1 Cellulitis: a non-suppurative inflammation of subcutaneous tissue, extending along connective tissue planes and across intercellular spaces.

Spreading inflammation in the tissue planes is called cellulitis. There is wide spread swelling, redness and pain without definite localization.

Caused by Streptococcus pyogenes.. If general condition of the patient is undermined, as in diabetes, cellulitis spreads rapidly and leads to Septicemia (infection in the blood).Redness, itching and stiffness is present in the site of inoculation (where the bacteria enter the skin), local Gangrene (death of the tissue) may occur. The appearance of skin creases or wrinkles, indicates resolution (healing).

Treatment

1. Rest , Appropriate antibiotics.

Cellulitis of the neck: Is a complication of wounds tonsillitis or mastoiditis Ludwig’s angina is the term applied to sub-maxillary cellulitis. The two dangers of cervical cellulitis are:

1. Oedema of glottis - with possible asphyxia (respiratory obstructon )

2. Mediastinitis - In ludwig’s angina the floor of the mouth become oedematous. The tongue can be seen displaced, turned upwards by swelling and oedema. The patient is unable to close the mouth owing to oedema of the tongue and the floor of the mouth. This can also CCC when the tongue is bitten by a wasp.

Ludwig’s angina: Ludwig - characterized by a brawny (non pitting) swelling of the sub-mandibular region, corn with inflammatory oedema of the mouth. It is the combined cervical and intrabuccal signs that constitute the characteristic feature of the lesion. The cause of the condition is virulent, usually streptococcal infection of the cellular tissue surrounding the sub-mandibular salivary gland.

Clinical features

 The swollen tongue is pushed towards the palate and forwards through the open mouth, while the cellulitis extends down the neck.

The most dangerous plane, is deep to the deep fascia.

Ludwig’s angina is an infection of closed fascial space and if .untreated, the inflammatory exudate often passes via, the tunnel occupied by stylohyhoid to the submucosa of glottis, in which event the patient is in immediate danger of death from oedema of the glottis.

Treatment

1. antibiotics on Early Diagnosis

2. In cases where the swelling, both cervical and intrabuccal, does not subside rapidly with such treatment, a curved incision, beneath the jaw is made and this decompresses the closed fascial space. The incision is deepened and after displacing the superficial lobe of the sub-mandibular salivary gland, the mylohyoid muscle are divided. This decompresses the closed fascjal space referred to. The wound is lightly sutured and drained. The operation can be conducted with greatest safety under local anaesthesia.

Bacteraemia and  Septicemia

Bacteraemia and septicaemia means the organisms are present in the blood. Clinical features are those of severe infection and shock: , Pyrexia is intermittent , Rigors ,  Jaundice is due to liver damage,  Acute renal failure may occur , Peripheral circulatory failure,  lntravascular coagulation indicates a fatal outcome

 causative focus found and treated surgically .g., Appendicetomy in perforated appendix

2. Blood culture taken

3. Broad spectrum antibiotic is given

4. Blood transfusion is given.

5. Injection hydrocortisone is given.

Pyaemia

Pyaemia is due to infected emboli circulating in blood stream. Pyaemia is characterized by: -

1. Rigors

2. Intermittent fever

3. Formation of abscess in vital organs like heart or brain.

Treatment

1. Is to prevent emboli reaching the blood stream

2. Broad spectrum antibiotic is given.

3. Abscess are incised and drained

If not treated portal pyaemia with multiple abscesses in liver occur, which is a dangerous condition.

Acute Abscess :  An abscess a collection of pus.

Bacteria which cause pus formation is called pyogenic organisms. Bacteria reach the infected area by:

1. Direct route: eg. Penetrating wound

Local extension: From adjacent focus of infection

2 Lymphatics

4. Blood stream

Pyogenic membrane surrounds the abscess and is infiltration with (leukocytes and bacteria.

Pus: Pus contains dead leukocytes and bacteria. It reaches the surface of the body or is discharged into a hollow viscous.

