What to Know About the Different Types of Cerebral Palsy

Cerebral Palsy, then commonly known as “cerebral paralysis”, was first recognized in 1860 by William Little, a British surgeon. Little increased the possibility that asphyxia during the birth of a child is the main cause. But not until 1897, a well known neurologist named Sigmund Freud suggested that difficult birth was not a basis but rather a symptom of some other effects on fetal progress. During the 1980’s, a research conducted by NINDS or National Institute of Neurological Disorders and Stroke, suggested also that only some cases are caused by asphyxia during child birth.

The word “cerebral” in medical term is for the brain while “palsy” means the disorder of the posture or movement. By the definition, it describes to a group of situation wherein the posture and movement are very affected as a result to the damage done to one or more parts of the brain.

Depending on which part of the brain was damaged, the following conditions may be present although every individual is affected in a very different way:

o Coordination and balance problems

o Difficulty in maintaining and controlling of posture (like when a person wants to sit upright, help is required)

o Having an epilepsy (one out of three in children have an epilepsy

o Difficulty in talking, drinking, and eating (swallowing)

o Difficulty in learning process

Types of Cerebral Palsy

This disorder can be categorized into four types and these are ataxic, athetoid, spastic, and mixed:

o Ataxic- this type of CP affects to about 5 to 10 percent of most CP patients. Ataxic is characterized by the deficits to the balance and depth sensitivity that results to poor coordination in fine motor tasks.

o Athetoid- a type of CP that affects to about 10 to 20% of most CP patients. Athetoid is characterized by very slow movements. Uncontrollable movements usually occur in hands, arms, legs, and feet. Also, face and tongue muscles can be affected that may result into drooling or grimacing. Affected tongue muscles may also result to difficulty in speaking.

o Spastic- the most common type of CP that accounts to about 70 to 80 percent of all CP patients. Spastic is characterized by the stiffing of limb muscles that can result to permanent contraction.

o Mixed- this type of CP affects to about 30 percent of all CP cases. Symptoms are like to one of the three types stated above. Furthermore, athetoid and spastic forms of CP can coexist.

In general, it is not a progressive type where the brain can’t get any worse. Application of regular and appropriate therapy is provided so as to improve mobility and coordination skills.

Information Overload – Whats Working Now?

Is this possible? Yes!

In today's environment, weather you're seeking information for personal growth, new business, or just to improve your existing skills, many people suffer from information overload.

Information overload is a real and sometimes debilitating problem for a lot of folks, especially when learning multiple new skills like internet marketing.

Recently Mike Dillard a very well known and respected internet marketing guru, released a video "Whats Working Now?" featuring a number of top 7 figure earning Internet and MLM marketers, in a nuts and bolts, cut to the chase formula, on how they combat this problem, along with candid practical details on what marketing techniques they are using right now, whats working and whats not working in their businesses today!

With the vast array of information products, systems and technology changes coming to market each day at record pace, it's easy to get bogged down in the learning curve and quickly find yourself stuck and overwhelmed.

A common thread that most really successful and productive marketing entrepreneurs have, is the ability to cut right through information overload with simply learned techniques.

The top three reasons folks get bogged down in the first place are:

1) They are looking for instant results and solutions.

2) Fear of not knowing enough and looking to learn anything and everything.

3) Moving on to the next best thing, before you have completed the last best

thing.

How do you get more done with less effort you ask?

How do you eliminate distracting information while leveraging your actions?

How do you produce productive effort and avoid paralysis of analysis?

1) Focus on what you want to accomplish (zero in on your desired results).

2) Visualize yourself already in receipt of your desire (see yourself in the picture).

3) Produce a journal of productive effort (a list) of specific intentions or goals.

4) Focus your effort on one thing at a time, (in the knowing that when you complete a task it brings you one step closer to accomplishing your desires or goals).

5) Align yourself with others with the similar goals or intentions (a group, coach or mentor).

Productive people all acknowledge, it starts with your mindset and your deliberate intention. When you focus your attention on what you want, instead of what you do not want or have (fear of what you lack), your mind will shift to create ways and ideas, the steps needed to bring you closer to your desires, and releasing you of the feelings of lack and anxiety.

Do not feel alone, for most people this is a skill that was learned and needs to be practiced.

Embrace these feelings as your friend. Learning new information is also about changing your old way of thinking, and as a result getting you closer to your goals.

Lastly, aligning yourself with others of like interests and desires can have a powerful effect on your efforts when you're feeling stuck or overwhelmed. Seeking out others and sharing can inspire powerful creativity, balance and focus on your tasks at hand.

