Browsing by Author "Shrestha, BL"
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Publication Analysis of Ear, Nose and Throat Foreign Bodies in Dhulikhel Hospital(Kathmandu University, 2012) Shrestha, I; Shrestha, BL; Amatya, RCMABSTRACT Background Foreign body in ear nose and throat are commonly encountered by otolaryngologists, pediatricians and primary care physicians. Objective The aim of this study is to analyze different types of foreign bodies and socio- demographic correlates of self-inflicted foreign body insertion in ear–nose–throat. Method This was a two year hospital based cross sectional descriptive study performed in the Department of ear nose and throat (ENT), Dhulikhel Hospital - Kathmandu University from June 2009 to June 2011 after verification from the Institutional Review Committee. Using a predesigned questionnaire, socio-demographic data was collected prospectively by examining clinically all patients attending with foreign body and interviewing the caregivers of pediatric patients after removal of foreign body. The data collected from 312 patients was entered and analyzed by using descriptive and analytical statistical methods using SPSS version 16.0. Results The mean age was 21.26 years with majority between 0-10 years (50.6%). Male predominance was noted (58.97%). Most patients or caregivers were illiterate (35.1%) or literacy up to primary level(21.12%).Foreign body of the ear was found to be most frequent ( 47.4%) and mostly they were non-living (96.1%). Most patients presented late (80%) and had history of prior attempted removal (67%). Pearsons chi square test between education level and duration of time was significant (p value- 0.0000). One way ANOVA test between type of foreign body and age was significant (p value- 0.001). Conclusion Foreign bodies are common in adult and pediatric ear, nose and throat. They can potentially be associated with significant complications if not taken care of immediately. KEY WORDS Foreign body, inorganic, living, non- living, organicPublication Artificial Intelligence in Medical Practice: The Promise and the Challenges(Kathmandu University, 2023) Shrestha, BLNAPublication Blood Splashes Risk During Otorhinolaryngology Surgery: A Tertiary Care Hospital Based Study(Kathmandu University, 2018) Shrestha, BL; Dhakal, A; Karmacharya, SABSTRACT Background ENT (Ear, Nose and Throat) surgeons are particularly at high risk of exposure with blood and body fluid related infections both in Outpatient and during surgical procedures. They do take precaution to avoid the needle stick injuries but few pay attention on blood or body fluid splashes into eye. Objective To find out the risk of blood splashes to both surgeon and assistant during otorhinolaryngology surgeries. Method This was an descriptive study and data were collected prospectively in Department of Ear, Nose and Throat-Head and Neck Surgery of Dhulikhel Hospital, Kathmandu University Hospital in 1 year period from 1st January 2017 to 1st January 2018. All the surgical cases were included in the study. The surgeon and assistant wore the glass and mask during the surgery. At the end of the surgery, the glass, mask and gown were inspected for any blood splashes and information was recorded. Result There were total 272 patients with male 119 and female 153. The amount of blood splatter in glass, mask and gown is most common in modified radical mastoidectomy surgery. Likewise, the blood splatter is most common in tonsillectomy in throat surgery and in head and neck surgery, the blood splatter is common in all head and neck surgery. Conclusion The blood splashes is high in various Ear, Nose and Throat surgeries. So it is important to take precaution by surgeon and assistant, like protective mask and glass worn during surgeries to protect from various blood-borne infection transmissions. KEY WORDS Blood splashes, Glass, Gown, Mask, SurgeryPublication Clinical Profile and Diagnosis of Obstructive Sleep Apnea Syndrome using Overnight Polysomnography in a Tertiary Care Hospital(Kathmandu University, 2021) Pokharel, M; Shrestha, BL; Dhakal, A; Rajbhandari, P; Shrestha, KS; KC, AK; Bhattarai, A; Karki, DRABSTRACT Background Obstructive sleep apnea is a highly prevalent yet largely under-diagnosed disease that poses a significant burden on the healthcare system. Objective To determine the role of predictors for Obstructive sleep apnea syndrome and its severity in Nepalese population. Method Prospective and analytical study conducted in the Department of Otorhinolaryngology and Head and Neck surgery at Kathmandu University Hospital between March 2018 and June 2020. A total of 85 