How To Cure Insomnia Naturally ???

How to Cure Insomnia Naturally – Learn How to Cure Insomnia Naturally

 What Is Insomnia?

Insomnia is the perception or complaint ofinadequate or poor-quality sleep because ofone or more of the following:

  • difficulty falling asleep
  •  waking up frequently during the nightwith difficulty returning to sleepn
  •  waking up too early in the morning
  • unrefreshing sleep

Insomnia is not defined by the number ofhours of sleep a person gets or how long ittakes to fall asleep. Individuals vary normallyin their need for, and their satisfactionwith, sleep. Insomnia may cause problemsduring the day, such as tiredness, a lack ofenergy, difficulty concentrating, and irritability.

Insomnia can be classified as transient (shortterm), intermittent (on and off), and chronic(constant). Insomnia lasting from a singlenight to a few weeks is referred to as transient.If episodes of transient insomniaoccur from time to time, the insomnia is saidto be intermittent. Insomnia is consideredto be chronic if it occurs on most nights andlasts a month or more.

What Causes Insomnia ?

Certain conditions seem to make individualsmore likely to experience insomnia.Examples of these conditions include:n advanced age (insomnia occurs more frequentlyin those over age 60)n female gendern a history of depressionIf other conditions (such as stress, anxiety, amedical problem, or the use of certain medications)occur along with the above conditions,insomnia is more likely

Treatments For Insomnia

Insomnia is not a disease but a disorder caused by other problems. Before you can find a cure for insomnia, you have to learn to deal with your problems. Whether the cause is stress, depression, or other reasons, you will probably need to discus your sleep issues with a doctor. They prescribe medications or treatments that will help with anxiety and depression. However, be aware that these medications, if taken over extended periods of time, may interfere with your sleep as well and could be addictive. Medications may have side effects such as drowsiness and lack of focus during the day. Remember that insomnia is a symptom brought on by other problems. Medication may prove effective for short term but to get a healthy night’s sleep, you need to find and treat the cause of the problem. Besides your family doctor, a psychologist might be able to help with insomnia. They can give you techniques to help you relax and ease stress.

Other than professional help, there are some common methods you can use to help deal with insomnia. One of the most important is to keep regular bedtime and waking hours. Go to bed at the same time every night and try to wake up at the same time every morning. What this does is resets your body clock and trains your body to sleep regularly. If your daytime and nighttime hours are erratic, you will naturally have problems sleeping. Try not to nap during the day because that will only throw your body’s clock off. You want to train to sleep for a period of eight hours, not in blocks of a few hours at a time. Avoid napping during the day if you aren’t sleeping at night.

Being healthy is a key to a good night’s sleep and exercising can help with that. Try to exercise regularly but do it during the day or several hours before bedtime. Exercising right before bed will only interfere with sleep because your heart rate will be increased and it will only keep you awake.

Speaking of being healthy, don’t snack right before bedtime. Your last meal should be two or three hours before you go to sleep. Watch what you eat at night, too. A big, heavy meal at night is more difficult to digest. If you eat a huge meal right before you lay down, it can upset your digestive tract. If you are hungry and need a snack before bedtime, eat something healthy like fruit or yogurt. It is also a good idea not to drink any liquids before bedtime or else you may have to use the bathroom in the middle of the night which will interrupt your sleep.Above all else, don’t use excessive amounts of stimulants like caffeine. Too much coffee or sodas during the day (or at night) can make it difficult to go to sleep at a decent hour and stay asleep. Energy drinks are also a bad idea at night. Also, there are some medications such as diet pills and cold medications that actually speed up your body’s metabolism. These medications will only interfere with getting to sleep. And never use alcohol as a remedy for insomnia. While moderate amounts of alcohol might make you relaxed, the continued use of alcohol will only end up having the opposite effect by keeping you up at night. As your body adjusts to the alcohol levels in your blood, you will have to consume more in order to get drowsy enough to get to sleep. Before too long, the alcohol will become a problem all its own.

There are alternative treatments also available to cure insomnia naturally a part from medications and other over the counter treatments.

Toenail Fungus – Natural Remedies for Toenail Fungus

Toenails of people of all ages can undergo a range of changes, some of which are relatively common. They can become thick, brittle, curved, discoloured, infected, clubbed, bumpy and grooved. In some cases, the nail falls off and a new one grows in. As we grow older, we are more likely to develop toenail problems.

Toenail problems are common complaints in the podiatrist’s office. They include thickening, brittleness, discoloration, and ingrown toenails. Nails, like hair, are an appendage of the skin. They are formed by layered sheets of protein with traces of other substances. Contrary to popular belief, there is very little calcium in nails. The normal toenail may be from 0.05 to 1.0 mm thick, and grows its full length in about six to twelve months. Nails are harder than skin, due to their high sulfur content and lack to water. The normal nail is translucent, and one can see the underlying pink nail bed.