Symptoms: patient feels ill., Throbbing pain is characteristic of suppuration. Pain becomes more severe in the dependent position. E.g. infected finger,

Classical signs

Temperature is elevated , Rigors, inflammation

Fluctuation: Present in the later stages, and reveals the presence of pus. Prevention

1. An abscess can sometimes be aborted by antibiotics in the early stage.,. Rest,  Elevation of the affected part.

Treatment

Is incision and drainage of abscess

Hilton’s method of opening an abscess:

It is used where important anatomical structures like the blood vessels and nerves are preesnt, as in the neck, axilla and groin. The skin and superficial fascia is incised. A sinus forceps is thrust into the abscess  cavity. The blades are opened and the pus is drained. A gloved finger is introduced and loculi are broken. A ribbon gauze is lightly packed and antibiotics are given. This is done under surface anaesthesia i.e., ethyl chloride spray.

Antibioma

 If antibiotic is given the pus in the abscess frequently becomes sterile and a large brawny edematous swelling remains which takes many weeks to resolve.

Treatment: explore the mass with a wide-bore aspirating needle

 Most antibiornas are due to late, inadequate, and ineffective antibiotics.

CANCRUM ORIS

Is an infective gangrene of cheek and lip.

may occur as a complication of kala azar, enteric fever and  children with poor oral hygiene.

The lesion starts as an acute inflammatory patch on oral mucosa which is seen ulcerated.

The affected part of the cheek or the lip gradually becomes gangrenous.

Focal vascular thrombosis and sepesis occur.

When slough separates, a part of the cheek or lip sloughs out to form a buccal fistula with ugly deformity. The adjacent jaw may be infected too.

Various organisms are found - specially Fusiform bacillus and_Borrellia vincenti.

The foetid odour, gangrenous patch of cheek or lip, purulent discharge from the mouth, fever and toxaemia are the characteristic features. The patient is unable to open the mouth properly.

Treatment

1. Antibiotics, multivitamins and repeated mouth washes

2 Neostibamine in kala-azar. Sequestrectomy in chronic osteomyelitis of the mandible.

4. Plastic reconstruction of the lip or cheek for unsightly deformity undertaken.

CARBUNCLE

Is an infective gangrene of the subcutaneous tissue. It is due to staphylococcal aureus infection. It is uncommon before the age of 40. Males are the usual sufferers. Diabetes may be present. It often occurs on the nape of the neck.

Clinical features

Subcutaneous tissue becomes painful and indurated. Ove skin is red. Unless treated promptly, extension will occur and late softening. The skin gives way and thick pus and slough are discharged.

Usually, there is one central large slough, surrounded by smaller areas of necrosis. Infection extends widely and fresh openings appear

Treatment

1. Many carbuncles are aborted, if penicillin is used adequately in the early stage.

2. Local treatment consists of hygroscopic dressings being given ie. magsulph-glycerin dressing Later the carbuncle is excised with a cruciate incision.

3. If the gap is large and when the granulation tissue comes to the surface, skin grafting is done.

An ulcer is a break in the continuity of the skin or the mucous membrane.

Mode of onset:  Traumatic ulcers heal when the traumatic agent is removed., If it persists it becomes chronic as in the case of dental ulcer of the tongue. Ulcers may develop spontaneously as in the case of gumma (syphilitic ulcer). It may develop with varicose veins called varicose ulcer, which develops in the lower third of the leg.

Sometimes a malignant ulcer develops in a scar called Marjolin’s ulcer. Special features are:

 No pain - as there are no nerves. It does not spread - as there is scar tissue. No metastases - as there are no lymphatics Treatment:- Wide excision.

Classification of Ulcer

A) Pathologically

I. Non-specific ulcers:

a. Due to infected wound after trauma, that is physical or chemical agents.

b. Due to local infection example dental ulcer, pressure sore

 Specific ulcers: Caused by specific infection

a. Syphilitic ulcers (Hunterian chancre)

b. Tubercular  ulcers, actinomycosis

Trophic ulcer:- Caused by two factors:

Diminished nutrition due to inadequate blood supply to the tissues

Eg. Ulcers in Buerger’s Disease, Artherosclerosis

b. Diminished or absence of sensation of the skin leading to perforating ulcer of the foot

iv. Malignant ulcer: Due to squamous cell carcinoma, rodent ulcers and melanoma.

B) Clinical classification of ulcers

1. Acute Ulcer:  The edge is inflamed oedematous and painful with slough in the floor and n o granulation tissue. Profuse purulent Discgarge seen

2. Healing ulcers: edge sloping with bluish margin The floor is covered with a red, healthy granulation tissue.

3. Chronic or callous ulcer (non- healing) There is no tendency to heal by itself, the base is jndurated  unhealthy granulation tissue is present in the floor The edge is rounded and thickened.