adult patients with Obstructive sleep apnea with an Epworth sleepiness score greater than 10 were included. Overnight polysomnography was done and scoring of sleep associated events were done according to the American Academy of Sleep Medicine criteria. Participants were classified as simple snoring and mild, moderate or severe Obstructive sleep apnea syndrome groups depending on the Apnea Hypopnea Index values. Relationship of Apnea hypopnea index was analyzed with age, neck circumference, body mass index and Epworth Sleepiness score. Result Simple snoring was seen in 18(21.17%) patients, 14(16.47%) had mild Obstructive sleep apnea, 13(15.29%) had moderate Obstructive sleep apnea, whereas the severe group consisted of 40(47.05%) patients. The minimum Epworth Sleepiness Score was 10 and the maximum was 25. The Apnea hypopnea index correlated positively with Body mass index (p=.010) and Epworth sleepiness score (p<.001). However, Apnea hypopnea index had no association with age (p=.437) and neck circumference (p=.118). Conclusion Health professionals need to be extremely vigilant while examining patients presenting with Obstructive Sleep Apnea. Polysomnography is the investigation of choice in the early identification of this treatable disease. KEY WORDS Apnea hypopnea index, Obstructive sleep apnea, PolysomnographyPublication Clinicoradiologic Evaluation of Eagle’s Syndrome and its Management(Kathmandu University, 2013) Pokharel, M; Karki, S; Shrestha, I; Shrestha, BL; Khanal, K; Amatya, RCMABSTRACT Background Eagle’s syndrome (Elongated styloid process) is often misdiagnosed due to its vague symptomatology. The diagnosis relies on detail history taking, palpation of styloid process in tonsillar fossa and imaging modalities. Objective To assess the length and medial angulation of elongated styloid process with the help of three dimensional computed tomography (3D CT) scan and to describe our clinical and surgical experience with patients suffering from Eagle’s syndrome. Method Prospective, analytical study conducted from August 2011 to August 2012 among 39 patients with Eagle’s syndrome. Detailed history taking, clinical examination and 3D CT scan was performed. Length and medial angulation was calculated. Patients with styloid process length longer than 2.50 cm underwent surgical excision via intraoral approach. Medial angulation of styloid process on both sides was correlated with each other using rank correlation coefficient. Wilcoxon Signed Rank test was applied to test significant difference between pre-operative and post- operative symptoms scores. Result Significant positive correlation was found between the medial angulation of styloid process on right side and left side (ρ =0.81, p<0.001). Significant difference was also observed between pre and post-operative symptoms scores (z=-5.16, p<0.001) . Conclusion Possibility of Eagle’s syndrome should always be considered while examining patients with vague neck pain. 3D CT reconstruction is a gold standard investigation which helps in studying the relation of styloid process with surrounding structures along with accurate measurement of its length and medial angulation. KEY WORDS Eagle’s syndrome, elongated styloid process, three dimensional computed tomographyPublication Comparison of clinical presentation between Chronic Otitis Media Mucosal with Squamous.(Kathmandu University, 2010) Shrestha, BL; Shrestha, I; Amatya, RCABSTRACT Background Chronic otitis media is a chronic inflammatory disease of the middle ear cleft which is manifested as deafness and ear discharge. It is a common condition affecting 0.5 – 30% of any community worldwide, and most common in developing countries. The prevalence mainly depends on age, low socio-economic status, overcrowding and limited medical facilities. Objective To compare the clinical presentation between chronic otitis media mucosal with squamous types. Methods A prospective, longitudinal and analytical study performed among 200 patients who have features of chronic otitis media and were attended to in the ear, nose and throat outpatient department of Dhulikhel Hospital - Kathmandu University Hospital, Dhulikhel, Nepal from January 2010 to January 2011. Patients who had already undergone surgery and came back to the hospital, with inadequate information were excluded from the study. Results The results showed that, out of 200 cases, 120 (60%) were chronic otitis media- mucosal and 80 (40%) were chronic otitis media – squamous. Patients < 30 years were affected in both groups. The male to female ratio in chronic otitis media mucosal was 1.14:1, whereas in chronic otitis media squamous, it was 