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Functional Endoscopic Sinus Surgery Tips

Can a Sinus Infection (Rhinosinusitis) Cause Spinal Meningitis?

Dr. Anurag 90% (215 ratings)
MBBS, MS - ENT
ENT Specialist, Delhi

The answer is unfortunately. Yes!
Meningitis, sometimes referred as spinal meningitis, is an inflammation of the membranes surrounding the brain and spinal cord. Usually caused by a viral infection, but it can also be caused by a bacterial or fungal infection.
 
Among pediatric patients admitted for treatment of sinusitis, 3.2% were found to have an intracranial complication. Infection of the sphenoid sinuses, however, merits concern. These thin-walled sinuses develop late in childhood, and their deep location places them adjacent to the dura mater and other critical structures.
 
Sphenoid sinusitis is identified in approximately 3% of cases of acute sinusitis, typically in the context of pansinusitis. Significant development of the sphenoid sinuses does not begin until age 4 to 6 years, thus, sphenoid sinusitis is restricted.
 
Viral infection causes most cases of spinal meningitis. Viral meningitis is usually mild and heals without treatment. Bacterial meningitis is more severe and requires treatment with antibiotics. Streptococcus pneumoniae and neisseria meningitidis are strains of bacteria that cause pneumococcus and meningococcus meningitis respectively.
It can be life threatening condition owing to its proximity to brain and spinal cord and infective media is the fluid surrounding them.
 
Diagnostic tools:
• Lumbur puncture – csf examination (cell count, glucose, proteins) and culture

Blood culture
• Chest x ray
• CT scan of head and nose – pns
MRI brain
 
Symptom checker in meningitis secondary to sinusitis:
Fever (92%)
• Headache (85%)
Nausea, vomiting (62%)
• Altered consciousness (31%)
• Seizure (31%)
• Hemiparesis (23%)
• Visual disturbance (23%)
• Meningismus (23%)
 
Conclusion and quick pearls:
• Complications that are less common with antibiotics
• Orbital (cellulitis, abscess)
• Intracranial (subdural empyema, thrombosis of cavernous sinus)
Bony osteomyelitis.
• Can result in drastic sequelae
• Drain abscess and open involved sinuses
Ent surgical involvement – functional endoscopic sinus surgery
- Usually amenable with medical treatment
- Drain sinuses if no improvement after 48 hours
• Ophthalmology check up
• Neurosurgery intervention
 
A low index of suspicion is necessary for early diagnosis and treatment of sphenoid sinusitis, orbital complications and prevention of intracranial complications including meningitis.

2 people found this helpful

Adenoids and Endoscopic Adenoidectomy!

Dr. Sarika Verma 92% (121 ratings)
MBBS Bachelor of Medicine & Bachelor of Surgery, Diploma In Otorhinolaryngology (DLO), DNB - ENT, Allergy Testing
ENT Specialist, Gurgaon
Adenoids and Endoscopic Adenoidectomy!

Adenoids are part of the ENT (ear-nose-tongue) area. They are basically lump of tissues situated at the back of the nose and higher up in the throat passage. Along with tonsils, they form a part of the lymphatic system and are also known as pharyngeal tonsils. They work in conjunction with tonsils to keep infections and viruses at bay. They also help in maintaining the body fluid balance.

Adenoids mostly occur in children. They basically start to grow from birth and can become enlarged between the ages of 5 to 7 years. They become swollen by fighting some bacteria or virus. However, by teenage years they start to shrink and completely disappears by adulthood. They do not help in fighting diseases and the body develops other ways to fight germs and bacteria.

Problems Caused by Adenoids:
Although adenoids are not harmful, they can become enlarged or swollen when fighting bacteria or viruses. In such situations, it is best to consult pediatric or ENT specialists. However, there are certain symptoms that occur in children:

  1. Breathing problems- Children may experience difficulty in breathing through the nose. Instead, they breathe through the mouth which might lead to dry mouth resulting in bad breath and cracked lips.
  2. Sleeping problems- Children having swollen adenoids having difficulty in having sound sleep. They might snore or experience sleep apnea (irregular breathing or might stop breathing for few seconds).
  3. Ear infections- Have ear infections and even develop glue ear (the ear duct is filled with fluids).
  4. Sinus problem- Your child may experience runny nose or facial pain.