Fungal infections are common on both fingernails and toenails. Toenail fungus also known as onychomycosis is caused by a group of fungus called dermatophytes. These fungus are harmful because as they grow they feed on the keratin that makes up the surface of the toe nail. The two fingers that are more likely to be affected are the big toe finger and the little toe finger. Toe nail fungus causes disfiguration and discoloration of the nails. It is a contagious disease and some times it may be hereditary.

Natural Remedies for Toenail Fungus

Put equal amount of tea tree oil and lavender oil on a cotton ball or swab. Dab it under the top edge of the toe nail and surrounding area 2 or 3 times a day. Tea tree oil is natural antibiotic and lavender will help fight the infection and prevent skin irritation.

Soaking the affected nail(s) with distilled vinegar kills off the fungus rather quickly. Apply daily after bathing and let the vinegar dry thoroughly before dressing.

The best shoes to wear are those that allow plenty of air and moisture exchange. Look for air-breather holes on the sides, natural materials (plastic shoes do not allow air and moisture to pass through), and a comfortable fit. If you have a fungal condition already, sprinkle into your shoes a good anti-bacterial powder.

Half soy sauce and half pine sol in a dropper for as long as it takes your toe nails to grow back out, a few drops after every shower, this is an old chinese remedy. My toe nail was brand new in 10 months!

vinegar being used as a non-toxic household cleaner. But most people have probably never heard of it being used to get rid of nail fungus. Vinegar is an acid. Nail fungus does not like an acidic environment. What you are supposed to do is spread the vinegar all around the infected toenail. Be sure to get it under the nail where the toenail fungus lives. You can’t skip a week or even a day! You must keep vinegar on for as long as it takes to get rid of the fungus. Basically that means until every bit of the infected toenail has grown out. If you skip a day the fungus will move right back into the newly grown toenail and you will have to start the process over again.

Kerosene helps reduce the irritation of hemorrhoids and will help stop the bleeding and infection of a cut. While he does not list its use in his book, Duplantis said many people have used turpentine as an arthritis rub and even mixed it with honey and lemon for cough suppressant.

Toenail Fungus Cure With Home Remedies

Nail fungal infections are common forms of infections where the fungus attacks the nails of the finger and toe. These infections normally start from one area and then spread on to the entire foot. If not nipped in the budding stage, they can be really painful and damaging. Toenail fungus infections are more common because the foot normally remains covered with socks and the dampness proves to be a nurturing ground for the fungus.

During earlier days, surgery was treated as the option to cure fungus from the affected part. With the advancements in medicine science, we are lucky to have medications in the form of ointment and capsules for treating toenail fungal infections. Nevertheless, nothing can substitute the natural home remedies to cure toenail fungus.

The toenail affected by fungal infection generally turns yellowish in color due to accumulation of pus and fungus. The fungus activity can also cause the area to get inflamed and this can be extremely painful. At times there is a pus discharge that can lead to the spreading of the infection and the toenail can become vulnerable.

There are some tried and tested natural home remedies that seem to be effective in curing and preventing toenail fungus infection. These remedies have also won recognition from the medical fraternity for being faster and 100% safer remedy for toenail fungal infection.

Damp off: One of the popular remedies is “Damp Off”. This is an effective cure for not only toenail fungal infection but also for stomach related disorders such as diarrhea, gastritis, gastroenteritis etc. The common ingredients used in this are a scientific mix of Atractylodis Alba, atractyloidis, polypolus, poria cocos, citri reticulate, alismatis, cinnamomi, jujube etc.

This Home remedy is good for your spleen as well. As the name suggests, this prevents dampness of the toenail area and helps it remain dry. It is extremely effective in treating toenail fungal infection and even infection caused by yeasts.

Fungo off: This preparation is available in capsules form. It is meant to boost the immunity of the body. It is one of the best available oral cure for toenail fungus infection. This remedy provides a faster and effective protection from fungal and yeast infections of the toenail. The contents of this preparation include viride, citrus peel, capilaris, poria, tokoro, atractylodis, gypsum etc.

It completely destroys the infection and also prevents the infection from recurring. The pricing of $35 per 90 capsules makes it very competitive and easily accessible.

Fungo balm: This balm is priced at $27 for 60gms. Its softer and smoother feel heals the fungal infected toenail by forming a thick layer of protection from moisture and thus helps in keeping the area dry. This is also effective in curing ringworm, athlete’s foot and tinea infection. It contains active ingredients such as kochiae, gypsum, zinc oxide, cnidium etc.

Fungo lotion: This natural home remedy for toenail fungus contains melia, dictamium, borel, and cnidium in vinegar -sugar solution. When used in combination with fungo balm, this yields faster results. This lotion should be massaged on the infected toenails (for approximately 5 minutes) followed by the fungo balm. It costs $27 for a 60 ml bottle.

Symptoms and Treatment of Ankle Sprains

Swelling of the lower leg and ankle is a common problem. Determining the cause of ankle swelling is the first step to finding effective treatment. Once the cause of the ankle swelling is determined, effective treatment can be initiated. Painless swelling of the feet and ankles is a common problem, particularly in older people. It may affect both legs and may include the calves or even the thighs. Because of the effect of gravity, swelling is particularly noticeable in these locations.

