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Hypoglossal Nerve Te root of the neck also contains the source of many of the vessels that eventually supply the majority of the vascular Te hypoglossal nucleus originates from the medulla oblon- supply of the neck purchase geriforte online now herbals 4 play monroe la. Te subclavian artery arches superiorly gata generic geriforte 100 mg line top 10 herbs, and the hypoglossal nerve arises from the cell bodies of over the frst rib effective geriforte 100 mg ratnasagar herbals pvt ltd, becoming the axillary artery and giving of the hypoglossal nucleus. Te path of this nerve is also important thyrocervical trunk, and costocervical trunk. It ends as Nerves it extends upward along the hyoglossus muscle and into the genioglossus, fnally reaching the tip of the tongue. Although metastatic neck disease is one of the most Marginal Mandibular Nerve important factors in the spread of head and neck squamous (see Figure 7-2) cell carcinoma from primary sites, it is not encountered as Te marginal mandibular nerve is an important landmark, frequently as some of the other potential pathologies associ- and care should be taken to ensure its preservation during ated with the neck. It is most often injured during dissections common in the typical maxillofacial practice, and as such it at Level Ib. It is located 1 cm anterior and inferior to the is important to understand the key anatomic landmarks in angle of the mandible at the mandibular notch, deep to the the neck. Control of the neck is one of the most important fascia of the submandibular gland (superfcial layer of deep aspects of the successful management of these particular cervical fascia) and superfcial to the adventitia of the facial pathologies. It is important to note that more than one branch is leagues regarding treatment and patient management man- often present, and during surgical procedures, the sensory dates an understanding of important anatomic sites. Te fascia of the head and neck is composed of loose fbrous masseter, is rhomboidal in shape, and is important in cos- connective tissue envelopes and may be divided into the metic surgery (such as lower [cervicofacial] facelifts), because superfcial and deep fascia. Between the fbers of the matrix dissection is bloodless and provides safety for all facial nerve 2 are interstices that are flled with tissue fuid or ground sub- branches, as they are located outside this plane. Te loose fbrous connective tissue that makes up the the platysma muscle that arises superiorly from the fascia fascia of the head and neck is found in varying degrees of over the zygomatic arch. Tese four subtypes are the fascial spaces of the superfcial temporal fascia superiorly, superfcial to the the face, suprahyoid fascial spaces, infrahyoid fascial spaces, parotideomasseteric fascia, and it connects to the fascial mus- and the fascial spaces of the neck. Location and anatomic identifcation of this layer are impor- 3 tant in surgical manipulation for both reconstructive and Fascial Space Subtype 4 cosmetic procedures. Fascial Space Subtype Components Fascial spaces of the Canine, buccal, parotid, face infratemporal, Deep Fascia masticatory spaces Te deep fascia begins at the anterior border of the masseter — Masseteric muscle, attaches to the superior temporal and nuchal lines, — Pterygomandibular and posterior and inferior to these margins it continues crani- — Temporal ally as the pericranium. Te deep facial fascia represents a Suprahyoid fascial Sublingual, submental, continuation of the deep cervical fascia cephalad into the face spaces submandibular, lateral and, more posterior, invests the muscles of mastication, the pharyngeal, peritonsillar surgical importance of which lies in the fact that the facial Infrahyoid fascial spaces Pretracheal 1 nerve branches within the cheek lie deep to this fascial layer. Fascial spaces of the Retropharyngeal, danger, neck carotid sheath Fascial Spaces of the Face Superfcial Fascia Te fascial spaces of the face are subdivided into fve spaces: the canine space, the buccal space, the masticatory space Te superfcial fascia of the head and neck lies just under the (further divided into the masseteric, pterygomandibular, and skin, as it does in the entire body, invests the superfcially temporal spaces), the parotid space, and the infratemporal situated mimetic muscles (platysma, orbicularis oculi, and space (Figure 8-1, A). Infection spreads to the deep fascia, which covers and invests the structures lying this space through the root apices of the maxillary teeth, deep to the skin while maintaining the movability of the skin, usually the canine. Direct surgical access is achieved through with the two layers allowing for separation during blunt incision through the maxillary vestibular mucosa above the dissection. Te areolar cleavage plane overlies the lower mucogingival junction (Figure 8-1, B). Te buccal and posterior directions, which permits the spread of pathol- space frequently communicates posteriorly with the mastica- ogy both to and from the buccal space. Surgical access to this space may be space and suspicion of malignancy, may require a preauricular achieved intraorally in the case of simple infections, but may or submandibular approach. Infection in this space may temporal line and passes inferiorly to the zygomatic arch. However, primary infection in this is rare extremely dense and frm fbrous connective tissue. Com- and is generally blood-borne or retrograde through the municating facial-zygomaticotemporal nerve branches pierc- parotid duct. Te fascia that forms the borders of the masseteric space is a well-defned fbrous tissue that surrounds the muscles of mastication and contains the internal maxillary artery and Suprahyoid Fascial Spaces the inferior alveolar nerve. It is bounded anteriorly by the mandible, posteriorly by the parotid gland, medially by the Sublingual Space lateral pharyngeal space, and superiorly by the temporal space. Te sublingual space is bounded between the mylohyoid Most masseteric space infections are of odontogenic origin muscle and the geniohyoid and genioglossus muscles. Te Periapical molar infections may perforate the lingual man- submasseteric space is bounded laterally by the masseter dible cortex above the mylohyoid line and spread to this muscle, medially by the mandible ramus, and posteriorly by space.