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

Exercises For Back Pain

The lower back is the pivot point of the body, bearing most of the weight with only a tiny spinal column and a few muscles to hold it all up. We add a lot of stress to our backs, by lifting and twisting in unnatural positions and by not exercising to strengthen back muscles. If we're lucky, the pain we get in our backs is only muscle strain. If not, it could be arthritis, osteoporosis, disc injury or fracture. This article offers simple exercises to strengthen the back, preventing or relieving back pain.

See A Doctor: This is a great place to start with back pain. Many injuries and strains can cause back pain. Only some of these can be relieved by exercise. In many cases, the other injuries can be worsened by trying to exercise. While it's a good idea for any kind of back pain and before starting any back exercise routine, it's essential to see a doctor in every case where numbness or sharp pain is experienced. Do not be like my brother, who pressed on through the pain only to require major surgery to reinforce his lower back.

You Can not Exercise Bones: What my brother did not realize is, you can not exercise bones …. all you can do is further harm them. What started as a simple dislocation ended with several of his vertebra being fractured because he refused to heed the pain warnings his back was giving him. Whether we like it or we think it's convenient, the pain is there for a reason. We ignore it at our own risk. Have I warned you enough to see a doctor? Good!

Preventing Back Pain: The old adage, "lift with your legs" comes to mind. So many of us try to lift with our backs bent over, it's amazing there are so few injuries. When we bend our backs to lift, we force our spine and those few muscles to lift the weight of our package and the weight of most of our body at the same time. Because of the leverage involved, we're putting several hundred pounds of pressure on a structure less than 2 inches in diameter. When you lift, keep your back straight, your knees together, lift your head back to look straight ahead. Then your legs, with their strong bones and huge muscle groups, do the work.

Another way to prevent back pain is by stretching after any activity that requires back work, including gardening, swimming, rowing, running, walking, sports, bicycling, etc. Just stand on a level surface with your feet straight ahead and a natural distance apart. Slowly bend over at the waist and hang there with your arms hanging down for about a half minute, then slowly straighten back up. This stretches all the muscles in your back from the knees to the head. I've found it's necessary to do even after fishing or long drives.

Simple Back Pain Exercises: 1. Push-backs: This exercise helps us prevent back pain by avoiding weight gain. Just push back from the dinner table a little early. 2. Abdominal pressure: Sometimes our muscles pull us out of alignment. We can ease this pain by laying flat on our backs on a hard floor, with our knees up, literally pushing down with our stomach muscles. 3. Knee lifts: From the same position, slowly lift one knee at a time, using your arms to pull it to your chest. 4. Bending: Stand straight up on a level surface and slowly bend forward, back, Left and Right. 5. Light dumbbells: Standing straight up on a level surface with your feet about 18 "apart, extend your arms slowly out to the sides and front with a dumbbell (2-5 #) in each hand.

To prevent injury, do not ever try to force back exercises. Many repetitions of very light exercise is what's needed to strengthen back muscles. As the muscles get stronger, the pain goes away. This takes a lot of the stress off of the vertebra and allows the muscles to do the work.

I've known many people who work out for good looks and completely ignore the back. My brother is one who worked all the muscle groups that gave your that "buff" look. He's one of the best looking people I know who have severely limited mobility due to back injury. If you're going to spend the time to exercise at all, do it for fitness and physical ability … not looks. Once we've seen the doctor, we can prevent back injury and relieve back pain, simply by regularly doing the right exercises and back stretches. Back pain exercise are one area where an ounce of prevention is worth a thousand pounds of cure.

Understanding Influenza

According to US Centers for Disease Control and Prevention (CDC), nearly 35 to 50 million people fall prey to influenza during the flu season (November to March), every year. Viral in nature, influenza is a respiratory disease that is highly contagious. In the year 1918, nearly 100 million people died in the influenza pandemic that spread across the world, including remote regions in the arctic and the pacific islands. It was the worst natural disaster the world ever saw.

Symptoms and Diagnosis of Influenza:

The symptoms of influenza are very similar to those of the common cold, and therefore influenza is sometimes mistakenly diagnosed as a cold. The symptoms are:

  • High fever
  • Headache
  • Extreme tiredness or fatigue
  • Sour throat
  • Cough
  • Stuffed or runny nose
  • Body aches
  • Diarrhea and vomiting (this occurs more often in children as opposed to adults)

Due to the symptoms’ similarity to cold and other infectious diseases, a diagnosis is to be made very carefully. Self-diagnosis is not advised, and it is essential to visit a doctor. If tested within the first 2 or 3 days, a clear diagnosis can be made. There are specific tests that used for diagnosing influenza.

