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The afterward with meticulous and delicate surgical technique buy discount avana on-line, arterial supply of that segment is reliable and the venous careful anesthetic technique and monitoring purchase 50mg avana free shipping, and devoted pedicle short and less prone to kinking or twisting quality avana 200 mg. The colon serves as a passive conduit and does not have Replacing or Bypassing the Esophagus: effective peristalsis. Gastrocolic reflux occurs routinely, and Stomach, Colon, or Jejunum the refluxate is slowly cleared, but the reflux is seldom symp- tomatic. The transit time for a bolus of food to pass into the The stomach is the closest we have to the ideal esophageal stomach is invariably slow but variably symptomatic. When fully mobilized and based on the gastro- or malignant disease of the colon may preclude its use; and epiploic arcades, the apex of the stomach reaches the naso- the mesenteric vascular arcade is variable, especially on the pharynx. The interposed colon is also subject to venous infarc- neck, it becomes a tubular organ of modest diameter, with tion by trauma to the colon mesentery or compression at the the fundus at its apex and the site of the gastroesophageal hiatus. The jejunum retains effective peristalsis when used to Its arterial supply and venous drainage are reliable and replace a segment of the esophagus. Short-segment jejunal difficult to compromise even if the lesser curvature arcades interposition has been used effectively as a salvage operation are divided to gain length. The stomach is thick walled to prevent reflux when multiple direct operations on the 102 T. Without special techniques, the jejunum does not the esophagus whose significance depends on the severity of reach above the inferior pulmonary vein. A tions of jejunal interpositions have been solved by microvas- sliding hiatus hernia is sliding both in the anatomic sense cular techniques, which allow either free transfer of jejunum (one wall of the hernia is made up of the visceral peritoneum to replace segments of the pharynx or proximal esophagus or covering the herniated stomach) and in the direction it herni- interruption of the mesentery with a second proximal vascu- ates (the gastroesophageal junction migrates cephalad along lar anastomosis. The hiatus hernia must be reduced and the hiatus tion to using jejunum or colon as an esophageal substitute repaired as part of the operation to control reflux. Mobilizing the bowel with hernia, is best conceived as a disease of the diaphragm. In careful preservation of both arterial and venous circulation this case the gastroesophageal junction is in its normal posi- can be difficult and time-consuming. Although experienced tion, and the stomach with the attached greater omentum and surgeons have reported excellent results with both colon and transverse colon herniates into the posterior mediastinum jejunum, higher mortality and morbidity rates are the rule. This hernia has a The higher complication rate for interposition operations true sac of parietal peritoneum. The problems associated likely reflects both the additional surgery required and the with paraesophageal hernias are the same as those with any more complicated nature of the patients who require such an abdominal wall hernia with the additional special problems approach. When approaching a patient who needs an intesti- of having the acid-secreting stomach involved. Patients with nal interposition, the surgeon must know as much as possible paraesophageal hernia are more often older and frequently about the condition of the bowel and its vascular supply. They usually do not have significant Endoscopy, contrast studies, and vascular studies by angiog- reflux but often have abnormal esophageal peristalsis. Many raphy or magnetic resonance angiography should be per- are entirely asymptomatic, and the diagnosis is suggested by formed and the bowel prepared both mechanically and with the presence of a mediastinal air-fluid level on chest radiog- antibiotics in every case. Unlike sliding hernias, all patients who have a signifi- well thought-out if the originally selected segment of bowel cant paraesophageal hernia should undergo repair to avoid is not usable or the adequacy of the blood supply is the mechanical complications of the hernia unless they are questionable. All symptomatic Effective complete vagotomy is likely after any esopha- patients require surgical repair because this disease is caused geal resection. Although it may not be necessary in more by a mechanical problem for which there is no medical ther- than a minority of cases, I do not hesitate to do a pyloromy- apy. The essentials of the operation