HEAD & NECK 2

2.1 CLEFT PALATE.

The two maxillary shelf's may fail to unite in the midline

leaving a gap in the palate, or it may extend to the premaxillar in the

front leaving a complete gap leading into the nosal cavity

This defect causes feeding problems because of regurgitating of food.

This defect occurs in 1-3 births/1000

TREATMENT

Repair of these defects surgically is attempted between 9months to 1 year

years.

This repair and are its steps shown in Fig.above 

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HEAD & NECK 1

HEAD AND NECK

1. INTRODUCTION

The  face  and neck are prominent visible parts of the  body  and

used for human communication through facial expression, movements of  the  head  and speech. 

They deserve  special  attention  from treating surgeons in all disorders of this region so as to ensure patient's acceptance of the results of treatment and thus  insure

his satisfaction.

 

2. CONGENITAL DEFECTS

CLEFT LIP (HARE LIP)

- The incidence is one in 800 to 1300 live births.

- This defect can be unilateral or bilateral and can be  complete

  with  the defect running into the nose. the minor form of a  small

  notch in the lip or partial. 

- There is also hypoplasia of the muscle of the upper lip.  

- The cleft lip is associated with a cleft of the palate on that side.

 

TREATMENT

 

The  clefts  of the lip are closed within the first 3  months  of

life. The margins of the cleft are incised at the margin of  skin

and  mucosa.   The  flaps mobilised and mucosa  muscle  and  skin

margins sutured accurately

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Malignant Breast Carcinoma 7

8. Male Breast Cancer

It is an infrequent cancer for a 100 cancers in the female breast

one occurs in the male. 

These are infilterating duct carcinomas. 

There is early involvement of Pectoralis Major

TREATMENT

In most cases is a radical mastectomy

PRIMARY CARE PRECEPTS

1. Prevent  breast infection by nipple hygiene  simple  cleansing

   using clean water during lactation.

2. If  excess  pain or tension is felt use manual  extraction  of

   milk or breast pump.

3. If  pain in one breast and fever with local heat  and  redness

   refer for surgery.

4. If  there  is  a firm painless lump in the  breast  refer  for

   investigation and surgery to district hospital.

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MALIGNANT Breast Cancer 6

7. TREATMENT

The treatment modes available for Cancer Breast are:

   1.  Surgery

   2.  Radiotherapy

   3.  Chemotherapy

   4.  Hormonal therapy

*  Surgery is reserved for early cancer breast in cases of  stage

   I(T1 No) and stage II(T1, T2, N1).

   The operations in use today are:

   1.  Radical Mastectomy (Halstead)

       This  procedure is aimed at removing the whole  breast  the

       underlying  Pectoralis  major and minor  and  the  regional

       lymph  nodes  along  the  axillary  vein.   No   prosthatic

       reconcentration  is possible after the chest  wall  muscles

       have been removed.

   2.  Modified Radical Mastectomy (Patey's)

       In  this procedure all the structure accept the  Pectoralis

       Major are removed

   3.  Modified Radical Mastectomy (Maddon's)

       In  this procedure the pectoralis minor is divided but  not

       removed

   4.  Simple Mastectomy and clearance of lymphnodes from the

       axilla

       The  skin incision is eliptical and starts at over  rectus

       sheath and includes the nipple and the upper end is  above

       the  margin of the pectoralis major.  Both upper flap  are

       mobilised till the upper and lower limits of breast tissue

       are expanded.  The breast tissue (and nipple) are directed

       off  the pectoralis major.  The later end of the  incision

       allows excessing axillary lymph nodes.

   5.  Wide  local  excision of the tumour  with  preservation  of

       breast followed by radiation.

The  surgical procedure is dependent on the  surgeons  preference

and  the  clinical  stage of the disease. There is  a  trends  to

choose a less radical procedure among surgeons today.

*   Chemotherapy and hormone therapy (adjuvant therapy)is added to

    surgery in cases of Stage II.

It  has  been shown that chemotherapy has benefitted  both  those

with  nodes and those without nodes. 

Tomoxifen has also been  of benefit  to receptor positive and receptor poor tumours when  the

patient is over 50 years.

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MALINANT Breast Cancer 5

6. SPECIAL INVESTIGATIONS

 

6.1 MAMMOGRAPHY

 

Mammography is an X-ray examination of the breast.

 

This technique is helpful in diagnosis in cases where the mass is

ill-defined in outline.

 

This  is true mostly in large fatty breasts where tumours  cannot

be easily felt.

 

6.2 THERMOGRAPHY

 

This  techniqe  measures  the amount of  heat  in  masses,  since

tumours  are more vascular they are detected by heat scanners  as

hot spots on a film

 

It  is worth remembering that infections may also be  represented

as hot spots because of the accompanying vascularity.

To day a combination of:

Clinical examination

Ultrasound

And NMR are most depended on.

 

 

6.3 FINE NEEDLE ASPIRATION CYTOLOGY(FNAC)

 

An experienced cytologist can usually give an accurate  diagnosis

on the small amounty of cellular material made available by  fine

needle  aspiration of a breast lesion.  The level of accuracy  is

variable.

 

6.4 EXCISION BIOPSY

 

This method is perhaps the most dependable means of coming to  an

accurate tissue diagnosis.

 

In  all suspicious masses information can be obtained  by  frozen

sections  and surgery planned during the same  anaesthetic  after

obtaining results.

 

6.5 ESTROGEN RECEPTORS

 

Estrogen  sensitive  target tissues (Breast,  uterus  etc.)  have

specific protein receptors for this hormone.

 

   *  Breast  cancer  tissue can also retain ability  to  produce,

      these receptors(receptor positive cases).

   *  These  cases have a better prognosis and are responsive  to

      hormone  manipulation.  The change in hormonal  environment

      is achieved by:

      i)   Oophorectomy

      ii)  Stilbestrol therapy

      iii) Tamoxifen therapy

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MALIGNANT Breast tumour 4

4.7 CLINICAL FEATURES

 

*  Carcinoma  of  the  breast  is relatively slow-growing tumour.

   Average  expectation  of  life  in  a  patient  that  gets  no

   treatment is three years.

*  It  appears as a small (1 cm.) nodule in any quadrant  of  the

   breast.

*  This   slow  growing  nodule  is  painless;  usually  has   no

   accompanying symptoms.

*  On  palpation,  a  lesion  is firm  to  hard,  its  edges  are

   distinct, usually irregular, at an early stage the nodule  may

   show  no evidence of attachment to  surrounding  structuresand

   move freely.

*  This  type of presentation is no problem as  regard  diagnosis

   and occurs in nearly 80% of all breast cancers.

*  The sites of the lesions and examination methods are  depicted

   in Fig. 13.6

 

The  remaining  tumours (20%) the presentation  is  atypical  and

requires distinguishing from other benign lesions of the breast.

 

5. T.N.M. CLASSIFICATION

 

The  details  are  giv  in  Table above  the  purpose  of  this

classification is to be able to accurately record, the extent  of

lesion  (to compare results with other people's cases) and to  be

able to give a reasonably accurate prognosis.

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Malignant Breast tumour 3

4.3 CLINICAL EXAMINATION

History  and physical examination of the breast is, perhaps,  one

of  the  most  important aids to diagnosis in a  case  of  breast

lesion 

    * A  firm  to hard, painless mass in the breast of  a  female

      over the age of twenty is highly suspect of malignancy.

    * There are however,other significant clinical manifestations

      - like indrawing of the nipple.

      - asymmetry of the breast,

      - involvement of the skin leading to

      - fixity  to  the skin and orange peal  appearance  of  the

        skin, later frank infiltration and ulceration.

    * There is on occasions a weeping eczematous condition,of the

      nipple  and areola in cases with underlying  breast  cancer

      which  is  reffered  to as Pagets' disease  of  the  nipple

      already mentioned above.

      High risk factors are history of breast cancer in the patients past or in the family.History of cancer in situ in the patient ia also a high risk factor. 

All these  must be enquired into while taking a history and recorded.

 

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