Stenson's duct of parotid gland is a major duct which drains saliva into the oral cavity. Deep penetrating wound in the form of cut or crush injury to the buccal area carries the risk of parotid duct injury. It is in the form of ductal exposure, laceration, total severing, or crushing of the duct. These conditions are difficult to diagnose because of complex anatomy and variable nature of injury. Successful management of parotid duct injury depends on early diagnosis and appropriate intervention, failing of which may lead to complications like sialocele or salivary fistula. Many techniques have been proposed for diagnosis and management of parotid duct injuries. This article presents an easy and novel technique to diagnose and manage the parotid duct injuries using an "epidural catheter" which is often used for inducing spinal anesthesia. The technique of epidural catheter usage, its advantages, and limitation over other techniques proposed for the management of parotid duct injury are discussed.

Acinic cell carcinoma is an uncommon low-grade malignant tumor of salivary glands. It was first described by Nasse in 1892, arising in parotid salivary gland. Salivary gland tumors are also known to develop within jaw bones, arising within the jaw as a primary central lesion, and are extremely rare with only a few cases reported. We present a rare case report of 65-year-old woman with intraosseous acinic cell carcinoma of left side of the mandible.

with Fentanyl 25ug, total of 8ml supplemented through the epidural catheter 12 hourly for 48 hours. Remaining part of postoperative stay was uneventful. She remained clinically stable and was discharged on the 6 th postoperative day. DISCUSSION:People with diabetes undergoing surgery have an almost 50% greater chance of postoperative mortality and morbidity than those with normal glucose tolerance. Mortality rates in diabetics following surgery are estimated to be 5 times greater than in non-diabetic counter parts; often due to end organ damage and infections.Thoracic epidural anesthesia (TEA) has been established as a cornerstone in perioperative care after thoracic and major abdominal surgery providing most effective analgesia. (8) It is possible to use single dose TEA for oncology mastectomies with axillary clearence, and this technique has many advantages when compared with general anesthesia. (4) TEA is associated with decreased incidence of nausea and vomiting and earlier discharge from the hospital compared to patients with general anesthesia. (9) Successful use of high TEA avoids problems of difficult tracheal intubation, stress of anesthesia and surgery and hemodynamic changes associated with tracheal intubation. Stress associated with anesthesia and surgery results in increased catecholamine levels, increased left ventricular afterload, heart rate, and cardiac complications. TEA has been shown to decrease adverse perioperative cardiac events, morbidity and mortality after cardiac and non-cardiac major surgery. (10,11) Autonomic neuropathy and macro vascular complications can lead to silent ischemia and myocardial infarction in long standing DM usually on the 2 nd or 3 rd post-operative day usually in the night. A segmental temporary sympathetic block provided by TEA is assumed to be an important beneficial factor of perioperative effects of TEA. (12,13) As patient was a known case of long standing type 2 DM and hypertension, we planned the procedure under sole anesthetic technique of TEA which provided safe and excellent surgical conditions. Patient tolerated the procedure well without any perioperative complications with additional benefit of prolonged postoperative analgesia. But TEA is also associated with complications hence one should always assess the risk and benefit ratio before planning the procedure. All the equipment and drugs should be kept ready to manage the complications and supplement general anesthesia if block fails or results in the inadequate block. Common complication of the technique is dural puncture, neurological injury and epidural hematoma9 (14) . With maximum precautions in experienced hand dural puncture is rare and incidence of neurological injury is 0.01-0.001%. (15) CONCLUSION: In conclusion, thoracic epidural anesthesia can be a better option to general anesthesia for modified radical mastectomy in high risk patients with long standing DM with co morbidities. Among the benefits of the technique includes a good postoperative analgesia, lower incidence of post-operative nau...

Gilbert's syndrome is characterized by mild unconjugated hyperbilirubinemia without either structural liver disease or hemolytic anemia. Bilirubin is produced during the breakdown of hemoglobin and hemoproteins. Since bilirubin is insoluble in water, it must be converted into a soluble conjugate form in the liver before elimination from the body. In the liver, enzyme uridine diphosphate (UDP) glucoronosyltransferase converts the bilirubin into the mixture of monoglucoronides and diglucoronides referred as conjugated bilirubin. The relative deficiency of UDP glucoronosyltransferase results in reduced activity nearly 10-30% normal, leading to unconjugated hyperbilirubinemia, Gilbert's Syndrome (GS). Since majority of anesthetic agents require this enzyme for their metabolism and excretion, its deficiency leads to potential accumulation of such drugs resulting in anesthetic toxicity with adverse outcome. Anesthetic management of Patient with Gilbert's Syndrome is quite challenging. A thorough knowledge of pathophysiology and precipitating factors of GS are essential for safe administration of anesthesia.

Background: Limited studies are available for assessing the optimal pillow height for sniffing position to obtain the best glottic view during laryngoscopy and intubation in the Indian population. Aims: This study was designed to evaluate laryngoscopic view and intubation conditions in sniffing position using three different pillow heights (without a pillow, 4 cm, and 7 cm) during direct laryngoscopy. Settings and Design: This prospective analytical study was done in a tertiary care teaching institute. Materials and Methods: In 60 patients, direct laryngoscopy was performed in the sniffing position first without a pillow (0 cm), followed by a 4-cm pillow, and then a 7-cm pillow to assess the glottic view after administration of anesthesia. The laryngoscopic views were graded using the percentage of glottic opening (POGO) score and Cormack and Lehane (CL) grade. The pillow with the best laryngoscopic view was subsequently used to intubate the patient. Intubation difficulty was assessed by the Intubation Difficulty Score (IDS). The patient was followed up for 24 h postoperatively to evaluate postoperative complications due to intubation. Statistical Analysis: The categorical data were expressed in frequency and percentages and analyzed using the Chi-square test. Results: With a 4-cm pillow, there are a lower CL grade and a higher POGO score compared to views without a pillow and a 7-cm pillow which was statistically significant. There is a significantly lesser IDS score with a 4-cm pillow. Conclusions: The sniffing position with a 4-cm pillow provides a better laryngoscopic view and improved intubation condition than without a pillow and a 7-cm pillow in the study population.