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TRACHEA
TRACHEA
TRACHEA
Vivek
Student:- Dr.Imran
Contains Trachealis
glands, small muscle
arteries, overlies
nerves, esophage
lymph al muscle
vessels and and
elastic fibers epithelium
Average cross-sectional
area of the male adult
trachea is approximately
2.8 cm2
Transverse (lateral)
diameter of 25 mm and
sagittal (anteroposterior)
diameter of 27 mm are the
upper limits of normal
(males)
The lower limit of normal
for both transverse and
sagittal diameters is about
13 mm in men and 10 mm
in women
U-shaped trachea (27%)
A C E
B D F
18
Cervical Tracheal
Relationships-
Anterior
Skin
Superficial & Deep
fascia.
Tracheostomy is an operative
procedure that creates a surgical
airway in the cervical trachea .
What is this & what are its indications ???
RELATIVE
Laryngeal CA(strong)
CBC
Patient/apotropus confirmation
Types of Tracheostomy
1) Open procedure
2) Percutaneous procedure
High tracheostomy (Cricothyroidectomy)
Landmark
Cricothyroid membrane Crycoid cartilage
Thyroid cartilage
Emergency Cricothyrotomy Protocol
Indications:
A patient that requires intubation and
Unable to intubate and
Unable to adequately ventilate
Conditions:
Patient 40 kg and 12 years old
Contraindications:
Suspected fractured larynx
Inability to localize the cricothyroid membrane
Techniques
2) Needle Cricothyrotomy
Low Tracheostomy
Draping
Transversely
Retracted as shown
Strap msc is divided
longitudinally at
midline
Thyroid
ismuth is
divided at
midline by 2
haemostat
and cut edge
secured by
2/0 vicryl
Depending on
the TT size abt
4cm longitudinal
opening is made
in trachea below
2nd ring
Tube is
anchored
Percutaneous Dilational
Tracheostomy
Benefits include elimination of need for
operating room use or anesthesia, and
significant reduction in cost.
Strong Analgesia
Antibiotics
Obesity
Smoking
Poor nutrition
Alcoholism
Chronic illness
Diabetes
Apnea due to loss of hypoxic respiratory drive.
This is mainly important in the awake patient.
Ventilatory support must be available .
Falseroot
Bleeding
Pneumothorax or pneumomediastinum
Damage to the vocal cords (direct)
Injury to adjacent structures: recurrent
laryngeal nerves, the great vessels, and the
esophagus.
Post-obstructive pulmonary edema
Hypotension
Arrhythmia
Early bleeding: This is usually the result of increased
blood pressure as the patient emerges from
anesthesia and begins to cough.
Plugging with mucus
Tracheitis
Cellulitis
Tube displacement
Subcutaneous emphysema
Atelectasis
Bleeding - tracheoinnominate fistula
Tracheo- and laryngomalacia
Stenosis
Tracheoesophageal fistula
Tracheocutaneous fistula
Granulation
Scarring
Failure to decannulate
Tube changes:
Indications: soiled, cuff rupture.
Complications: insertion into a false passage bleeding,
and patient discomfort.
Avoid within 1st week.
First tube change by surgeon.
Difficult cases (obese, short and thick neck), be
prepared for endotracheal intubation.
Tracheostomy tube cuff pressures ---20 to 25 mm Hg.
Overly low cuff pressures < 18 mm Hg, may cause the cuff
to develop longitudinal folds, promote microaspiration of
secretions collected above the cuff, and increase the risk
for nosocomial pneumonia.
Thermovent
Indications For Suctioning
Various diameters
To protect airway
To allow ventilation
Uncuffed Cuffed
Allow patient to
ventilate past tube via
upper airway
Allow speech
Double lumen allows
easy cleaning
Single lumen has a
greater internal
diameter
Other Types of Tubes
Montgomery T-Tube
Bivona Fome-Cuff Single Cannular Shiley
Tracheaostomy Tube Pediatric TT
Tracheostomy Speaking Valve
Passy-Muir
Jacksons tracheostomy
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Edition: ENGLISH DEUTSCH ESPAOL FRANAIS PORTUGUS
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NEWS & PERSPECTIVE DRUGS & DISEASES CME & EDUCATION ACADEMY
Practice Essentials
Practice Essentials
During the 1800s, the mortality rate from thyroid
Overview surgery was approximately 40%. Most deaths were
caused by infection and hemorrhage. Sterile
Bleeding surgical arenas, general anesthesia, and improved Recommended
surgical techniques have made death from thyroid
Injury to the Recurrent surgery extremely rare today.