1.96:1. Similarly in etiological factors, oil and water exposure (76%) was the most common cause in chronic otitis media mucosal, whereas in chronic otitis media squamous, oil and water exposure (62.5%) and recurrent upper respiratory tract infection (62.5%) were the most common causes. Of all the clinical features, ear discharge was the leading feature in both chronic otitis media mucosal (98%) and squamous (100%) cases. The complications were mainly seen in the chronic otitis media squamous and the most common complication was mastoid abscess (5%). Conclusions The frequency of chronic otitis media is higher in the younger age group and those lacking in health education. As a result, it is important to disseminate the health education regarding the ear disease which will help in decreasing the frequency of the disease in developing countries like ours. Key Words chronic otitis media, mastoid abscess, upper respiratory tract infectionPublication Comparison of Hearing Result and Graft Uptake Rate between Temporalis Fascia and Tragal Cartilage in Endoscopic Myringoplasty(Kathmandu University, 2022) Shrestha, BL; Shakya, S; Pradhan, A; Dhakal, A; KC, AK; Shrestha, KS; Pokharel, MABSTRACT Background There are different methods to repair the perforation of the tympanic membrane. Recently cartilage has been used for the repair and results are comparable to temporalis fascia. For surgical procedure endoscope had added good assistance in middle ear surgery. Though the one hand technique the image quality and results are on par with the use of a microscope. Objective To compare the graft uptake rate and hearing results between temporalis fascia and tragal cartilage in endoscopic myringoplasty. Method This is a prospective, longitudinal study conducted among 50 patients who underwent endoscopic myringoplasty using temporalis fascia and tragal cartilage with 25 patients in each group. The hearing was assessed by comparing pre with post-operative ABG (Air bone gap) and ABG closure in speech frequencies (500Hz, 1 KHz, 2 KHz, 4 KHz). The status of graft and hearing results was evaluated on 6 months of follow up in both the groups. Result Out of total 25 patients enrolled for study in both (temporalis fascia and cartilage) groups, 23 (92%) patients in each group had graft uptaken. The audiological gain in the temporalis fascia group was 11.37±0.32 dB whereas in the tragal cartilage group it was 14.56±1.22dB. The audiological gain between the two groups did not show any statistically significant (p = 0.765). However, the pre and post-operative hearing difference was statistically significant in both temporalis fascia and tragal cartilage group. Conclusion Tragal cartilage has similar graft uptake rate and hearing gain when compared with temporalis fascia in endoscopic myringoplasty. Hence, tragal cartilage can be used for myringoplasty whenever required without any fear of deterioration in hearing. KEY WORDS Air bone gap, Endoscopic myringoplasty, Temporalis fascia, Tragal cartilagePublication Comparison of Ketamine, Fentanyl and Clonidine as an Adjuvant During Bupivacaine Caudal Anaesthesia in Paediatric Patients(Kathmandu University, 2012) Singh, J; Shah, RS; Vaidya, N; Mahato, PK; Shrestha, S; Shrestha, BLABSTRACT Background Caudal epidural analgesia with bupivacaine is very popular in paediatric anaesthesia for providing intra- and postoperative analgesia. Several adjuvants have been used to prolong the action of bupivacaine. Objectives To compare the efficacy of ketamine, fentanyl and clonidine in terms of quality and duration of analgesia they produce when added with caudal bupivacaine by single shot technique in children. Methods Eighty children, age one to ten years, undergoing sub-umbilical surgery, were prospectively randomized to one of four groups: caudal analgesia with 0.75 ml/ kg of 0.25% bupivacaine in normal saline (Group B) or caudal analgesia with 0.75 ml/kg of 0.25% bupivacaine with 1 μg/kg of clonidine in normal saline (Group BC) or caudal analgesia with 0.75ml/kg of 0.25% bupivacaine with ketamine 0.5mg/kg (Group BK) or caudal analgesia with 0.75ml/kg of 0.25% bupivacaine with fentanyl 1mcg/kg (Group BF). Post-operative pain was assessed for 24 hours using the FLACC scale. Results The mean duration of analgesia was significantly longer in Group BC (629.06 ± 286.32 min) than other three groups P < 0.05. The pain score assessed using FLACC scale was compared between the four groups, and children in Group BC had lower pain scores, which was statistically significant. The requirement of rescue medicine was lesser in Group BC. Clonidine in a dose of 1 μg/kg added to 0.25% bupivacaine