Connie K. Kraus, PharmD, BCACP
- Professor (CHS), University of Wisconsin-Madison, School of Pharmacy
- Clinical Instructor, University of Wisconsin-Madison, Department of Family Medicine and Community Health, Madison, Wisconsin
https://apps.pharmacy.wisc.edu/sopdir/connie_kraus/
Posteriorly lies the trachea with the oesophagus immedi ately behind it lying against the vertebral column birth control 2 periods in one month buy levlen with a mastercard. Course and relations Cervical In the neck it commences in the median plane and deviates slightly to the left as it approaches the thoracic inlet birth control pills in shampoo purchase levlen 0.15 mg on-line. Thoracic the thoracic part traverses rst the superior and then the posterior 46 the thorax mediastinum birth control for women 7-day 0.15mg levlen fast delivery. From being somewhat over to the left birth control pills 50 mg buy levlen 0.15mg low cost, it returns to the midline at T5 then passes downwards, forwards and to the left to reach the oesophageal opening in the diaphragm (T10). For con venience, the relations of this part are given in sequence from above downwards. On the left side it is related to the left subclavian artery, the termi nal part of the aortic arch, the left recurrent laryngeal nerve, the thoracic duct and the left pleura. In the abdomen, passing forwards through the opening in the right crus of the diaphragm, the oesophagus comes to lie in the oesophageal groove on the posterior surface of the left lobe of the liver, covered by peritoneum on its anterior and left aspects. Structure the oesophagus is made of: 1 an outer connective tissue sheath of areolar tissue; 2 a muscular layer of external longitudinal and internal circular bres which are striated in the upper two-thirds and smooth in the lower one-third; 3 a submucous layer containing mucous glands; 4 a mucosa of strati ed epithelium passing abruptly into the colum nar epithelium of the stomach. The lymphatic drainage is from a peri-oesophageal lymph plexus into the posterior mediastinal nodes, which drain both into the supra clavicular nodes and into nodes around the left gastric vessels. It is not the mediastinum 47 uncommon to be able to palpate hard, xed supraclavicular nodes in patients with advanced oesophageal cancer. Anteriorly, the normal oesopha gus is indented from above downwards by the three most important structures that cross it, the arch of the aorta, the left bronchus and the left atrium. Development of the oesophagus the oesophagus develops from the distal part of the primitive fore gut. From the oor of the fore-gut also differentiate the larynx and trachea, rst as a groove (the laryngotracheal groove) which then converts into a tube, a bud on each side of which develops and rami es into the lung. Less commonly, the upper part of the oesophagus opens into the trachea, or oesophageal atresia occurs without concomitant stula into the trachea. It drains lymphatics from the abdomen and the lower limbs, then passes upwards through the aortic opening to become the thoracic duct. On the right side, the right subclavian, jugular and mediastinal trunks may open independently into the great veins. Usually the sub clavian and jugular trunks rst join into a right lymphatic duct and this may be joined by the mediastinal trunk so that all three then have a common opening into the origin of the right brachiocephalic vein. This usually results in lymphoedema of the legs and scrotum but occasional involvement of the main channels of the trunk and thorax is followed by chylous ascites, chyluria and chylous pleural effusion. If the accident is missed, there follows an unpleasant chylous stula in the neck. They lie medial to the sympathetic trunk on the bodies of the thoracic vertebra and are quite easily visible through the parietal pleura (For their distribution see pages 429 and 430). Centering and density of lm the sternal ends of the two clavicles should be equidistant from the shadow of the vertebral spines. Unless this procedure is carried out systematically, important diagnostic clues. Special note should be made of the size of the heart, of mediastinal shift and of the vessels and nodes at the hilum of the lung. On the examination of a chest radiograph 53 Lung elds Again, systematic examination of the lung elds visible in each inter costal space is necessary if slight differences between the two sides are not to be overlooked. Abnormalities When this scheme has been carefully followed, any abnormalities in the bony cage, the mediastinum or lung elds should now be appar ent. The right border of the mediastinal shadow is formed from above down wards by the right brachiocephalic vein, the superior vena cava and 54 the thorax Fig. The shadow of the inferior border of the heart blends centrally