Laryngeal Nerve DISEASES & CONDITIONS
Hypothyroidism
Impact of New
Technology
Guidelines Summary
Show All
Media Gallery
Anatomy of the recurrent laryngeal nerve
References (RLN).
Minor complications
Postoperative surgical site seromas may be
followed clinically and allowed to resorb, if small
and asymptomatic; large seromas may be aspirated
under sterile conditions. Poor scar formation is
frequently preventable with proper incision location
and surgical technique.
Postoperative bleeding
The incidence of bleeding after thyroid surgery is
low (0.3-1%), but an unrecognized or rapidly
expanding hematoma can cause airway
compromise and asphyxiation. Patients present
with neck swelling, neck pain, and/or signs and
symptoms of airway obstruction (eg, dyspnea,
stridor, hypoxia). Evaluation is as follows:
Prevention
Evaluation
Presentation
Treatment
Hypoparathyroidism
Hypoparathyroidism can result from direct trauma
to the parathyroid glands, devascularization of the
glands, or removal of the glands during surgery.
Postoperative hypoparathyroidism, and the
resulting hypocalcemia, may be permanent or
transient. Hypocalcemia after thyroidectomy is
initially asymptomatic in most cases.
Treatment is as follows:
Thyrotoxic storm
Thyrotoxic storm is an unusual complication that
may result from manipulation of the thyroid gland
during surgery in patients with hyperthyroidism. It
can develop preoperatively, intraoperatively, or
postoperatively. Signs and symptoms of thyrotoxic
storm are as follows:
Treatment is as follows:
Presentation
Evaluation
Treatment
Hypothyroidism
Hypothyroidism is an expected sequela of total
thyroidectomy. Measurement of TSH levels is the
most useful laboratory test for detecting or
monitoring of hypothyroidism in these patients.
Next: Overview
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ANATOMY OF LUNGS
-
1. Gross Anatomy of Lungs 6. Histopathology of
Alveoli
2. Surfaces and Borders of
Lungs 7. Surfactant
3. Hilum and Root of Lungs 8. Blood supply of lungs
4. Fissures and Lobes of 9. Lymphatics of Lungs
Lungs
10. Nerve supply of Lungs
5. Bronchopulmonary
11. Pleura
segments
12. Mediastinum
GROSS ANATOMY OF LUNGS
Texture -- Spongy
Color Young brown
Adults -- mottled black due to
deposition of carbon particles
Weight-
Right lung - 600 gms
Left lung - 550 gms
THORACIC CAVITY
SHAPE - Conical
Apex (apex pulmonis)
1. Vertebral Part
2. Intervertebral Discs
4. Splanchic Nerves
RELATIONS OF ANTERIOR PART
RIGHT SIDE LEFT SIDE
2. Pulmonary artery.
3. Bronchus.
ARRANGEMENT OF STRUCTURES IN
THE ROOT
ABOVE DOWNWARDS
A. Right Side
1. Eparterial Bronchus.
2. Pulmonary Artery.
3. Hyparterial Bronchus.
4. Inferior Pulmonary
Vein.
.
ARRANGEMENT OF STRUCTURES IN
THE ROOT
ABOVE DOWNWARDS
B. Left Side
1. Pulmonary artery.
2. Bronchus.
Lobar Bronchi(Secondary)[2L,3R]
Segmental Bronchi(Tertiary)[8L,10R]
Respiratory Bronchioles
Alveolar ducts
ACINUS
Alveolar sacs
Alveoli
The ultimate pulmonary unit from respiratory
brochiole to alveoli is called Acinus.
1. Shorter 1. Longer
2. Wider. 2. Narrower.
Right upper lobe Bronchus Right Middle lobe Bronchus Right Lower Lobe Bronchus
Apical
Apical
Medial Anterior
Anterior
Lateral Posterior
Posterior
Medial and Lateral
BRONCHOPULMONARY SEGMENTS
Apical
Anterior Superior Lingular Anterior
Apico-posterior Inferior Lingular Posterior
Lateral
These segments are pyramidal in shape with
apex towards the root of lung.
