• In emergency situations it is performed under local anaesthesia
• In elective condition it is performed under general anaesthesia.

POSITION:

• Supine with neck hyper extended

INCISION:

• Emergency tracheostomy is performed with the vertical incision extending from the lower border of cricoid cartilage up to 2 cm above the supra-sternal notch in mid line. The area is also known as space of Burns and is devoid of deep cervical fascia.
• Elective tracheostomy is performed through a horizontal incision 2 cm above the sternal notch.

SOFT TISSUE DISSECTION:

• When we approach the trachea in the mid line, it is found under the following structure:

1. The subcutaneous tissue
2. Platysma
3. Superficial fascia
4. Branches of anterior jugular vein
5. Strap muscle
6. Thyroid isthmus at the level of 2nd tracheal ring
7. Pre-tracheal pad of fat through which inferior thyroid vein may wander and sometime thyroid ima artery may be found in tissue plane.

• Incision is given through platysma, cervical fascia
• Branches of anterior jugular vein if any are ligated and divided.
• Strap muscles are bluntly dissected and retracted.
• Isthmus is either retracted upward or ligated and divided.
• Pretracheal fascia is splitted and tracheal rings are clearly identified.
• A syringe with normal saline is inserted and air is aspirated to confirm.
• A vertical incision is made between the 2nd – 3rd tracheal ring.
• Tracheostomy tube is inserted into the tracheal opening and the cuff is inflated.
• The wound is closed loosely & the tube is secured by tying the knot around the neck with neck flexed or in neutral position. It should be tight enough to allow one finger to be inserted between the tapes & the skin. Flanges are sutured to the skin.
• A wet gauze is placed over the tracheostome.
• A proper instruction is to be given about a tracheostomy care & management of any complications if arises to all the staff taking care of the patient.

Most common variety.

BPPV is the most common cause of vertigo constituting 20-40% of all patient with peripheral vestibular disease. Mean age of on set ranging between 4th and 5th decades. women outnumbering men by 2:1.

DIGNOSIS is always clinical.

History: Patient c/o severe vertigo associated with change in head position. Symptoms are always sudden in nature never lasting more than one minute.The patient may even volunteer provocating postures.

On examination: The classic eye movement associated with Dix Hallpike manoeuver is seen. Dix-Hallpike maneuver: The patient is positioned on the examination table in such a way that when he/she  is placed supine, the head extend over the edge. The patient is lower with the head supported and turned 45 degrees to one or the other side. The eyes are carefully observed, if no normal eye movements are seen, the patient is returned to upright position.

This same manoeuver is repeated with the head in the opposite direction and the patient’s symptoms are noted. The pattern of response consist of the following:

• Nystagmus is a combination of vertical up-beating and rotary (torsional) beating towards the downward eye. Pure vertical nystagmus is not seen in BPPV.
• There is no often a latency of onset of nystagmus.
• Duration is less than a minute
• Vertiginous systems are invariably seen
• Nystagmus disappears with repeated testing (fatiguability)
• Symptoms often recur with the nystagmus in opposite direction on return of the head to upright position.

Canalithiasis involving the posterior canal is the commonest cause of BPPV. Posterior canal BPPV may rarely be bilateral, but while testing the head must be positioned in the

Lateral canal BPPV:

Lateral canal has also been identified as the offender in 17 % of cases with BPPV. Lateral canal BPPV can be detected by a variation of Dix Hallpike maneuver. The patient’s head is first brought to the supine position resting on the examination table (not hyperextended). The head is then turned rapidly to the right so that the patient’s right ear rests on the table. The eye movements of the patient are monitored with Frenzel’s glasses for 30 seconds. The patient’s head is then turned to the supine position (eyes looking upward) and is then rapidly turned to the left so that the left ear rests on the table. Eye movements are monitored. The nystagmus with lateral canal BPPV is horizontal and may beat toward (geotropic) or away (ageotropic) from the downward ear. It begins with a short latency, increases in magnitude progressively, and is less susceptible to fatigue with repetetive testing than the vertical torsional nystagmus of posterior canal BPPV.