are reduction of the otomy to facilitate gastric emptying. Patients who do not have if the patient does not have scarring from peptic disease. Although a matter of judgment, a tures of both paraesophageal hernia and sliding hernia with pyloromyotomy, or other drainage procedures should be reflux. Although balloon dilation They require an anatomic repair and an antireflux is usually sufficient, reoperation in this area is extremely dif- procedure. Laparoscopy has become the standard approach for both antireflux surgery and for repair of paraesophageal hernias. A posttraumatic hernia may involve any injured portion Hiatus Hernia and Reflux Disease of the diaphragm. Deceleration injuries from blunt trauma usually involve the apex of the left hemidiaphragm. These With the exception of traumatic diaphragmatic rupture, vir- hernias are usually large and are detected soon after injury tually all acquired diaphragmatic hernias enter the chest from a fall or motor vehicle accident. Parahiatal hernia occurs but is involving penetrating trauma, on the other hand, can be small a rare finding of no particular significance. Any atypical diaphragmatic hand, it is essential for a surgeon to understand the difference hernia that appears to arise away from the hiatus should raise between a sliding and a paraesophageal hiatus hernia and to the suspicion of previous injury. Because these hernias do 13 Concepts in Esophageal Surgery 103 not have sacs, the abdominal contents are adherent to intra- Sliding Hiatus Hernia thoracic structures if time has passed between the time of injury and the time of repair. Consequently, all such hernias The presence of a sliding hiatus hernia is not an indication should be approached through the abdomen if repaired at the for operation. An asymptomatic patient with a sliding hernia time of the injury and through the chest if operated late. Late recognition of injury leads to incarceration of and esophagitis may be greatly improved by medical therapy the viscera in the chest. It is generally agreed that medical management stances is injury to both the viscera and the lung. The abdom- is the treatment of choice for patients who have symptomatic inal contents are adherent to the edges of the diaphragmatic reflux with minimal esophagitis. Surgery is most clearly hernia, the lung, and the pleura and can much more safely be indicated for patients with reflux that causes significant freed via the thoracic approach. Patients whose symptoms are completely relieved or greatly improved by modern medical management are also excellent Complicated Paraesophageal candidates for surgery if their symptoms recur after the with- Hiatus Hernia: Obstruction, drawal of therapy (as is likely but not certain). Patients Gastric Volvulus, and Strangulation whose reflux symptoms cannot be controlled even by esca- lating doses of proton pump inhibitors should be carefully The patient with a large paraesophageal hernia may have a evaluated prior to operation to exclude other causes for their large portion of the stomach in the chest. Atypical symptoms not clearly related to reflux stomach herniates, the fixed ends at the pylorus and the episodes are rarely improved by antireflux operations. The esophagogastric junction come close together, and volvulus use of antireflux surgery for patients with Barrett’s esopha- becomes likely with intermittent obstruction. More com- gus (columnar-lined esophagus with intestinal metaplasia) is plete volvulus leads to the rare but lethal complication of still an unresolved issue at this time. The develop- esophagus is clearly a premalignant lesion, it is less clear that ment of a paraesophageal hernia after repair of any hiatal it can be eliminated by antireflux surgery. It must be medical and surgical treatment in controlled studies have considered an incarceration with a high potential for compli- proven the superiority of surgical control of reflux during cations. More commonly, patients develop gastric ulcer with every era of medical treatment: antacids, H2 blockers, and bleeding or obstruction with pain. Surgical control of usually causes severe substernal or epigastric pain, often reflux also has the advantage of controlling all the refluxate— with an inability to vomit because of obstruction at the duodenal as well as gastric—whereas medical therapy at best esophagogastric junction. It may be hazardous toms should include esophagoscopy with biopsy to confirm to insert a nasogastric tube for the same reason the patients the presence of esophagitis and a barium contrast foregut cannot vomit. A timed esophageal pH study confirms the relation of safely, but in either case it should be inserted carefully with symptoms to episodes of acid reflux.