Diagnosis
If your child is experiencing the above symptoms and having difficulty breathing, its best to visit an ENT specialist to get the adenoids checked out. The adenoids cannot be seen through normal eyes and has to be examined using special methods like endoscopy. An endoscope is a long flexible tube with a light, it is inserted through the mouth and the image of the inside of the mouth is seen on a screen.

Treatments for Adenoids:
Depending on the severity of the adenoids, it can be treated with nasal sprays or drops and antibiotics suggested by a doctor. If the adenoid does not shrink or the problem persists, it’s best to go for adenoidectomy.
What is Adenoidectomy? Adenoidectomy is the surgical removal of adenoids. It is generally performed by an ENT surgeon and carried out through the mouth under general anesthesia. The whole operation only requires a day. Your child is released at the end of the day.

Recovery:
After the surgical procedure, your child may experience:

  1. Sore throat
  2. Ear ache
  3. Stiff jaw
  4. Runny nose
  5. Bad breath

All of these difficulties pass away within a week or two. However, you should be careful as there is always a risk of infection after an operation. In case of excessive bleeding, known as hemorrhage, your child may need another surgery where the bleeding is stopped by cauterization.

Moreover, food and drink should be monitored carefully. As your child will have difficulty in swallowing food, it’s best to have fluids like soups or yoghurt. Remember to give them plenty of water to avoid dehydration.

Adenoids are not scary diseases. So don’t be scared and give your child all the care and support when they are facing difficulty in breathing or sleeping.

1 person found this helpful

Common FAQs About Endoscopic Surgery!

Dr. Praveen C R 90% (10 ratings)
MBBS, MS - General Surgery, Diploma In Minimal Access Surgery
General Surgeon, Bangalore
Common FAQs About Endoscopic Surgery!

Nowadays, people do not have to go for open surgeries for the treatment of certain conditions. You need not have large incisions on your body for getting a surgery done. It can be done with a few small incisions. This kind of surgery has a lot benefits over the open surgery such as less pain, less recovery time, fewer scars and less time in the hospital. So, with so many benefits, who would choose an open surgery? For those who are opting for an endoscopic surgery for any problem and have no knowledge about it, here are some common FAQs about endoscopic surgery.

What is endoscopic surgery?
Endoscopy means inserting a small tube into the body, to inspect the interior. A small endoscope is inserted, which has a camera and light attached to it. This will help in seeing the internal organs of the body without having to cut open the body. Usually, this procedure is used for diagnosing certain health conditions. But in some conditions, it is also used for providing treatment.

Is there anything I should know before the endoscopic surgery?
Yes, your doctor will help you understand what to eat and what not to eat, also he will tell you about when to stop eating. Your body has to be prepared for the endoscopy.

Are there any kind of side effects of endoscopic surgery?
Any kind of surgery will have some pain. It is the same with endoscopy as well. With endoscopic surgery, the pain is less but there is no surgery with zero pain. Hence, you will have some pain at the place of the surgery. This depends on the place of surgery and how far the incisions are made.

Are there any chances of moving to an open surgery during the endoscopic surgery?
This happens in very rare conditions that you need to switch to an open surgery. You need to discuss this with your doctor in advance in order to understand whether it can happen. Not all surgery will require this.

How long does it take for recovery?
Usually, endoscopic surgeries are performed even on an outpatient basis. That means you need not even have to get admitted to the hospital for getting the surgery done. You can take care of yourself at home and keep visiting the doctor as suggested.

What kind of medicine is usually prescribed?
Depending on the type of surgery that you have undergone, you will be prescribed medicine. Along with that, you will also be prescribed painkillers after any kind of surgery. The pain is usually less but taking one or two pills may be required.  In case you have a concern or query you can always consult an expert & get answers to your questions!

1901 people found this helpful

Can Pollutants Lead To Sinus Problem?

MBBS, MS - ENT
ENT Specialist, Ghaziabad
Can Pollutants Lead To Sinus Problem?

Sinusitis refers to a common condition characterised by inflammation and swelling of cavities surrounding nasal passages, commonly known as your sinuses. When something interferes with the flow of air into the sinuses and obstructs mucus drainage out of it, sinus infection or sinusitis mainly occurs.
The most common symptoms of this condition include headache or pain in the facial region, nasal congestion and discharge, loss of smell and fever in some cases. To ensure that you opt for the correct treatment it is necessary to identify the causes of blockage. Here are the chief causes responsible for giving you a sinus infection.