Cupulolithiasis, either alone or in combination with canalithiasis is more likely to be involved in the etiology of lateral canal BPPV than in the case of posterior canal BPPV. If the nystagmus is geotropic, the particles are likely to be in the long arm of the lateral canal relatively far from the ampulla, if the nystagmus is ageotropic, the particles could be in the long arm relatively close to the ampulla or on the opposite side of the cupula either floating within the endolymph or embedded in the cupula.

Superior canal BPPV:

Incidence of superior canal BPPV is very rare.

Standard electro-oculography or two dimensional video nystagmography devices does not record the movement of eye associated with BPPV. Thus clinical examination of the patient is very important to dignose.

These are more often from the oval window.

AETIOLGY

1°fistula

• Risk is more with Stapedectomy compared to stapedotomy (Stapedectomy > stapedotomy)
• The surgeon creates a fistula at every stapedectomy operation and seal the opening.
• In most operation there is enough surgical trauma to the oval window microperiosteum to lead to the production of an inflammatory repair envelope around the prosthesis sealing the opening.
• Fistula more common c interposition technique but hearing better with prosthesis.
• Persisting Conductive hearing loss after operation –Peri Lymphatic Fistula

2° or acquired fistula

• Barotrauma
• Head injury
• Cholesteatoma
• Neoplasia
• Congenital
• Spontaneous (no recognizable aetiological)

SYMPTOMS AND SIGNS

• History of head injury or stapes or other middle ear surgery or other events associated ↑Intra Cranial Pressure such as coughing, straining / aviation/ diving.
• Unsteadiness and dizziness c marked positional element which tends to persist until the fistula is closed either by spontaneous healing or by surgery.
• Hearing loss: persistent or fluctuating: Sensory Neural Hearing Loss /Conductive Hearing Loss / mixed.
• Tinnitus. (28-45%)
• Sometime present c recurrent meningitis or CerebroSpinal Fluid  behind the TM.

Examination of ear: Unremarkable c rarely TM retraction or evidence of middle ear fluid

• Fistula text: is usually, but not always negative(1/3) (This test is for a third opening into the inner ear) Fistula test with  electro-nystagmography – Quick phase always from the effected ear accurate but negative response doesn’t rule out diagnosis of fistula.
• Positional nystagmus: The characteristics that differentiate the positional nystagmus from BPPV are:
  1. There is either a short or no latent period.
  2. Nystagmus is not violent as in BPPV.
  3. The duration tends to be longer c the nystagmus fatiguing slowly or not at all
  4. The nystagmus rarely reverses direction when the patient is bought to the sitting position.
  5. The nystagmus doesn’t necessarily beat toward the involved ear.
  6. The nystagmus is only occasionally rotary.

DIAGNOSIS

Audiometric tests

Initially: pure tone SNHL in the low frequencies

Flat loss which fluctuates & Recruitment ±

Initially speech discrimination fluctuate c the pure tone threshold, but later they may be disproportion lower than expected when compared to stapedius reflex threshold.

Frazier’s test– an improvement in pure tone threshold when lying for 30 minutes compared to sitting.

Romberg test may be +ve

Caloric test:

• Canal paresis or hypoactive response
• After stapedectomy high incidence of ↓ caloric response.
• Caloric test: little value in diagnosis fistula.

Electronystagmography:

• May reveal a directioned fixed positional nystagmus but this cannot be relied upon.

Diagnosis by radioactive tracer method/ Fluorescein

• Radioactive indium -111 DTRA is injected into the lumbar subarachnoid space.
• The demonstration of ↑ radioactivity in nasopharyngeal secretions strongly supports the fistula.

MRI and High Resolution CT (HRCT): low predictive value

• Intralabyrinthine air
• Fluid in non diseased mastoid or m/e and in round window niche on T2 weighted MRI.

Diagonisis can be confirmed only by surgical exploration

MANAGEMENT:

Medical management:

• Bed rest for minimum 5 days c the head of the bed elevated 30-40°.
• Sedation and faecal softeners should be prescribed.
• Symptoms settled – limit activity for further 10 days and avoid exertion.

Surgical management

Indication : If medical treatment fails, if symptoms persist for over 1 month.