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It is interesting to note that if metastases develop later erythrocytosis returns 50 mg avana for sale. Hypochromic anaemia sometimes occurs in association with pyelonephritis cheap avana 100mg online, uraemia and even carcinoma buy cheapest avana. Urine is first voided in a test tube for about 10-15 ml and then the stream is directed to the 2nd test tube for the same amount of sample. Turbidity in the first glass suggests urethritis whereas turbidity in the 2nd glass suggests cystitis. First of all general microscopic examination of the urine should be performed for presence of R. Cytological examination of urinary sediment is sensitive and specific for poorly differentiated cancer cells anywhere in the urinary tract. Culture in ordinary or special culture media should be performed if bacteria and/or pus cells are detected in the urine. Sensitivity test to various antibiotics (antibiogram) should be performed when the culture becomes positive. When the urine is acid in reaction, contains pus cells and is sterile in ordinary culture, one should suspect renal tuberculosis. Acid-fast staining should be performed with the centrifuged sediments from 15 ml of urine. In the latter case the result is obtained in three weeks instead of six weeks as in animal inoculation. Specific gravity of the urine is also examined particularly of the morning sample collected after 12 hours of overnight restriction of fluid. Dipsticks impregnated with chemicals which change colour in presence of blood, sugar or protein are convenient way to screen urine for various abnormalities. Specific gravity of urine voided in the early morning is important and if it is less than 1. The patient is allowed to drink no more than 20 ml of water during each of the two subsequent half hour periods. The average amount of dye normally recovered in the first half- hour sample is 50 to 60%, the 2nd sample contains 10 to 15% (thus one hour excretion is about 60 to 75%). Levels of blood urea and serum creatinine are useful clinical guide to overall renal function. Creatinine clearance will give an approximate value for glomerular filtration rate. Estimation of clearance of chromium -51-labelled ethylenediaminetetra-acetic acid is probably more accurate in this respect. It must be remembered that kidneys have large functional reserve and 70% of function of kidneys must be lost before renal failure becomes evident in various tests. With an enlarged prostate, obstruction is encountered after the catheter has gone beyond the apex of the prostate (i. In case of urethral stricture, obstruction is obtained below the perineal membrane since the bulb of the urethra is the commonest site of stricture formation. The position of the obstruction can be further determined by a finger in the rectum. J Similarly an enlarged kidney from hydronephrosis, polycystic disease or renal cancer can be diagnosed. A normal kidney f extends from the top of the 1st to the * bottom of the 3rd or middle of the 4th Fig. In 90% of cases the right spine, kidney is lower than the left because of displacement by the liver. Localized swelling as may be caused by a carbuncle, a tubercular cyst, a simple cyst or a tumour can be diagnosed. It is very difficult to assess the exact position of the radio-opaque stone in straight X-ray of the abdomen. A lateral view or visualization of the urinary tract with radio-opaque dye is necessary. Numerous small calcific bodies in the parenchyma of the kidney may suggest tuberculosis or medullary sponge kidney or nephro-calcinosis caused by hyperparathyroidism. A renal calculus has to be differentiated from (i) a gallstone, (ii) calcified lymph nodes, (iii) calcified costal cartilage, (iv) || phlebolith, (v) calcified aneurysm of the abdominal aorta or renal artery and (vi) small calcific bodies the substance a kidney as discussed above. A stone in the appendix or a faecolith in the colon may be confused with a stone in the ureter. It must be remembered that for the diagnosis of a stone either in the kidney, ureter or bladder, a straight film is all that r I is required, not a urogram. It is an imaginary line passing along the tips of the transverse processes of the lumbar vertebrae, over the sacro-iliac joint, down to the ischial spine from where this line deviates medially. A space-occupying lesion of the renal pelvis revealed in excretory urogram may show a faint opaque body compatible with stone but not tumour in the tomogram studies. If symptoms and signs of hypersensitivity appear during injection, it should be stopped immediately. Warning signs are respiratory difficulty, itching, urticaria, nausea, vomiting and fainting. Routine radiograms are taken at 10 seconds for nephrogram effect and at 5, 10 and 15 minutes with the patient in supine position. For hypertensive patients films should be taken 2 and 3 minutes after the beginning of the injection. Delayed concentration of dye in one kidney may suggest decreased renal blood flow and function. At 25 minutes a film is taken in erect posture to note the efficiency with which the renal pelvis and ureters drain, ureterograms and also the mobility of the kidneys. All films should include kidney, ureter and bladder areas, as fine changes in the ureters which imply the presence of vesico-ureteral reflux may be detected. It is advisable to inject additional radio-opaque medium if there is impaired concentration in the initial films. In infants and children the films should be taken at 3, 5, 8 and 12 minutes as their kidneys excrete the fluid more rapidly than do those of the adults. X-ray of the bladder region after voiding should be routine in all urologic patients. At the conclusion of the urographic study, the patient is instructed to pass urine and a film of the bladder area is taken immediately. Excretory urogram is contraindicated in (i) allergic patients, (ii) multiple myeloma (the dye makes insoluble complex with Bence-Jones protein and precipitate in the renal tubules), (iii) congenital adrenal hyperplasia, (iv) diabetes and (v) primary hyperparathyroidism. Excretory urogram is a physiological and as well as an anatomical test since it not only determines the function of the kidney but also clearly demonstrates the contour of the renal pelvis and calyces. About 2 ml per kg body weight of contrast medium in an equal volume of normal saline is infused in a subcutaneous vein slowly for over a period of 10 minutes. Diluted contrast medium is infused into the subcutaneous tissue alongwith hyaluronidase (hylase). If filling is not complete, more dye is instilled before further X-rays are taken. A stone may show some opacification, but a tumour will not, but both these will cause a filling defect in the pelvis or calyx in excretory urogram.

