Parotid tumors can recur as single solitary mass or multifocal tumors. Recurrence of the tumor is either due to tumor implantation or inadequate surgical excision during primary surgery. Most tumors of parotid are benign Pleomorphic adenomas and surgery as enucleation or limited local excision can results in a high rate of recurrence.

Even after careful surgical excision the pleomorphic adenoma can still recur, and this is due to either tiny microscopic extensions of the tumor beyond the pseudocapsule of the tumor or rupture of the capsule of the tumor during primary surgical excision. Rupture of the capsule during surgery can also cause spillage of tumor cells in the parotid bed causing recurrence.

Pre op evaluation

Once a parotid tumor does recur, however, its successful surgical excision is facilitated by adequate preoperative clinical, radiographic and cytologic evaluation.

Patients with recurrent parotid tumors need careful preop work up including Ultrasound guided fine needle cytology and MRI imaging. MRI imaging will be very useful to assess the extent of the recurrent tumor and also the amount of parotid tissue left over. The Facial nerve anatomy can be assessed. All these helps in revision surgery.

Surgical tips

Surgical treatment in recurrent parotid tumor can be tedious and technically challenging.

An unhurried and meticulous dissection with careful localization and preservation of the facial nerve can be obtained by using an operating microscope and also nerve stimulator.

Facial Nerve status in Redo Surgery

The status of facial nerve function after revision surgery is an important issue. After revision surgery, if superficial lobe is already removed in primary, the chances of damage to facial nerve as neuropraxia or permanent damage can occur. Lot of scarring and fibrous tissue adhesion can make the revision surgery extremely difficult. To avoid careful pre op assesment with MRI imaging and a careful unhurried dissection is required.

Post op Radiation Therapy

Some surgeons advocate post of radiotherapy after second or third revision surgery to prevent further recurrence. If there are malignancy changes in mixed parotid tumors, then radiotherapy must be given.

If there was facial nerve weakness following the initial surgery, revision surgery will be more tedious and have a higher rate of facial nerve neuropraxia or permanent paralysis. Finally it is important to determine if there was a history radiation exposure or the use of therapeutic radiation in the past.

(Revision Parotidectomy can be difficult and tedious as one should be careful NOT to cause facial nerve injury. Proper preoperative evaluation and unhurried meticulous dissection is needed. Here an young lady under go revision Parotidectomy in Jubilee Hospital Trivandrum in South India).

A mantra is a sacred verbal formula or phrase repeated over and over again during prayer and meditation. A sacred verbal formula repeated in prayer, meditation, or incantation, Mantras originated in the Vedic tradition of India thousands of years ago.

Mantra contains mystic sounds which produce certain type of energies. When we repeatedly utter a Mantra we are tuning to a particular frequency and this frequency establishes a contact with the cosmic energy and drags it into our body and surroundings. Thus we can balance the energies and also increase the level of a certain type of energy, which promote certain actions and events.

GAYATHRI MANTRA

Gayathri Mantra the foremost mantra in Hinduism .The Gayatri Mantra is a highly revered mantra in Hinduism, second only to the mantra Om. The Gâyatrî Mantra is from the Rig Veda (iii, 62, 10), which has existed in written form for at least 2500 to 3500 years.

Gayathri’ is not actually the Goddess, which sounds surprising but she is held in equal reverence because she is the mother of the Vedas or Divine Knowledge.

The word Gâyatrî is made from these two words:

gaya – vital energies

trâyate – preserves, protects, gives deliverance, grants liberation.

So, the two words “Gâyatrî Mantra” might be translated as: a prayer of praise that awakens the vital energies and gives liberation.

By many Hindus, the Gayatri is seen as a Divine awakening of the mind and soul, and within it a way to reach the most Supreme form of existence, and the way to Union with Brahman. Understanding and purely loving the essence of the Gayatri Mantra is seen by many to be one, if not the most powerful ways to attain God.

The Mantra

Om bhoor bhuvaswahah

tat savi tur varenyam

bhargo deyvasya dhi mahhi

dheeyo yoh na pracho dayaht

Meaning of the Mantra

Oh God, Thou Art the Giver of Life,

Remover of Pain and Sorrow,

The Bestower of Happiness,

Oh! Creator of the Universe

May We Receive

Thy Supreme Sin-destroying Light

May Thou Guide Our Intellect

In the Right Direction

Its meaning is that “May the Almighty God illuminate our intellect to lead us along the righteous path”. The mantra is also a prayer to the “giver of light and life”

The Gayathri Mantra has been revered for thousands of years by both Hindus and Buddhists alike. It is considered a supreme vehicle for enlightenment in Kundalini yoga. It is called “The Mantra of Spiritual Light” because it infuses the Spiritual Light of Creation into all the seven Chakras in ones body…It is said that ‘there is no great Mantra than Gayatri and there is no great god than the Mother’. It heals the body, feeds the Spirit and illumines the Intellect.

“May the Almighty God illuminate our intellect to lead us along the righteous path”.

Airway management after Nasal and Throat surgery can be associated with serious complications like aspiration of retained blood clots while extubating.The incidence of this fatal complication is very rare. The Surgeon and the anesthetist should be vigilant in waking up the patients from anesthesia. Proper nasal suction and removal of clots or any bits of tissues have to be done before taking the endotracheal tube out.

(Aspiration of retained clot after adenoid surgery is fatal, if unnoticed.Dr.Thomas, the senior anesthetist of Jubilee Hospital explains…)

Case Report: 40 year old otherwise healthy patient developed post op apnea after a nasal surgery. She failed to recover from the effects of scoline given during surgery. Hence she was put on ventilator and she was out of the ventilator after 8 hrs. The Psudocholine esterase deficiency was suspected and the blood enzyme level was very low (84U/L Normal range 5320-12920U/L).

(Dr.Thomas, the Senior anesthetist of Jubilee Hospital Trivandrum South India, explains the issues).

About Pseudo cholinesterase deficiency

Pseudo cholinesterase deficiency is a condition that results in increased sensitivity to certain muscle relaxant drugs like Succinylcholine used during general anesthesia. This condition is recognized most often when respiratory paralysis unexpectedly persists for a prolonged period of time following administration of standard doses of succinylcholine. A variety of pathologic conditions, like liver and renal pathology and medications also can lower plasma pseudo cholinesterase enzyme activity. Pseudo cholinesterase deficiency occurs in 1 in 3,000 to 1 in 5,000 people. It is more common in certain populations, such as the Arya Vysa and Persian Jewish community.

Pseudo cholinesterase deficiency is an inherited enzyme abnormality.

The mainstay of treatment in these cases is ventilatory support until diffusion of succinylcholine from the myoneural junction permits return of neuromuscular function of skeletal muscle. The diagnosis is confirmed by a laboratory assay demonstrating decreased plasma cholinesterase enzyme activity. The condition causes no other signs or symptoms and is usually not discovered until an abnormal drug reaction occurs.

The main complication resulting from pseudo cholinesterase deficiency is the possibility of respiratory failure secondary to succinylcholine induced neuromuscular paralysis. Individuals with pseudo cholinesterase deficiency also may be at increased risk of toxic reactions, including sudden cardiac death, associated with recreational use of cocaine.

People with pseudo cholinesterase deficiency may also have increased sensitivity to certain other drugs, including the local anesthetic procaine, and to specific agricultural pesticides.