Ankle sprains are one of the most common musculoskeletal injuries. Sprains are injuries to the ligaments of the ankle, causing them to partially or completely tear as a result of sudden stretching. They can occur on either or both of the inner and outer portions of the ankle joint. Ankle sprains more commonly happen when there is a preexisting muscle weakness in the ankle area or a history of previous ankle injuries. The typical injury occurs when the ankle is suddenly “twisted” in a sports activity or by stepping off an uneven surface.

Ligaments are injured when a greater than normal stretching force is applied to them. This happens most commonly when the foot is turned inward or inverted. This kind of injury can happen in the following ways:
Awkwardly planting the foot when running, stepping up or down, or during simple tasks such as getting out of bed
Symptoms
When you sprain your ankle there is sometimes a snapping or popping sound and a feeling of “giving way” as a ligament is torn or bone cracked. A sprain can be very painful, with the pain getting worse when you move your ankle. With a severe sprain, you may not be able to bear weight on your leg.
You may have swelling and bruising. Swelling happens soon after the injury but bruising can take up to 24 hours to fully develop. The swelling around your ankle can make it difficult to move your foot, and your ankle may feel unstable.

Relief and Prevention:
The hallmark of treatment is to reduce foot, leg and ankle swelling, and the first line of defense: leg elevation. Elevate legs above the level of the heart, which puts minimal pressure on the backs of the knees and thighs and lower back. Just sitting in a reclining chair in front of the TV is a great way to elevate your legs. Many products, for use at home or at work, can also help reduce swelling.
Brace- Wear a brace that compresses the injured area but allows full range of motion. A compressive brace will help control swelling and provide gentle support to a weakened joint. A brace made of elastic or neoprene will work great. Older braces should be replaced with new ones to make sure to keep its compressive ability.

Exercise: When able to bear weight without pain, stand in a doorway placing all your body weight on the injured ankle. Balance yourself by holding on to the door. As you start to gain more balance, close your eyes. This isolates the ankle and re-trains the proprioceptive receptors (tiny nerves receptors found in the joint) to improve your balance and to stabilize your ankle. If you perform this activity for 5 minutes every day for 2 weeks your ankle will feel much stronger.

Electric Shavers: Enjoy Cut and Bruise Free Shaving

If once a week, you get unwanted cuts and bruises while shaving then there is a good news for you. The experts have come with an electronic shaver, so that the users can enjoy the smooth shaving process without any displeasing experience. With the help of electric shaver, one can get away from any sort of unwanted irritations. Nowadays, these widgets have become choice of men, all over the world.

While using the electric shavers, one can experience close and fine shave with a great comfort. As a matter of fact, these shavers comprise of an oscillating and moving blades. Furthermore, the moving blades help to trim and cut facial hairs on the men skin. In the shaving process, users are free from basic requirements such as shaving soaps, creams or foams. The basic necessity in the electric shaver is the electricity, which could be either batteries or main power. Usually, these electric devices come with a DC powered motor.

The electric shavers can categorised as–rotary and foil. The rotary shavers are good for cleaning or trimming the longer hairs and are sometimes preferred over foil shavers. The rotary shavers are easier to use even around difficult areas of body such as a chin and neck. Importantly, in power failure circumstances, the users need not have to be worried about the process, as built-in battery gives tremendous support. The power storage system of this widget is great, as it enables storage of emergency power in the battery.

While buying an electric shaver, one must consider some important things. The most important of all is that this device should have a battery indicator. The battery indicator makes it possible for the people to manage their shaving, properly. Moreover, one should also check whether it adjusts to the power rating norms of residing country.

To conclude, the people have started accepting the electric shavers, as t it eliminates all chances of getting cuts and bruises. As a matter of fact there are some special covers over the shavers that helps the gadget to avoid unwanted cuts.

Causes and Treatment of Peptic Ulcer

In the digestive system, ulcer comprises the area where the tissue has been destroyed by gastric juices and stomach acid. Peptic ulcer disease is a general term used for ulcers that occur in the stomach or duodenum (upper part of the small intestine) or esophagus. A peptic ulcer is a sore formed due to injury in the gut lining of the stomach, duodenum, or esophagus. A peptic ulcer of the stomach is called a gastric ulcer; of the duodenum – a duodenal ulcer; and of the esophagus – an esophageal ulcer.

An ulcer occurs when the body’s acidic digestive juices, which are secreted by the stomach cells, erode the lining of these organs. Thus, the mucous membrane lining of the digestive tract is damaged causing gradual breakdown of tissue.

What are the causes of the peptic ulcer?

The main causes of peptic ulcer are –

1. Peptic ulcer is mainly caused due to an infection by a bacteria called Helicobacter pylori – also referred to as H. pylori. It is considered the primary cause of ulcers. This bacterium is found in the stomach, and along with acidic secretions can damage the tissue of the stomach and duodenal, causing inflammation and ulcers.