It is important that the diagnosis be made on time because the flu can cause some serious complications. Bacterial pneumonia and severe dehydration are some of the complications that can occur. If you have a pre-existing medical condition like congestive heart failure, diabetes, asthma extra care needs to be taken for influenza can worsen the condition alarmingly. Sinus problems and ear infections may also be developed by adults and children alike.

More often than not, people recover completely from influenza, but it is still a dangerous disease if not treated in time. Young children, older people and people with medical conditions like heart disease diabetes and asthma are at a higher risk for complications arising due to influenza and the disease can prove the be fatal to them.

How it spreads, prevention and treatment

The influenza virus is an airborne virus that spreads from the infected person when he or she coughs or sneezes. People often develop the infection up on touching something that has the virus on it, like clothing etc. and touching the unwashed hand to their mouth eyes, or nose.

Infection can spread from one healthy adult to another one day before getting the symptoms and up to five days after. So one can spread it to others before one knows they’re sick, and of course after they develop the disease.

Influenza can be prevented by getting vaccinated against it every year. Two types of vaccines are available in the United States:

  • The “Flu Shot”: this is a normal injection type vaccine that contains the inactive form of the influenza virus. It is safe for use by healthy people above six months of age, including elderly people and those who have pre existing medical conditions.
  • The nasal spray flu vaccine: this contains a weakened version of the influenza virus, and is safe for use with healthy people between the ages of 2-49, not including pregnant women.

The yearly vaccine cycle should ideally begin in September as influenza viruses are active at the earliest by October, and are at their peak during January.

Treatment of influenza is usually through prescription medicines. Since these are strong antibiotics it is highly advisable to accompany their course with a reliable multi vitamin capsule.

Ancient Visitors

I go through life with an open mind about everything. There are very few things that I can say 100% that I do not believe in because in my eyes, anything could be possible given the knowledge of its process. I’m sure that hundreds of years ago the thought of having light at the flick of a switch without a flame would have been an impossible thought. The idea of watching a box with a glass front that shows pictures and sound would have been a marvel, yet here we are with it all around us taking everything for granted without giving it a seconds thought.

What if we wanted to think bigger? What if we look to the skies for inspiration on this thought? More specifically out in to space. How could those reported flying discs have made it all the way to our planet? What are they doing here and how did they get here? The theory is that nothing can travel faster than light so disregarding any wormhole theories or the bending of space itself then we have a bit of a pickle.

I watched a program on the TV the other day called Ancient Aliens. A lot of it seemed like ‘episode fillers’ in my opinion but there are a few things that stick in my mind. Particularly the ancient depictions and drawings of the visitors from out of space. They seem incredibly human like in most cases, but what if they were human? How could that be possible? Well here is a curved ball I will throw out there. Given my initial thought that anything could be possible with the right knowledge, who is to say that those ancient visitors and the discs that some people claim to see flying around the world are not humans from the future? What if somewhere in the distant future some clever scientists put their minds together and devised a way to travel back in time? We would not be able to see much evidence of this because no doubt it would be heavily policed. As with any society though there are always law breakers, maybe somewhere, someone decided to go back in time and help the civilizations of the past. It would certainly give an explanation as to how certain things were built or created that seem far too advanced for its time and in some cases too advance for us.

Is it possible that the pictures and carvings we see of the people of the skies are actually humans from the future? Well all I can say is it’s certainly not impossible!

Natural Chronic Pain Relief Using Combination Tens – Interferential Device at Home Or Office

Tens and interferential units are both used to block the pain signals along sensory nerve routes and often are used as natural and effective pain management. Interferential Stimulation differs from TENS because it allows a deeper penetration of efficacious electrical current in the tissue with more comfort (compliance) and increased circulation. ‘For example, at a frequency of 4,000 Hz (Interferential unit) capacitive skin resistance is eighty (80) times lower than with a frequency of 50 Hz (in the TENS range).

TENS (Transcutaneous Electrical Nerve Stimulation) was designed to stimulate sensory nerve endings in order to decrease the perception of pain. The stimulus blocks pain signals passing along the nerves to the central nervous system. There are many articles that also say TENS will produce excess production of natural pain killers which will control pain but in practice this methodology with TENS rarely is efficacious. TENS blocks pain signals to the brain/spinal cord. TENS stimulation is characterized by biphasic (positive/negative) balanced charges and user selectable pulse width and pulse rate.

