thinking about how they feel.

To detect someone that is lying it is important to understand how their eyes move normally and then take notice when the behavior of these changes. For instance your friend is telling you about his recent vacation and is looking up-right while describing the hotel and the places he visited. Suddenly his eyes move to the upper left and he tells you about this girl that he met while he was there. There is a very good chance that he is lying about the girl.

Many people have become good at lying by learning to mask the signals of a lie. If you watch their eyes, they will likely maintain eye contact while telling a lie, or will shift them away from you. Once again, notice how they were moving them when they were telling the truth and then compare this to when you think they are lying.

Knowing how read people’s eyes can be a huge asset when communicating in person. You will know instantly when someone is lying and will be able to catch them before it slips by.

How to Avoid Panic Attacks

Anyone who has ever had a panic attack knows how life stopping these events can feel. A panic attack can seriously hurt your quality of life by causing you become terrified of a repeat episode. This terror is just another negative side effect of panic attacks, and you should learn to think of it as such so that you can get on with your life without the constant fear of a panic attack hanging over your head. Worrying about having a panic attack all the time might even cause you to trigger panic attacks later.

Panic attacks feel a lot like heart attacks. A panic attack might cause your heart to race, and it might cause you to become short of breath. You might find that you feel dizzy or light headed, and they are characterized with the feeling of life or death importance. It is not uncommon to believe that you are dying or about to die when you are having a panic attack. Fortunately for sufferers, they are usually not of a long duration, and will stop when they have run their course, usually a few minutes, or when the cause of the panic is removed.

If you are terrified that you might have another panic attack, you may just end up cutting yourself off from everything in order to avoid having another. You might hide from the world, or otherwise separate yourself from the friends and family who might otherwise be able to help you. If this sounds familiar to you, then you need to consider seeking professional help to empower you to dispel the threat of panic attacks that hangs over your head.

You may also be able to help yourself by avoiding the situations that cause you to have your panic attacks in the first place. One of the biggest causes of panic attacks is stress, and if you are constantly in stressful situation, then you will be at a much higher risk for panic attacks in the future. This stress is not necessarily the stress that comes over a few days over a particular event; panic attacks are triggered by constant stress over a period of months or sometimes even longer. This stress is often too much for people to bear, and even if we do not realize that, our bodies do, and they rebel.

Panic attacks can also be caused by certain situations. If you get a panic attack every time you are running late, or stuck in traffic, or going over a bridge, then you need to make sure to avoid those situations to prevent these same events from triggering more panic attacks in the future. You can take a different route to work, leave early, and avoid roads that you know will be snarled with traffic or even head to a local place for dinner after work before facing the drive home.

If you practice avoiding panic attacks and chart where you were, what you were doing, and how you felt immediately prior to each panic attack, then you can use this information to avoid the things that trigger you. You may be able to save yourself a lot of trouble with your mental and even your physical health later down the road.

Panic attacks do not just feel remarkably like heart attacks; recent studies have linked experiencing panic attacks with an increased likelihood of actually having a heart attack later. Keep your odds low and keep your stress levels down to avoid panic attacks and to remain as healthy as possible. No one likes to suffer, and panic attacks certainly fall into the category of suffering.

If you are at risk for panic attacks or you have had them in the past, then you should examine the past causes of your panic attacks so that you can help yourself to avoid similar situations in the future. You should also get in contact with your doctor to find out if you may need medication or therapy to help you take charge of your life and get away from the panic attacks. It can be difficult to determine exactly the best means of preventing panic attacks, but you may get better results when pairing the practice of avoiding triggers with medication to help you feel calmer. A therapist can also help you learn mental tricks to help you ride through the panic attacks without completely losing your cool the next time you feel one coming on.

Dangerous Assumptions – Broken Relationships

Healthy individuals are slow to make assumptions. They check the facts, ask questions, and explore other perspectives before moving forward in their thinking or behavior. By contrast, those who live in dysfunctional mental health routinely make faulty and even dangerous assumptions. Consider a few examples:

o Many teens believe, “that would never happen to me” and then, based upon that faulty assumption, drive fast, abuse drugs and alcohol, or engage in risky sexual behaviors.

o A partner routinely “mind-reads” their spouse, creating false assumptions which lead to withdrawal. Over time, the marital relationship begins to crumble.

o A boy’s parents believe there is a “right way” to do something, insisting that coloring within the lines of life is better than straying outside them. Based upon that assumption, the child’s creativity is squashed while his fear of failure skyrockets. This often leads to child anxiety and a strained parent/child relationship.

With faulty assumptions causing so many problems, why do people make them? Why are they not more careful to check their assumptions? Three thoughts:

1.) Assumptions are often made to reduce fears, paradoxically causing even more disequilibrium within a individual when the assumptions fail. Human beings hate vulnerability and strive to create a personal world free from mystery, risk of failure, and exposure to humiliation. Citizens of the United States are particularly disillusioned by the belief they can control their environments and determine their destinies. Twenty-percent of adult Americans are disordered with anxiety whereas ninety-four percent of adult Mexicans have NEVER experienced a depressive or anxious episode. What’s the difference? The illusion of control and the accompanying assumptions. Two hurricanes strike Mexico in one year, injuring thousands and leaving many homeless. The citizens pick up the pieces and rebuild with little drama. They make no assumptions regarding their control over the environment or their government’s ability to respond to devastating disasters. Katrina hits New Orleans, millions of dollars and countless hours are spent to determine who’s to blame for not being more prepared. The assumption is that the consequences of a category 5 Hurricane can be predicted and properly managed. The assumptions lead to anger and anxiety when they are not fulfilled.