with that of the diaphragm, but on either side the two shadows are separated by the well-de ned cardiophrenic angles. The heart and great vessels in anterior oblique radiographs the left oblique view (Fig. This border can be de ned more accu rately by giving the patient barium paste to swallow; the outlined oesophagus is indented by an enlarged left atrium. The costal margin extends from the 7th costal carti lage at the xiphoid to the tip of the 12th rib (although the latter is often dif cult to feel); this margin bears a distinct step, which is the tip of the 9th costal cartilage. Identify this tubercle by direct pal pation and also by running the ngers along the adductor longus tendon (tensed by exing, abducting and externally rotating the thigh) to its origin at the tubercle. Trace the vas upwards and note that it passes medially to the pubic tubercle and thence through the external inguinal ring, which can be felt by invaginating the scrotal skin with the ngertip. Pancreas the transpyloric plane de nes the level of the neck of the pancreas the fasciae and muscles of the abdominal wall 61 which overlies the vertebral column. From this landmark, the head can be imagined passing downward and to the right, the body and tail passing upwards and to the left. Kidneys the lower pole of the normal right kidney may sometimes be felt in the thin subject on deep inspiration. Anteriorly, the hilum of the kidney lies on the transpyloric plane four nger breadths from the midline. In the perineum it is attached behind to the perineal body and posterior margin of the perineal membrane and, laterally, to the rami of the pubis and ischium. It is because of these attachments that a rupture of the urethral bulb may be followed by extravasation of blood and urine into the scrotum, perineum and penis and then into the lower abdomen deep to the brous fascial 62 the abdomen and pelvis plane, but not by extravasation downwards into the lower limb, from which the uid is excluded by the attachment of the fascia to the deep fascia of the upper thigh. The muscles of the anterior abdominal wall these are of considerable practical importance because their anatomy forms the basis of abdominal incisions. Posteriorly they are not in evidence and, in consequence, the Anterior layer of rectus sheath Anterior layer of rectus sheath Rectus abdominis Tendinous intersection External oblique Anterior cutaneous nerves Fig. Posteriorly lie the pos terior part of this split internal oblique aponeurosis and the aponeu rosis of transversus abdominis. At this point the inferior epigas tric artery and vein (from the external iliac vessels) enter the sheath, pass upwards and anastomose with the superior epigastric vessels which are terminal branches of the internal thoracic artery and vein. The lateral muscles of the abdominal wall comprise the external and internal oblique and the transverse muscles. They are clinically important in making up the rectus sheath and the inguinal canal, and also because they must be divided in making lateral abdominal incisions. Medially, as already noted, they constitute the rectus sheath and thence blend into the linea alba from xiphoid to pubic crest. The obliquus externus abdominis (external oblique) arises from the outer surfaces of the lower eight ribs and fans out into the xiphoid, linea alba, the pubic crest, pubic tubercle and the anterior half of the iliac crest. The obliquus internus abdominis (internal oblique) arises from the lumbar fascia, the anterior two-thirds of the iliac crest and the lateral two-thirds of the inguinal ligament. Note that the external oblique passes downwards and forwards, the internal oblique upwards and forwards and the transversus trans versely. The anatomy of abdominal incisions Incisions to expose the intraperitoneal structures represent a compro mise on the part of the operator. The nerve supply to the lateral abdominal muscles forms a richly communicating network so that cuts across the lines of bres of these muscles, with division of one or two nerves, produce no clinical ill the fasciae and muscles of the abdominal wall 65 effects. The adherence of the anterior sheath to the rectus muscle at its tendinous intersections means that the sheath must be dissected off the muscle at each of these sites, and at each of these a segmental vessel requires division. The poste rior sheath and the peritoneum form a tough membrane down to half-way between pubis and umbilicus, but it is much thinner and more fatty below this where, as we have seen, it loses its aponeurotic component and is made up of only transversalis fascia and peri toneum. The inferior epigastric vessels are seen passing under the arcuate line of Douglas in the posterior sheath and usually require division in a low paramedian incision.