Interferential therapy (IF/ IFC) is often described as ‘deep TENS’. Interferential therapy is two high frequencies of 4,000 cycles per channel, overlapping, resulting in 8,000+ pulses per second in the affected area. That enables the electrical currents to penetrate deeper into the tissues. The extra frequency allows the frequency over 8,000,(1- 150) the benefit of low frequency stimulation without the uncomfortable effects of TENS. Interferential therapy offers not only pain relief, but also contributes to acceleration in healing, increased blood flow and edema reduction.

The basic goal of interferential current therapy is to give a pleasant sensation during treatment and achieve deeper tissue penetration allowing carryover pain relief. The uncomfortable sensation felt by many patients using TENS is due to the resistance of the skin to the passing electrical currents. The level of discomfort is inversely proportional to the frequency of stimulation. Hence, the lower the frequency applied, the greater is the discomfort felt. Interferential current therapy uses two medium frequencies applied at the same time in such way that their paths cross and interfere with each other. The interference between them leads to changes producing modulated frequency that has the same therapeutic effects as low frequency stimulation, but without the normal side effects of unpleasant sensation or discomfort.

Interferential therapy is safe and has no side effects. While the interferential therapy is very effective, it causes a minimum skin sensation and the level of discomfort related to the electrical stimulation.

Conditions that respond to TENS & Interferential include the following:

-Rheumatoid Arthritis,

-Osteoarthritis,

-Post Amputation Pain/Phantom Limb Pain

-Back Pain,

-Lumbago,

-Sciatica,

-Whiplash,

-Sports Injuries,

-Neuralgia,

-Skeletal Pains,

-Muscle Aches,

-Cancer Pain,

-Menstrual Pain,

-Labour Pain,

-Tension – Migraine

-Travel Sickness

-Insurance Reimbursable

Tens has been recognized as efficacious and the rent and purchase paid by almost all major insurance companies for decades, including Medicare (HCFA), when used for chronic pain. Medicare will pay for an interferential treatment in a health facility but does not pay for the rental/purchase of an interferential unit. Many patients have not had the money to pay out of pocket for an interferential unit even though the benefits are obtained in the clinical setting . In certain instances a patient may have coverage for “DME”, durable medical equipment, such as wheelchairs, potty seats, canes, crutches, and walkers. If the patient has DME coverage then in almost all situations Interferential may be covered.

The combination of TENS and IFC in one unit now means when the unit is prescribed for chronic pain that even Medicare will cover it. The new combination IFC/TENS device with both modalities will open up new treatment parameters for patients now that an IFC unit can be rented or purchased by a patient.

Chest Pain: Causes and Treatment

In medicine, chest pain is a symptom of a number of serious conditions and is generally considered a medical emergency, unless the patient is a known angina pectoris sufferer and the symptoms are familiar (appearing at exertion and resolving at rest, known as “stable angina”). When the chest pain is not attributed to heart disease, it is termed non-cardiac chest pain.

Chest pain is one of the most frightening symptoms a person can have. It is sometimes difficult even for a doctor or other medical professional to tell what is causing chest pain and whether it is life-threatening.

Chest pain and heart attack

Chest discomfort or pain is a key warning symptom of a heart attack. Heart attack symptoms include:

1. Chest discomfort or pain that is crushing or squeezing or feels like a heavy weight on the chest.

2. Chest discomfort or pain that occurs with:
a. Sweating.
b. Shortness of breath.

Causes

causes of chest pain include:

1. Asthma, which is generally accompanied by shortness of breath, wheezing, or cough.

2. Pneumonia, a blood clot to the lung (pulmonary embolism), the collapse of a small area of a lung (pneumothorax), or inflammation of the lining around the lung (pleurisy). In these cases, the chest pain often worsens when you take a deep breath or cough and usually feels sharp.

3. Chest pain is merely a symptom, not a diagnosis. Many medical problems can cause chest pain, and before the chest pain can be adequately treated, the actual underlying cause needs to be identified. The following is a list of the more common causes of chest pain, roughly in order of the frequency in which they are seen in the emergency room.

4. Heart attack. A heart attack can cause pressure, fullness or a crushing pain in your chest that lasts more than a few minutes.

5. Pericarditis. Inflammation of the sac surrounding your heart (pericarditis) causes sharp, piercing and centralized chest pain. You may also have a fever and feel sick.

6. A broken rib can be quite painful, especially when you cough or try to take a deep breath.

7. A blood clot in the lung (pulmonary embolism), which usually causes deep chest pain with the rapid development of extreme shortness of breath.