Permeatal: Standard tympanotomy

Elevation of tympanomeatal flap

Inspect middle ear avoiding trauma as it can produce serous ooze.

If ↓d/A: Valsalva manouevre may help identify leak. Inspect round window and oval window.

If ↓G/A: Identification of the site of leak.

• Place the patient in Tredelenberg head down position
• ↑ Ventilatory pressure.
• Use of intrathecal fluorescein like in Cerebrospinal Fluid leak (controversial)
• Pragmatic approach
• Look carefully in turn
  1. At round window and oval window
  2. Around middle ear

• Eustachian orifice

TOPODIAGNOSTIC TESTS ARE AS FOLLOWS:

1. Schirmer test
-Test for greater superficial petrosal nerve
-Compares the lacrimation of two sides
-A strip of filter paper is hooked in the lower fornix of each eye and the amount of wet strip is measured.
(>10 mm wet ~ adequate function)

2. Stapedial reflex test
– Tested by Impedence audiometry
-It is a test for nerve to stapedius

3. Taste test
-Also known as Electrogustometry
-Tests for Chorda Tympani branch of facial nerve

4. Submandibular salivary flow test
-Measure the function of Chorda Tympani
-Polythene tubes are passed into both warton ducts and drops of saliva counted during one minute.

• High risk patient with High risk tumour & N1b nodal status and M0
• T1 N1 Mo with high risk (stage IV A)

Total thyroidectomy c parathyroid preservation and Selective neck dissection IIb-Vb +Post operative radiotherapy and RIA should be the choice of treatment.

History

Detailed history should include:

Age , Sex, Hoarseness, Obstructive symptoms, Progression, Pain, dysphagia, H/o childhood irradiation, Family history, Symptoms of toxicity.

Physical examination

• General
• L/E THYROID IS DONE ONE SIDE AT A TIME : Look for overlying skin consistency + Examination of neck nodes, Pharynx, Larynx and trachea
• Indirect Laryngoscopy: Fibre-optic endoscopy of vocal cord to rule out palsy/ invasion

Chest radio graph

• Tracheal shift
• Mediastinal external
• Pulmonary metastasis
• Other co-morbid

Ultrasonography

• Difference cystic/nodular
• Solitary or multinodule (cystic up to 1 mm/solid up to 3mm)
• Tumour size
• Calcification(MTC)
• Extracapsular extension
• Vascular invasion
• Neck nodes(level i-vii)
• Assist FNAC
• Involvement of contralateral lobe

Radiology

• Extent and relationship
• Indication: Large retrosternal extension
• Multiple LN deposits
• Pulmonary metastasis
• Abdominal CT lymphoma staging
• MRI may detect vessel involvement

Laboratory investigation

• T3 and T4
• Serum calcium
• Thyroid antibodies
• Thyroglobulin
• Calcitonin

Cytology: FNAC is cheap, safe and reliable

• FNAC do not distinguish between benign and malignant follicular neoplasm
• FNAC can miss multifocal cancer.

• Gold standard
• visualizes nodules greater than 5 mm
• uses- 123I – Thyroid pathology
  • 123I-MIBG -(monoiodobenzyl guanidine) MTC, suspect of MEN
  • Ga citrate- lymphoma (use in long standing Hashimoto thyroiditis)
  • 99m Tchnetium now used for various reasons like  half life of 6 hrs, cheap readily available, low radiation dose. It is trapped but not organified.

Total thyroidectomy with level VI dissection and palpation of level II-IV and VII should be the treatment of choice.

Suspicious – Frozen section

Positive

Selective Neck dissection(II, IV  & lower V)

After case + Post  operative radiotherapy Radio iodine treatment

If the diagnosis of Papillary Thyroid Cancer is  made after lobectomy, completion thyroidectomy is required and should be done within 8 weeks of histological diagnosis.

The mouth is separated from the pharynx by the buccopharyngeal membrane which disappears around the end of 3^rd week when a series of arches appears in the wall of pharynx. These arches are formed by mesodermal condensations and are known as the branchial arches.The arches fuse ventrally, thus forming u-shaped structures which support the pharynx. Initially there are 6 of these arches, but the 5^th is vestigial and rapidly disappear.