They all greatly enjoyed the learning delegate should also understand the effect of sessions because of the informal close interac steam on veins birth control pills 50 mcg buy levlen 0.15mg free shipping. Coordination and collaboration of Angiologist birth control for women eau discount levlen 0.15 mg on line, Endovascular Therapist and Vascular Surgeon are key to precise indications and effective treatment birth control for women 6 pack 0.15mg levlen fast delivery. Such a goal can only be reached in well organised multidisciplinary Vascular Centres birth control essure cheap levlen 0.15mg. Angiologists and Vascular Surgeons are present in such Commission in equal numbers. The mandate was to take as a base the "Guidelines for the Organisation of Vascular Centres in Europe", already published in Int. The Commission worked up the Main Criteria for assessment, the practical Rules of Procedure to assure smooth operations and provided also a standard Application Form for the best convenience of whoever likes to apply. The workshop is open to all specialty physicians, including physicians in training, wanting to learn the latest in venous disease management. We have not changed recommendations for who should stop anticoagulation at 3 months or receive extended therapy. We suggest thrombolytic therapy for pulmonary embolism with hypotension (Grade 2B), and systemic therapy over catheter-directed thrombolysis (Grade 2C). See text for factors that in uence choice of recommendations that are newly added or have been therapy. The order of our presentation of the 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C), non-vitamin K oral anticoagulants (dabigatran, or edoxaban (Grade 2C). The complete 3 months over (i) treatment of a shorter period disclaimer for this guideline can be accessed at. Use of aspirin should also be reevaluated 3 months of anticoagulant therapy over extended when patients stop anticoagulant therapy because therapy (no scheduled stop date) (Grade 1B). Remarks: Patient sex and D-dimer level measured a month after stopping anticoagulant therapy may in uence the decision to stop or extend anticoagulant Whether and How to Anticoagulate Isolated therapy (see text). Patients and physicians (i) recommend no anticoagulation if the thrombus are more likely to opt for clinical surveillance over does not extend (Grade 1B), (ii) suggest anticoagulation anticoagulation if there is good cardiopulmonary reserve if the thrombus extends but remains con ned to or a high risk of bleeding. For patients with acute or who have severe symptoms or marked cardiopulmonary chronic symptoms, a trial of graduated compression impairment should be monitored closely for stockings is often justi ed. Since then, a substantial amount of new evidence recommendations for 3 new topics. Then, the editor nominated the project processes (duplicate independent work with agreement checking and executive committee, the chair, and the remaining panelists (see disagreement resolution) for title and abstract screening, full text Acknowledgments section). Throughout guideline development, panelists were required to disclose any potential nancial or intellectual con icts of interest by topic. For each outcome of primary (more serious) or secondary (less serious) (e-Table 1). We related topic areas, but could participate in discussions provided they used a xed-effects model when pooling data from two trials, or when refrained from strong advocacy. Next, all panel members voted baseline risks, ideally estimated from valid prognostic observational on whether each topic should be included in the update. When full panel reviewed the results of the vote and decided on the nal credible data from prognostic observational studies were not list. For update topics, we searched the literature evidence and was based on the study design, risk of bias, from January 2005 to July 2014. For new topics, we searched the imprecision, inconsistency, indirectness of results, and likelihood of literature from 1946 (Medline inception) to July 2014. All searches publication bias, in addition to factors speci c to observational were limited to English-language publications. Summary of Findings tables presented in the main text, and a more detailed version called Evidence Pro les presented in the online When we identi ed systematic reviews, we assessed their quality 3 supplement. The evidence pro les also explicitly link according to the Assessment of Multiple Systematic Reviews tool. We used those that were of highest quality and up to date as the source of evidence. To achieve consensus and be included in the nal manuscript, each recommendation had to have at least the chair drafted the recommendations after the entire panel had 80% agreement (strong or weak) with a response rate of at least reviewed the evidence and discussed the recommendation. All recommendations achieved Recommendations were then revised over a series of conference calls consensus in the rst round. We then used an iterative approach and through e-mail exchanges with