Treatment of Chest Pain

Taking care of yourself at home
If your doctor has ruled out serious causes of chest pain, it is likely you will make a full recovery. General self-care suggestions include:

* Follow your doctor’s advice about treatment.
* In the first few days at home, try to take it easy.
* Rest if you feel tired.

Standard treatment begins with coronary angiogram to determine the presence of disease and medication therapy. As disease severity progresses, treatment moves to interventional strategies, such as stents or coronary artery bypass surgery. The majority of patients with coronary artery disease achieve excellent results with these standard therapies.

Extenze Review – Enlarge Your Penis Naturally by Using Extenze

There are several male enhancement pills on the market but Extenze happens to be the most talked about supplement that enlarges your penis naturally. Apart from increasing the size, it also enhances your sexual stamina for longer erection. As advertised in the info commercials, Extenze is indeed the most natural supplement that helps you experience the most satisfying sex.

Scientists have constantly been at work to find a way to increase man’s potency and sexual performance. Viagra and other such enhancement pills have also been tried and tested by many of us. However the problem with Viagra is that it is a prescription drug therefore most people do not visit a physician in the first place. Even if they consult a doctor they often feel embarrassed to report the weekly progress to the doctor which results either in side effects or no effects at all.

On the other hand Extenze is a non prescription supplement therefore any one can use it. It is a complete herbal product therefore it does not require FDA approval either. It works on the simple principle of pushing more and more blood to the penis which stretches the blood chambers. When you keep using Extenze on regular basis i.e. just one pills a day; the blood chambers of your penis are stretched to their maximum possible limits. The net result is a longer and harder penis.

Following are some of the most important benefits of Extenze:

  • It is made of herbal ingredients therefore you need not worry about any side effects.
  • It makes your erection very hard that lasts longer resulting in the most satisfying orgasm that you can imagine.
  • Unlike other penis enhancement pills, Extenze can be used by men of any age group
  • It starts working instantly. Some people start experiencing the difference in their libido and sexual performance within a day or two.
  • Results are permanent therefore you need not spend money on useless products that give you temporary satisfaction.
  • Free trial offer of Extenze guarantees the results they claim in commercials. There is no risk in trying it.

Unlike many other penis enlargement programs like pumps and weights; it is the safest product on the market. As already mentioned above it works within a day or two. Even if your body is slow in responding, it does not take more than a week to show the results. Extenze has been ranked as the most effective penis enlargement pill on the market today.

Tips to Reduce Risk of Type 2 Diabetes

Type 2 diabetes is a noteworthy health risk over the world. Diabetes risk groups incorporate overweight, obese person and additionally the individuals who have a family history of diabetes. Know how to reduce the risk of this disease through this article.

Type 2 diabetes affects a many people over the world consistently. In fact, it has turned into a primary cause of death amongst elderly people. Unfortunately, many young people are additionally falling prey to this disorder. An unhealthy lifestyle can be credited to diabetes at young age. Diabetes, as it may be, can’t be cured totally. Fortunately, it can be controlled with the help of specific medications and lifestyle changes. People who are at high risk of developing type 2 diabetes must go for diagnostic test to prevent the risk of developing one.

Ways to Avoid Type 2 Diabetes

Diabetes is a condition which results because of poor use of insulin in the body. Insulin is a hormone produced by pancreas. It is mainly in charge of maintaining normal glucose levels in the body. When you eat, the food is separated into sugar or glucose. This glucose enters the bloodstream to achieve the cells, where it gets changed over into energy. However, when the insulin is not absorbed or used properly, the process of conversion of glucose to energy can’t be completed. As a result of this, the blood glucose levels in the body remain for all time elevated. This leads to hardship of energy to cells of different organs. Prolonged diabetes may result in kidney dysfunction, liver damage, blindness or stroke.

In the event that you have diabetes in your genes, you beyond any doubt can’t make a move. Yet, you can keep a tab on it, on the off chance that you know you have a place with the risk group. People who are obese have a far superior shot of controlling diabetes, as they should simply lose weight. It has been logically demonstrated that a little percentage of weight loss definitely cuts down your risk of developing diabetes. The percentage can be as little as 5 to 7%. People weighing 200 pounds or more, can lose 10 to 15 pounds on the off chance that they go for this little percentage loss.

The most effective method to Reduce Diabetes Naturally

Diet and exercise are the main ways of controlling diabetes naturally. Practicing helps you to hold your weight under control. Secondly, it additionally helps in maintaining hormonal balance in your body. This results in proper absorption of insulin in the body. In this way, your odds of regulating glucose levels in the body are moved forward. People suffering from the risk of diabetes can benefit a great arrangement by working out for no less than 5 days a week. On the off chance that you are not a gym person, then you can in any case accomplish weight loss by brisk walking for 60 minutes day by day or 5 days a week.

