NEET MDS Lessons
General Surgery
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.
Walsham’s Forceps
Walsham’s forceps are specialized surgical instruments used primarily in the manipulation and reduction of fractured nasal fragments. They are particularly useful in the management of nasal fractures, allowing for precise adjustment and stabilization of the bone fragments during the reduction process.
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Design:
- Curved Blades: Walsham’s forceps feature two curved blades—one padded and one unpadded. The curvature of the blades allows for better access and manipulation of the nasal structures.
- Padded Blade: The padded blade is designed to provide a gentle grip on the external surface of the nasal bone and surrounding tissues, minimizing trauma during manipulation.
- Unpadded Blade: The unpadded blade is inserted into the nostril and is used to secure the internal aspect of the nasal bone and associated fragments.
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Usage:
- Insertion: The unpadded blade is carefully passed up the nostril to reach the fractured nasal bone and the associated fragment of the frontal process of the maxilla.
- Securing Fragments: Once in position, the nasal bone and the associated fragment are secured between the padded blade externally and the unpadded blade internally.
- Manipulation: The surgeon can then manipulate the fragments into their correct anatomical position, ensuring proper alignment and stabilization.
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Indications:
- Walsham’s forceps are indicated for use in cases of nasal fractures, particularly when there is displacement of the nasal bones or associated structures. They are commonly used in both emergency and elective settings for nasal fracture management.
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Advantages:
- Precision: The design of the forceps allows for precise manipulation of the nasal fragments, which is crucial for achieving optimal alignment and aesthetic outcomes.
- Minimized Trauma: The padded blade helps to reduce trauma to the surrounding soft tissues, which can be a concern during the reduction of nasal fractures.
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Postoperative Considerations:
- After manipulation and reduction of the nasal fragments, appropriate postoperative care is essential to monitor for complications such as swelling, infection, or malunion. Follow-up appointments may be necessary to assess healing and ensure that the nasal structure remains stable.
Zygomatic Bone Reduction
When performing a reduction of the zygomatic bone, particularly in the context of maxillary arch fractures, several key checkpoints are used to assess the success of the procedure. Here’s a detailed overview of the important checkpoints for both zygomatic bone and zygomatic arch reduction.
Zygomatic Bone Reduction
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Alignment at the Sphenozygomatic Suture:
- While this is considered the best checkpoint for assessing the reduction of the zygomatic bone, it may not always be the most practical or available option in certain clinical scenarios.
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Symmetry of the Zygomatic Arch:
- Importance: This is the second-best checkpoint and
serves multiple purposes:
- Maintains Interzygomatic Distance: Ensures that the distance between the zygomatic bones is preserved, which is crucial for facial symmetry.
- Maintains Facial Symmetry and Aesthetic Balance: A symmetrical zygomatic arch contributes to the overall aesthetic appearance of the face.
- Preserves the Dome Effect: The prominence of the zygomatic arch creates a natural contour that is important for facial aesthetics.
- Importance: This is the second-best checkpoint and
serves multiple purposes:
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Continuity of the Infraorbital Rim:
- A critical checkpoint indicating that the reduction is complete. The infraorbital rim should show no step-off, indicating proper alignment and continuity.
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Continuity at the Frontozygomatic Suture:
- Ensures that the junction between the frontal bone and the zygomatic bone is intact and properly aligned.
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Continuity at the Zygomatic Buttress Region:
- The zygomatic buttress is an important structural component that provides support and stability to the zygomatic bone.
Zygomatic Arch Reduction
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Click Sound:
- The presence of a click sound during manipulation can indicate proper alignment and reduction of the zygomatic arch.
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Symmetry of the Arches:
- Assessing the symmetry of the zygomatic arches on both sides of the face is crucial for ensuring that the reduction has been successful and that the facial aesthetics are preserved.