Recommendations for Clear Liquids: At Least 2 Hours The primary support for the task force recommendations comes from a meta- analysis of randomized controlled trials comparing fasting times for clear liquids of 2 to 4 hours versus more than 4 hours geriforte 100 mg fast delivery herbals and anesthesia. Adult patients fasting for 2 to 4 hours had smaller gastric volumes and higher gastric pH values compared to those fasting more than 4 hours discount geriforte 100 mg herbals dario bottineau. Examples of clear liquids include buy 100mg geriforte with amex herbals for hot flashes, but are not limited to, water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee (no alcohol). They found that the literature is insufficient to evaluate or support the effect of administering any of these classes of drugs on the perioperative incidence of emesis/reflux or pulmonary aspiration. Therefore, they could not recommend the routine preoperative use of such drugs for patients who have no apparent increased risk for pulmonary aspiration. Table 23-13 Summary of Fasting Recommendations for All Ages to Reduce the Risk of Pulmonary Aspiration Histamine-2 (H-2) Receptor Antagonists Meta-analyses of randomized placebo-controlled trials support the efficacy of the H-2 receptor antagonists cimetidine, ranitidine, and famotidine in reducing gastric volume and acidity. Multiple-dose regimens may be more effective in increasing gastric pH than a single dose before operation on the day of surgery. Cimetidine Cimetidine is usually administered in 150- to 300-mg doses orally or parenterally. The gastric effects of cimetidine last as long as 3 or 4 hours; thus, this drug is suitable for operations of that duration. Side effects of cimetidine include inhibition of the hepatic mixed-function oxidase enzyme system; therefore, it can prolong the half-life of many drugs, including diazepam, chlordiazepoxide, theophylline, propranolol, and lidocaine. The clinical significance of this after one or two preoperative doses of cimetidine is uncertain. Life-threatening cardiac dysrhythmias, hypotension, cardiac arrest, and central nervous system depression have been reported after cimetidine administration. These side effects may be especially likely to occur in critically ill patients after rapid intravenous administration. Ranitidine Ranitidine is more potent, specific, and longer acting than cimetidine. The usual oral dose of 150 mg or 50 mg given parenterally will decrease gastric fluid pH within 1 hour. It is as effective in reducing the number of patients at risk for gastric aspiration as cimetidine and produces fewer cardiovascular or central nervous system side effects. Thus, it may be superior to cimetidine at the conclusion of lengthy procedures in reducing the risk of aspiration pneumonitis during emergence from anesthesia and extubation of the trachea. Famotidine Famotidine is another H-2 receptor blocker that is given preoperatively to raise gastric fluid pH. The pharmacokinetics are similar to those of cimetidine and ranitidine, with the exception of having a longer serum elimination half- life than the other two drugs. Randomized controlled trials support their efficacy in reducing gastric volume and acidity. Oral doses of 40 mg to 80 mg must be given 2 to 4 hours before surgery to be effective. The nonparticulate antacids do not produce pulmonary damage themselves if aspiration should occur. Although colloid antacid suspensions may be more effective in increasing gastric fluid pH, aspiration of particulate antacids may cause significant and persistent pulmonary damage. Withholding antacids because of concern about increasing gastric volume is not warranted, considering animal evidence documenting markedly increased mortality after aspiration of low volumes of acidic gastric fluid (0. Gastrokinetic Agents: Metoclopramide Metoclopramide is a dopamine antagonist that stimulates upper gastrointestinal motility, increases gastroesophageal sphincter tone, and relaxes the pylorus and duodenum to reduce gastric volume. A meta-analysis of randomized placebo-controlled trials supports the efficacy of metoclopramide to reduce gastric volume, but is equivocal regarding its effect on gastric acidity during the perioperative period. Administration intravenously over 3 to 5 minutes usually prevents the abdominal cramping that can occur from more rapid administration. The clinical usefulness of the gastrokinetic agents is found in those patients who are likely to have large gastric fluid volumes, such as parturients, patients scheduled for emergency surgery, obese patients, trauma patients, and those with gastroparesis secondary to diabetes mellitus.