If there are signs of systemic disease purchase avana australia, scleroderma purchase avana on line, amyloidosis buy avana american express, and cystic fibrosis should be considered. The presence of an abdominal mass should suggest obstructive jaundice, pancreatic carcinoma, and hemochromatosis. Chronic pancreatitis may also present with an abdominal mass if there is a pseudocyst of the pancreas. Serum carotene levels taken following a loading dose of oral carotene for 3 to 7 days will diagnose malabsorption syndrome in many instances. A D-xylose absorption test will help differentiate primary diseases of the small intestines. An abnormal yield of labeled carbon dioxide after ingestion of a 14 meal with radioactive C-glycocholate will help diagnose bacterial overgrowth. Intubation and analysis of pancreatic secretion of enzymes after pancreozymin or secretin injection will help differentiate 590 pancreatic disorders. Intestinal biopsy with a Crosby capsule may help differentiate primary intestinal diseases also. Consult a gastroenterologist before ordering many of these expensive diagnostic tests. A therapeutic trial with pancreatic enzymes, antibiotics, or even a gluten-free diet may also assist in the diagnosis. The presence of a urethral discharge is suspicious for urethritis, gonorrhea, or prostatitis. This makes cystitis, vesicular calculus, vesicular tumor, or tuberculosis very likely. In this case, one should consider uterine fibroids, ovarian cyst, or tumor pressing on the bladder. If none of the above associated signs is present, one should consider hemorrhoids, anal fissure, tabes dorsalis, or bladder neck obstruction as the most likely cause. If these tests fail to detect the cause, an urologist must be consulted for cystoscopy and intravenous or retrograde pyelography. The patient loses control of the bladder when he or she coughs, laughs, or sneezes and consequently leaks small amounts of urine. In postmenopausal women, there is often an atrophic vaginitis due to the deficiency of estrogen. You can ask the patient to cough during a vaginal examination, and the urine will trickle out. If that does not establish the diagnosis, have the patient drink a lot of water and not void until he or she returns to the office. Then you can have him or her cough in the recumbent or erect position, and the urine will be released. In the Q-tip test, a Q-tip is inserted in the tip of the urethra, and the patient is asked to cough or strain. The Q-tip will move at least 30 degrees above the horizontal in cases of stress incontinence. However, purple striae of the abdomen, especially when they are associated with moon facies or a buffalo hump, should immediately call to mind Cushing’s syndrome. If the patient is a child, acute epiglottitis, acute laryngotracheitis, foreign body, congenital laryngeal stridor, laryngismus stridulus, and a retropharyngeal abscess should be considered. If the patient is an adult, myasthenia gravis, bulbar and pseudobulbar palsy, recurrent laryngeal palsy, pharyngitis, laryngotracheitis, carcinoma of the larynx or trachea, angioneurotic edema, foreign bodies, thyroid disorders, and disorders of the mediastinum should be considered. The presence of stridor of acute onset would suggest acute epiglottitis, acute pharyngitis, laryngotracheitis, angioneurotic edema, retropharyngeal abscess, laryngismus stridulus, and foreign body. The presence of fever would suggest acute laryngotracheitis, diphtheria, subacute thyroiditis, retropharyngeal abscess, and mediastinitis. On ear, nose, and throat examination, the clinician may find pharyngitis, acute epiglottitis, a foreign body, tenderness of the thyroid suggesting thyroiditis, and thyroid masses. Neurologic abnormalities may be found in myasthenia gravis, bulbar and pseudobulbar palsy, bilateral recurrent laryngeal nerve palsy, and comatose states. Direct laryngoscopy can now be done in the office with the fiberoptic laryngoscope. An ear, nose, and throat specialist should be consulted before ordering expensive diagnostic tests. Intermittent stupor should suggest epilepsy, chronic illicit drug use, transient ischemic attacks, migraine, and insulinoma. The presence of focal neurologic signs may mean cerebral vascular disease, advanced brain tumor, cerebral abscess, encephalitis, subdural hematoma, central nervous system lues, Wernicke’s encephalopathy, and subarachnoid hemorrhage or meningitis. The presence of nuchal rigidity would suggest a subarachnoid hemorrhage or meningitis, but it could occasionally indicate an intracerebral hemorrhage. Besides alcohol, uremia, diabetic acidosis, and liver failure may be suggested by a characteristic odor to the breath. A cerebral vascular disease may need further investigation, including carotid duplex scan and cerebral angiography. If