Pavement epithelial
cells of alveoli .
Less in no. than
type II.
More surface
area(flattened)
Contain pinocytic
vesicles.
Specialized for
diffusion of gases.
Type II Pneumocytes
More numerous than
type I.
Cuboidal in shape.
Rich in
mitochondria, ER
and vacuoles
containing
osmiophillic lamellar
bodies.
Type I are
precursors of type II.
ENDOTHELIAL CELLS
Most numerous .
Presence of
pinocytic vacuoles
that meet the
luminal surface to
form caveolae.
Walls of caveolae
has, ACE.
Source of NO,
natural pulmonary
vasodilator.
ALVEOLAR MACROPHAGES
Primary defence
mechanism.
Takes part in
inflammatory and
immunological
reactions.
Activates lysosomes ,
proteases,complement
, thromboplastin,
cytokines - IF-, TNF-
, IL-1, IL-8.
SURFACTANT
Lines the inner layer of alveolar epithelium.
Function
1. To reduce the surface tension of alveoli mainly during
expiration, thus reduces the work of lung inflation.
2. Waterproofing.
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NASAL CAVITIES
Uppermost parts of the
respiratory tract and contain
the olfactory receptors
Elongated wedge-shaped
spaces with a large inferior
base and a narrow superior
apex
Skeletal framework
consisting mainly of bone
and cartilage
Nares external opening of
nose
Choanae - open into the
nasopharynx
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Skeletal framework
Bones that contribute to the skeletal framework of
the nasal cavities include
Unpaired: ethmoid, sphenoid, frontal bone, and vomer;
Paired: nasal, maxillary, palatine and lacrimal bones, and
inferior conchae
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Ethmoid bone
Most complex bones in the skull
Contributes to the roof, lateral wall, and medial wall
of both nasal cavities, and contains the ethmoidal cells
(ethmoidal sinuses)
Cuboidal in overall shape
Two rectangular box-shaped ethmoidal labyrinths one
on each side
These are united superiorly across the midline by a
perforated sheet of bone (cribriform plate).
A second sheet of bone (perpendicular plate) descends
vertically in the median sagittal plane to form part of
the nasal septum
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Ethmoid bone
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External nose
Pyramidal in shape with its apex anterior in
position
Composed partly of bone and mainly of
cartilage
Bony parts - continuous with the skull bones and
parts of the maxillae and frontal bones
Cartilaginous Part - anteriorly, and on each side
Laterally - lateral processes of the septal cartilage,
major alar and three or four minor alar cartilages
Single septal cartilage in the midline that forms the
anterior part of the nasal septum
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Nasal Cartilage
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NASAL
CAVITIES
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NASAL CAVITIES
The nasal cavities are
separated - each other by
a midline nasal septum
Oral cavity below by the
hard palate
Cranial cavity above by
parts of the frontal,
ethmoid, and sphenoid
bones
Each nasal cavity has a
floor, roof, medial wall,
and lateral wall www.facebook.com/notesdental
Lateral wall
Characterized by three curved shelves of bone
(conchae)
One above the other and project medially and
inferiorly across the nasal cavity
The medial, anterior, and posterior margins of
the conchae are free
Increase the surface area of contact between
tissues of the lateral wall and the respired air
Openings of the paranasal sinuses, which are
extensions of the nasal cavity
Opening of the nasolacrimal duct
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Lateral wall
Conchae divide each nasal cavity into four air channels
Inferior nasal meatus between the inferior concha and the
nasal floor
Middle nasal meatus between the inferior and middle concha;
Superior nasal meatus between the middle and superior
concha;
Spheno-ethmoidal recess between the superior concha and
the nasal roof
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Lateral wall
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Medial Wall
Mucosa-covered surface of the thin nasal
septum
Oriented vertically in the median sagittal plane
Separates the right and left nasal cavities from
each other
It consists of
Anteriorly: Septal nasal cartilage
Posteriorly: mainly the vomer and the perpendicular
plate of the ethmoid bone;
Nasal spine of the frontal bone - meet in the
midline
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Medial Wall
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Floor
Smooth, concave, and much wider than the roof
It consists of
Soft tissues of the external nose;
Upper surface of the palatine process of the maxilla,
Horizontal plate of the palatine bone, which together
form the hard palate
Naris opens anteriorly into the floor,
Superior aperture of the incisive canal - deep to
the mucosa
immediately lateral to the nasal septum
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Floor
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Roof
Narrow and is highest in central regions where it is
formed by the cribriform plate of the ethmoid bone
Anterior to the cribriform plate - roof slopes inferiorly
to the nares and consist
nasal spine of the frontal bone and the nasal bones
lateral processes of the septal cartilage and major alar
cartilages
Posteriorly, the roof slopes inferiorly to the choana and
is formed by
Anterior surface of the sphenoid bone;
Ala of the vomer
Medial plate of the pterygoid process.