1. Viruses
In most cases, a sinus infection is triggered by common cold and flu, which are caused by viruses. Swelling of nasal tissues occurs due to cold, in turn creating a blockage for the holes that are meant for draining mucous. In this case, rather than opting for antibiotics, take precautions against flu and cold. You can even consider getting a flu shot.

2. Pollutants
Certain pollutants and allergens or deviation of septum can be the cause behind sinus infections as they trigger coughing, irritation of the nose and inflammation. Some of these pollutants are dust, smoke and harmful gases present in the air or substances with a strong odour (certain foods, flowers, perfumes etc). To minimize chances of sinusitis, try to stay away from these irritants to the maximum extent possible. Moreover, you can also use an air purifier to reduce the effects of air pollution.


3. Long term use of nasal decongestant sprays
Nasal decongestant sprays may help you get rid of congestion, but on the other hand they are responsible for the constriction of the blood vessels present in your nose. Moreover, if used for a long time, these nasal products may worsen the symptoms of sinusitis, especially if the directions for use are not correctly followed. Also, prolonged use of the sprays can give rise to rebound nasal congestion, which is basically a relapse of congestion. So, try to minimise the use of it and follow directions very carefully if you do need to use it.

4. Smoking
Smoke from cigarettes has an effect similar to pollutants on your nose. Cigarette smoke plays a significant role in degrading the natural sinus-cleaning system of your body resulting in more gunk build up in the sinuses, in turn clogging nasal passages. Moreover, smoking also leads to inflammation, triggering sinus infections. So, try to cut down on your smoking if not quit altogether. If you wish to discuss about any specific problem, you can consult an Ent Specialist.

4181 people found this helpful

Sinus Problem - Reasons Behind It!

Dr. Shashidhar 90% (58 ratings)
ECFMU, MS - ENT, MBBS, Certificate in Pediatric Otolaryngology - Head and Neck Surgery, Robotic Surgery Familiarization (France)
ENT Specialist, Gurgaon
Sinus Problem - Reasons Behind It!

Sinusitis refers to a common condition characterised by inflammation and swelling of cavities surrounding nasal passages, commonly known as your sinuses. When something interferes with the flow of air into the sinuses and obstructs mucus drainage out of it, sinus infection or sinusitis mainly occurs.
The most common symptoms of this condition include headache or pain in the facial region, nasal congestion and discharge, loss of smell and fever in some cases. To ensure that you opt for the correct treatment it is necessary to identify the causes of blockage. Here are the chief causes responsible for giving you a sinus infection.

1. Viruses
In most cases, a sinus infection is triggered by common cold and flu, which are caused by viruses. Swelling of nasal tissues occurs due to cold, in turn creating a blockage for the holes that are meant for draining mucous. In this case, rather than opting for antibiotics, take precautions against flu and cold. You can even consider getting a flu shot.

2. Pollutants
Certain pollutants and allergens or deviation of septum can be the cause behind sinus infections as they trigger coughing, irritation of the nose and inflammation. Some of these pollutants are dust, smoke and harmful gases present in the air or substances with a strong odour (certain foods, flowers, perfumes etc). To minimize chances of sinusitis, try to stay away from these irritants to the maximum extent possible. Moreover, you can also use an air purifier to reduce the effects of air pollution.


3. Long term use of nasal decongestant sprays
Nasal decongestant sprays may help you get rid of congestion, but on the other hand they are responsible for the constriction of the blood vessels present in your nose. Moreover, if used for a long time, these nasal products may worsen the symptoms of sinusitis, especially if the directions for use are not correctly followed. Also, prolonged use of the sprays can give rise to rebound nasal congestion, which is basically a relapse of congestion. So, try to minimise the use of it and follow directions very carefully if you do need to use it.

4. Smoking
Smoke from cigarettes has an effect similar to pollutants on your nose. Cigarette smoke plays a significant role in degrading the natural sinus-cleaning system of your body resulting in more gunk build up in the sinuses, in turn clogging nasal passages. Moreover, smoking also leads to inflammation, triggering sinus infections. So, try to cut down on your smoking if not quit altogether.

Sinus can be treated with the help of medications or through endoscopic sinus surgery.