the entire panel. A major aim that involved review by, and approval from, all panel members for was to ensure recommendations were speci c and unambiguous. Methods for Achieving Consensus Peer Review We used a modi ed Delphi technique17, 18 to achieve consensus on External reviewers who were not members of the expert panel reviewed each recommendation. These reviewers included content interaction bias and to maintain anonymity among respondents. Moderate quality: Further research is likely to have an important impact on our con dence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our con dence in the estimate of effect and is likely to change the estimate. We have revised the wording of this text for factors that in uence choice of therapy. Antiplatelet therapy should be avoided if possible in patients on anticoagulants because of increased bleeding. Further Previous bleeding185, 191-193, 198, 201-204 more, a single risk factor, when severe, will result in a high risk of bleeding (eg, major surgery within the past 2 d; severe thrombocytopenia). Cancer187, 191, 195, 198, 205 e Compared with low-risk patients, moderate-risk patients are assumed to Metastatic cancer181, 204 have a twofold risk and high-risk patients are assumed to have an eightfold risk of major bleeding. Bleeding Low Moderate Riske Riske High Riske another 18 months of treatment or to placebo, and then (0 Risk (1 Risk ($2 Risk Factors) Factor) Factors) followed both groups of patients for an additional 24 months after study drug was stopped (Table 12, Anticoagulation 60 0-3 mof e-Table 13). This new information has after rst 3 mof not increased the quality of evidence for comparison of a Baseline risk (%/y) 0. The risk of bleeding with different anticoagulants is not addressed in this table. No study stopped early for bene t; 3 stopped early because of slow recruitment (Campbell et al, 222 Pinede et al, 223 Eischer et al227) and 1 because of lack of bene t (Agnelli et al224). Patients and caregivers were blinded in Couturaud et al, 60 but none of the other studies was. All studies used effective randomization concealment, intention-to-treat analysis, and a low unexplained dropout frequency. In this subgroup of patients, patient sex and D-dimer level measured about 1 month 6. We compared with those with a negative D-dimer, and suggest treatment with anticoagulation for 3 months the predictive value of these two factors appears to be over extended therapy if there is a low or moderate additive. The risk of recurrence in women with a bleeding risk (Grade 2B), and recommend treatment negative posttreatment D-dimer appears to be similar for 3 months over extended therapy if there is a high to the risk that we have estimated for patients with a risk of bleeding (Grade 1B). In these trials, the bene ts of and a (ii) high bleeding risk (see text), we recom aspirin outweighed the increase in bleeding, which was mend 3 months of anticoagulant therapy over not statistically signi cant (Table 13, e-Table 14). Consequently, we (see text), we suggest 3 months of anticoagulant do not consider aspirin a reasonable alternative to therapy over extended therapy (no scheduled stop anticoagulant therapy in patients who want extended date) (Grade 2B). We consider thrombosis that is con ned to the muscular veins of the anticoagulation if the thrombus extends into the calf (ie, soleus, gastrocnemius) to have a lower risk of proximal veins (Grade 1B). Two new systematic 89-92 76, 77 83 appears to be cost-effective (Table 14, e-Table 15). Bibliography: Watson et al229used for all outcomes except patency and QoL; Enden et al90 used for patency estimates; Enden et al230 used for QoL estimates. Riskfactorsforbleedingatcriticalsites(eg, intracranial, intraocular) or noncompressible sites are stronger contraindications for because it is uncertain if there is bene t to placement of an thrombolytic therapy. For patients with acute or and study personnel were not blinded to stocking use (no chronic symptoms, a trial of graduated compression 103-105 stockings is often justi ed.
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Figure 4-6: An angioectasia under white light and at x50 and x100 magnification showed a coral reef-like pattern of small vessels birth control for women xxxl cheap levlen uk. A novel method of their size birth control for women reading generic levlen 0.15mg free shipping, hydration birth control pills 1957 purchase 0.15mg levlen, hemoglobin level birth control missed pill generic 0.15 mg levlen with mastercard, blood flow, and treating colonic angiodysplasia. A 20-year-old Thai male presented with anemic long, was visualized as a nearly circumferential symptoms for one week. He came lesion, and after water flushing, there was no further to the emergency room with another episode of acute active bleeding. This mass appeared as multiloculated cystic lesions without definite contrast enhancement. Discussion: Lymphangioma is a benign neoplastic lesion of polypoid tumor, yellowish-white to tan. The histopathology showed