2.) Assumptions are often made to answer the question “why?” Human brains are pattern oriented in thought and behavior. The saying, “I’m a creature of habit” has scientific validity. When an experience is outside a person’s pattern of understanding, an alarm goes off inside the brain which causes anxious feelings. When Keith girlfriend unexpectedly broke-up with him, he was shocked and bewildered, wondering WHY it happened. To calm his anxious feelings regarding his part in the break-up, he creates assumptions, assumptions that help him make sense of it and place him in a more favorable light. “She must not be ready for a mature relationship,” he tells himself. The fear that it could be something more significant within him that needs changing is too threatening to consider, so he places the blame on her to help him cope with his anxious feelings.

3.) Assumptions are made when communication breaks down. A couple, or a parent and child, may be trapped in the vortex of anger, disappointment, and shame. Communication may be fragile or even at a complete standstill. Because communication is fractured, assumptions fill the void of understanding. When feelings between individuals are negative, so will be the assumptions. There’s no alternative. Fearful emotions produce faulty, negative assumptions which then are projected onto the other as if they have been proven in a court of law. When dialog resumes, the conversation centers upon the faulty assumptions and not on the actual truth. The individuals find themselves saying things like, “I know you were thinking that, don’t lie”, countered with, “I never thought that”, “that’s not what I meant”, “that’s not what I believe.” It becomes a duck-and-roll exercise to fend off the assumptions.

How many people have been wronged by faulty assumptions? How many relationships have fallen under the attack of such assaults? Faulty assumptions destroy friendships and families, convince people to make bad financial investments, and lead individuals to experience depression and anxiety. Impulsively reacting based upon faulty assumptions may ease short-term anxiety, but tends to create further damage and destruction which only heightens fear and worry all the more. How fear is managed is exceedingly important.

So, the next time you find yourself so sure about something, SLOW DOWN and determine if your surety is based upon an assumption or something more substantial and credible. Ask questions. Be humble and maintain an attitude of grace and patience. Explore different perspectives. Seek understanding more than being understood. Cultivating healthy communication allows us to reduce our faulty assumptions and live free of many fears and anxieties. Healthy individuals deal with reality rather than deny it or run from it. Keith may experience pain in dealing with the truth of the break-up, but he will mature through the process and become a better person. As the Bible says, “But let everyone be quick to hear, slow to speak and slow to anger” (James 1:19); for “On the lips of the discerning, wisdom is found” (Proverbs 10:13). By doing this, being slow to form assumptions, you will save yourself and others from a world of pain.

Christopher T. McCarthy, M.Ed., LPC ( www.myanxiouschild.com )

Novel Stem-Cell Procedure Saves A Boy’s Leg

Stem cells have opened so many gateways to personalized medicine that no one could ever imagine a few years back. Not only the traditional transplants, with stem cells, medical practitioners are now able to treat many rare conditions. Thanks to the researchers and their novel techniques, involving stem cells.

This is a story of Javier Tan, a 9 year old boy, who was suffering from a rare genetic illness, Fanconi anaemia, which led his blood count drop to a significantly low levels. He required a stem-cell transplant; so that his body would be able create new blood cells

He received his first stem cell transplant when he was 7. The surgery was meant to save his life but call it irony of fate that it turned his life into a nightmare. Instead of healing, he contracted a bone infection. His condition was so severe that his doctors anticipated he would lose the limb.

In that scenario, the optimum option was to wait for another donor, which might have taken several months. Instead his doctors administrated another transplant and that too within weeks. When his doctors realized that they would require the donor to be only a 50% and not 100%, his father became the donor, who was earlier rejected.

Human leukocyte antigen (HLA) matching is important in both cord blood and bone marrow transplant. It’s a protein, which is found in cells, used to match a donor’s stem cells with that of the patient’s. However, this time Javier’s doctors went for a different method, called haploidentical transplant. In this process, the T-cells, the immune cells that are responsible for attacking foreign elements in the body were removed. So in Javier’s case, the T-cells could not attack the newly transplanted cells.

After seeing the immense improvement, Javier’s mother is very happy. Mrs Vivian Tan recalled the day when doctors told her that they might need to amputate his son’s leg. And now look at him. He is a healthy student of Primary 3, excelling in English and Chinese. His surgery was done in January and Javier was back in school in May. She said, “I am definitely relieved and thankful that he has his health back.”

Dr Rajat Bhattacharyya, the consultant at the department of paediatric sub-specialities at KK Women’s and Children’s Hospital (KKH) confirmed that the new transplant method is versatile enough to find anyone the suitable donor. However, the technique has been in existence since 2010. The National University Hospital (NUH) successfully conducted the procedure successfully on 38 children. The National University Cancer Institute, Singapore (NCIS) has administrated 8 transplants on adults. KKH doctors have treated 4 kids with this technique since October 2014. 10 adult leukaemia patients have been treated with this method by Singapore General Hospital (SGH) since 2004.

The number of patients undergoing haploidentical transplant is gradually increasing. And why not! Without the procedure, the chances of finding the most suitable donor might take several months or year. The haploidentical transplant offers hope for patients, who suffer from rare conditions and are left with minimum hope to live a healthy life ahead.