Regular screening for diabetes additionally results in early discovery of abnormal sugar levels. This can help you in taking appropriate measure. Diabetes may likewise happen briefly in pregnant women. Symptoms of diabetes in pregnant women are like chronic diabetic patients. However, to reduce the risk of diabetes amid pregnancy, one ought to consult their doctor.

In this manner, diabetes can be controlled by receiving certain straightforward measures. A healthy lifestyle goes far in keeping diabetes as well as many different diseases under control.

Natural Remedies For Bronchitis

Natural remedies for bronchitis can be used to relieve symptoms related to the disease. These are wheezing, an expectorant cough, fever, fatigue, shortness of breath and chest pains. The wheezing and shortness of breath is as a result of mucous building up in the airways to the lungs and thus blocking the passage.

Remedies can be taken to deal with this problem. Since bronchitis is as a result of inflammation of the airways by pathogens, measures should be taken to get rid of them. These are viruses and bacteria. Viruses that cause the condition are: syncytial, rhino virus, influenza and adenoviridae viruses. The bronchitis infections caused by these viruses usually disappear on their own after a few days.

Natural remedies for bronchitis should be taken after a diagnosis by a doctor. This is the only way you can confirm that you are suffering from bronchitis. The diagnosis involves tests done to the sputum and blood. They reveal the pathogens causing the infection.

Most people take natural remedies for bronchitis as an alternative for bronchitis medication. Most people take self medication without consulting a doctor. This is highly discouraged as this can lead to health problems. Bronchitis if not treated can progress to pneumonia or asthma. If you are taking the natural remedies for bronchitis and the expectorant cough persists for more than a month, you should seek medical attention. This cough may be as a result of other conditions apart from bronchitis. You should also ensure that your immune system is at its peak.

Obesity: Three Things to Avoid

By general acceptance, obesity is the result of bad nutritional habits.

A bad habit is like second nature and it is acquired over a long period of time. They are implemented into the subconscious driving human behavior to negative consequences.

Bad nutritional habits influence weight condition leading to obesity. Some of the causes of bad nutrition habits are boredom, stress, tension and different complexes. Food becomes the substitution for these causes and before too long, obesity sets in. Most people become concerned that they're obese, eat more and a vicious cycle is established.

If you are desperately trying to keep your own front in the battle of overeating, then here is something that you should be wary of: stress, sleep deprivation and tempting food.

  1. Stress. Stress and obesity go together. In essence, stress itself is not negative but its outcomes are. Overweight-ness and obesity are related to stress in more than one ways. Stress may leads lack of control of over eating. Stress is associated with bad nutritional habits like eating much more rapidly than normal or eating until feeling uncomfortably full. You must have experienced that you subconsciously tend to eat unhealthy food in unreasonable amounts when you are tense.
  2. Sleep deprivation. Get some sleep. It a surprisingly strong link between the amount of shut-eye people get and their risk of becoming obese. Sleep deprivation lowers leptin, a blood protein that suppresses appetite and seems to affect how the brain senses when the body has had enough food. Sleep deprivation also raises levels of grehlin, a substance that makes people want to eat.
  3. Tempting food. Studies have shown that when there is more choice available people tend to eat more. Even the sight or smell of tempting food can override the body's natural mechanism of regulation so people eat large amounts of food when not feeling physically hungry.

Live Worm Fishing

The very first time that you went fishing, what did you use to catch fish? I mean way back, when you were a kid, what did you used to use to catch fish? More than likely a live worm. Everyone knows that live worms are a great way to catch fish. The problem is that many anglers either stop fishing with worms after the age of 12 or continue to fish in the same manner that they did when they were 12 for the rest of their lives. This makes no sense to me, we don’t do anything in our lives in the same manner as we did when we were kids, except of course the way we fish a live worm!

Most people tie on a large hook (size 4 or bigger) and then attempt to “thread” a live worm onto that hook. Either that or they simply hook the worm over and over again, thus creating what I like to call a “worm ball”. You see, this is fine when you’re a kid, because you don’t know any better, and aren’t really “fishing” anyway. When you’re a kid, you’re just trying to catch a fish.

Now that we’re all adults, we need to begin fishing live worms properly. What’s properly? Properly is making that live worm look as natural as possible. In order to consistently catch fish, and more importantly to catch trophy fish, a live worm needs to be presented naturally. Your worm needs to look as if you simply threw it in the water. Do you honestly think that a worm ball or a worm that’s been threaded on a size 4 hook looks natural?