thin-walled 1 cystic masses with smooth gray, pink, tan, or yellow location for this entity since lymphangioma comprises 2 external surface. They can lead to distinct symptoms including mid-gastrointestinal macroscopic interconnecting cysts (often referred as 3 cystic hygroma or cystic lymphangioma) or microscopic bleeding, abdominal pain and protein-losing enteropathy. They are the malformation of sequestered lymphatic cysts (cavernous lymphangioma). Endoscopic jejunal lymphangioma: an unusual case with diagnosis of lymphangioma of the small intestine. He had been diagnosed as carcinoma of capsule retained in one of diverticuli until the battery sigmoid colon and had undergone left hemicolectomy ran out. Later a capsule was successfully jejunal diverticuli (Figure 1), and patient reported no retrieved by a basket. The presence of Discussion: diverticulum during wireless capsule endoscopy has Capsule retention is defined as a failure to pass been previously reported in the literature as part of a the wireless capsule from the alimentary tract after 2 series of capsule-related complications. These diverticula associated with a regional transit abnormality include known intestinal or colonic strictures, and/or (ie, failure of capsule passage from a focal region in the 1 ongoing small-bowel obstruction. Application of visible vessel double-balloon enteroscopy in jejunal diverticular bleeding. Dis Colon Rectum Astley Cooper in 1807, is a rare lesion of the small 1992;35:381-8. J Clin diverticulum is asymptomatic, but the diverticulum Gastroenterol 2001;33:412-4. Acquired without bowel perforation, intestinal obstruction, and jejunoileal diverticulosis and its complications: a bleeding. A previously healthy 24-year-old man presented cm in diameter with multiple lymphangiectatic macules with iron deficiency anemia. Lymphangiomas are utility of double balloon enteroscopy for diagnosis unusual benign tumors of the small bowel comprising and management. Dig Dis Sci 1997;42: proliferation and accumulation of fluid account for the 1179-83. Bleeding jejunal finding is an elevated polypoid tumor, yellowish-white to lymphangioma diagnosed by double-balloon tan. On cut section, lymphangiomas: imaging features with pathologic they vary in appearance and may contain large correlation. A 68-year-old woman presented with chronic area with intervening normal small bowel mucosa watery diarrhea for a month. The most common side effects are ulcers in enteropathy determined by double-balloon the digestive tract including stomach, small bowel, endoscopy: a Japanese multicenter study. A 68-year-old man presented with epigastric demonstrated increased vascular pattern (Figure 1B and pain for 2 weeks. The evidence base for endoscopic resection of duodenal adenomas is Discussion: limited, but it provides a promising result. They often have with the chance for complete removal ranges from 79 1-4 1-4 been discovered incidentally and usually asymptomatic. Endoscopic management of with non-ampullary adenoma, and increases with the nonampullary duodenal polyps. An 83-year-old man presented with epigastric Therefore, Nasogastroscopy with duodenal dilation was pain and melena. Figure 1: Duodenal stricture Figure 2: Post dilation of duodenal stricture Diagnosis: duodenal segments. Discussion: Lymphoma is one of the most common References gastrointestinal malignancies and frequently involves 1. A 5 0 y e a r o l d w o m a n p r e s e n t e d w i t h the ongoing bleeding per rectum. She had been well until 3 deep ulcers with blood oozing it the distal jejunum weeks prior to admission; she had a low grade fever with and upper ileum (Figure 1-2). Endoscopic treatment, surgery and arterial embolization have been References used to control the massive gastrointestinal hemorrhage, 1. Inflixmab as a however, the management for severe gastrointestinal possible treatment for the hemorrhagic type of bleeding remains a great challenge. Biopsy form the ulcers confirmed the presence of carried out but the capsule failed to pass the pylorus jejunal metastasis of cholangiocarcinoma. Mid-gastrointestinal bleeding: capsule endoscopy and push-and-pull enteroscopy give Discussion: rise to a new medical term. Small intestinal bleeding can develop detectability, positive findings, total enteroscopy, from various causes such as vascular abnormality, ulcers, and complications of diagnostic double-balloon 2 diverticulum, and neoplasm. Previous reports of jejunal endoscopy: a systematic review of data over the metastasis were mostly from lung cancer and malignant first decade of use. Small intestinal metastasis from intrahepatic cholangiocarcinoma: report of a case. Narrowing of duodenal portion between aorta and superior mesenteric artery (thick arrow) with mark dilatation of proximal duodenum and stomach (thin arrow), B. A B Figure 2: Direct endoscopic percutaneous jejunostomy: A) Needle punctured through proximal jejunum after illumination guidance, B) A snare was applied over the needle maintain the needle position. Superior mesenteric artery