for caudal analgesia, during sub-umbilical surgeries, prolongs the duration of analgesia of bupivacaine, without any side effects in compare to fentanyl or ketamine. Conclusion We conclude that clonidine in a dose of 1 μg/kg, added to 0.25% bupivacaine for caudal analgesia and administered as a 0.75 ml/kg mixture in children, for sub- umbilical surgery, significantly prolongs the duration of post-operative analgesia when compared to 0.75 ml/kg of 0.25% bupivacaine in normal saline than 0.75 ml/kg of 0.25% bupivacaine with ketamine 0.5 mg/kg or 0.75 ml/kg of 0.25% bupivacaine with fentanyl 1 mcg/kg or 0.75 ml/kg of 0.25% bupivacaine alone, without any side effects. KEY WORDS Bupivacaine, caudal analgesia, clonidine, fentanyl, ketamine, post-operative analgesia, sub-umbilical surgeryPublication Comparison of Surgical Outcome of Bipolar Scissors with Conventional Cold Dissection Tonsillectomy(Kathmandu University, 2023) Shrestha, BL; Khadka, L; KC, AK; Dhakal, A; Shrestha, KS; Pokharel, MABSTRACT Background The tonsillectomy is the most common Ear, Nose, and Throat (ENT) surgical procedure. Different methods have been used to improve the outcome of the surgery. One such method is tonsillectomy performed with bipolar scissors. In our scenario, the comparison of bipolar scissors tonsillectomy with conventional cold dissection has not been done. Objective To compare the surgical outcomes of bipolar scissors tonsillectomy and conventional cold dissection tonsillectomy. Method A prospective randomized study was conducted in 40 patients who underwent tonsillectomy on one side using bipolar scissors and on the other side using conventional cold dissection. Intraoperative blood loss, operation time, postoperative pain, and postoperative hemorrhage were all analyzed in both surgical techniques. Result The median operative time was 10 minutes for bipolar scissors compared with 12 minutes for conventional cold dissection, with a p-value of 0.390 which was not statistically significant. The median blood loss was 48 mL on the bipolar scissors side and 60 mL on the conventional cold dissection side, with a p-value of 0.232 which was also not statistically significant. The overall postoperative hemorrhage rate was 12.5%. Of these, 4 (10%) occurred on the bipolar scissors side (left side mainly) and 1 (2.5%) on the conventional cold dissection side (also left side), with a p-value of 0.002 which was statistically significant. There was no statistically significant difference in the pain scores between the two methods in both rest and swallowing (p > 0.05). Conclusion The bipolar scissors did not show any benefit over conventional cold dissection in terms of surgical time, intraoperative blood loss, or postoperative pain. However, postoperative hemorrhage was more common with bipolar scissors. Therefore, conventional cold dissection remains a safe technique for tonsillectomy in adult patients. KEY WORDS Intraoperative blood loss, Operation time, Postoperative hemorrhage, Postoperative painPublication Correlations Between Symptoms, Nasal Endoscopy Computed Tomography and Surgical Findings in Patients with Chronic Rhinosinusitis(Kathmandu University, 2013) Pokharel, M; Karki, S; Shrestha, BL; Shrestha, I; Amatya, RCMABSTRACT Background Although Chronic rhinosinusitis (CRS) is increasing in prevalence and incidence, its diagnosis and treatment still pose a challenge. The Task Force on rhinosinusitis (TFR) advocates the use of symptom based criteria. However, many otorhinolaryngologists depend on diagnostic nasal endoscopy and computed tomography(CT) of paranasal sinuses for diagnosis of CRS. Computed tomography has been extensively relied upon in confirming the presence of CRS, in assessing severity of disease, surgical planning and management decisions. Despite its widespread use, several studies have failed to correlate findings on CT with symptom severity. Objective To determine the correlations between symptoms described at presentation, radiological findings, endoscopy and extensiveness of surgery. Methods Longitudinal, prospective, analytical study conducted from August 2011 to August 2012 among 87 patients diagnosed as CRS according to the TFR criteria. Symptom, endoscopic, radiological and surgical scoring was done by using Lund and Mackay staging system. Pearson correlation coefficients between scores for symptoms, endoscopy, sinus CT and surgery was determined. Results When overall symptom score was correlated with radiological score and endoscopy score, it was found to be statistically significant (p= <0.01). However, no significant relationship was found between Lund and Mackay symptom and surgery score. Conclusion The symptom criteria used by TFR for CRS diagnosis are not very specific for sinus disease. A detail assessment of the subjective and objective criteria (CT and endoscopy) is necessary for tailoring surgical plan but should not be relied upon for determining the extensiveness of surgical intervention. KEY WORDS Chronic rhinosinusitis, lund and mackay staging system, task force on rhinosinusitisPublication Dhulikhel Hospital Checklist Protocol for Temporal Bone Computed Tomography Scan Analysis: How We Do It?