2. Acid and pepsin – When one eats, the food is partially digested in the stomach and the rest gets carried forward to the duodenum. Our body’s defense mechanisms are such that the stomach can protect itself from the digestive juices in various ways like production of mucus by stomach, which protects stomach tissues, and also the blood circulating in the lining of the stomach protects it. But, when the hydrochloric acid and pepsin enzymes overcome this defense mechanism of the gastrointestinal tract, it causes erosion of the mucosal wall resulting in peptic ulcer.

3. NSAIDs – Non Steroidal Anti-Inflammatory Drugs –

The most common NSAIDs which cause ulcers are aspirin, ibuprofen. Others medicines used to treat several arthritic conditions also lead to the same. They can fail the stomach’s defense mechanisms, making it vulnerable to harmful effects of acid and pepsin by reducing the stomach’s ability to produce mucus and bicarbonates, and also reducing the blood flow and cell repair in the stomach lining.

4. Smoking –

Researches show that cigarette smoking increases chances of developing an ulcer. Smoking also reduces the healing rate of existing ulcers and contributes to ulcer recurrence.

5. Caffeine –

Caffeine rich beverages and foods stimulate acid secretion in the stomach. Also it can aggravate an existing ulcer.

6. Alcohol –

While no direct causal relationship has been established which goes on to prove that alcohol causes peptic ulcer, but high co-relationship has been found which indicates that people who consume large amount of alcohol are more prone to peptic ulcer.

7. Physical stress –

Physical stress can increase the risk of developing ulcers, especially in the stomach. Examples of physical stress that can lead to ulcers are injuries such as severe burns and any major surgery.

What are symptoms of peptic ulcer?

Many a times, symptoms of peptic ulcer are late to show up. The common symptoms of ulcer disease are several and mostly include –

1. Abdominal pain –The pain is usually in the upper middle part of the abdomen, above the navel and below the breastbone. The pain often occurs several hours after a meal, which becomes worse at night and early morning, when the stomach is relatively empty. Temporary relief from pain is possible if some amount of food, if antacids are taken.

2. Burning pain in the gut

3. Nausea, vomiting, loss of appetite and unexplained loss of weight are some of the associated symptoms.

4. Bleeding – In very severe ulcers cases, bleeding in the stomach or duodenum may also occur. Bleeding can be either in the form of vomiting of blood or blood in the stool.

5. Chest pain

6. A slowly bleeding ulcer can also cause anaemia, where there are not enough red blood cells to transport oxygen around the body.

How is peptic ulcer diagnosed?

Peptic ulcer is mainly diagnosed after analyzing the symptoms, lifestyle and diet of the person. Some tests that help diagnose ulcer include a blood test, endoscopy and an upper gastrointestinal test with barium.

What increases a person’s risk of getting peptic ulcer?

A person is more likely to develop a peptic ulcer if he:

• has an H. pylori infection

• uses NSAIDs quite often

• smokes cigarettes, eats tobacco

• chronic alcoholic

• have relatives with peptic ulcers

• are older than 50 years.

How is it treated ?

A customized treatment is required based on age, condition and the extent of the ulcer, and the person’s compatibility with drugs. Generally, doctors prescribe some antacids, or inhibitors of the proton pump. If H. Pylori causes the ulcer, the patient will be prescribed some antibiotic drugs too.

Apart from drugs, few lifestyle changes are also recommended. Smoking and drinking alcohol and coffee must be totally abandoned. Avoid taking foods that causes pain and burning in the gut. The person should lose excess weight, if overweight. In case medicinal treatment is not effective, then surgery is the ultimate solution.

How to prevent peptic ulcer?

One can prevent peptic ulcers by avoiding alcohol, smoking, taking aspirin and non-steroidal anti-inflammatory drugs, which trigger break down of the stomach’s protective barrier and increases stomach acid secretion.

To prevent infection from H pylori, one should avoid contaminated food and water and observe complete personal hygiene.

Types of Ovarian Cysts

What is an Ovarian Cysts?

Ovarian cysts are small fluid-filled sacs usually found on the surface of a woman’s ovaries. They’re part of a woman’s monthly menstural cycle but rarely show signs or symptoms of ovarian cysts. However, some types of ovarian cysts can cause serious health problems.

Types of Ovarian Cysts

1) Functional (physiologic) cysts – This is the most common type of ovarian cysts. Fuctional cyst are caused mainly by slight changes during the menstural cycle. Normally your ovaries grow small cysts like structures called follicles at the end of the ovualtion period and every. Tthese small cysts like stuctures usually go away by themselves but sometimes the fluid-filled cyst doesn’t die off like it should and stays around for a little while.

There are two types of functional cysts: follcular cysts and Corpus leteum cyst which are named according to the half of the cycle at which they appear. Follicular cysts appear in the first half; luteal cysts appear in the second half.

    Follicular cyst – Each month an egg-making follicle of your ovary releases an egg. This process is called the “LH surge”. However, in the case of follicular cysts, the egg isn’t released or ruptured and the follicle continues to grow until it becomes a cyst. These type of cysts rarally have symptoms and are usually harmless. They can disappear within two or three menstrual cycles and may only be diagnosed when you happen to be seeing your doctor for other reasons.

