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Salivary and Thyroid Surgery - Coggle Diagram
Salivary and Thyroid Surgery
1.
Acute Parotitis
Cause
Dehydration
Poor oral hygiene
Organism
Staphylococcus
Clinical picture
Painful parotid swelling
Pus from Stensen duct
Prevention
Good hydration
Good oral hygiene
Treatment
Antibiotics
Salivary Gland Stones (Sialolithiasis)
Most common gland
Submandibular gland
Symptoms
Swelling and pain increased with eating
Pain referred to ear
Examination
Enlarged tender gland
Investigations
First step: intraoral X ray
Second step: sialogram if X ray negative
Salivary Gland Tumors
Most common benign
Pleomorphic adenoma
Most common malignant
Mucoepidermoid carcinoma
Special type
Warthin tumor
Bilateral
Hot spots
Clinical features
Benign
Painless
Slowly growing
Well defined
Does not affect facial nerve
Malignant
Rapid growth
Painful
Affects facial nerve
Facial nerve palsy
Investigation of choice
Biopsy
Management
Benign tumor: superficial parotidectomy
Malignant tumor: total parotidectomy
Important nerve
Facial nerve at risk during surgery
Sequence of Investigation in Salivary Gland Swelling
Solid Mass
First: CT scan
Investigation of choice: biopsy
Start with FNAC
If inconclusive: core biopsy
If cancer suspected: CT head and neck to assess invasion
Inflammatory Swelling
First investigation: ultrasound
Stones
First investigation: X ray
Investigation of choice: sialogram
Soft Tissue Disorders
Keloid and Hypertrophic Scar
Keloid
Extends beyond original scar
Cortisone can be used
Hypertrophic scar
Confined to original scar
Acute Paronychia
Definition
Infection of nail bed
Clinical picture
Localized pain
Tenderness
Treatment
Warm soaking
Antibiotics
Incision and drainage if abscess
Hand Space Infection
Main route
Direct inoculation
Clinical picture
Localized pain
Tenderness
Treatment
Incision and drainage
Tenosynovitis (De Quervain)
Risk factors
Repetitive wrist and thumb movements
Workplace overuse
New mothers
Clinical picture
Pain and swelling over radial styloid
Pain worsens with thumb movement
Pain with wrist deviation
Severe pain on passive finger extension
Finger swollen along entire length
Treatment
First line: splint and NSAIDs
Second line: corticosteroid injection
Dupuytren Contracture
Epidemiology
Middle aged men
Positive family history
Causes
Alcoholism most important
Trauma
Smoking
Diabetes mellitus
Important
Check blood glucose
Pathology
Thickening
Fibrosis
Shortening of palmar fascia
2.
Dupuytren’s Contracture
Epidemiology
Middle aged men
Positive family history
Causes
Alcoholism most important
Trauma
Smoking
Diabetes mellitus
Important
Check blood glucose level
Pathology
Thickening and fibrosis
Shortening of palmar fascia
Clinical picture
Flexed fingers
Examination
Nodules in palmar fascia
Recurrence
High recurrence rate
Investigation
Ultrasound
Must be done before surgery
Treatment
Early cases: physiotherapy
Definitive treatment: surgery
Volkmann’s Ischemic Contracture
Pathophysiology
Ischemia → muscle fibrosis → permanent muscle shortening
Cause
Supracondylar fracture most common
Brachial artery injury → ischemia
Treatment
Physiotherapy
Surgery
Ingrown Toenail
Age
Young males
Risk factors
Tight shoes
Faulty nail trimming
Treatment
Antiseptic soaked gauze
Proper shoe size important
Definitive: wedge resection
Thyroglossal Cyst
Nature
Congenital
Persistence of thyroglossal duct
Time of appearance
Late childhood
Site
Midline neck cyst
Clinical picture
Midline swelling
Moves up with tongue protrusion
Most common fate
Infection
Treatment
Surgical removal
Thyroid Cancer
Sex
More common in females
Types
Papillary carcinoma
Most common
Psammoma bodies
Follicular carcinoma
Differentiated from adenoma by capsular infiltration
FNAB shows follicular cells → core biopsy to assess capsule
Medullary carcinoma
Familial
Lateral aberrant thyroid
Enlarged deep cervical lymph node
Normal thyroid gland
Bad prognostic sign
Hoarseness of voice
Indicates RLN infiltration
Main treatment
Total thyroidectomy
Diagnosis
Cervical lymph node biopsy showing thyroid tissue
Complications of Thyroidectomy
1. Stridor
Cause
Blood collection under fascia (hematoma)
Management
Immediate removal of all sutures
Open wound immediately at bedside
Note
Can occur after any neck surgery
2. Thyroid Crisis (Acute Hyperthyroidism)
Timing
Immediately after operation
Clinical picture
Hyperpyrexia
Tachycardia
Tachypnea