Similarly order geriforte 100 mg on line herbalism, if a gap is noted at the inferior border purchase generic geriforte from india shivalik herbals, this Injury to the facial and inferior alveolar arteries and ret- often closes with postoperative clenching exercises geriforte 100 mg with visa herbals and anesthesia. Active should be elevated from the inferior border to minimize the range-of-motion exercises are initiated during the fourth risk of soft tissue trauma from the oscillating blade. Passive range-of-motion exercises are union is extremely uncommon, even with no internal fxation. Postoperative Considerations Te position of the proximal segment should be confrmed with postoperative panoramic imaging. Oral Surg Oral Med Oral means of plastic oblique osteotomy of the and refnement of the intraoral vertical sub- Pathol Oral Radiol Endod 111:557, 2011. Blinder D, Peleg O, Yofe T et al: Intraoral Surg Oral Med Oral Pathol 10:677, 1957. Van Sickels Armamentarium Te inverted L osteotomy can be performed either extraorally or intraorally. For the purpose of this chapter, the instruments for the extraoral approach are listed frst and then the separate instruments used for the intraoral procedure. Extraoral Approach #9 Molt periosteal elevators (two) Langenbeck retractors (toe in and toe out) Plating system of surgeon’s choice #15 Scalpel blade Local anesthetic with vasoconstrictor Rake retractors #703 Bur Metzenbaum scissors Reciprocating /oscillating saw Adson with teeth or Cushing/bone Minnesota retractor Senn retractors forceps Needle electrocautery Tonsil hemostat (one or more) Appropriate sutures Nerve stimulator Wire drivers and cutters Intraoral Approach #9 Molt periosteal elevators (two) Kelly clamp Needle electrocautery Appropriate sutures Kocher with umbilical tape Oscillating saw Bauer retractor (optional) LeVasseur Merrill retractor Plating system of surgeon’s choice Coronoid notch retractor Local anesthetic with vasoconstrictor Reciprocating saw J-strippers Minnesota retractor History of the Procedure Indications for the Use of the Procedure 1 According to Steinhauser, the inverted L osteotomy was frst Te inverted L osteotomy may be the operation of choice for described by Trauner in 1955. In 1957 and 1958, Schuchardt large advancements (greater than 12 mm) with counterclock- and then Immenkamp suggested the use of an autogenous wise rotation or for large setbacks (greater than 10 mm). Te extraoral technique described by Speissl2 in his ramal morphology and in patients with masseter hypertrophy 1989 textbook is very similar to what is used today. In 1990, Van Sickels et al3 discussed the rigid fxation of the intraoral inverted L osteotomy. However, today it generally is used for complicated technique described by Van Sickels et al3 was used for man- large advancements either because an alternative intraoral dibular setbacks. It used a condylar positioning device to procedure is not feasible or because the mandibular anatomy control the proximal segments during surgery. Limitations and Contraindications Tere are only a few limitations and contraindications to the Intraoral Approach use of an inverted L osteotomy. Te extraoral approach Te major advantage of the intraoral approach over the extra- includes a skin incision, which may result in an unsightly scar oral approach is avoidance of a skin incision; this eliminates and possible damage to the facial nerve. Injury to the inferior facial scarring and greatly reduces the risk of injury to the alveolar nerve is much less likely with a vertical ramus pro- marginal mandibular branch of the facial nerve. Tey concluded that the medical and lateral sides, and choosing the best types of rigid long-term prognosis for resolution of postsurgical neurosen- 3,4,7,8 fxation to fx the segments. Te intraoral inverted L sory disturbances was better for the patients who underwent osteotomy can be used for small mandibular setbacks and the inverted L osteotomy. As with the extraoral movement between the segments infuenced postsurgical osteotomy, it can be used for mandibular asymmetries and neurosensory disturbances immediately after the inverted L advancements. Several authors have advocated its use for osteotomy but that the relationship diminished with time. Tis equally advantageous for cases in which the preoperative technique may be less stable and may result in nonunion if computed tomogram shows a thin ramus. The masseter muscle is incised and retracted, and gain access to the lateral ramus of the mandible. Once the skin the sigmoid notch, anterior ramus, and posterior border of the and subcutaneous tissues have been incised, a nerve stimulator mandible are identifed (Figure 32-1, A). Usually a fne chisel is used to gently ascending ramus to a point slightly posterior and superior to separate the segments. The procedure then is performed on the the estimated location of the mandibular foramen. Then, while the condyle is The teeth are placed in occlusion or into the surgical splint. The placed into the fossa and the preplanned gap between the seg- segments are fxed with plates and screws. Typically the plate is ments is maintained, the distal segment is fxed (Figure 32-1, C).