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Roof
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Regions of Nasal Cavities
Each nasal cavity consists of three general regions
Nasal vestibule
small dilated space just internal to the naris that is lined
by skin and contains hair follicles
Respiratory region
Largest part of the nasal cavity
Rich neurovascular supply
Lined by respiratory epithelium composed mainly of
ciliated and mucous cells
Olfactory region
small, is at the apex of each nasal cavity
Lined by olfactory epithelium which contains the
olfactory receptors
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Regions of
Nasal
Cavities
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Functions of Nasal Cavities
Main: housing receptors for the sense of smell
(olfaction)
Accessory
Adjust the temperature and humidity of respired air -
action of a rich blood supply,
Trap and remove particulate matter - hair in the
vestibule
Capturing foreign material in abundant mucus.
Mucus normally is moved posteriorly by cilia on
epithelial cells in the nasal cavities and is swallowed
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Nerve Supply of Nose
Three cranial nerves
Olfaction - the olfactory nerve [I]
General sensation - the trigeminal nerve [V],
Anterior - ophthalmic nerve [V1]
Posterior - maxillary nerve [V2]
Glands - parasympathetic fibers in the facial nerve
[VII] (greater petrosal nerve),
Join branches of the maxillary nerve [V2] in the
pterygopalatine fossa.
Sympathetic fibers are ultimately derived from
the T1 spinal cord level
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Nerve Supply
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Blood supply
Blood supply to the nasal cavities is by
Terminal branches of the maxillary and facial
arteries - originate from the external carotid
artery (ECA)
Ethmoidal branches of the ophthalmic artery,
which originates from the internal carotid artery.
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Blood Supply
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Blood Supply : Nasal Spetum
The anterior part of the septum contains a highly
vascularized area called Kiesselbachs area
Supplied by vessels from both major arteries.
This area is the most common site of significant
nose-bleed due to anastomoses.
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Lymphatics
Anterior regions
drains forward onto
the face by passing
around the margins of
the nares -
submandibular nodes
Posterior regions of
the nasal cavity and
the paranasal sinuses
drains into upper deep
cervical nodes through the
retropharyngeal nodes
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PARANASAL SINUS
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PARANASAL SINUS
Invaginations from the
nasal cavity that drain into
spaces associated with the
lateral nasal wall
There are four paranasal air
sinuses
Ethmoidal cells,
Sphenoidal,
Maxillary,
Frontal sinuses
Functions: skull lighter and
add resonance to the voice
Infection causes Sinusitis
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PARANASAL SINUS
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PARANASAL SINUS
Rudimentary or even
absent during birth
Enlarges rapidly at the
age of 6 to 7 yrs then
after puberty
Increase in size due to
Enlargement of Bones :
birth till adult life
Resorption of Bones:
old age
Lined by a respiratory
epithelium
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PARANASAL SINUS
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Frontal sinuses
One on each side
Variable in size and are the most superior of the
sinuses average size 2.5 cm
Each is triangular in shape
Rudimentary at birth and usually well-developed by
the age of 7 or 8 years
Part of the frontal bone under the forehead
Drains onto the lateral wall of the middle meatus via
the frontonasal duct
which penetrates the ethmoidal labyrinth and continues
as the ethmoidal infundibulum at the front end of the
semilunar hiatus
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Frontal sinuses
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Frontal sinuses
Relations of Sinus
Superior: anterior cranial fossa and contents
Inferior: orbit, anterior ethmoidal sinuses, nasal
cavity
Anterior: forehead, superciliary arches
Posterior: anterior cranial fossa and contents
Medial: other frontal sinus
Location of Ostium : Middle meatus
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Frontal sinuses
Branches of the supra-
orbital nerve and
Supra-trochlear nerve
from the ophthalmic
nerve [V1]
Blood supply is from
branches of the
anterior ethmoidal
arteries, supraorbital
and supra-trochlear
artery www.facebook.com/notesdental
Ethmoidal Sinus
Composed of three sets of ethmoidal air cells
Anterior
Middle
Posterior
3 to 18 ethmoid air cells on each side
Thin-walled, bony, honeycombed spaces collectively
form the ethmoidal labyrinth located between the
orbits and the nasal fossae
May invade any of the other 3 sinuses
Ethmoid bulla: middle ethmoid air cells produce the
swelling on the lateral wall of the middle meatus
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Ethmoid Sinus
Relations of Sinus
Superior: anterior cranial
fossa and contents,
frontal bone with sinus
Medial: nasal cavity
Lateral: orbit
Location of Ostium
Anterior: middle meatus
(frontonasal duct or
ethmoidal infundibulum)
Middle: middle meatus
(on or above ethmoid
bulla)
Posterior: superior
meatus
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Ethmoid Sinus
Innervated by:
the anterior and posterior ethmoidal branches of the
nasociliary nerve from the ophthalmic nerve [V1]
the maxillary nerve [V2] via orbital branches from the
pterygopalatine ganglion.