There are 4  branchial pouches internally, 4 branchial grooves externally. These separate the remaining five branchial arches.

Each branchial pouch is lined by endoderm and branchial grooves by endoderm. These pouches and grooves are separated by a thin layer of mesoderm. If this endoderm, mesoderm & ectoderm layers break down a branchial fistula is formed.

A central core of cartilage develop in each arch and muscles differentiate from the surrounding mesoderm.
Each arch is supplied by Cranial Nerve and by an artery.

1^st Branchial arch –

• Maxilla, Incus, Malleus, Anterior ligament of malleus, sphenomandibular ligament, Mandible
• Muscles- Muscles of mastication
• Nerve- Mandibular Branch of the Trigeminal Nerve
• Artery- Maxillary artery

2^nd Branchial arch-

• Stapes, styloid process, stylohyoid ligament, lesser cornua and upper part of the body of the hyoid bone.
• Muscles of facial expression, Posterior belly of Diagastric
• Stylohyoid muscle
• Auricles muscles stapedius muscles
• Nerve- Facial
• Artery- 2^nd aortic arch Rarely persist as stapedial

3^rd Branchial arch

• Greater cornua and lower part of the body of the hyoid bone
• Muscles- Stylopharyngeus
• Nerve- Glossopharyngeal Nerve
• Artery – 3^rd aortic artery which persist as part of the Internal Carotid Artery

4^th Branchial arch

• Thyroid and epiglottis
• Muscles- cricothyroid, all  muscles of palate except tensor veli palatini
• Artery- left aorta, Rt- subclavian artery

5^th Brachial arch

• Cricoid, Arytenoid, corniculate, cuneiform
• Muscles:  All muscles of pharynx except cricothyroid
• Artery- Pulmonary

1^ST Branchial Pouch:

Growth laterally to form: The Eustachian tube and the middle ear.

2^nd Branchial Groove:

Deepens to form (only Dorsal part) External auditory meatus and remaining disappear but if it persist collaural fistula is formed.

Pinna

Number of tubercles appear at the dorsal each of the first and 2^nd branchial arches. These tubercles surrounds the dorsal end of the 1^st groove which is to be form the External Auditory Canal.

2^nd /3^rd /4^th  Branchial pouches and grooves

2^nd pouch –Dorsal part contribute to middle ear

ventral part – supra tonsillar fossa.

Externally 2^nd Branchial arch grow caudally and covers over 3^rd 4^th 6^th arch

3^rd pouch –Dorsal part Inferior parathyroid gland

Ventral part- Thymic part

Deep pit/sinus lined by ectoderm. Its lip fuse and ectoderm lining cystic space is produced which disappear later.

The lymphatic system arises from 5 primitive sacs developed from the venous system

– 2 Jugular sacs

– 2 posterior sciatic sacs

-Single retroperitoneal sac

From these, endothelial buds extends centrifugally to form the peripheral lymphatic system. Two principal theories have been postulated to explain the origin of other lymphangiomas.

• Sequestration of lymphatic tissue derived from segments of the primitive sacs which retain the proliferative growth potential bear no connection with the normal lymphatic system.
• Endothelial fibrillar membrane proliferation from the walls of the cyst, penetrate the surrounding tissue along the line of least resistance between muscles and vessels to canalize and produce more cysts.These lesion are congenital arising from localized lymphatic stasis caused by congenital blockage of regional lymphatic drainage.

  TYPES OF LYMPHANGIOMA

A) Morphological types:

1. Lymphangioma simplex (capillary lymphangioma) -40%
   1. composed of the walled, capillary sized lymphatic channels
   2. Usually asymptomatic
   3. Present as pole, small vesicle like lesions visible on the skin or oral cavity.
2. Cavernous lymphangioma (35 to 45%)
   1. composed of dilated lymphatic spaces
   2. Often has fibrous adventitia
   3. Typically occurring in the tongue, cheeks and lips
   4. Present as patient diffuse swelling.
3. Cystic hygroma (20-25%): Macro cystic lesion c well defined margin
   1.  composed of cysts and sinuses
   2. Varying in size from a few mm to several cm in diameter.
   3. Present as a cystic mass of varying diameter containing eosinophilic acellular lymph fluid.
   4. Thin walled sinuses are lined by flat endothelial cells.
   5. These larger cystic masses which may communicate or be isolated.