The most effective way to present a live worm naturally is through the use of gang hooks. What are gang hooks? A set of gang hooks is simply 2 small hooks ties in tandem. A set of pre-tied gang hooks enables the angler to present a live worm in a completely natural manner. When rigged on a set of gang hooks, a live worm looks the same as it does without any hooks in it! This is an incredibly big advantage to the angler. Not only that, but the fact that there are 2 hooks effectively doubles your caches of a hook set!

When it comes to live worm fishing, gang hooks are the only way to go. If you fish with live worms, a set of gang hooks will literally help you catch more fish. You don’t watch the same movies as you did when you were a kid, so why fish a live worm in the same way?

Snowboarding And Skiing Injuries Advice Including Acl Injury And Achilles Tendon Rupture

It is that time of year again when many people go skiing and snowboarding only to return as ‘patients’, following a variety of different injuries.  The two sports are quite different and so are their injuries.  We shall look at a knee injury common in skiing, an ankle injury common in both sports and a wrist injury common in snowboarding.

Knee injury – Anterior Cruciate injury

What is the injury
The Anterior Cruciate Ligament (ACL) joins the ends of your thigh bone (femur) and your shin bone (tibia) together, and through little strain gauges within it, helps your brain understand the amount of pressure going through your knee.  This allows your brain to make reflex decisions about how much muscle strength to switch on to protect your knee when you’re skiing.  Sometimes when your muscles are weak, you are untrained or if you were to hit a mogul abnormally, this usually efficient process doesn’t work and you get injured, sometimes tearing or rupturing your ACL.  When this happens you will often hear a snap or tear in the knee and immediately know that it ‘went’.  Your knee will usually swell and it often becomes difficult to take weight through your knee too due to pain and also because it feels unstable.  Sometimes this injury will require surgery.

How it is treated
Acute  As with any acute traumatic injury, Rest, Ice, Compression and Elevation (R.I.C.E) can be useful. While there is swelling in the joint, a compressive knee brace can help reduce the fluid build-up and also protect it while it is vulnerable.
Brace/support – Compression Cold Therapy – Cryo/K

Rehab  Once the swelling has gone down you can start to think more about getting the knee stronger again and to start to use it more normally.  At this time its really helpful to use a Rehab-type brace to provide extra protection while you are starting to put the joint under more controlled pressure and also to keep the swelling in check.

Brace/support – ACL/PCL Functional Knee Brace
Part number: CIFK

Prevention For a period of time after your injury it is often advisable to wear a sports brace to provide support as you build back into skiing again.  It is important that the brace is not too cumbersome so as to prevent freedom of movement and also not being too supportive to prevent the muscles from learning how to work properly again.
Brace/support – CoolMesh Hinged Patella Control Support
Part number: MPHK

Exercise tip
During the acute phase it is important to rest the joint so it has time to recover, but it is also important to keep it as mobile as possible.  Getting the balance right between the 2 is crucial to a quick and effective recovery.  Sitting on a friction-free surface like a wooden floor and slowly bending and straightening your knee can be very helpful if your knee is stiff, gradually increasing the range as you work at the exercise.

Ankle injury – Achilles Tendon rupture

What is the injury
Although over the last 20 years the number of ankle injuries have reduced while skiing and snowboarding, they can still occur, even inside a protective ski or snowboarding boot.  One example is a ruptured Achilles Tendon (AT), particularly common if you are male and over 40, when the tendon tends to weaken anyway.  The AT is part of the calf muscle and its job is to push you forward when you walk and to help control the landing when you ski or snowboard.  If the landing is ill-timed or awkward then you are more at risk of rupturing your AT.  You will often know if you have ruptured it from a sharp stabbing pain at the back of your leg near your heel, people typically will feel like they’ve been shot.  This means you will not be able to walk and when you are lying on your front you will not be able to point your foot.  This is a very serious injury and

needs to be managed quickly and correctly to get you back skiing or snowboarding again.