3971 people found this helpful

Reasons Behind Sinus Problem!

MS - ENT
ENT Specialist, Nagpur
Reasons Behind Sinus Problem!

Sinusitis refers to a common condition characterised by inflammation and swelling of cavities surrounding nasal passages, commonly known as your sinuses. When something interferes with the flow of air into the sinuses and obstructs mucus drainage out of it, sinus infection or sinusitis mainly occurs.
The most common symptoms of this condition include headache or pain in the facial region, nasal congestion and discharge, loss of smell and fever in some cases. To ensure that you opt for the correct treatment it is necessary to identify the causes of blockage. Here are the chief causes responsible for giving you a sinus infection.

1. Viruses
In most cases, a sinus infection is triggered by common cold and flu, which are caused by viruses. Swelling of nasal tissues occurs due to cold, in turn creating a blockage for the holes that are meant for draining mucous. In this case, rather than opting for antibiotics, take precautions against flu and cold. You can even consider getting a flu shot.

2. Pollutants
Certain pollutants and allergens or deviation of septum can be the cause behind sinus infections as they trigger coughing, irritation of the nose and inflammation. Some of these pollutants are dust, smoke and harmful gases present in the air or substances with a strong odour (certain foods, flowers, perfumes etc). To minimize chances of sinusitis, try to stay away from these irritants to the maximum extent possible. Moreover, you can also use an air purifier to reduce the effects of air pollution.


3. Long term use of nasal decongestant sprays
Nasal decongestant sprays may help you get rid of congestion, but on the other hand they are responsible for the constriction of the blood vessels present in your nose. Moreover, if used for a long time, these nasal products may worsen the symptoms of sinusitis, especially if the directions for use are not correctly followed. Also, prolonged use of the sprays can give rise to rebound nasal congestion, which is basically a relapse of congestion. So, try to minimise the use of it and follow directions very carefully if you do need to use it.

4. Smoking
Smoke from cigarettes has an effect similar to pollutants on your nose. Cigarette smoke plays a significant role in degrading the natural sinus-cleaning system of your body resulting in more gunk build up in the sinuses, in turn clogging nasal passages. Moreover, smoking also leads to inflammation, triggering sinus infections. So, try to cut down on your smoking if not quit altogether.

Sinus can be treated with the help of medications or through endoscopic sinus surgery. If you wish to discuss about any specific problem, you can consult an Ent Specialist.

2603 people found this helpful

Pilonidal Sinus - Say No To Surgery!

Dr. S K Singh 91% (651 ratings)
M.S. (Ayurveda), Bachelor of Ayurveda, Medicine and Surgery (BAMS)
Ayurveda, Delhi
Pilonidal Sinus - Say No To Surgery!

Pilonidal Sinus is a disease commonly seen in the people with hairy skin. Disease presents as a small nodular swelling in the lower spinal region with off and on blood mixed pus and watery discharges. This sinus is formed because of underlying hairs which are impacted beneath the skin and act as a source of infection. Once the pus is formed; it creates a passage to come out on the skin; thus a sinus is formed.This disease is usually not curable by oral medication like anti biotics etc., Ayurvedic as well as homeopathic oral medication is also of not much help. 

Now a days; pilonidal sinus patients are treated with surgery/ Z plasty. With these surgical procedure; chances of recurrence are as high as 15 %. 

How ever in Ayurveda; Pilonidal Sinus can be very effectively and very conveniently treated by Graded Ksharsutra. In this procedure; first the sinus tract is defined with respect to its depth, direction  and branching pattern with careful probing and sinogram. Once the sinus tract has been precisely defined; medicated Ksharsutra is placed in the tract with the help of certain instruments.  Now from this medicated thread; medicine is gradually released in the tract. This medicine (Kshara) induces a potent debridement effect on the sinus tract as a result all the unhealthy fibrogranulomatous tissue, pus pockets and accumulated hairs etc. are cleared from the tract. The medicinal coating on the thread gets dissolved hence the thread has to be replaced by a new thread with in a week or two. 

The sinus tract heals at the rate of 0.5 to 1 cm per sitting. Thus a small sinus tract which is around 4-5 cm long may take around 8-10 sittings  to heal completely. The chances of recurrence of Sinus tract after Ksharsutra treatment are predictably ZERO. 