(Kathmandu University, 2022) Shrestha, BL; KC, AK; Karmacharya, SABSTRACT The temporal bone is very complicated anatomical structure. Any disease process within this structure mandates thorough anatomical knowledge of the corresponding structure. The High resolution computed tomography (HRCT) temporal bone is the best way to look inside this complex bone. The importance of knowledge about how to read and look inside the CT scan temporal bone lead us develop the Dhulikhel Hospital Check list protocol. This protocol will help aspiring otologist and otolaryngologist to read and know details about the underlying structures. KEY WORDS High resolution computed tomography, Otologist, Temporal bonePublication Does the Preoperative Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio Associate with Clinic-pathological Characteristics in Papillary Carcinoma of Thyroid(Kathmandu University, 2021) Shrestha, BL; KC, AK; Rajbhandari, P; Dhakal, A; Shrestha, KSABSTRACT Background Thyroid cancer is associated with local and systemic inflammatory activities. Many systemic inflammatory markers including the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) had shown credible and independent prognostic biomarkers in different malignant conditions. These markers are easy to reproduce, measure and inexpensive also. So, the preoperative evaluation of NLR and PLR is helpful in evaluating tumor growth and prognosis of papillary carcinoma of thyroid. Objective To evaluate the association of pre-operative NLR and PLR with clinic-pathological characteristic in papillary carcinoma of thyroid. Method This was a retrospective study performed in thirty one patients with the diagnosis of papillary carcinoma of thyroid. Preoperative NLR and PLR values were correlated with the clinical parameters like age, gender, lymph node metastasis, tumor size and pathological features (e.g., multifocality, bilaterality, extrathyroidal spread). Result There were thirty one patients, amongst which 13 were male and 18 were female. Similarly, the age distribution ranges from 27-68 years. The value of NLR was 2.37±1.09, and the value of PLR was 96.69±49.53.The increase in NLR was associated with increase in tumor size with statistically significant results. Similarly, increase in PLR was associated with increase in tumor size and multifocality with statistically significant results. Conclusion Increase NLR and PLR is associated with lymph node metastasis, extra thyroidal extension, multifocality of tumor and also bilaterality, so the risk can be stratified beforehand with measurement of NLR and PLR. KEY WORDS Lymph node metastasis, Neutrophil-to-lymphocyte ratio, Papillary carcinoma of thyroid, Platelet-to-lymphocyte ratioPublication Endoscopic Ear Surgery in Dhulikhel Hospital: A decade of Experience(Kathmandu University, 2022) Shrestha, BLABSTRACT Endoscopic ear surgery is one of the most commonly performed surgeries in Dhulikhel hospital. In the past eleven years, there have been different endoscopic ear surgeries performed with a very good outcome. The main benefit of endoscopic ear surgery is; to let the surgeon see better, proceed with the surgery through the trans-canal, teaching and training of the students. There are some drawbacks of endoscopic ear surgery like the one-handed technique and learning curve. With repeated practice and the help of motion parallax, the trainee can overcome the drawback of the procedure. KEY WORDS Endoscopic ear surgery, Motion parallax, Teaching and trainingPublication Publication Endoscopic Sphenopalatine Artery Cauterization in Recurrent Posterior Epistaxis: An Experience at Dhulikhel Hospital, Kathmandu University Hospital(Kathmandu University, 2014) Shrestha, BLNAPublication Endoscopic stapes surgery: How I do it?