B. Histological classification

1. Macro cystic
   1. large and compressible
   2. frequently multilocular
   3. ususally infrahyoid
2. Microcystic
   1. smaller and firmer
   2. Suprahyoid usually
3. Combined

PRESENTATION

1. Although congenital and in majority of cases present at birth they become clinically evident by 2-3 year of life
2. M:F =1:1
3. R=L=1:1
4. They can appear anywhere in the head and neck and about 75% of  cases of lymphangiomas are in head and neck region.
5. Simple and cavernous lymphangioma occurs where the tissue planes are relatively tight eg. tongue, lips cheeks
6. Acytic hygroma aeise mainly in neck where it has more lax.
7. Most lesions appears in posterior triangle often occupying the supra  clavicular fossa.
8. Commonest salivary region involved in parotid gland area.
9. Oral: 35%
10. cervical: 25%
11. Axillary: 15%
12. 75% of all lymphomas are located in neck, usually in posterior triangle with 10% extending to mediastinum
13. Smooth, soft, cystic, trans illuminate and demonstrate ballotment
14. Usually asymptomatic and slow growing except a distressing cosmetic problem. Cystic hygroma and cavernous lymphangioma either grow progressively or remain static and there have also been reports of involution.(stell & marans)

Rapid growth leading to pain airway compromise occur due to:

• Trauma causing internal venous haemorrhage
• Infection
• Rapid growth may lead to enlargement of affected side of face obscuring eyes and distorting mouth.There may be hypertrophy of mandible or maxilla but not so apparent.
• Airway obstruction more with intraoral/ intralingual lymphangioma.
• Another danger of excessive growth is damage to bone by pressure, absorption and vascular compression.
• The facial nerve is very resistant and is almost never damaged.
• Brachial plexus if compressed- pain and hyperaesthesia

Natural history

• Cystic hygromas of head and neck do not involute spontaneously.
• Some progression may take place with enlargement and infiltrative growth into previously unaffected areas sometime.
• Recurrent episodes of acute infection may arise and the lesion will become larger painful and inflamed. As a result of this infection, related IV can become enlargement
• The activity in cystic hygroma may subside with increasing age.
• There is no potential for malignant change.
• Rarely sequestration of fluid within a cystic hygroma especially in neonates may result in hypovolemic shocks and widespread intravascular thrombosis.

It is  the new intralesional injection used to treat lymphangioma. It is named OK-432 (picinabil). The following are the advantages of OK-432:

• Promising result
• It is an immuo-modulatory agent and a lyophilized incubation material derived from group A pyogenic streptococcal culture.
• It induces an intense inflammatory reaction within the hygroma and leads to adhesion or increase permeability of the endothelial lining increasing the rate of drainage from the lesion. Thus obliterates the cystic spaces.
• It also causes thrombosis with subsequent necrosis.
• Dose: 4 does at 6-8 wk intervals.
• 86% successful outcome predominantly for macro-cystic cases.
• It may be less effective in cavernous lymphangioma and lymphangioma with haemangiomatous elements.

P.S . more effective treatment in cystic type

Others:

1. Interferon
2. Fibrin-sealant
3. Sirolinus

SURGERY

• Surgical excision remains the treatment of choice though challenging because cystic hygroma has an apparent disregard for an anatomical planes which makes total excision difficult.
• Surgery can be helped by the injection of tissue blue into the lymphatic spaces.
• Some surgeons thus prefers less radical surgical decompression using vacuum drains and/or marsupialization of the cysts(Thomson)
• More radical approach should be made in gross cases without regard for the facial nerve (Mustarde) + (very extensive +- tracheostomy)
• Since the gross involvement and stretching of the facial muscles renders their preservation pointless and usually impossible.
• A series of planed resection and subsequent reconstruction may be needed complication: residual disease (50%) residual/ recurrence more in suprahyoid  disease due to complete anatomy.
• Impairment of speech swallowing and breathing(44%) cosmetic deformity (36%)

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