The treatment is far better than surgery as- 

  1. No hospitalization or bed rest required
  2. Patient can continue his normal routine activities
  3. Chances of recurrence are predictably ZERO
  4. No shaving of hairs or laser treatment for hair removal required

 

2 people found this helpful

Know About The Surgery For Pilonidal Sinus!

Dr. Prafull Arya 91% (373 ratings)
MBBS Bachelor of Medicine and Bachelor of Surgery, MS - General Surgery
General Surgeon, Ludhiana
Know About The Surgery For Pilonidal Sinus!

Pilonidal Sinus refers to the small channel in your skin. When the channel is filled with pus or fluid, it leads to the formation of cysts or an abscess. A pilonidal cyst usually occurs at the top of the buttock crease near the tailbone, and consists of dirt, debris, and hair. When the cyst becomes infected or inflamed, it causes severe pain and discomfort.

Pilonidal sinus mostly affects men in their puberty. This condition is usually seen among people who sit for longer periods. For instance- truck/cab drivers, or desk-job workers, etc.

What causes Pilonidal sinus?

Pilonidal sinuses are most often caused due to the following factors-

  1. Dense Hair on back
  2. Hormonal changes during puberty
  3. Friction from wearing tight clothes
  4. Prolonged sitting

These factors prompt the hair growing in the region to burrow back beneath your skin. Your body considers the retracted hair as a foreign particle and launches an immune response. The cyst forms due to this response.

In certain cases, the patient may develop multiple sinuses which connect under the skin.

Identifying the early signs of Pilonidal sinus-

The first noticeable sign of Pilonidal sinus disease may be a small dimple near the tailbone. The symptoms become more prominent and troublesome once the channel gets infected or develops cysts/abscess. People with infectious sinus encounter the following symptoms-

  1. Swelling of the sinus
  2. Low-grade fever
  3. Pain while standing or sitting
  4. Redness or soreness around the affected area
  5. Discharge of pus or blood
  6. Foul odor
  7. Hair sticking out of the lesion
  8. Formation of multiple holes/sinus tracts in the skin

Risk factors associated with Pilonidal sinus-

There are a few factors that increase your chances of developing pilonidal cysts. The common risk factors are-

  1. Inactive lifestyle
  2. Obesity
  3. Excess hair on the body
  4. People in their twenties

Surgical treatment for Pilonidal Sinus-

Diagnosis of Pilonidal sinus does not require a lab test. The doctor will clinically diagnose the condition before recommending the treatment method. Although Pilonidal sinus usually goes away on its own, you will need to undergo a surgery if the cysts are infected. There are few common techniques of Pilonidal sinus surgery:

  1. Simple drainage of pus: needs painful daily dressings for months, has high recurrence rate.
  2. Excision of Sinus and Keep the wound open to let it heal slowly with cumbersome daily dressings, has more than 40% recurrence rate. Still popular mode.
  3. Excision of Sinus and closure with Limberg’s Flap, no wound, recurrence rate low. Popular.
  4. Excision of Sinus and closure with special Flap Advancement Technique, no wound, Patient can go home next day. No recurrence so far in author’s( Dr Prafull Arya) long series. So the results are long-term.

Pilonidal sinuses are nonthreatening but bothersome chronic infective disease. One needs to maintain good hygiene and an active lifestyle to avoid getting affected by it.

Once you have it, you need to meet an experienced surgeon specialising in pilonidal sinus surgery.

1966 people found this helpful

Pilonidal Sinus - Say No to Surgery!

Dr. S K Singh 91% (651 ratings)
M.S. (Ayurveda), Bachelor of Ayurveda, Medicine and Surgery (BAMS)
Ayurveda, Delhi
Pilonidal Sinus - Say No to Surgery!

Pilonidal Sinus/ Cyst is Characterized By 
•    Small nodular swelling in the lower spinal region with occasional discharges that may stain undergarments. Sometimes mild pain may also be noticed. 
•    It is usually seen in adults of college/ school going age & with hairy skin. 

Pilonidal Sinus/ Cyst seldom heal with medicinal treatment. Any medication whether allopathic, Ayurvedic or homeopathic may show some temporary relief but do not eradicate the problem. In most of the patients having pilonidal sinus/ cyst, surgeons usually recommend surgical procedures like Z-plasty etc. Even after surgery the chances of recurrences are always there. Post operative pain, hospitalization and chances of recurrence are the factors which suggest that surgery is not the appropriate method of treating pilonidal sinus/ cyst. 