Hypertension
Agitation and irritability
Tremors
Dyspnea
Convulsions
Prevention
Proper preoperative preparation
Management
Symptomatic treatment
Propranolol
Carbimazole
Corticosteroids
3. Recurrent Laryngeal Nerve Injury
Timing
Immediate or delayed (days to weeks)
Unilateral injury
Hoarseness of voice
Bilateral complete injury
Aphonia
Dyspnea
Bilateral incomplete injury
Aphonia
Stridor
4. Hypoparathyroidism
Cause
Removal of all parathyroid glands
Clinical picture
Perioral numbness
Tetany
Treatment
First step: IV 10% calcium gluconate slowly
Maintenance: oral calcium + vitamin D
Postoperative Fever (Postoperative Agitation)
Day 1
Cause
Atelectasis
Days 2–3
Causes
UTI
Endometritis
Pneumonia
Days 5–7
Causes
DVT
Pulmonary embolism
Wound infection
Abscess
Atelectasis
Timing
First postoperative day
Clinical picture
Fever
Dyspnea
Agitation
Risk factors
Suppressed cough reflex (anesthesia)
Old age
COPD
Smoking
Investigations
First: pulse oximetry
Then: X ray
Then: ABG
Treatment
Oxygen first step
Breathing exercises treatment of choice
Best prevention
Incentive spirometry
Urinary Tract Infection
Symptoms
Urgency
Frequency
Dysuria
Endometritis
Clinical picture
High grade fever
Foul smelling lochia
Uterine tenderness
Pneumonia
Clinical picture
Fever
Cough
Dyspnea
Secretions
Pulmonary Embolism
Symptoms
Chest pain
Dyspnea
Hemoptysis
Best investigation
CTPA
Wound Infection
Signs
Pain
Redness
Swelling
Discharge
If fluctuant swelling
Abscess
Incision and drainage
Treatment
Antibiotics
3.
Mastitis
Clinical picture
Breast pain
Redness
Management
Continue breastfeeding
If cannot breastfeed from affected side
Evacuate breast using a pump
Shock
Main Clinical Features
Tachycardia
Hypotension
Types of Shock
Neurogenic shock
Only type causing bradycardia
Cardiogenic shock
Only type with increased CVP
Septic shock
Only type with increased cardiac output
Hemorrhagic shock
Most common cause of hypovolemic shock
Initial Management
Hypovolemic shock: fluids first step
Neurogenic shock: fluids first step
Septic shock: antibiotics then fluids
Cardiogenic shock: inotropes first step
Fluids for Resuscitation
Normal saline or lactated Ringer
Blood Transfusion
Packed RBCs
Low hemolysin O blood
Used if urgent blood needed
CVP
Normal CVP: 8–12 cm
Postoperative patient with CVP 2 cm: give fluids
Post MI patient with CVP 16 cm: give inotropes
Post MI with low BP: give inotropes
Postoperative Fluid Management
Daily requirement
2–3 liters per day
Dextrose 5% + 1 liter normal saline
Deficit therapy
Normal saline
Potassium
Add 20 mmol per liter
Minimum daily requirement: 60 mmol
Urine output
Should be > 0.5–1 ml/kg/hour
Input ≠ output
Most common cause: calculation error
Output > input on day 5 postop
Resolution of paralytic ileus
Postoperative Oliguria
Step 1: fluid challenge (250 cc bolus)
If no response
Step 2: urinary catheter or bladder ultrasound
Step 3: urea, creatinine, electrolytes
If oliguria + fever
Suspect sepsis
Send cultures
Burns
Percentage of Burn (Rule of Nines)
Head and neck: 9%
Whole arm: 9%
Front of arm: 4.5%
Front of chest and abdomen: 18%
Back of chest and abdomen: 18%
Whole leg: 18%
Front of leg only: 9%
Perineum: 1%
Types of Burn
First degree
Epidermis only
Second degree
Epidermis + part of dermis
Third degree
Full thickness skin
Pain
Most painful: first degree
Painless white burn: full thickness
Complications of Burns
1. Inhalation Injury
Asphyxia
Laryngeal edema
Immediate intubation if
Soot in airway
Husky or soft voice
2. Stress ulcer
3. Infection
Timing: 5–7 days
Most common organism: Pseudomonas
4. Eschars
Immediate step: escharotomy
Not fasciotomy
Management of Burn (ABC)
Step 1: check airway
Intubate if
Soot in airway
Burns of head and neck
Fluid Resuscitation in Burns (Parkland Formula)
4 ml × body weight (kg) × % burn area
Fluid: lactated Ringer
50% in first 8 hours
Remaining 50% over next 16 hours
Best fluid in burns: lactated Ringer
Prognosis of Burns
Most important factor: surface area
Depth of burn
Site
Face is very serious
Central Venous Catheter Complications
1. Infection
Most common complication
Organism: Staphylococcus
Clinical picture
Pain
Pus around catheter
Treatment
Remove catheter
2. Pneumothorax
3. Thrombosis
Site: upper limb
Investigation: duplex ultrasound
Complications During Line Removal
Dislodgment of thrombus
Vessel injury
Clinical picture
Marked swelling of face and neck
Investigation
CT with contrast
4.