they are heard with the stethoscope in a patient with abdominal disturbance, they are of pathologic significance. When there are associated hyperactive and/or high-pitched bowel sounds, intestinal obstruction should be considered. When there are hypoactive bowel sounds, paralytic ileus or peritonitis should be considered. Succussion sounds coming from the chest are because of hydropneumothorax or hemopneumothorax. Other rare causes of succussion sounds are acute gastric dilatation, chronic pyloric obstruction, subdiaphragmatic abscess, and pneumoperitoneum. The diagnostic workup will be determined by associated symptoms and signs (vomiting, page 352; abdominal pain, page 16; abdominal mass, page 24). Following the algorithm, you ask about convulsive movements, incontinence, or tongue lacerations following these episodes and there are none of these signs. Examination shows a normal pulse, no murmurs or cardiomegaly, and the conjunctivae are not pale. On further questioning the patient tells you, she gets numbness and tingling of her lips and fingers just before she passes out. The husband confirms that the patient has rapid deep breathing during these attacks confirming your suspicions of hyperventilation syndrome. The presence of convulsive movements should suggest convulsions, and the differential diagnosis of this is discussed in page 108. The presence of a slow or absent pulse would suggest heart block, vasovagal syncope, and carotid sinus syncope. The presence of a normal pulse rate would suggest anemia, aortic stenosis, aortic insufficiency, and cyanotic congenital heart disease. The presence of a rapid pulse would suggest the various types of ventricular and supraventricular tachycardias, including auricular fibrillation and flutter, and it should also suggest heat exhaustion or heat stroke. The presence of a rapid regular pulse should suggest supraventricular or ventricular tachycardia, heat exhaustion, or heat stroke. Carotid sinus massage can help distinguish supraventricular tachycardia from sinus tachycardia.

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O catgut purchase avana without a prescription, whereas the mucoperiosteal flap on the buccal side is sutured with fine silk buy avana without prescription. A transverse incision is made on the posterior pharyngeal wall at the level of Passavant’s ridge through the mucous membrane and the constrictor pharyngis superior at the level of the anterior arch of the atlas purchase avana from india. The incision is closed vertically taking big bites from the salpingopharyngeal folds. Thus not only the diameter of the nasopharynx is reduced, but also the muscular folds become prominent particularly at the time of deglutition. Besides these there are also the anterior lingual glands and numerous small glands in relation to the mucous membrane of the lips, cheek and roof of the mouth and in the mucous membrane of the tongue. It projects forwards on to the surface of the masscter where a small part of it may be detached and lies between the zygomatic arch above and the parotid duct below. On its outer side the true capsule is covered by a layer from the deep cervical fascia which is called a false capsule. At the inferior border of the parotid gland the investing layer of deep cervical fascia splits to enclose the parotid gland. The superficial layer which covers the parotid gland extends upwards under the name of the parotid fascia and is fixed to the zygomatic arch. The deep part of the fascia which passes deep to the parotid gland is attached to the styloid process and the mandible and acquires the name of the stylomandibular ligament. It is also attached to the tympanic plate and blends with the fibrous sheaths of the muscles related to the gland. The stylomandibular ligament is thickened and it intervens between the parotid and the submandibular glands. It must be remembered that the parotid fascia is quite thick and tough so much so that the parotid abscess does not show fluctuation until very late. The superficial surface is covered by the skin and the superficial fascia which contains the facial branches of the great auricular nerve and the superficial parotid lymph nodes. The anteromedial surface is grooved by the posterior border of the ramus of the mandible. It covers theposteroinferior part of the masseter muscle, the adjoining part of the mandibular ramus and the lateral aspect of the temporomandibular joint. It also passes forwards on the deep aspect of the ramus to reach the medial pterygoid muscle. The branches of the facial nerve emerge from under cover of the anterior margin of this surface. The posteromedial surface is moulded on the mastoid process, stemomastoid muscle, the posterior belly of the digastric, the styloid process and the styloid group of muscles. The