TREATMENT OF CHOICE (AYURVEDA) - 
In Ayurveda, a parasurgical treatment known as Ksharsutra therapy is an effective treatment for pilonidal sinus/ cyst. Treatment method includes proper identification of sinus tract wrt. to its depth, direction and branching pattern. This could be achieved via sinogram or skilled probing. Once the sinus tract has been properly identified, a super specialized medicated thread i.e. Graded ksharsutra™ is placed in the tract. The medicine from the medicated thread is gradually released which leads to debridement of the sinus tract which means unhealthy tissue, pus, hairs are expelled out from the tract. The proper and complete debridement of the tract induces healing of the sinus which subsequently heals. The medicine coated thread remains effective for 7-10 days after which it has to be replaced by a new thread.

Usually, in a sinus of approx. 5 cm length, 6-8 sittings of medicated thread replacement are required at a weekly interval. Ksharsutra therapy being a non surgical opd procedure doesn't involve any hospitalization or bed rest and patients can resume their routine work immediately after treatment. Graded ksharsutra™ treatment is the treatment of choice for Pilonidal Sinus as chances of recurrence are seldom seen. The facility of Graded ksharasutra™ is available only at Sushruta Anorectal Institute.

Pilonidal Sinus/ Cyst Treatment FAQs

Question 1 - What is Pilonidal Sinus/ Cyst Disease?

Answer - Pilonidal Sinus disease is seen as a small nodular swelling in the lower spinal region with occasional discharges of pus & blood. It is most commonly found in people with hairy skin. Some times mild pain may also be noticed. The main problem is that it keeps on developing again and again after short period of remission. As the problem aggravates, the size of the swelling & pus discharges also increase. It is usually not noticeable in the beginning till it keeps recurring again and again. It is advisable not to get it operated as the chances of recurrence after surgery are pretty high, where as in Ayurveda with the help of Graded ksharsutra™, this problem can be completely cured without surgery. *(There is no guarantee of specific results and the results can vary.)

Question 2 - What are the Causes of Pilonidal Sinus Disease?

Answer -Pilonidal sinus is also known as the jeep riders back problem. The problem was first recorded on a large scale during world war II in the soldiers who rode jeeps and motorbikes on a frequent basis. Though, the reason behind the occurrence of the issue is really not known it is believed that in growing hairs and hairs penetrating the skin are main cause. The problem is more common in people who have hairy skin. Home remedies for Pilonidal Sinus? Answer - Pilonidal Sinus is an infective condition usually seen in hairy skin individuals. As such there is no home remedy for Pilonidal Sinus. So instead of wasting time in searching for home remedies; you should plan for complete treatment i.e. Ksharsutra Treatment for Pilonidal Sinus as soon as possible.

Question 3 - What are the ways of identifying a Pilonidal Sinus and Recognizing Signs of Infection?

Answer -The main problem with identifying Pilonidal Sinus Infection is; it cannot be done till it grows to a certain extent. At first, it appears like a normal boil on the skin. When it does not go away with time; pus starts discharging out of it. We have demarcated a few of the signs that may help you in detecting the problem.

  1. Sensation of pain while sitting or standing in the low back region.
  2. The cyst appears swollen
  3. Pus and blood mixed watery discharge from the cyst
  4. eddened skin near the cyst
  5. Cyst forming again and again

In case you have a concern or query you can always consult an expert & get answers to your questions!

5458 people found this helpful

Endoscopic Vein Harvesting for Bypass Surgery!

M.Ch Cadiac Surgery, M.S
Cardiothoracic Vascular Surgery, Mohali
Endoscopic Vein Harvesting for Bypass Surgery!

Sarwalheartsurgery at max institute of ctvs, max superspeciality hospital, mohali has launched endoscopic vein harvesting (taking out veins through key hole) on a regular basis for bypass surgery. We are the pioneers in this region north of delhi with no other hospital offering this so far on routine basis the procedure is of immense benefit. No long incisions on leg, low or no infection rates and no uneasiness, less swelling of legs at a very economical cost extra to the package. It has huge benefit in females cosmetically and no infections especially in obese and diabetic patients.

2 people found this helpful
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