    Corpus luteum cyst – This type of ovarian cyst develops in the second half of the cycle after the egg has been released. When there is a successful “LH surge” and the egg is released or ruptured, the follicle responds by becoming a new, temporarily little secretory gland called the corpus luteum. The corpus luteum produces large amounts of progesterone in anticipation of pregnacy. If the egg is not fertilised by a sperm cell, then the corpus luteum dies, progesterone levels fall and a period occurs. A luteal cyst is formed when the corpus luteum fails to die when it should, and fills with blood instead. This type of cyst will usually disappear after a few weeks. Rarely, it will grow to 3″-4″ in diameter and potentially bleed into itself, or twist your ovary, thus causing pelvic or abdominal pain.

2) Dermoid cysts – A dermoid cyst is mainly fat but can also contains a mix of different tissues. This type of ovarian cysts rarely occurs. They’re classed as turmours rather than simply cysts. They’re often small and usually don’t have symptoms. Very rarely, they become large and rupture, causing bleeding into the abdomen, which can turn into a painful medical emergency.

3) Endometrioma or “chocolate cyst” – These type of cysts form when endometrial tissue (the type that lines the inside of the uterus) invades an ovary. It is responsive to monthly hormonal changes, which cause the cyst to fill with blood. It’s called a “chocolate cyst” because the blood is a dark, reddish-brown color. Multiple endometriomas are found in the condition called “endometriosis”. Every month during your period these endometrial patches of tissues that have become encapsulated in a cyst will bleed. Because there is no outlet for the bleeding, the cyst becomes larger. Even small chocolate cysts can rupture, although they may grow very large causing severe pain.

4) Cystadenoma – Cystadenomas are cysts that develop from cells on the outer surface of your ovary. Occasionally, they grow to a large size and thus interfere with abdominal organs and cause pain. The cysts themselves may not cause any noticeable symptoms, but they can twist on their stems and then rupture, which can be extremely painful, and require emergency surgery.

5) Multiple cysts the polycystic ovary” – Women who don’t ovulate on a regular basis can develop multiple cysts. These type of ovaries are often enlarged and contain many small clusters of cysts. Polycystic ovarian syndrome is a complex condition that involves multiple hormonal symptoms and organ system dysfunction.

About Colon Cancer

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When cells that are not normal grow in the rectum or in the colon colorectal cancer occurs. This is also called cancer of the colon or rectal cancer. It forms tumors as it grows. This type of cancer usually occurs in the life of people above 50 years of age and is one of the most common types of cancer in today. It is the second leading cancer deaths in America today and what makes it to be complex is that it is not detected easily.

Usually, it starts as polyps which are little growths inside the colon or the rectum. Colon polyps are very common though not all of them turn out to become cancer. However, it is very difficult to tell ahead which polyp will graduate to cancer and which one will not. This is why it is very important for people over 50 years old to go for test and ascertain if they have any polyps and if there is, it is necessary that they be removed.

What makes this particular type of cancer to be very dangerous is that it does not have any known symptom or the symptom may hide until it begins to spread. But while observing your body, which is a normal thing to do, if you notice the following symptoms in your body, you should try to see a doctor, because probably, colon cancer might be in place.

*Pain in the stomach (belly)

*When you begin to notice blood in your stool or you notice that your stool is unusually hard.

*When you are experiencing constant spooling or you notice that your bowels are not completely emptied after trying to do so, colon cancer may be in the pipeline.

In order to be sure that you are free from colorectal cancer, or to know if you have one, the first thing to do is to subject yourself to thorough medical check up. You have to go for a test called Colonoscopy. This test helps the doctor to see the entire inside of the colon and the rectum. The doctor will then, either remove the polyps, if there is any, or take tissue samples from areas that he thinks that are not normal. He will then examine these tissues through a microscope to be fully sure if there is any atom of colon cancer or not. There are other tests that can be carried out to know if there is colon cancer in the body or not, and this type of tests are called Barium enema or sigmoidoscopy.

In treating colon cancer, there are many methods of doing so, but the most common means of treatment is by surgery. Surgery is simply a process of removing the cancer when it is detected and the best time for the surgery is at the early stage of development. However, if the cancer has spread to the walls of the colon, it may not necessary need surgery; rather, more advanced method will be applied. This advanced method is called radiation or chemotherapy. Though these methods have side effects, with proper home care and medicine, it can be taken managed. When somebody discovers that he or she has cancer, it is advised that the person should seek for counseling or advice from a doctor instead of keeping quiet and he or she will be advised on what to do thereby reducing the tension that might occur because of the cancer. Also it is necessary that the person should try and meet with people suffering from cancer like him and know how they are coping. No matter how upset the person may be, it is advised that he should not keep quiet, but rather go out and seek for counsel.

How do we prevent colon cancer?