How it is treated

Acute – very early on a decision needs to be made whether you will need surgery or not, and your background and sports intensity and frequency will have a bearing on the right decision for you.  As with all soft tissue injuries Rest, Ice, Compression and Elevation (R.I.C.E) is helpful while this decision is being made.  Your medic or therapist will supervise this but if surgery is not required in your case, then you will need a brace that completely fixes your ankle and stops it from moving.  This may allow the 2 ends of the AT to knit together again. 
Brace/support – CRYO/A – Compression Cold Therapy

Rehab – Once the AT has started to knit together (with or without surgery), then you must start to use it again and gradually build up its strength and mobility.  At this point a support to allow controlled movement while still offering some protection is important.
Brace/support – AAB

Prevention – The best way to prevent this injury is to have great calf flexibility and strength.  If you perform a sport that requires a lot of jumping or landing your AT should be quite well prepared for skiing and snowboarding. 
Brace/support – Stirrup Ankle Brace with Air/Gel Pads
Part number: AGSAB

Exercise tip
Calf stretching with your knee bent and straight is important to regain the full bend in your ankle again.  Also your calf strength must be regained quickly too.  Sitting with a weight on your knee while raising your heel up and down will help to strengthen the right muscles.  Try putting the balls of your feet on a 2″ block, this is will increase the stretch at the bottom of the movement.

Wrist injury – Dislocation of the carpal bones in the wrist

What is the injury
The carpals are the small, delicate bones at the bottom of your hand where it joins your wrist.  They can be dislocated by a heavy fall while you are snowboarding, and can very painful indeed. It is initially hard to tell the difference between this dislocation and a fracture.

How it is treated
Acute – Make sure its a dislocation of the carpals and not a fracture by seeing a doctor and getting an x-ray. Assuming its a dislocation then it should be protected by using a firm brace and the R.I.C.E method.
Brace/support – CoolMesh Wrist Palm Brace
Part number: MWP

Rehab – when you have clearance to do so, you need to start to gently mobilise the wrist by doing specific exercises which you will be shown by your therapist.

Prevention – People often find that a support to help you return to snowboarding gives you the confidence to start to use it again yet still provide some help until its stronger.
Brace/support – 3D Wrist Palm Support With Gel Pad – FKW – BB
Part number: BM/EWB

Exercise tip
A good one to start with when you are ready is to hold your hands up in front of you with your palms facing each other as if you were praying, with your fingers pointing to the ceiling.  Keep your arms still and elbows as high as they will go.  Keeping your hands together, slowly turn your hands so your fingers are pointing away from you and then towards you.  Start slowly and gradually increase over the coming weeks.

For more information about Pain Control and to purchase a knee support

Visit http://www.paincontrol.co.uk

Dry Skin Rash – How To Cure Your Eczema

Dry Skin Rash, Psoriasis or eczema are all unpleasant skin conditions. I should know I suffered for over thirty-five years with the dreaded skin disease.

But now I am totally cured. I cured myself by seeking information from doctors, skin specialists and friends. It took a while but eventually I found a treatment that not only transformed my skin but also eliminated my eczema completely.

The most important aspect of the treatment was that it was all natural; no drugs, no magic potions and no cortisone ointment.

Within a few days my skin healed and become smooth and velvety. The itching first deteriorated and then stopped altogether. There were other benefits to my health that were unexpected including feeling more energetic, and having stronger hair and nails.

Here are a few of the things I did in order to totally cure my Dry Skin Rash:

#1 – Dry Skin Rash – How to Cure Eczema

One of the first things I did immediately was to increase the amount of raw foods that I ate and decrease the amount of cooked foods. At least once a day I eat a meal that was at least 65% raw which included loads of fresh chopped vegetables, a mixture of two or three bean sprouts, a large plate of fresh salad and a little bit of fruit. I included some fish as a protein source.

This sort of meal delivered the much needed vitamins, enzymes and minerals a problematic skin needs.

#2 – I also ensured that I prepared two large fruit or vegetable juices per day. Sometimes I added wheatgrass and sometimes I included bean sprouts. The beneficial nutrients in juices are delivered to every cell in the body within 20 minutes of consumption. Juices are excellent detoxifiers which cleanse and nourish the deprived skin.

#3 – I tossed out all the dairy products from my kitchen. That included cheese, milk, yoghurt and eggs. My skin tends to react to dairy products but I sometimes developed a strong craving. Since changing my eating habits however this craving has totally disappeared.

#4 – I included several tablespoons of omega 3 and omega 6 into my meals by eating foods that contained essential fatty acid. Very good sources include Extra virgin olive oil, advocado and flax seeds. Essential fatty acids lubricate the skin from the inside and help quicken the healing process of broken or damaged skin.

Dry Skin Rash, Psoriasis and eczema are unpleasant. If you want to use a treatment that doesn’t involve using drugs or cortisone ointments you should look at the foods you eat.

I was able to totally transform my skin, my general health and the way I looked within a very short space of time, although I had suffered badly with skin problems for over thirty five years.

Look to change the foods you eat. You will not regret it. But don’t expect miracles overnight. Stick with the food transformation and you will eliminate your skin problems.

Here’s to smooth, velvety skin.