Chronic ulcer occur due to:

Chronic infection , Defective circulation , Foreign body, Persistent local oedema , Malignancy , Diabetes , Malnutrition (loss of proteins), Gout

Specific Ulcers

Tubeculous Ulcer

Edge Undermined, floor contains granulation tissue a watery discharge is present. Caseous material is found in the floor of the ulcer. It usually occurs in tubercular lymphadenitis in the neck, axilla or groin.

Syphilitic Ulcer

a) Huntarian Chancre or  primary sore or hard chancre: usuaIly occurs over the genitalia especially on penis. Occurs in the primary stage of syphilis Ulcer is round or oval, it is hard,indurated, elevated and painless It feels like a button, discharges serum containing spirochetes (cork screw) which is highly infective.

b) In the Secondary stage mucous patches and condylomata occurs The ulcers are shallow white patches, of sodden thickness which occur in the mouth and tongue. Condyloma are hypertrophied epithelium with serous discharge occurring in mucocutaneous junction around the anus. The regional lymphnod (inguinal transverse chain) are enlarged.

c) In tertiary stage of syphilis gummatous ulcers occur They have a punched  out edge and wash Ieather floor. They occur on the subcutaneous bones like sternum and tibia. They are painless and refuse to heal.

Soft Sore (chanchroid)

They are painful muitiple ulcers, with copious discharge. They are caused by Bacillus Ducrey  lncubation time is 3 to 4 days. located on glans penis and prepuce is due to venereal infection. They are associated with enlarged called bilateral inguinal lymphnodes

Tropical ulcer:

a) Oriental Sore - due to L. Tropica (lieshmaniasis)

b) Ulcers and sinuses are due to guinea worm abscess

c) Histoplasmosis with multiple ulcers on the tibia.

d) Chronic ulcers due to yaws

e) Amoebic ulcers occur in colon_and rectum , flask shaped ulcers , undermined edge , caused by  Entamoeba Histolytica

Varicose Ulcer:

Associated with varicose veins. Occurs on the inner aspect of the lower third of leg , chronic ulcer The surrounding area is pigmented and eczema is present. The sore is longitudinally oval It does not penetrate the deep fascia and is painless The base is adherent to the periosteum of the tibia

Rodent ulcer

Usually Occurs on the face above a line joining the lobule of the ear to the angle of the mouth. Usually occurs at the inner canthous of the eye . Edge is raised and rolled, Erodes the deeper structures and the bone, the lyrnph nodes are not involved.

Treatment: If small wide excision is done with skin grafting, If large, radiotherapy is given.

Malignant Ulcer

Occurs due to chronic irritation as in the case of malignant ulcer of the tongue. The edge is everted. The floor is covered with slough and tumor tissue The regional lymph nodes are hard.

Initially mobile later becomes hard

Treatment: Wide excision is done.

Marjolin ulcer: Malignant Ulcer occurring on scar of Burns

Types of Brain Injury

Brain injuries can be classified into two main categories: primary and secondary injuries. Understanding these types is crucial for effective diagnosis and management.

1. Primary Brain Injury

• Definition: Primary brain injury occurs at the moment of impact. It results from the initial mechanical forces applied to the brain and can lead to immediate damage.
• Examples:
  • Contusions: Bruising of brain tissue.
  • Lacerations: Tears in brain tissue.
  • Concussions: A temporary loss of function due to trauma.
  • Diffuse axonal injury: Widespread damage to the brain's white matter.

2. Secondary Brain Injury

• Definition: Secondary brain injury occurs after the initial impact and is often preventable. It results from a cascade of physiological processes that can exacerbate the initial injury.
• Principal Causes:
  • Hypoxia: Reduced oxygen supply to the brain, which can worsen brain injury.
  • Hypotension: Low blood pressure can lead to inadequate cerebral perfusion.
  • Raised Intracranial Pressure (ICP): Increased pressure within the skull can compress brain tissue and reduce blood flow.
  • Reduced Cerebral Perfusion Pressure (CPP): Insufficient blood flow to the brain can lead to ischemia.
  • Pyrexia: Elevated body temperature can increase metabolic demands and worsen brain injury.

Glasgow Coma Scale (GCS)

The Glasgow Coma Scale is a clinical tool used to assess a patient's level of consciousness and neurological function. It consists of three components: eye opening, verbal response, and motor response.