Colon or rectal cancer is common among people who are 50 years and above, so the best the best way to prevent it is to start earlier going for screening tests. During this period, if there are certain diseases or other conditions that may lead to cancer, it will be discovered and removed. Anybody who has a family history of colon cancer should not joke with this but rather take this screening exercise serious and it must be started early.

The most common screening tests are listed below:

* Facial occult blood test. This is a process whereby a small sample of stool is collected on a special card provided by the doctor and sent for an analysis in the laboratory. Some chemical substances will be dropped on the stool and if the solution changes color, it is an evidence of the presence of cancer.

** Sigmoidoscopy. In this process, the doctor will fix a flexible viewing tube from the rectum down to colon to enable him see the lower part of the intestine which is where most of the colon cancer grows.

***Barium enema. In this process, Barium which is a whitish liquid is poured into the rectum and the colon. This white liquid makes the colon more visible with an x-ray machine.

**** Colonoscopy. Here, the doctor puts a long flexible viewing tube into the rectum and the colon. This tube will be linked to a monitor that is similar to a T.V. screen .

Surgical treatment of uterine fibroids

Mainly used in surgical treatment of large uterine fibroids, the symptoms can cause significant secondary anemia, with poor results after conservative treatment.

First, myomectomy (treatment of uterine fibroids)

1. Abdominal myomectomy for 40 years of age, unmarried or fertility, although no growth requirements, but do not want a hysterectomy were asked to retain the uterus. The advantage is to retain the uterus does not affect ovarian function; to have the chance of pregnancy as required by birth; to maintain the integrity of the female endocrine axis. Recurrence rate of 25% to 35%, possibly due to a minor surgery when fibroids are missing, after growing up, patients with fibroids Furthermore, risk factors, occurrence of new fibroids, multiple myoma recurrence rate is higher than solitary fibroids.

2. Vaginal myomectomy for pedunculated generally submucosal fibroids, surgery is simple, safe, no need to cut the uterus.

Second, after abdominal hysterectomy

1. Hysterectomy: requirements for non-reproductive, uterine> 3 months of pregnancy uterine size, fibroids, but symptoms were not large, the bladder or rectum compression symptoms, conservative treatment failure or recurrence after myomectomy, fibroids fast-growing malignant can not be excluded. The advantage is a hysterectomy and cervix removal at the same time, can avoid the future occurrence of cervical stump cancer threat.

2. Subtotal hysterectomy: 40 years of age for voluntary retention of the cervix, patients generally need to win time to rescue critical, serious medical complications can not tolerate a long surgery, severe pelvic adhesion removal of the cervix have difficulty. The advantage is the small bladder and sexual function; simple operation, short time, less surgical injury and complications.

3. Fascial hysterectomy: retained subtotal hysterectomy on bladder and sexual function in the small advantages of eliminating the retention of cervical cancer occurring in the future the threat of cervical stump; reduce the hysterectomy surgical injury and concurrent disease.

Third, endoscopic surgery of uterine fibroids

1. Laparoscopic myomectomy can be done it can also be done in the microscope, hysterectomy, abdominal surgery indication and the same, the advantage of trauma and rapid recovery. However, the high cost of its requirements of high technology, hospitals are not yet popular at the grassroots level.

2. Hysteroscopy for submucous myoma, uterine intramural fibroids the uterine cavity, some sudden, cervical fibroids, the advantage is less invasive, it can keep the uterus, and rapid recovery.

In addition, the pregnancy with the incidence of uterine fibroids fibroids account for 0.5% of patients with 1%, accounting for 0.7% of pregnancy 7.2%, during pregnancy, does not require treatment if asymptomatic, regular inspection, if the occurrence of red degeneration of fibroids, subserosal leiomyoma torsion, can be treated conservatively, if conservative treatment fails, or incarcerated in the pelvic fibroids affect pregnancy to continue, or fibroids compress the adjacent organs, severe symptoms, surgical treatment should be.

Ovarian Cysts and Endometriosis Treatment

Endometriosis is a condition caused by excess estrogen created each month in the female body. Endometriosis affect an estimated 89 million women (usually around 30 to 40 years of age who have never been pregnant before) of reproductive age around the world. Endometriosis can also cause scar tissue and adhesions to develop that can distort a woman’s internal anatomy. It is estimated that 30-40% of women with endometriosis are infertile. Endometriosis is a condition where tissue similar to the lining of the uterus (the endometrial stroma and glands. Endometrial cells are the same cells that are shed each month during menstruation. The most common symptom of endometriosis is pelvic pain. Other symptoms may include diarrhoea or constipation (in particular in connection with menstruation) ,abdominal bloating heavy or irregular bleeding and fatigue.

Ovarian cysts are enlargements of the ovary that appear to be filled with fluid. The ovaries are two organs — each about the size and shape of an almond — located on each side of a woman’s uterus. Small cysts are formed outside of the ovary, which enlarge and produce endometriosis of the ovary. Hormone stimulation during the menstrual cycle produces many small cysts that eventually occupy the normal ovarian tissue. Ovarian cysts can be categorized as noncancerous or cancerous growths. All of the following are noncancerous ovarian growths or cysts. A woman may develop 1 or more of them.Cysts are painful and potentially harmful conditions. They are an important cause of pain in the lower abdomen ( pain in area below the belly button).