Necrotizing Fasciitis
Risk factors
Diabetes mellitus
Severe infection
Organism
Streptococcus pyogenes
Management
Most important first step: Debridement
Antibiotics
If patient on ABX and infection worsens with black spots: debridement immediately
Gas Gangrene
Organism
Clostridium perfringens
Cause
Lacerated wound
Clinical picture
Swollen wound with gas, pain, and numbness
Black muscle with offensive odor
Management
Debridement (most important first step)
Antibiotics
Hazards of Splenectomy
Infections at risk
Meningococcal
Pneumococcal
Haemophilus influenzae
Prophylaxis
Most important vaccine: Pneumococcus
Timing: 3 weeks before surgery and every 5 years
Long-acting penicillin
Influenza vaccine
Meningococcus vaccine
Dehiscence of Abdominal Incision
Definition
Partial or total separation of wound edges due to wound healing failure
Complication
Visceration
Timing
Usually one week after surgery
Clinical picture
Serosanguinous discharge
Risk factors
Paralytic ileus
Hematoma formation
Management
Conservative: abdominal strapping if no evisceration
Urgent surgery: if evisceration occurs
Tetanus-prone Wounds
Types
Compound fractures
Bite wounds
Deep penetrating wounds
Wounds with extensive tissue damage (contusions, burns)
Contaminated with soil or dust
Management
Step 1: Debridement (most important)
Step 2: Tetanus prophylaxis
Step 3: Antibiotics
Immunization Guidance
≥3 doses: clean minor wounds → no TIG, other wounds → yes if >5 yrs
<3 doses or unknown/unimmunized: TIG + vaccine for all wounds
Vaccine by age
<10 yrs: DTPa
≥10 yrs: dTpa
Cancer Tongue
Risk factors
Old age male
Smoker
Type
Squamous cell carcinoma (SCC)
Premalignant lesion
Leukoplakia
Clinical picture
Bloody saliva
Dysphagia with enlarged cervical lymph node
Pain referred to ear
Investigation
Biopsy if positive
CT head and neck for metastasis
Key notes
Any old male smoker with tongue complaint or ear pain → suspect tongue cancer until proven otherwise
Any head and neck cancer → follow with CT to check metastasis
Tonsil lump in alcoholic smoker → SCC
Cancer Larynx
Risk factor
Smoking (most common)
Clinical picture
Hoarseness of voice
Middle-aged male
Investigation
Indirect laryngoscopy
Biopsy
Whipple’s Triad (Insulinoma)
Attacks of hypoglycemia
Low blood glucose during attacks
Symptoms relieved by glucose
Rectus Sheath Hematoma
Clinical picture
Abdominal pain referred to back
Hypovolemic shock with pallor
Investigation
CT scan
Management
Mainly conservative
First step: resuscitation
If patient on warfarin → immediate fresh frozen plasma
Zenker (Pharyngeal) Diverticulum
Location
Neck area
Patient
Old age male
Clinical picture
Dysphagia
Regurgitation
Swelling and gurgling in neck
Investigation
Barium swallow
Management
Myotomy with excision of diverticulum
Endoscopic stapling as alternative