It receive their blood supply through branches of
the anterior and posterior ethmoidal arteries
Primary lymphatic drainage
Submandibular lymph nodes - anterior and middle
ethmoid sinuses
Retropharyngeal lymph nodes - posterior ethmoid
sinus
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Ethmoid Sinus : Blood Supply
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Opening of Paranasal Sinus
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Ethmoid Sinus : Nerve Supply
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Maxillary sinuses
One on each side, are the
largest of the paranasal
sinuses 3.5 X 2.5 X 3.5 cms
Completely fill the bodies of
the maxillae
Pyramidal in shape
Roof : inferior orbital margin
Floor : Alveolus of the maxilla
Base: lateral wall of nose
Apex : zygomatic process of
maxilla
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Maxillary sinuses
Relations of Sinus
Superior: orbit, infraorbital nerve and vessels
Inferior: roots of molars and premolars
Medial: nasal cavity
Lateral and anterior: cheek
Posterior: infratemporal fossa, pterygopalatine fossa and
contents
Location of Ostium : near the top of the base, in the
center of the semilunar hiatus, which grooves the
lateral wall of the middle nasal meatus
2nd opening may be present at the posterior end of hiatus
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Maxillary sinuses
Size of opening is large in isolated maxilla, but
it gets reduced in intact skull 3-4 mm
Unicate process of ethmoid and descending part
of lacrimal bine
Below - Inferior nasal conchae
Behind perpendicular plate of palatine bone
Further reduced by thick mucosa of nose
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Maxillary sinuses
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Maxillary sinuses
Innervated by infra-orbital and alveolar
branches of the maxillary nerve [V2],
Receive their blood through branches from
the infra-orbital and superior alveolar
branches of the maxillary arteries
Primary lymphatic drainage is to the
submandibular lymph nodes
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Maxillary sinuses: Blood Supply
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Maxillary sinuses : Nerve Supply
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Sphenoidal sinuses
Two large, irregularly shaped cavities
Separated by an irregular septum
Relations of Sinus
Superior: hypophyseal fossa, pituitary gland, optic
chiasma
Inferior: nasopharynx, pterygoid canal
Medial: other sphenoid bone
Lateral: cavernous sinus, internal carotid artery,
cranial nerves III, IV, V1, V2, and VI
Anterior: nasal cavity
Location of Ostium : Sphenoethmoidal recess
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Sphenoidal sinuses
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Sphenoidal sinuses
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Innervation
Innervation of the sphenoidal sinuses is
provided by
the posterior ethmoidal branch of the ophthalmic
nerve [V1]; and
the maxillary nerve [V2] via orbital branches from
the pterygopalatine ganglion.