syndrome is characterized by compression of the third portion of References duodenum due to narrowing space between the 1. Enteral feeding distal to jejunostomy feeding tubes in patients with the obstruction such as jejunal tube or jejunostomy is intestinal dysmotility. The chronic watery diarrhea with significant weight loss for a follow-up colonoscopy revealed worsening changes of year. There was no Therefore, double balloon enteroscopy was performed granuloma seen from the biopsy. Subsequently, exudate and inflamed surrounding mucosa along his hemoglobin dropped from 13 g/dl to 9 g/dl in a jejunum and ileum (Figure 1-6). Diagnostic the yield is highest when the indication is to detect and therapeutic impact of double-balloon 2, 4, 5 stricture. Figure 1-2: A deep oval ulcer with a large non-bleeding visible vessel Figure 3: Histoacryl was injected directly into Figure 4: After histoacryl injection, mucosa was the visible vessel discolored Diagnosis: bipolar coaptation, hemoclipping, and argon plasma Small bowel ulcer with non-bleeding visible 3 coagulation. Figure 1: A duodenal polyp with erosion on top at duodenal bulb, size 6 mm in diameter (yellow arrow). Figure 5-6: Microscopic examination showed a large polyp and containing structure was compatible with Brunner gland hyperplasia Diagnosis: Brunner glands, glandular lobulation and intervening Brunner gland hyperplasia 3 bands of paucicellular fibrous tissue. Endoscopic polypectomy is Brunner gland hyperplasia is not common considered for large, solitary, or suspected lesions to finding in duodenal bulb. The etiology and pathogenesis aid definitive diagnosis and prevent complications of these polyps are uncertain. Typical endoscopic findings are often no evidence to support the endoscopic surveillance of diffuse, sessile, and multiple lesions smaller than 10 mm 1 patients with Brunner gland polyp. The worm was removed showed typical iron-deficiency anemia with microcytic endoscopically with forceps and the hookworm was hypochromic erythrocytes. Nevertheless, when a round worm is found in the duodenum during upper gastrointestinal Discussion: endoscopy, differential diagnosis is necessary to Hookworm is distributed everywhere in the determine the final diagnosis and treatment. Necator americanus are widespread among humans and distinguished from each other by the morphological References differences of their mouth capsules, bursa and spicules. J is estimated to justify the host hemoglobin concentrations Clin Gastroenterol 2011;45:6-15.
Pre and post-treatment counselling may minimise the effects birth control no condom buy levlen 0.15mg on line, but many of these changes will 349 be long-term or permanent birth control pills 3 weeks of bleeding buy 0.15 mg levlen overnight delivery. Support is generally best provided by the team who coordinated treatment birth control pill 93 discount levlen 0.15mg on line, as primary care physicians are unlikely to have great experience of these rare conditions birth control pills ovulation buy levlen on line. Most recurrences present within the first 12 months (70 per cent) and 90 per cent within the first 2 years. Patients who present with recurrence following a major resection are unlikely to be suitable for curative treatment and will often be best managed in a palliative care setting. At 5 years many patients can be discharged from oncological surveillance, but may require ongoing support from other members of the team. C the presence of nodal metastasis is the most significant prognostic factor, although all others will have an impact on the patient, their response to treatment and their subsequent outcome. Treatment and outcomes in oropharyngeal cancer 1G If histology demonstrates extracapsular spread following a staging neck dissection for the clinically node-negative neck, postoperative radiotherapy is used to reduce the chance of local recurrence. The radiotherapy changes can also interfere with interpretation of future biopsies if required. B A benign salivary mass involving the parotid and submandibular glands Anatomy, physiology and C A mucous retention cyst originating pathology of the salivary from the sublingual glands, limited by glands the mylohyoid muscle D A mucous retention cyst originating 1. The minor salivary glands contribute from the submandibular and sublingual what percentage of the total salivary glands which perforates the mylohyoid volume What percentage of minor salivary is not an anatomical relation to the gland tumours are malignant A 50 per cent A the anterior facial vein B 60 per cent B the facial artery C 70 per cent C the inferior alveolar nerve D 80 per cent D the lingual nerve E 90 per cent. Which structure marks the posterior describes the anatomy of the boundary of the submandibular duct sublingual glands A the third molar tooth B They drain either directly on to the floor B the body of the submandibular duct of mouth or into the submandibular duct. C the lingual nerve C They consist of two lobes separated by D the posterior edge of the mylohyoid the