Eye Opening (E)

• Spontaneous: 4
• To verbal command: 3
• To pain stimuli: 2
• No eye opening: 1

Verbal Response (V)

• Normal, oriented: 5
• Confused: 4
• Inappropriate words: 3
• Sounds only: 2
• No sounds: 1

Motor Response (M)

• Obeys commands: 6
• Localizes to pain: 5
• Withdrawal flexion: 4
• Abnormal flexion (decorticate): 3
• Extension (decerebrate): 2
• No motor response: 1

Scoring

• Best Possible Score: 15/15 (fully alert and oriented)
• Worst Possible Score: 3/15 (deep coma or death)
• Intubated Cases: For patients who are intubated, the verbal score is recorded as "T."
• Intubation Indication: Intubation should be performed if the GCS score is less than or equal to 8.

Additional Assessments

Pupil Examination

• Pupil Reflex: Assess size and light response.
• Uncal Herniation: In cases of mass effect on the ipsilateral side, partial third nerve dysfunction may be noted, characterized by a larger pupil with sluggish reflex.
• Hutchinson Pupil: As third nerve compromise increases, the ipsilateral pupil may become fixed and dilated.

Signs of Base of Skull Fracture

• Raccoon Eyes: Bilateral periorbital hematoma, indicating possible skull base fracture.
• Battle’s Sign: Bruising over the mastoid process, suggesting a fracture of the temporal bone.
• CSF Rhinorrhea or Otorrhea: Leakage of cerebrospinal fluid from the nose or ear, indicating a breach in the skull base.
• Hemotympanum: Blood in the tympanic cavity, often seen with ear bleeding.

Inflammation is the respone of the body to an irritant.

Stages of Inflammation

1. General: Temperature Raised. In severe cases bacteremia or septicemia ,rigors may occur.

2. Local: classical signs of inflammation are due to hyperemia and inflammation exudate

i) Heat:  inflammed area feels warmer than the surrounding tissues.

ii) Redness

iii) Tenderness: Due to pressure of exudate on the surrounding nerves  If the exudate is  under tension, e.g. a furuncle (boil) of the ear, pain is severe.

iv) swelling

v) Loss of function.

The termination of Inflammation

This may be by:1. Resolution 2. Suppuration 3. Ulceration 4. Ganangren s. Fibrosis

Management

i. Increase the patients resistance., Rest,  Relief of pain by analgesics,  Diet: High protein and high calorie diet with vitamins,  Antibiotics,  Prevent further contamination of wound.

Surgical measures

1. Excision: If possible as in appendicectomy.

2. Incision and drainage: If an abscess forms.

Ludwig's Angina

Ludwig's angina is a serious, potentially life-threatening cellulitis or connective tissue infection of the submandibular space. It typically arises from infections of the teeth, particularly the second or third molars, and can lead to airway obstruction due to swelling. This condition is named after the German physician Wilhelm Friedrich von Ludwig, who first described it in the 19th century.

Etiology

• Common Causes:

  • Dental infections (especially from the lower molars)
  • Infections from the floor of the mouth
  • Trauma to the submandibular area
  • Occasionally, infections can arise from other sources, such as the oropharynx or skin.

• Microbial Agents:

  • Mixed flora, including both aerobic and anaerobic bacteria.
  • Common organisms include Streptococcus, Staphylococcus, and Bacteroides species.

Pathophysiology

• The infection typically begins in the submandibular space and can spread rapidly due to the loose connective tissue in this area.
• The swelling can lead to displacement of the tongue and can obstruct the airway, making it a medical emergency.

Clinical Presentation

• Symptoms:

  • Swelling of the submandibular area, which may be bilateral
  • "Brawny induration" (firm, non-fluctuant swelling)
  • Pain and tenderness in the submandibular region
  • Difficulty swallowing (dysphagia) and speaking (dysarthria)
  • Fever and malaise
  • Possible elevation of the floor of the mouth and displacement of the tongue

• Signs:

  • Swelling may extend to the neck and may cause "bull neck" appearance.
  • Trismus (limited mouth opening) may be present.
  • Respiratory distress due to airway compromise.

Diagnosis

• Clinical Evaluation: Diagnosis is primarily clinical based on history and physical examination.
• Imaging:
  • CT scan of the neck may be used to assess the extent of the infection and to rule out other conditions.
  • X-rays may show air in the soft tissues if there is a necrotizing infection.

Management

Initial Management

• Airway Management:
  • Ensure the airway is patent; this may require intubation or tracheostomy in severe cases.