Partial hypophysectomy for acromegaly: with remarks niques until compelled to do so buy generic geriforte 100mg on-line kairali herbals malaysia. Ann Surg 1909;50:1002–1017 almost always at the mercy of the skills order geriforte overnight herbs plants, transparency discount geriforte 100mg herbals that prevent pregnancy, and 7. Remarks on the operative treatment of tumors of the reporting of those initiating the advance. Even with properly hypophysis: with report of two cases operated on by an oronasal executed, evidence-based investigation, there would still be method. Surg Gynecol Obstet 1910;10:494–502 the matter of surgical judgment and patient selection as key 8. Endonasal method of removal of hypophyseal tumors with elements in the application of surgical therapies, new or old. Pituitary tumours: their classifcation and treat- select patients, or make surgical judgments—that is the ment. Neurochirurgia (Stuttg) 1959;1:133–150 To make matters more imprecise, the world is smaller to- 11. Curr Probl Surg day than it ever was thanks to the Internet, globalization, 1981;18:609–679 wireless communication, and the unfettered access to infor- 12. Transsphenoidal and transcranial surgery for pitu- mation and disinformation, so that it is just as easy to spread itary adenomas. Trans-sphenoidal surgery of pituitary fossa practitioners partially educated or vulnerable to self-claims tumors with televised radiofuoroscopic control. J Neurosurg of evangelists not vetted by scientifc tribunals or other more 1965;23:612–619 trusted discourse. In spite of this, surgical innova- Can 1967;96:702–712 tion, has survived and will continue to survive, bypassing 15. Acta Neurochir (Wien) 1978;41:163–175 We must foster and breed bold shifts and advances in 16. Endoscopic endonasal transsphenoidal surgery: our surgical portfolio, and change must occur for the feld to experience with 50 patients. Endoscopic repair of cerebro- shed our willingness and readiness to query, assess, and re- spinal fuid fstulae and encephaloceles. Laryngoscope 1996;106 port the gains or cost of such advances so that those who (9 Pt 1):1119–1125 23 Microscopic and Endoscopic Transsphenoidal Pituitary Surgery: A Reasoned and Balanced Dialectic 247 19. Transsphenoidal scope 2001;111:2131–2134 microsurgery of pituitary macroadenomas with long-term follow- 20. J R Soc Med 1986;79:262–269 transsphenoidal microsurgical approach to the sella turcica. J Neurosurg 1978;49:138–142 plications of transsphenoidal operation for pituitary adenomas. The “classic” transsphenoidal approach Neurosurgery 1987;20:920–924 for resection of pituitary tumors. Neurosurgery 1997;40:225–236; discus- sellar region: anatomic comparison of the microscope versus endo- sion 236–227 scope. Endoscopic endonasal patients who underwent transsphenoidal surgery for Cushing’s dis- transsphenoidal surgery. J Neurosurg 2009;111:545–554 pituitary tumors in the United States, 1996–2000: mortality, mor- 28. Combined micro-endoscopic trans-sphenoid excisions of bidity, and the efects of hospital and surgeon volume. Surgical complica- Surg 2000;126:1487–1490 tions after endoscopic transsphenoidal pituitary surgery. Endoscopic transsphenoidal approach rosci 2009;16:786–789 through a widened nasal cavity for pituitary lesions. Flexible endoscope-assisted 1529–1530 endonasal transsphenoidal surgery for pituitary tumors. The use of the rigid endoscope [Endoscope-assisted microsurgery for invasive endo- and suprasellar in trans-sphenoidal pituitary surgery. J Laryngol Otol 1994;108: pituitary macroadenomas: a consecutive retrospective study with 19–22 13 patients]. J Neurooncol croscopic approach for pituitary adenomas and other parasellar tu- 2001;54:187–195 mors: a 10-year experience. Endoscopic endonasal 256, discussion 256 transsphenoidal approach: outcome analysis of 100 consecutive pro- 52.
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