(Kathmandu University, 2021) Shrestha, BLABSTRACT The use of endoscope in the field of ear surgery has done the revolutionary changes. The optical advantage of endoscope helps the otologist to perform the stapes surgery very conveniently. The main advantage of the endoscope in stapes surgery over the microscope is; the better preservation rates of the chorda tympani nerve (CTN), minimal curetting of the outer attic wall, hence minimizing the iatrogenic injury to the CTN. Apart from that, the audiometric results following the endoscopic stapes surgery is comparable with the microscopic surgery. We had performed the stapes surgery with the rigid nasal endoscopes (Karl Storz) of 4-mm diameter and 18-cm length. Our preliminary results showed that transcanal endoscopic stapedotomy is a reliable and safe technique for the surgical management of otosclerosis. KEY WORDS Endoscope, Microscope, Otosclerosis, Stapes surgeryPublication Endoscopic Transcanal Atticoplasty: How we do it?(Kathmandu University, 2023) Shrestha, BL; KC, AK; Karmacharya, SABSTRACT Endoscopic otological surgery has revolutionized ear surgery. Endoscopes are frequently used in myringoplasty and tympanoplasty, and their use in attic reconstruction (atticoplasty) is gaining popularity. While microscopic surgery for limited attic cholesteatoma and attic retraction (grade III and IV) is difficult especially anterior area, the endoscope has emerged as a new treatment option, offering a 360-degree view of the attic and facilitating the complete removal of diseased tissue.1 We had performed atticoplasty with rigid nasal endoscopes (Karl Storz) of 4 mm diameter and 18-cm length. Our preliminary results showed that transcanal endoscopic atticoplasty is a reliable and safe technique for the surgical management either attic retraction pocket (grade III or IV) or limited attic cholesteatoma. KEY WORDS Atticoplasty, Attic retraction, Endoscope, Ear surgeryPublication Evaluation of Etiology of Epistaxis and its Management in Dhulikhel Hospital(Kathmandu University, 2015) Shrestha, I; Pokharel, M; Shrestha, BL; Dhakal, A; Amatya, RCMABSTRACT Background Epistaxis is one of the most common and most difficult emergencies presenting in 7-14% of the general population each year. Although its lifetime incidence is about 60%, only 6% require formal medical intervention but they can be serious and even life threatening. Objective The main objectives are to study different etiology, types, modality of treatment of epistaxis. Specific objective is also to find out if the modality of treatment is associated with age, site, amount of bleeding and etiology. Method It is a prospective, cross sectional, longitudinal, analytical study done in Department of ENT, Dhulikhel hospital, Kathmandu University School of Medical Sciences (KUSMS) from Aug. 2010 to Aug. 2013. Data was collected. This study was cleared through institutional review committee of hospital. Statistical analysis was done using SPSS 16.0. Result 487 patients were studied during the period. There was significant association between age group with type of treatment (p value 0.002); and with admission (p value < 0.001). Significance in the study was also shown in the correlation between site of bleeding and the type of treatment and also with alcohol intake with site of bleeding (p value < 0.001).However there was no significance between hypertension and the type of treatment methods chosen (p value >0.01). Conclusion Management of epistaxis is challenging. Most are managed by non surgical means whereas some by surgical treatment. Non surgical treatment is still useful, safe and cost effective. Type of treatment and need for hospital stay is related to age and site of bleeding. KEY WORDS Age group, epistaxis, modality of treatment, site of bleedingPublication How I Do It? Endoscopic Modified Inlay Butterfly Cartilage Perichondrium Myringoplasty(Kathmandu University, 2013) Shrestha, BLNAPublication Huge Lipoma of Left Parotid Region with Intra-Parotid Extension(Kathmandu University, 2023) Amatya, N; KC, AK; Shrestha, BL; Shrestha, KSABSTRACT Lipoma is a benign mesenchymal tumor originating from adipose tissue. The occurrence of this tumor in head and neck is less frequent and it rarely involves parotid gland. These are asymptomatic and occur both in the deep and the superficial lobe of the parotid. The most favored age group is from the fifth to sixth decade of life and is 10 times more common in the males. A 66-year-old male patient, with left parotid region lipoma is reported in this article. A fine-needle aspiration biopsy and ultrasonography were performed to establish the preoperative diagnosis and to plan the correct surgical approach. It was managed by surgical excision of lipoma with removal of cuff of superficial parotid tissue on superior aspect with preserving facial nerve. Follow-up examinations were planned to assess any facial nerve injury complications. KEY WORDS Adipose tissue, Lipoma, Parotid gland, Superficial lobe