1. Composite defect of oral cavity.
2. Three layer (through and through) defect of oral cavity.
3. Total or near total pharyngoesophageal defects.
4. Extensive skull base defects.
5. Massive defect not readily addressed with other techniques.
6. Situation where there is lack of other reconstructive options (failure/ patient’s limitation).
7. Salvage surgery to chemo-radiation failure.

1. Neoplasia
2. Infection
3. Osteoradionecrosis
4. Congenital defect
5. Trauma
6. Secondary to reconstruction

DELTOPECTORAL FLAP:

• It is a distant axial flap.
• It was first described by Bakamjian and Littlewood. So The deltopectoral (DP) flap is also called by some as the Bakamjian flap.
• It is an axial pattern flap designed on the anterior chest wall between the line of clavicle and the level of anterior axillary fold.
• VASCULAR SUPPLY: It is supplied by upper 3 or 4 perforating branches of the internal mammary artery. It emerges through the medial end of intercostal spaces.
• BOUNDARIES: 

-Superiorly: Clavicle

-Laterally: Acronium

-Inferiorly: A line running through the anterior axillary fold to above the nipple inferiorly.

• The flap can extend to any site of the neck and occasionally upto the level of zygoma. This flexibility is due to:

1. Ability to retract from side to side after it has been elevated.
2. Anomalous pivot point that is due to considerable laxity of the skin on the anterior axillary fold with abducted arm and thus lower border of flap is longer than upper part.

KEY POINTS DURING PROCEDURE OF RAISING DP FLAP:

• While raising the flap it should not be extended beyond the deltopectoral groove because it results on failure of the tip of the flap.
• Elevation has to begin laterally and the pectoral fascia is left on the flap, leaving the muscle fibre below absolutely bare.
• While elevating the flap if any branches of acrominothoracic axis is encountered it should be ligated.
• Diathermy must be used judiciously.
• When raising the flap the retraction should be upward applied by an assistant using skin hook and precaution should be taken to avoid buttonholing.
• The pivot point on the flap is thus at the medial end of the upper limit and not the lower limit.
• The donor site is usually covered with a split skin graft.

USES OF DELTOPECTORAL FLAP:

1. Allows one stage reconstruction of the anterior neck skin.
2. To reconstruct the defect by passing as a bridge over the normal skin.
3. To reconstruct the large defect of the lower face and the upper neck.
4. May be used in repair of pharyngeal fistula

[table id=45 /]

[table id=44 /]

commonly treated tumours

1. Meningioma (skull base most benefited)
2. Paraganglioma(skull base most benefited)
3. Juvenile angiofibroma
4. Hemangiopericytoma

Less frequently treated tumours

1. Schwannoma
2. Carcinoid
3. Alveolar sarcoma
4. Thyroid carcinoma
5. Granular cell myoblastoma
6. Capillary haemangioma
7. Esthesioneuroblastoma
8. Neuronoma

P.S.

Meningiom (meningeal branches from both ICA and ECA)

Paraganglioma: Ascending pharyngeal artery- 10% multifocal, 5% ecrete catecholamines

• Labyrynthine fistula is a leak through an abnormal third window.

CAUSES:

1. Traumatic
2. Following active mucosal disease
3. Following COM squamosal ( Cholesteatoma)
   -4-13 % of cases
   -Most common complication
   -LSCC is the most common site
4. Localized infection in CWD Mastoidectomy cases

DIFFERENT STAGES AND NYSTAGMUS IN VARIOUS STAGES:

• PRE-LIMINARY STAGE →Bony erosion with blue line of labyrinth.
• STAGE  → Endosteal membrane exposed but intact.
• STAGE II → Membranous SC in contact with cholesteatoma matrix and perilymphatic space open. This is the irritative phase which shows nystagmus with slow phase in contralateral side and fast phase in ipsilateral side.
• STAGE III → Direct involvement of membranous labyrinth. This is a paralytic phase in which  the slow phase is in   ipsilateral side and fast phase in contralateral side.

TREATMENT:

• Many fistula shows spontaneous bony closure after removal of the offending cholesteatoma or infection.
• If severe: Most surgeons recommends CWD Mastoidectomy and closure.
  -The cholesteatoma matrix should be left undisturbed over the SCC until all other disease is removed and all
  aspect of procedure such as meatoplasty is completed.-Then the matrix should be carefully lifted and the fistula is identified. The matrix should be peeled off the mebranous labyrinth very meticulously following which the fistula must be sealed immediately with fascia and bone dust.

• It is defined as the discharge from the ear.

Q. WHAT ARE THE DIFFERENT TYPES OF OTORRHOEA AND THE CHARACTERISTICS OF DIFFERENT TYPES?

1. Serous : Like serum
2. Serosanguinous : Serum + Blood tinged
3. Mucoid : Mucin tread seen while suckiing or moping the discharge
4. Mucopurulent : Mucoid discharge + pus
5. Purulent : Pus, yellow in colour and may be foul smelling
6. Watery : Water like
7. Blood : bright red or dark red

Q. WHAT ARE THE DIFFERENT CONDITIONS WHERE VARIOUS TYPES OF DISCHARGE ARE OCCUR?

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Q. WHAT ARE THE CAUSES OF OTORRHOEA ACCORDING TO ANATOMICAL SITES IN EAR?

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Q. HOW DO YOU CONFIRM IF THE WATERY DISCHARGE IS CSF OR NOT?

• It is assessed by following test:

1. Halo Sign: Clear halo like ring is formed if CSF discharged if dropped on the filter paper.
2. Glucose estimation can be done which is > 30 mg/dl
3. ß2 Transferring band is present on Immunoelectrophoresis. It is the most confirmatory test for CSF otorrhoea.