Treatment options for endometriosis can depend on your age. Surgery is one of the most effective methods of treating endometriosis so long as all the endo has been removed from the offending areas. Danazol therapy should be started when the patient is menstruating. Testosterone derivatives are another medication that was developed just for endometriosis. Hysterectomy – the uterus is removed, along with endometrial implants, cysts and adhesions. Major Surgery. For severe cases of endometriosis, major surgery used to be the mainstay to remove thick adhesions and excise endometriomas (endometriotic cysts of the ovary). Surgery to remove most of the endometrial patches followed by hormone treatment may be better at long-term easing of symptoms than just surgery alone. Some women with endometriosis who want to have children may need fertility treatment.

Endometriosis Treatment Tips

1. Surgical treatment is the preferred approach to infertile patients with advanced endometriosis.

2. Oral contraceptive pills (OCPs) suppress LH and FSH and prevent ovulation.

3. Gestrinone is similar to danazol, but you only need to take it twice a week rather than daily.

4. Birth control pills help shrink endometrial tissue and improve pain for most women.

5. Stronger hormone therapy such as therapy with a gonadotropin-releasing hormone agonist (GnRH-a), high-dose progestin.

6. Caffeine, sugar and alcohol are the three most often cited items that women have removed from their diets.

Candidiasis-definition, Causes, Symptoms and Treatment

Candidiasis- Causes, Symptoms and Treatment
Definition
Candidiasis ,commonly known as a yeast infection, is a common fungal infection that appears when there is a growth of the ubiquitous fungus called Candida .Studies shows that there are more then twenty species of Candida,Out of which Candida albicans are so common that they can be found throughout the world as normal body flora.
It is also prove that when the infection appears in the mouth, it is known as thrush. If an baby has this infection, there is a possibility that the baby also has a yeast infection in the diaper area.
These fungus are exist on all surfaces of our bodies in small amounts. Under certain conditions,such as when the abnormal acidity of the vagina or when hormonal imbalance , Candida can take growth in numbers & multiply it self & cause infections, specifically in warm and moist regions. Vaginal yeast infections, thrush , skin and diaper rash , and nailbed infections are some of the examples of such infection.
Causes
This organisms are always exist in all people,. The Candida albicans organism is found in the vaginas of almost all women and generally causes no harm. But when there is imbalance with the other normal flora,It results to yeast infection. Some antibiotics , and diabetes mellitus can cause an increased incidence in yeast infections.
Candidiasis simulates number of organ systems in the body.They generally exist in warm moist body region such as underarms of the body exposed to the environment is susceptible to infection.
Generally skin effectively stops yeast, but any injuries or cuts in the skin may permit this organism to penetrate.They affected the infants in the areas include the mouth and diaper areas.
There are some common illustrative’s of this are vaginitis:

  • Vulvar rash.
  • Oral thrush.
  • Conjunctivitis.
  • Endophthalmitis.
  • Diaper rash.
  • Infections of the nail.
  • Rectum symptoms.

Symptoms
Almost all women’s have experience the genital itching or burning in some part of there life. Males with genital candidiasis may feel an itchy rash on the penis.
If it occurs in the mouth as a thrush then the tongue becomes white & white patches on the cheeks or throat & these white injury do not scrape off easily.If it occurs in the diaper area then very red lesions may be raised.
There are some of its symptom given below are:

  • Severe itching.
  • Burning.
  • Soreness.
  • Irritation of the vagina.
  • Whitish-gray discharge.

Treatments
Candidiasis is successfully cured either with home remedies or, in the case of a more severe infection, with either over-the-counter substances or recommended anti fungal treatments .An anti-fungal diaper cream can be used in the diaper areas.
Home treatments for candidiasis are the inhalation or direct application of yogurt , which retains lactobacillus , acidophilus capsules or salves, and even small crushed cloves of garlic , which yield allicin , an anti fungal.
One of the home remedy include is boric acid which act as a treatment to cure yeast infections when gelcaps are filled with boric acid powder and two are inserted at bedtime for 3 to 4 nights.
Candidiasis can be treated if it is occur in the mouth as a thrush then use anti-fungal remedy that is applied on the injury in the mouth .In case of oral candidiasis use the systemic anti fungal such as ketoconazole and fluconazole has proved effective and may have advantages over topical agents for patients experiencing mucositis.
Amphotericin B, fluconazole, ketoconazole, and nystatin are some commonly used drugs to treat candidiasis.

Symptoms of Liver Failure and Treatment of Liver Failure

Liver failure are leading causes of morbidity and mortality in the United States, with the majority of preventable cases attributed to excessive alcohol consumption, viral hepatitis, or nonalcoholic fatty liver disease. Cirrhosis often is an indolent disease; most patients remain asymptomatic until the occurrence of decompensation, characterized by ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, or variceal bleeding from portal hypertension.

