1. case presentation
 Dr. M. Naim Manhas
 m.s.,m.b.b.s.
 E.N.T. Specialist
 King Abdul Aziz
Hospital
1Dr. Naim Manhas

2. 2Dr. Naim Manhas

3. what is calculus/ lith/stone
Calculus:- / lith
Concretion of
material mainly
composing of
mineral salts.
Formation :-
lithiasis
3Dr. Naim Manhas

4. common sites:-
Uro-genital system: kidney,ureter, bladder
Gall bladder
Salivary gland submandibular gland
parotid gland
Tonsillis palatine
lingual
Nasal cavity
4Dr. Naim Manhas

5. Effects on organs

Disruption of normal
flow
Disrupting the function
of organ in question
Late effects of
obstruction on organs
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6. etiology
Excessive levels of minerals
• Usually increase levels of calcium
slow flow rate
• infection
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7. Calculi in E.N.T. Practice
Rhinolith :-
Calculus present in nasal
cavity
Actually exogenous foreign
body ,blood clot, or secretion
is covered by slow deposition
of calcium and magnessium
salts over a period of time.
Causes nasal obstruction ,
unilateral prulent nasal
discharge,epistaxis,sinusitis
or epiphora.
7Dr. Naim Manhas

8. Calculi in E.N.T. Practice
Tonsilliar lith :-
Tonsilliar stone or tonsilliar calculi
Clusters of calicified material in the
tonsillar crepts.
Tonsilliar lith have been recorded
weighing from 300 mg to 42 G
Composed mostly of calcium, but
may contain other minerals like
phosphorus , magnessium.
May be asymptomatic
One of causes of Helitosis
8Dr. Naim Manhas

9. case presentation
30 years old saudi
lady presented to
E.N.T. clinic with file
No.494114 .
History of swelling in
submandibular
space, since 6
months increasing in
size during meals.
h/o pain was present
during meals
9Dr. Naim Manhas

10. presentation
Recurrent swelling
Pain which is
excerbated with
eating
Stones in duct can be
palpated
Imaging (C.T.) Scan is
best to detect calculi
UltraSound has not
proven useful
10Dr. Naim Manhas

11. Radio-opague shadow in submandibular gland-
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12. 12Dr. Naim Manhas

13. Incidence of salivary calculi
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14. saliva & its composition
saliva:- produced by clustered Acini cells and
contain electrolytes enzymes (e.g.ptylin and
maltase, carbohydrates, proteins, inorganic
salts and even some antimicrobial factors)
Approx. 500-1500ml of saliva is produced daily
and transpored to oral cavity by ductal
elements at an average of 1ml /mt
Obstruction :- causes stasis of salivary flow
14Dr. Naim Manhas

15. saliva & its composition
saliva
• composition
Abundant
• hydroxyapatite
• Aggregates of
mineralized
debris
Flow rate is
decreased
• Formation of
nidus
• Promoting
calculi
formation
15Dr. Naim Manhas

16. Submandibular gland
calculi
High salivary mucin and high
alkaline content
High concentration of calcium
and phosphate
Primarly of calcium phosphate
and hydroxyapatite
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17. Approxaimately 74% of single
stone is found in the gland,
and 26% in duct.
74%
26%
1st Qtr
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18. complications
 Persistant obstruction from
Sialiolithasis leads to salivary stasis
which predisposes gland to recurrent
infections and even abscess
formation.
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19. management
SURGICAL REMOVAL
Calculus impacted in duct:-
After palpation and fixation
of the calculi , duct is
opened and calculi
removed. Duct is kept open
as it heals by itself.
Larger stone get embeded
in the hilum or body of the
submandibular gland
require surgical excision of
the gland
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20. submandibular gland
specimen
Excised
submandibular
gland with
embedded stone
in the hilum of
the gland
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21. Recent advances
 Endoscopic techniques ;-
 Allow an intraoral endoscopic examination
of the duct and extraction of salivary
calculi
 If stone is impacted in gland then surgical
removal of gland is indicated
21Dr. Naim Manhas

22. Penetrating neck injuries
Penetrating injuries
caused by gunshots
and sharp edged
weapons have
different approach for
management.
Gunshot wounds in
the neck are divided
in three zones of
neck.
22Dr. Naim Manhas

23. Neck zones
Zone -1
Between suprasternal
notch to cricoid
cartilage.
Contains throacic
outlet structures
Proximal common
carotid ,vertebral and
subclavian arteries.
Trachea, esophagus, t
horacic duct, thymus
23Dr. Naim Manhas

24. Neck zones
Zone –II
Between carotid
cartilage and angle of
mandible.
Internal and external
caotid arteries, jugular
veins, pharynx, larynx, es
opahgus, recurrent
laryngeal nerve, spinal
cord, trachea, thyroid
and parathyroid.
24Dr. Naim Manhas

25. Neck zones
Zone –III
Between angle of
mandible and base of
skull.
It has distal
extracrainal carotid
and vertbral arteries
and uppermost
segments of the
jugular veins.
25Dr. Naim Manhas

26. Penetrating Neck Injury
The normal protocol
regarding the
management of
penetrating neck injuries
does not apply in cases like
this.
This egyptian man
reported to E.R. with
pentrating injury caused by
sharp edged weapon in
neck .
After airway was secured
by intubation patient was
shifted directly to O.R.
26Dr. Naim Manhas

27. point to remember
Tight facial compartments of
neck structures may limit
external hemorrhage from
vascular compartment.
These tight fascial boundaries
may increases risk of airway
compromise , because the airway
is relatively mobile and
compressible by an expanding
hematoma.
27Dr. Naim Manhas

28. Penetrating Neck Injury
The standard care is
immediate surgical
exploration who present
with signs and symptoms
of shock and continuous
hemorrhage from the
neck wounds.
The specific injuries are
confirmed and treated
during neck exploration
28Dr. Naim Manhas

29. vital structures
 Because of numerous vital structures that are
present in small area, the objective of surgical
exploration is to arrest hemorraghe yet maintain
cerebral flow and preserve neurologic function.
 Jugular vein injury repair depends upon type of
injury . Repair can be performed by simple lateral
closure, resection and reanastomosis or
saphenous vein graft reconstruction, particularly
Internal jugular vein.
29Dr. Naim Manhas

30. vital structures
 Nerve injuries account for about 1-3%, vagus and
recurrent laryngeal nerve.
 Thoracic duct injuries :- difficult to diagnose
intially but later on presents as chylous leak
 Needs reexploration and ligation of throacic duct
 Thyroid injuries :- can cause extensive bleeding.
Extensive injury require an ipsilateral lobectomy to
control the bleeding
30Dr. Naim Manhas

31. Don’t miss
Laryngo-tracheal
injuries are also
common (10%) .
Direct endoscopic
examination of Larynx
and esophaus is done.
After closing and airway
is secured by surgical
tracheostomy,endoscop
ic examination of
larynx and esophagus is
done . 31Dr. Naim Manhas

32. Before Decanulation
. Esophageal injuries are
the third most common in
penetrating neck trauma
(6%).
Early diagnosis lessens
probability of delayed
treatment and missed
injury, which can be
devastating.
After closure the airway is
secured by tracheostomy
and then endoscopic
examination is done .
32Dr. Naim Manhas

33. prepration for discharge
Oral feeding was
initiated after barium
study which shows no
evidence of leak.
Decanulation was
done after follow up
endoscopy of larynx
show no evidence of
any pathology .
33Dr. Naim Manhas

34. 34Dr. Naim Manhas