external carotid artery grooves this surface before it enters the substance of the gland. The styloid process and the styloid muscles intervene between the gland on the superficial side and the internal carotid artery and the internal jugular vein on the deep side. The anteromedial and the posteromedial surfaces meet along a medial margin which may project deeply as to be in contact with the side wall of the pharynx. The superiorsurface isconcave and is related to the cartilaginous part of the external acoustic meatus and to the posterior surface of the temporomandibular joint. The auriculotemporal nerve winds round the neck of the mandible and enters the gland through this surface. The lower extremity of the gland overlaps the posterior belly of the digastric and the carotid triangle to a variable extent. The maxillary artery leaves the anteromedial surface and runs deep to the neck of the mandible, while the superficial temporal artery gives off transverse facial branch and then ascends to appear at upper limit of the gland. The posterior auricular artery may arise from the external carotid artery within the gland and then leaves through the posteromedial surface. The retromandibular vein emerges from the gland behind its lower extremity and joins the posterior auricular vein to form the external jugular vein. Before it leaves the gland it gives off a communicating branch which leaves the gland in front of its lower extremity and joins the facial vein. The temporofacial nerve further subdivides into the temp >ral and zygomatic branches, whereas the cervicofacial nerve further divides into the buccal, the mandibular and the i ;rvical nerves. It ultimately leaves the gland through the superior surface and ascends posterior to the superficial temporal vessels. So, mainly the contents are the external carotid artery and its terminal branches, the retromandibular vein and its main tributaries and the facial nerve and its main branches. These three structures are placed in such a manner within the gland that the artery lies in the deepest plane, the vein lies in the middle and the facial nerve lies in the most superficial plane. It comes out through the anterior border of the gland, crosses the Masseter muscle and at the anterior border of this muscle it turns inwards nearly at a right angle, passes through the corpus adeposum of the cheek (suctorial pad of fat in the infant) and pierces the Buccinator. It then runs for a short distance obliquely forwards between the Buccinator and the mucous membrane of the mouth and opens into a small papilla in the mucous membrane of the cheek opposite the crown of the second upper molar tooth. The duct can be felt as it dips inwards at the anterior bordei of the masseter by pressing the index finger backwards on this border of the muscle (with the teeth clenched to make the muscle taut) and moving the finger up and down across the line of the duct. The nerve supply of the parotid gland is derived from both parasympathetic and sympathetic systems. The secretomotor or parasympathetic supply is through the auriculotemporal nerve, but these nerves are derived from the inferior salivary nuclcus via the otic ganglion through the tympanic branch of the glossopharyngeal nerve. This gland is also covered on both aspects by splitting of the investing layer of the deep cervical fascia. This fascia splits, the superficial part covers the submandibular gland and is attached to the inferior border of the mandible. The deep part covers the medial surface of the gland and is attached to the mylohyoid line on the medial surface of the mandible. The inferior surface, which is in fact the superficial surface of the gland is covered by the skin, platysma and the deep fascia. It is also in close relation with the submandibular lymph nodes and a few may actually be embedded within the gland. The lateral surface is in relation with the submandibular fossa of the inner surface of the body of the mandible and with the insertion of the Medial pterygoid muscle. The facial artery is embedded in a groove in the posterior and superior part of the gland. The artery first passes up between the lateral surface of the gland and the medial surface of the mandible and then curves downwards to reach the lower border of the mandible. Posteriorly this surface is in relation with the styloglossus muscle, the stylohyoid ligament and the glossopharyngeal nerve which separate it from the wall of the pharynx. In the intermediate part the medial surface is in relation to the hyoglossus muscle, the lingual nerve, the submandibular ganglion, the hypoglossal nerve and the deep lingual vein (in that order from above downwards). It is related above to the lingual nerve and the submandibular ganglion and below to the hypoglossal nerve and deep lingual vein.