Medical Treatment

• Antibiotics:
  • Broad-spectrum intravenous antibiotics are initiated to cover both aerobic and anaerobic bacteria. Common regimens may include:
    • Ampicillin-sulbactam
    • Clindamycin
    • Metronidazole combined with a penicillin derivative

Surgical Intervention

• Drainage:
  • Surgical drainage may be necessary if there is an abscess formation or significant swelling.
  • Incisions are typically made in the submandibular area to allow for drainage of pus and to relieve pressure.

Complications

• Airway Obstruction: The most critical complication, requiring immediate intervention.
• Sepsis: Can occur if the infection spreads systemically.
• Necrotizing fasciitis: Rare but serious complication that may require extensive surgical intervention.
• Thrombosis of the internal jugular vein: Can occur due to the spread of infection.

Prognosis

• With prompt diagnosis and treatment, the prognosis is generally good. However, delays in management can lead to significant morbidity and mortality due to airway compromise and systemic infection.

Types of Head Injury

1. Extradural Hematoma (EDH)

Overview

• Demographics: Most common in young male patients.
• Association: Always associated with skull fractures.
• Injured Vessel: Middle meningeal artery.
• Common Site of Injury: Temporal bone at the pterion (the thinnest part of the skull), which overlies the middle meningeal artery.
• Location of Hematoma: Between the bone and the dura mater.

Other Common Sites

1. Frontal fossa
2. Posterior fossa
3. May occur following disruption of major dural venous sinus.

Classical Presentation

• Initial Injury: Followed by a lucid interval where the patient may only complain of a headache.
• Deterioration: After minutes to hours, rapid deterioration occurs, leading to:
  • Contralateral hemiparesis
  • Reduced consciousness level
  • Ipsilateral pupillary dilatation (due to herniation)

Imaging

• CT Scan: Shows a lentiform (lens-shaped or biconvex) hyperdense lesion between the brain and skull.

Treatment

• Surgical Intervention: Immediate surgical evacuation via craniotomy.
• Mortality Rate: Overall mortality is 18% for all cases of EDH, but only 2% for isolated EDH.

2. Acute Subdural Hematoma (ASDH)

Overview

• Location: Accumulates in the space between the dura and arachnoid.
• Injury Mechanism: Associated with cortical vessel disruption and brain laceration.
• Primary Brain Injury: Often associated with primary brain injury.

Presentation

• Consciousness: Impaired consciousness from the time of impact.

Imaging

• CT Scan: Appears hyperdense, with hematoma spreading diffusely and having a concavo-convex appearance.

Treatment

• Surgical Intervention: Evacuation via craniotomy.
• Mortality Rate: Approximately 40%.

3. Chronic Subdural Hematoma (CSDH)

Overview

• Demographics: Most common in patients on anticoagulants and antiplatelet agents.
• History: Often follows a minor head injury weeks to months prior.
• Pathology: Due to the tear of bridging veins leading to ASDH, which is clinically silent. As the hematoma breaks down, it increases in volume, causing mass effect on the underlying brain.

Clinical Features

• Symptoms may include:
  • Headache
  • Cognitive decline
  • Focal neurological deficits (FND)
  • Seizures
• Important to exclude endocrine, hypoxic, and metabolic causes in this group.

Imaging

• CT Scan Appearance:
  • Acute blood (0–10 days): Hyperdense
  • Subacute blood (10 days to 2 weeks): Isodense
  • Chronic (> 2 weeks): Hypodense

Treatment

• Surgical Intervention: Bur hole evacuation rather than craniotomy.
• Anesthesia: Elderly patients can often undergo surgery under local anesthesia, despite comorbidities.

4. Subarachnoid Hemorrhage (SAH)

Overview

• Causes: Most commonly due to aneurysms for spontaneous SAH, but trauma is the most common cause overall.
• Management: Conservative treatment is often employed for trauma cases.

5. Cerebral Contusions

Overview

• Definition: Bruising of the brain tissue due to trauma.
• Mechanism: Often occurs at the site of impact (coup) and the opposite side (contrecoup).
• Symptoms: Can range from mild confusion to severe neurological deficits depending on the extent of the injury.

Imaging

• CT Scan: May show areas of low attenuation (hypodense) or high attenuation (hyperdense) depending on the age of the contusion.

Treatment

• Management: Depends on the severity and associated injuries; may require surgical intervention if there is significant mass effect.