mylohyoid muscle. E the marginal mandibular nerve D They are embedded in the intrinsic muscles of the ventral surface of the 7. The term plunging ranula refers to B Between the superior limit of the gland which clinical entity Which of the following complications lobe of the submandibular gland to is associated with mumps infection A Secretory otitis media A the hypoglossal nerve B Pancreatitis B the submandibular ganglion C Balanitis C the deep cervical fascia D Uveitis D the tendon of digastric E Inflammatory arthritis. Which of the following is not a associated with ascending bacterial complication of submandibular gland sialadenitis What percentage of submandibular the most common cause of bacterial tumours are malignant A 20 per cent A Staphylococcus aureus B 30 per cent B Staphylococcus epidermidis C 40 per cent C Streptococcus pyogenes D 50 per cent D Pseudomonas aeruginosa E 60 per cent. Which of the following structures B 20 per cent does not lie in the parotid gland C 30 per cent A the facial nerve D 40 per cent B Terminal branches of the external carotid E 50 per cent. A At the anterior border of the masseter A Gustatory sweating B Inferior to the angle of the mandible B Dry mouth due to reduction in salivary C As a parapharyngeal mass flow D Anterior to the ear C Development of a sialocele over the E Behind the angle of the mandible. How should a benign tumour parotid bulk involving the tail of parotid be E Hyperplasia of the contralateral parotid managed A Enucleation B Open biopsy prior to formal excision Degenerative conditions C Radiotherapy 27. Which nerve must be transacted as C It is associated with connective tissue part of a superficial parotidectomy A the facial nerve D the submandibular glands are more B the hypoglossal nerve commonly affected. A Acinic cell carcinoma A the insertion of sternomastoid B Adenoid cystic carcinoma B the greater horn of the hyoid C Carcinoma ex pleomorphic adenoma C the superior-most portion of the D Salivary sarcoma cartilaginous ear canal E Lymphoma. Which of the following branches A Botulinium toxin injection into of the facial nerve can be divided submandibular and parotid glands without the need for immediate cable B Radiotherapy to the salivary glands graft repair C Submandibular duct repositioning A Temporal D Bilateral submandibular gland excision B Oribtal E Excision of submandibular glands and C Zygomatic repositioning of parotid ducts. Investigation and management of submandibular gland disease A Sialogram B Floor of mouth X-ray C Orthopantogram 354 D Intermittent pain and swelling E Weight loss and otalgia F Dental infection G Submandibular gland excision H Transoral stone excision I Hypoglossal nerve J Lingual nerve K Submandibular nerve L Marsupialisation M Primary closure N Stenting of the duct Study Fig. A There are around 450 minor salivary glands distributed through the oral cavity, oropharynx, larynx, trachea and paranasal sinuses. E In contrast to the major salivary glands, tumours of the minor salivary glands are highly likely to be malignant. If lesions involve the hard palate, treatment involves excision with partial or total maxillectomy. D this rare form of mucous retention cyst arises from submandibular and sublingual glands. C the submandibular gland consists of two lobes which communicate around the posterior border of mylohyoid. The gland is drained by the submandibular duct, which drains against gravity up to the sublingual papilla in the floor of mouth. The marginal mandibular nerve is also at risk during surgery on the gland, due to its position in relation to the skin incision. The inferior alveolar nerve enters the mandible and is protected during surgery on the submandibular gland (see Fig. Damage to the nerves depicted Mandible Marginal mandibular branch of facial n Lingual nerve Submandibular salivary Hypoglossal nerve gland Incision for excision of submandibular salivary gland Figure 47. C Stones in the submandibular duct may be excised via an intraoral approach if they lie anterior to the lingual nerve, marked by the level of the second molar. The nerve is at risk if the duct is explored behind this level, where calculus disease should be managed with submandibulectomy and excision via a transcervical approach. The incision should be carried through platysma and on through the superficial layer of the deep cervical fascia which protects the marginal mandibular nerve, which lies in a subplatysmal plane. B the lingual nerve must be identified during excision of the submandibular gland. It lies in the deep surface of the gland and is tethered to it by the submandibular ganglion. There is often a blood vessel associated with the ganglion, and both structures should be clamped and tied. The nerve retracts up into the floor of the mouth, carrying the vessel with it, which can lead to troublesome bleeding. Damage to the lingual nerve causes anaesthesia of the tongue as well as taste disturbance. The nerve to mylohyoid supplies sensation to the submental skin, which can be damaged during the dissection.