Cirrhosis of the liver refers to a disease in which normal liver cells are replaced by scar tissue caused by alcohol and viral hepatitis B and C. This disease leads to abnormalities in the liver’s ability to handle toxins and blood flow, causing internal bleeding, kidney failure, mental confusion, coma, body fluid accumulation, and frequent infections.

What Causes Liver Failure

Acetaminophen (Tylenol) overdose
Reaction to a prescribed medication

In babies, the most common cause of cirrhosis is due to blocked bile ducts – a disease called biliary atresia. In this case, the bile ducts are absent or injured, causing the bile to back up in the liver. These babies are jaundiced (their skin is yellowed) after the first month of life. Sometimes, they can be helped by surgery in which a new duct is formed to allow bile to drain again from the liver.

Symptoms of Liver Failure

Intermittent recurrent abdominal or gastrointestinal upsets. loss of appetite, vomiting, diarrhea, constipation.
Progressive depression or lethargy. does not want to play anymore or refuses to go for walks.
Swollen belly with a “fluid filled” look. This is also known as ascites and is actually fluid accumulation in the belly due to circulation alterations in the abdomen.

The early symptoms of liver failure are similar to symptoms of many other conditions. Because of this, liver failure may initially difficult to diagnose. Some of the most common initial symptoms of liver failure are:

Nausea, Loss of appetite, Fatigue, Diarrhea

Intermittent recurrent abdominal or gastrointestinal upsets. loss of appetite, vomiting, diarrhea, constipation. Progressive depression or lethargy. does not want to play anymore or refuses to go for walks.

Alcoholic hepatitis is a syndrome with a spectrum of severity, and therefore presenting symptoms vary. Symptoms may be nonspecific and mild, and include anorexia and weight loss, abdominal pain and distention, or nausea and vomiting. Alternatively, more severe and specific symptoms may include encephalopathy and hepatic failure.

Weight loss- The poor appetite that occurs in liver disease eventually leads to loss of weight. Improper metabolism of fat, carbohydrates, and proteins complicates the situation also.

Treatment of Liver Failure

Currently, the goal of treatment for nonalcoholic fatty liver disease (NAFLD) patients who are obese and/or have elevated blood lipids (fat) is weight loss. Those who are diabetic with poor control of blood sugar should work with a diabetes specialist and dietitian to control their blood sugar. All patients with NAFLD should avoid alcohol.

Treatment depends on the type and stage of the cirrhosis. Its aim is to stop the progress of the cirrhosis, reversing (to whatever extent possible) the damage that has already occurred, and treating complications that are disabling or life-threatening.

If there is still not enough bile flow with the Kasai procedure, liver transplantation is a final option. A liver transplant operation removes the damaged liver and replaces it with a new liver from a donor.

After transplant surgery, the child’s health may improve quite quickly. However, the child’s body might reject the new organ. To prevent rejection, a strict schedule of anti-rejection medications must be taken.

Liver transplantation is a lengthy surgery and complications, such as infection, bleeding and even death are possible. In some cases, the new liver may be rejected by your body.

The wait for a liver donation can be long, so researchers are working on alternatives to donated livers, such as artificial livers and machines that can perform liver functions. Currently, their use is mostly limited to clinical trials.

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

The Emetophobia Recovery System

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Superfoods: Superfoods for Getting Over Food Poisoning

Food poisoning is an all-encompassing term involving the consumption of contaminated food, stomach flu, stress, drug interactions, nutrient deficiencies or their excess.  It can come on rather suddenly after eating; diarrhea or vomiting can begin 30 minutes to one hour after eating foods that are chemically poisonous; within one to 12 hours with bacterial poisoning, and 12 to 48 hours with viral or salmonella poisoning. Food poisoning can be serious and a medical professional should be contacted especially if it is accompanied by a difficulty in swallowing, speaking or breathing; if there is a fever of 100 degrees F; if the person can’t even hold down liquids; if there is severe diarrhea of more than two days.

The best remedy is to curtail eating until all the symptoms have subsided and the toxins have had the chance to exit your system. Drink plenty of fluids – vitamin C and blackberry and peppermint teas can be taken then to strengthen the stomach, along with yogurt that contains acidophilus to recolonize the lost flora in the bowel. Diluted sweetened drinks can also be consumed to replace the body’s lost fluid and electrolytes, and the BRAT diet (bananas, apples, rice and toast) can also be helpful in getting the toxins cleared from the body.
As a precaution against food poisoning, great care should be taken when preparing foods.   Avoid over-handling foods, and when in doubt, throw it out – don’t take a risk with leftovers if you’re just not sure how long they’ve been in your refrigerator.

Mint, lemon, raspberry, chamomile or teas might also be helpful in easing the stomach pain associated with food poisoning or stomach cramping.  Ginger tea is also good for settling an unsettled stomach, and promotes good digestion. Try to get plenty of rest as food poisoning can be an exhausting and nutrient-depleting chore for your body.  Once you’re feeling better, be sure to eat a well-balanced healthy diet that includes foods rich in iron, zinc, vitamin C to help your body get back to its old self again.