Supplied by branches of the pharyngeal
arteries from the maxillary arteries
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Sphenoidal sinuses: Blood Supply
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Sphenoidal sinuses: Nerve Supply
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Opening of Paranasal Sinus
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Clinical Correlate : SINUSITIS
An inflammation of the membrane of the sinus
cavities caused by infections (by bacteria or
viruses) or noninfectious means (such as allergy)
2 types of sinusitis: acute and chronic
Common clinical manifestations
sinus congestion
Discharge
Pressure
face pain
headaches
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Acute Sinusitis
The most common form of sinusitis
Typically caused by a cold that results in
inflammation of the sinus membranes
Normally resolves in 1 to 2 weeks
Sometimes a secondary bacterial infection
may settle in the passageways after a cold;
bacteria normally located in the area -
Streptococcus pneumoniae and Haemophilus
influenzae)
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Chronic Sinusitis
An infection of the sinuses that is present for
longer than 1 month and requires longer
duration medical therapy
Typically either chronic bacterial sinusitis or
chronic noninfectious sinusitis
Chronic bacterial sinusitis is treated with
antibiotics
Chronic noninfectious sinusitis often is treated
with steroids (topical or oral) and nasal
washes
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Chronic Sinusitis
Locations
Maxillary: the most common location for sinusitis;
associated with all of the common signs and symptoms but
also results in tooth pain, usually in the molar region
Sphenoid: rare, but in this location can result in problems
with the pituitary gland, cavernous sinus syndrome, and
meningitis
Frontal: usually associated with pain over the forehead
and possibly fever; rare complications include
osteomyelitis
Ethmoid: potential complications include meningitis and
orbital cellulitis
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References
Grays Anatomy for Students 2nd Edition
Head and Neck Anatomy for Dental Medicine
Head, Neck and Dental Anatomy, 4th Edition
Netters Head and Neck Anatomy for Dentistry,
2nd Edition Neil S norton
Oral Development and Histology, 3rd Edition
Woelfel's Dental Anatomy
Ten Cates Oral Histology - Development,
Structure, and Function, 7th Edition
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VOCAL CORD PARALYSIS
Presented by:
Dr. Priyanjal Gautam
PG 3rd Yr. (MS-ENT)
NIMS Medical College & Hospital, Jaipur
INTRODUCTION
1. Supranuclear : Rare
6. Idiopathic
VOCAL CORD POSITIONS
THEORIES ON POSITION OF VOCAL
CORD IN VOCAL CORD PARALYSIS
SEMONS LAW : states that, in all progressive organic
lesions, abductor fibres of the nerve which are
phylogenitically newer are more susceptible & thus the
first to be paralysed as compared to adductor fibres
Treatment : Generally no
treatment is required.
(B) BILATERAL (B/L Abductor paralysis) :
Clinical features :
- Dyspnoea
- Stridor
Movement of Vocal cord during
inspiration & expiration
Treatment :
Usually 6 months is an adequate time to wait for any spontaneous recovery.
Lateralisation of the vocal cord: Aim is to move & fix the cord in a lateral
position to improve the airway. The various procedures are:
(a) Arytenoidectomy
(d) Cordectomy
Causes : Causes:
- Thyroid surgery - Surgical or accidental trauma
- Thyroid Tumors - Diptheria
- Cervical lymphadenopathy
- Diptheria.
- Neoplastic disease
Clinical features : Clinical features:
- Weak voice with decreased pitch - Both V.C. paralysis
- Anaesthesia of the larynx on one side - Anaesthesia of larynx
- Occassional aspiration. - Cough
- Chocking fits
Laryngeal findings include : - Weak & husky voice
Aetiology :
Thyroid surgery
Lesions of nucleus ambigus which may lie medulla, post. cranial fossa,
jugular foramen or parapharyngeal space.
Clinical features :
All the muscles of larynx on one side are paralysed
V.C. lie in cadeveric position ie. 3.5mm from the midline
Glottic incompetence results in hoarseness of voice & aspiration of
liquids
Treatment:
1. Speech therapy
Clinical features :
1. Tracheostomy
2. Epiglottopexy
4. Total laryngectomy
CONGENITAL VOCAL CORD PARALYSIS
UNILATERAL BILATERAL
Causes :
More common
- Hydrocephalus
- Arnold-Chiari malformation
Causes :
- Intracerebral haemorrhage
- Birth trauma
- Meningocele
- Congenital anomaly of great
vessels or heart - Cerebral agenesis
Clinical features :
- Dyspnoea
- Stridor
EVALUATION OF VOCAL CORD PARALYSIS PATIENT
History Local Examination :
- MRI
DIFFERENTIAL DIAGNOSIS
2. Laryngeal malignancy: