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By L. Sanuyem. National Technological University. 2019.

Difficulty in swallowing first with solids and subsequently with liquids points to mechanical obstruction buy viagra professional no prescription. Difficulty in swallowing first with liquids and subsequently with solids is typical of achalasia (cardiospasm) order 50 mg viagra professional. In this case a lump in the neck may be visible which may be emptied with pressure discount 100mg viagra professional free shipping. But majority of patients with dysphagia will complain of some sort of discomfort at the site of obstruction. According to the site of obstruction this is felt either behind the upper part of the sternum or behind its lower part. When the oesophagus has been marked by dilatation the patient may complain of vomiting of foul-smelling stagnated intraoesophageal contents of 2 to 3 days old. Coughing, which occurs sometime after ingestion of meals may be due to regurgitation of food in case of cardiospasm or pharyngeal pouch. Similarly previous history of hiatus hernia repair indicates excessive tightness of the repair to be the cause of dysphagia. Anaemia is very much evident in Paterson-Kelly syndrome and carcinoma of oesophagus and in reflux oesophagitis. The tongue is also smooth, pale and devoid of papillae in Paterson- Kelly syndrome. A soft swelling which appear during meals just above the left clavicle is the third stage of pharyngeal pouch. The clinician stands behind the patient and holds the cricoid cartilage with a little upward traction. It must be remembered that if no relevant sign can be elicited on examination of the neck one must palpate the left supraclavicular fossa to exclude presence of enlarged lymph nodes which may be the only sign in case of carcinoma of the oesophagus. Aspiration pneumonitis, which may cause lung abscess, bronchiectasis, haemoptysis may be seen in achalasia. In this condition when the oesophagus is hugely dilated dyspnoea may be complained of with displacement of adjacent structures. On careful examination one may detect intra-thoracic hernial sac in case of paraoesophageal hernia. When the fluid is aspirated the cardiac orifice can only be located with difficulty due to its contracted condition. In case of benign stricture this investigation not only helps in the diagnosis but also can be used to dilate the stricture with an oesophageal bougie. In carcinoma of oesophagus it is not only diagnostic but also gives an indication about the histology of the cancer by taking biopsy specimen through oesophagoscopy. In reflux oesophagitis this investigation shows inflammation of the mucosa of the lower end of the oesophagus. In achalasia with a moderately dilated oesophagus if a lateral chest X- ray is taken a typical air-fluid level may be seen in the posterior mediastinum which along with the typical symptoms is diagnostic of achalasia. More or less all the conditions which may give rise to dysphagia will be diagnosed by this investigation. If a pharyngeal pouch is suspected a thin emulsion of barium should be used for barium swallow. This will show that the barium first feels the pharyngeal pouch, and then overflows from the top. In stricture the meal is first arrested in the dilated oesophagus immediately above the constriction and gradually trickles down through the stricture. The stenosed portion is usually smooth and does not produce any soft tissue shadow as may be obtained in carcinoma. In case of carcinoma the dilatation of the oesophagus above the tumour is less marked. In achalasia the radiographic appearance varies according to the extent of the disease. In early stage there is only mild dilatation of the oesophagus, whereas in late stage there is massive dilatation and tortuosity of the oesophagus. No benign oesophageal tumours produce characteristic features in barium swallow examination. In case of polyps there is also characteristic filling defect detected in this examination. In gastro-oesophageal reflux during the course of barium swallow examination reflux can be demonstrated. This study shows multiphasic, repeatitive and high-amplitude contractions that occur after swallowing in the smooth muscles of the oesophagus. In case of gastro-oesophageal reflux, pH recording in the oesophagus 5 cm above the distal oesophageal high-pressure zone shows decline in pH to less than 4, which is a clear evidence of gastro-oesophageal reflux. These investigations however may find out abnormal masses in the mediastinum and aortic aneurysm which may press on the oesophagus to cause dysphagia. The proximal oesophagus ends as a blind tube and the distal oesophagus is joined to the lower part of the trachea with a tracheo- oesophageal fistula. During foetal life this condition may be recognized by presence of hydramnios, but this may not be present. When the tip of this tube is radio-opaque, straight X-ray is situ can diagnose this condition. Straight X-ray also reveals intestinal gas which indicates communication of distal trachea with distal oesophagus. The greatest risk of this condition is that there is a great possibility of aspiration of gastric juice, which is highly injurious to the lungs. The patient is nearly always a middle-aged woman who presents with difficulty in swallowing. Dysphagia is due to spasm of the circular muscle fibres at the extreme upper portion of the oesophagus. It may be considered as a Pulsion diverticulum — herniation of the oesophageal mucosa and sub­ mucosa through the weakened area. Note the long age and more of the oesophagus above the smooth irregular narrowing with slight dilatation of frequently men narrowing of the lower end of the the oesophagus above the stricture. Sometimes the patients may wake up from sleep with a feeling of suffocation followed by a severe cough. When the pouch enlarges it tends to compress the oesophagus which leads to dysphagia. When the patient drinks the pouch can be seen to be enlarging with gurgling noise in the neck. X-ray with a very thin barium emulsion should be performed as thick mixture refuses to be washed out from the pouch following examination.

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The right renal artery is clearly detected in (b) ( yellow arrowhead) order viagra professional online, and the left renal artery is also detected well in this position (blue arrowhead ) 176 Chapter 4 · Nephrology a b 4 discount viagra professional 50 mg visa. This sign is caused by renal medullary arterial perfusion interruption in cases of renal artery obstruction purchase viagra professional american express, with preserved perfusion of the renal cortex by the capsular perforating vessels. This sign can be seen in cases of renal vein thrombosis, renal arterial occlusion, and acute tubular necrosis. This sign is seen in cases of compromised renal arterial perfusion in cases of cortical necrosis. Patients with aortic coarctation ofen present with severe hypertension that does not respond to antihypertensive med- ication and chest pain that radiates to the back. Patients with aortic coarctation carry the risk of aortic dissection, which is characterized by aortic wall intimal tear and leaking of the blood in between the aortic wall layers. When it is chronic, aortic coarctation causes dilatation of the internal mammary and intercostals arteries. Chronic high-pres- sure pulsation of the intercostals arteries over the inferior aspect of the ribs may result in rib notching. Coarctation of the aorta can be seen in up to 30 % in patients with bicuspid aortic valve. Pseudocoarctation of the aorta is a relatively rare condition characterized by kinking of the aorta at its isthmus near the ligamentum arteriosum without lumen narrowing. Pseudocoarctation resembles true coarctation; diferentiation is possible by looking for changes of the collateral circulation,. Te condition is symptomless aortic knuckle and can be associated with congenital bicuspid aortic valve. Stanford type A dissection involves dissection of the ascending aorta and the arch up to the origin of the left subclavian artery. Stanford type B dissection involves dissection of the descending aorta below the origin of the subclavian artery. Type A is managed surgically, while type B is managed medically, providing evidence of end-organ ischemia not being present. Polyarteritis nodosa commonly causes multiple arterial aneurismal wall formation, plus fragmentation and degenera- tion of the adventitia layer. Necrosis starts in the media layer and spreads to involve the entire width of the vascular wall. This infammation and necrosis are associated with eosino- philic infltration, fbrin deposition, and destruction of the elastic tissue and the intima layer. Vascular thrombosis or an aneurysm, mainly at the vessels bifurcation or the hilar region of viscera, may occur. Later, a granuloma is formed at the area of previous infammation with fbroblast proliferation. A healed stage is characterized by vascular recanalization and formation of a nonvascularized fbrous mass that completely replaces a section of the vessel wall. Te disease rapidly pro- gresses once started, and death may result from strokes or myocardial infarctions within 2–3 months afer onset. Te kidney is the most commonly involved (80–90 %), followed by the gastrointesti-. Clinically, patients present with aorta shows the inverted shape of 3, which is a characteristic of vague signs and symptoms like fever, myalgia, headache, and this condition (arrowhead ) malaise. Renal artery involvement, especially at the renal hilum, ofen results in rapidly progressing hypertension. Peripheral nervous system involvement compromises the nervous tissue Polyarteritis nodosa is a rare disease characterized by aneu- blood supply causing polyneuropathy. Other lesions involve rysmal, nodular lesions that afect the medium-sized and pericarditis, myocardial infarction, and purpuric skin rash. Up to 30 % of patients test positive to hepatitis B surface anti- Vasculitides are a diverse group of diseases characterized gens, and up to 50 % of patients have arthralgias. Tey are divided into large- eosinophilia (4%), anemia, uremia, and high erythrocyte sized vessel vasculitis (e. In contrast, the late phase Polyarteritis nodosa is suggested by detection of is characterized by arterial symptoms with no systemic symp- multiple aneurysms up to 1 cm in diameter within the toms. Te absence of the systemic symptoms in the late phase renal, mesenteric, hepatic, or central venous vasculature. In the late phase, the coro- patients with necrotizing angiitis associated with drug nary arteries might be afected. Te early phase is charac- (arrowheads), with occlusion of the right subclavian artery and terized by nonspecifc infammation in the blood vessels walls multiple aneurysms afecting the carotid arteries (not shown) afecting the media and the adventitia layers. Preeclampsia Preeclampsia is a pregnancy-related condition characterized by hypertension, lower leg edema, and proteinuria. In con- trast, eclampsia is a life-threatening condition characterized by the same symptoms as preeclampsia plus tonic–clonic seizures. Hypertensive disorders occur in about 3–10 % of all preg- nancies, and the incidence of preeclampsia ranges between 10 and 15% in primigravida (frst birth) and 5. Te aorta and progresses proximally to involve the renal arteries liver is uncommonly afected by preeclampsia (10 % of cases). Causes of nephrop- tosis include multiple pregnancies, rapid loss of retroperito- neal fat, variation in the shape of the spinal cord, shallow Riley–Day Syndrome (Familial Gerota’s fossa, and direct renal trauma. Te pain is attributed to intermittent functional and recurrent attacks of unexplained fever due to autonomic excretory obstruction, forceful traction of the renal artery nervous system dysfunction. Dietl’s crisis is a condition characterized by violent parox- infant or a child with recurrent attacks of unexplained fever, ysmal colicky fank pain, tachycardia, nausea, chills, oliguria, hypertension, and vomiting. Infants commonly have exces- hypertension, and transient hematuria or proteinuria. Te sive drooling with swallowing difculties, making them condition is caused by acute hydronephrosis due to kinking prone to recurrent aspiration pneumonia. The normal kidney is located caused by high-pressure exertion by the facial artery over the between the lumbar vertebral levels L1 to L4. Secondary hypertension: evaluation and concentric and typically found in moderate to severe treatment. Myocardial delayed contrast enhancement tricular hypertrophy can cause atrial fbrillation and arrhyth- in patients with arterial hypertension: initial results of car- mias. Abnormal collateral arterial system in Takaya- risk of stroke, a two- to threefold increase in coronary heart su’s arteritis and Lariche’s syndrome evaluated by whole disease, and a threefold increase in peripheral arterial disease. Takayasu’s arteritis and chronic autoimmune hypertensive heart disease can show intramural, thyroiditis in a patient with type 1 diabetes mellitus. Imaging characteristics of Takayasu arteri- myocardial ischemia, necrosis, or fibrosis tis. Imaging of acute neurological conditions in Simple renal cyst is the most common renal anomaly.

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Schistosomiasis Single or multiple discrete filling defects (may Usually caused by Schistosoma haematobium viagra professional 100mg without prescription. Fungus ball Single large or multiple small filling defects Most often caused by Candida albicans in patients that often contain gas that produces a mottled with debilitating diseases purchase generic viagra professional canada, diabetes mellitus buy cheap viagra professional 100 mg on-line, or appearance. Intraluminal or (“honeymoon cystitis”), interstitial cystitis (chronic intramural gas in emphysematous cystitis. Cystitis cystica/cystitis Lobulated contour of the bladder that contains Common chronic reactive inflammatory disorders glandularis nodular masses of varying size and number. Right posterior oblique view of the bladder shows an irregular, rounded filling defect along the posterior dome. The radiographic pattern may a history of recurrent or chronic urinary tract suggest a neoplastic process or severe cystitis. There may also be ureteral involvement (general dilatation with multiple filling defects or a scalloped appearance and occasionally a stricture). Irregular, lobulated filling defects (representing intense mucosal edema) at the base of the bladder. Less frequent causes include trauma, radiation therapy, foreign bodies, and abscesses. Fungus ball in bladder Soft-tissue mass containing gas (contrast Composed of layers of mycelia separated by air and material may enter the fungus ball and further proteinaceous material. Candida albicans, especially in severely debilitated patients undergoing prolonged antibiotic or steroid therapy. Barium enema exami- nation demonstrates contrast material in the fistulous tract (solid arrow) between the sigmoid colon and the bladder. Urethral stricture Smooth narrowing of the urethral lumen of Almost all congenital strictures occur in boys and varying length (multiple in approximately 10% are located in the bulbomembranous portion. The bladder neck often appears narrow (although it is usually normal in width) because of the disparity in size between it and the urethra bulging posteriorly beneath it. If the orifice is stenotic, proximal distention of the ureter under the submucosa of the bladder produces the eccentric filling defect. Foreign body Single or, less frequently, multiple filling defects In addition to causing urinary tract obstruction, that are usually radiopaque. There may occa- Controversial entity with such postulated causes as obstruction sionally be an anterior or posterior inden- muscular hypertrophy, fibrous ring, and bladder tation, diaphragm, or collar at the bladder neck neck dyskinesia. Urethral diverticulum Tubular, round or oval, smooth outpouching Diverticulum of the urethra distal to the external that is separate from the urethra but commu- sphincter is an uncommon but important cause of nicates with it. Congenital urethral Accessory urethra may be completely dupli- Extremely rare anomaly that almost always occurs duplication cated, join the main urethra distally, or end in males. Hypertrophy of Round or oval filling defect in the prostatic Rare cause of obstruction that is probably transient verumontanum urethra. May be secondary to inflam- matory lesions of the urethra and bladder in older boys and men. Hydrometrocolpos Extrinsic pressure narrowing of the urethra with Rare congenital anomaly associated with obstruc- proximal dilatation of the bladder and ureters. Calcification presumably occurs with greater frequency and at a younger age in diabetic men because this disease accelerates the degenerative process. Tuberculosis Inflammation causes partial or complete throm- bosis of the lumen of the vas deferens, resulting in intraluminal calcification. The calcification is more frequently unilateral and irregular than in the noninflammatory form (diabetes, degenerative change). Other infections Inflammatory intraluminal calcification, often unilateral and irregular like tuberculosis, can develop in gonorrhea, syphilis, schistosomiasis, and chronic nonspecific urinary tract infection. Adult polycystic kidney Enlarged kidneys containing many anechoic areas disease of variable size representing multiple cysts. The cyst displaces the pelvoc- alyceal echo complex, but does not separate it as would be expected in hydronephrosis. Unlike hydronephrosis, the calyces are not dilated nor do they communicate with the mass. As the obstruction of the urinary system progresses, there is separation of the normal echo complex of the collecting system. Eventually, the calyces become completely effaced and the normal kidney is completely replaced by an anechoic hydronephrotic sac. It is usually unilateral, but can be bilateral or segmental and may be associated with a hypoplastic or atretic renal artery, renal vein, ureter, and renal pelvis. Pathologically, the renal tissue is replaced by large cysts connected by fibrous tissue. The characteristic sonographic appearance is normal or enlarged kidneys with lobulated contours containing numerous cysts of varying sizes and shapes. Medullary cystic disease Multiple anechoic cystic structures (often very small) in the corticomedullary junction and the medulla. Clinical findings include anemia, polyuria, hyposthenuria, salt wasting, and renal failure. For example, uniform gelatin-like clots, abscesses consisting only of leukocytes without debris, and unclotted blood (as in hematomas and intrarenal vascular malformations and aneurysms) all show cystic patterns. A few solid lesions also occasionally produce a pattern that so closely simulates a cyst that only the most scrupulous and meticulous technique can differentiate them. In addition to vascular anomalies, hematomas, and abscesses, other lesions that may mimic renal cysts on ultrasound include urine collections (localized hydronephrosis, urinoma), cysts containing small mural tumors, and necrotic and hemorrhagic tumors. Obstructed renal pelvis and calyces produce the sonographic pattern of multiple communicating cystic structures (arrows). A similar appearance is seen with a neoplasm that has become necrotic and contains debris that is jellylike and acts as a homogeneous sound- transmitting medium. With meticulous tech- nique, low-level internal echoes are almost always detectable. In questionable cases, needle aspiration of the mass may be necessary to confirm the correct diagnosis. Cysts con- taining debris (infected cysts) or clot (hemorrhagic cysts) are also complex. Dysplastic kidney (the most common cause of an abdominal mass in the newborn) produces a disorganized cystic pattern with lack of renal parenchyma and reniform contour (unlike the precise organization of sym- metrically positioned fluid-filled spaces in hydro- nephrosis due to congenital ureteropelvic junction obstruction). Sagittal sonogram of the (K) shows multiple complex masses with cystic and solid kidney (K) shows that the cyst (C) contains a blood clot components. The mass may contain highly echogenic areas (usually peripherally located) due to gas formation within the abscess. Sagittal sonogram of the kidney (K) nstrates the solid renal tumor (arrow) within the cyst.

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Only in selected cases insertion of peri toneovenous shunt may help in relieving abdomi­ nal distension discount 100mg viagra professional with mastercard. If such agents cannot control the pain purchase viagra professional 50mg on-line, morphine sulphate slow-release tablets should be given together with antiemetics buy viagra professional from india. Diamorphin continuous infusion may be valuable in the terminal stages of the disease. Followings are the modes of treatment in various problems of advanced breast cancer — Problems Treatment Regional or local recurrence Local radiotherapy. Reconstruction using autologus tissue alone, either as a pedicle flap or a ‘free’ flap (e. The world-wide popularity of expanders implant reconstruction is related to the speed and apparent simplicity of this approach, which has no donor site morbidity and requires a short hospital stay and little convalescence. Following subpec­ toral placement of tissue expander, the breast mould is created by repeated outpatient expansion introduc­ ing saline through a remotely-sited or integral injection port. Modern breast implants are manufactured with an outer shell of polydimethylsiloxane (silicone) and contains a ‘filler’ material such as silicone gel which gives the implant its volume. A recent wave of adverse publicity that silicone is both immunogenic and carcinogenic are unfounded. Some small amounts of silicone gel ‘bleed’ through the shell of all implants into the surrounding tissues. The subcutaneous technique is often condemned as it frequently causes skin necrosis and extrusion. When inserting the implant subpectorally care must be taken to ensure that the prosthesis is in an appropriate position. There is a tendency of such implant to migrate superiorly, so it is necessary to divide the fascial bands between the insertion of pectoralis muscle and the rectus abdominis. The main problem is the formation of a capsule, which is unsightly and imparts hard texture to the breast. The Becker expander consists of an outer lumen filled with silicon gel and an inner chamber filled with saline with self­ sealing side port. This inner chamber with saline is gradually expanded to the desired volume over a number of weeks. Once expansion is complete the saline chamber is aspirated to allow creation of a reconstructed breast of similar volume to that of the opposite side alongwith providing some ptosis. The most commonly adopted technique has been the pedicled lattissimus dorsi myocutaneous flap due to its proximity and good blood supply. A few surgeons even use free transverse rectus abdominis flap with microvascular anastomosis between epigastric and thoracodorsal vessls. Unfortunately it is time-consuming proce­ dure which requires specific expertise with microvascular anastomosis. In contrast to prosthesis reconstruction, these autologus techniques are complex and more expensive procedures which require comprehensive training and experience. Lattissimus dorsi myocutaneous flap is used mainly in pedicle form and often used due to its proximity and good blood supply. Complications are mainly related to donor site morbidity including pain, seroma formation and scarring. Rectus muscle is taken with each pedicle to improve the circu­ lation and reduce the likelihood of flap necrosis. Excellent cosmetic results are achieved at the expense of 5 to 7 days hospital stay, a 4 to 6 weeks convalescent period and an overall complication rate of 16% to 28%. Major complications include abdominal weakness, abdominal herniation and flap loss. After separating the flap from its native blood supply and transpo­ sition into the empty breast pocket, circulation of the flap is re-established by performing a microvascular anastomosis between the inferior epigastric and the thoracodorsal or internal mammary vessels. Cystosarcomas are usually slow growing tumour and present as a large lobular mass in the breast. There may be ulceration in the skin through which the tumour may fungate, but this is not due to invasion into the skin. The tumour is so big that the skin overlying the tumour is stretched and ultimately gives way. A probe may be passed between the ulcerated skin margin and the tumour which is not at all possible had the tumour infiltrated the skin. The tumour is also free from the underlying structures and it can be movable along the direction of the fibres of the pectoralis major after this muscle is made taut. Local infiltration is the next type of spread, but it is much less in degree than scirrhous carcinoma. In case of small tumour one may get away with total mastectomy but perform wide excision of the tumour with 5 cm of healthy tissue around. If local recurrence occurs surgical reexcision in the form of total mastectomy and radio­ therapy should be the treatment of choice. Only the prognosis of angiosarcoma is worse as it tends to early blood-borne metastasise to the lungs. In civil practise chest injuries occur usually from road accidents and stab or gun-shot wounds. In war, of course, chest injuries are more common and it usually constitutes 10% of all wounds and 25% of those killed in battle. Injuries of the chest may often be associated with injuries elsewhere, particularly the head, abdomen and the limbs. Chest injuries should always get priority in the treatment in case of multiple injuries. Fracture of the ribs is occasionally seen in children as their ribs are more flexible and elastic. Crush injury — This injury is often caused by road accidents and aeroplane accidents. Multiple ribs may be fractured and the fracture usually occurs at the site of maximum curvatures in a single rib i. The clinician should run his finger along each rib in the region of injury to reveal local bony tenderness. The patient stands with both hand on the head and the clinician places the base of one hand on the sternum and the other hand on the spine and thoracic cage is compressed anteroposteriorly. Systemic analgesics may be administered orally or by injections every 6 to 8 hours on first 2 or 3 days. Pentazocine has now become very popular in this respect, though it has got some respiratory depression effect besides analgesia and sedation. Fortwin, Fortagesic and Foracet are the various available trading drugs containing this product, Acetyl salicylic acid is an old good drug.

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Muscular elements develop into (i) tensor tympani purchase 50 mg viagra professional with amex, (ii) tensor veli palatini and muscles of mastication which include (iii) the masseter generic 100mg viagra professional visa, (iv) temporalis muscle buy viagra professional with a visa, (v) medial and lateral pterygoids, (vi) mylohyoid and (vii) anterior belly of the digastric. According to some the maxillary artery may be the remnant of the first aortic arch. Thereafter it forms as it passes ventrally (ii) styloid process, (iii) stylohyoid ligament, (iv) the lesser cornu and (v) the upper part of the body of the hyoid bone. The ventral portion chondrifies and persists as the (i) greater comu of the hyoid bone and (ii) lower part of whole of the body of the hyoid. The external carotid artery appears as a sprout from the middle of the third arch and grows headwards. The ventral portion of the arch upto the sprout forms the common carotid artery and the dorsal portion from the sprout forms the internal carotid artery. The dorsal part disappears on the right side, while it persists on the left side as ductus arteriosus communicating with the arch of the aorta. Ductus arteriosus after birth becomcs obliterated and forms ligamentum arteriosum. The second arch gradually overlaps over the third and fourth arches at the end of the fifth week. The ridge produced by this arch grows downwards and meets caudally a smaller bridge termed the epipericardial ridge just above the pericardium. A small depression is formed which lies superficial to the third and fourth arches and deep to the second arch. So in fact, third and fourth arches do not take part in forming the ectodermal covering of the neck. From the ridge formed by the second branchial arch develops the stemomastoid and the trapezius muscles. If the sec­ ond arch fails to fuse with the 5th arch or epiper­ icardial ridge, a fistula develops and it connects the precervical sinus. If it arises from the internal branchial furrow the epithelium may be columnar and ciliated. The striking feature of this cyst is that its wall contains large amount of lymphoid tissue. The contents are viscid, mucoid, cheesy material and cholesterol crystals in large numbers. If infected the swelling may be painful and it becomes difficult to differentiate from acute lymphadenitis, chronic lymphadenitis or tuberculous lymphadenitis and cold abscess. The stemomastoid muscle develops from the migrated myotome in the ridge of the second branchial arch which covers the pre- cervical sinus. The branchial cyst develops from the precervical sinus, so it will always be deep to the stemomastoid muscle. The overlying skin looks normal, though if infected, may be red and angry looking. Fluctuation test will be positive, but is difficult to elicit when the cyst is small and the stemomastoid muscle is thick. Some amount of the content may be aspirated before dissection so that the wall of the cyst may be grasped with suitable forceps without injuring it. Sometimes it extends between the origins of the internal and external carotid arteries upto the pharyngeal wall. Hypoglossal and glossopharyngeal nerves lie deep to the cyst and they should be protected. It is usually situated in the upper or middle thirds of the neck and often continues to discharge. Congenital branchial fistula is often a branchial sinus without any communication inside. From the development it is clear that branchial fistula represents a persistent second branchial cleft which covers the third and fourth branchial arch. So usually there should not be any internal opening and in the true sense it is a ‘branchial sinus’. The membrane which intervenes between the second branchial cleft and the second branchial pouch which forms the supratonsillar fossa at times may disappear or perforate by injudicious use of probe and then a branchial sinus becomes a branchial fistula and opens in the anterior aspect of the posterior pillar of the fauces, just behind the tonsil. The fistula then passes through the bifurcation of the common carotid artery being superficial to the internal carotid artery and deep to the external carotid artery. As the fistula arises from the second branchial cleft being covered by the second branchial arch superficially, so all the structures derived from the second arch will be superficial to this fistula and the structures developed from the third branchial arch will lie deep to this fistula. Internal carotid artery is derived from the third arch while the external carotid artery sprouts out of the third arch and immediately becomes superficial, so the fistula traverses between these two arteries. The fistula passes deep to the posterioi belly of the digastric and the stylohyoid muscle. It crosses superficial to the internal jugular vein and the hypoglossal nerve, the glossopharyngeal nerve and the stylopharyngeus muscle (derivatives of 3rd arch). It then pierces the superior constrictor muscle and opens on the posterior pillar of the fauces behind the tonsil. The stratified squamous epithelium or pseudostratified ciliated columnar epithelium forms the epithelium lining. According to a few pathologists columnar ciliated epithelium forms the epithelium lining. But since this fistula is remnant of branchial cleft there is more possibility that the lining will be stratified squamous variety. Due to the presence of lymphoid tissue recurrent inflammation is common and not infrequently the epithelial lining is replaced by chronically inflamed granulation tissue. It often discharges from the external opening either mucoid or mucopurulent fluid. As the condition is not much troublesome patients often come to the clinician late. It is nearly always situated in the lower third of the neck near the anterior border of the stemomastoid muscle (cf. A sinogram may be made by injecting radio-opaque dye into the fistulous track to know the upper limit of the fistula. Gentle traction to the fistula track will facilitate identification of the fistula and its dissection upwards. A second incision may be required above the upper border of the thyroid cartilage transversely placed along the Langer’s line. The upper part of the track is dissected through this incision upto the pharyngeal wall. During dissection one must be careful, as many important nerves and blood vessels, which have been discussed earlier, are around. As a matter of fact a clinical diagnosis of branchiogenic carcinoma is rarely justified until and unless one very clearly excludes primary growth in the mouth, tongue, pharynx, larynx and external auditory meatus. Again at times a primary carcinoma of the mouth or pharynx may remain silent for months, the only evidence of its presence being a deep-seated cervical lymph node. This carcinoma is commoner in males and is situated deep in the neck near the bifurcation of the common carotid artery.

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