Surgical Short Cases

1. Surgical Short Cases Jonny Lenihan Surgical CT1 NWTD

2. Overview • Common pathologies • Examination technique • Presentation skills • Background Information • X-rays • Summary • Questions

4. Describing Surface Edge Pulsatility Mobility Transillumination Auscultation Local lymph nodes • Site • Size • Shape • Consistency • Colour • Tenderness • Temperature

6. Hypertrophic and Keloid Scars • Types of wound prone to these: • Infection; trauma; burns; tension • Hypertrophic occur soon after insult; spontaneously regress • Keloid scars appear months after and continue to grow • Rx: • Mechanical pressure dressings with topical agents • Surgical excision • Intralesional steroid therapy

11. Examination of an ulcer • Site • Size • Shape • Colour • Depth • Discharge • Tenderness • Temperature • Local lymph nodes • Local tissues • Edge: • Sloping = healing ulcer • Punched out = syphilis, trophic • Undermined = TB • Rolled = BCC • Everted = SCC • Base: • Red = granulation tissue • Grey = slough

12. Management • Keep clean and dry • Antibiotics if infected • Topical agents • Dressings: • 4 layered bandaged technique for venous ulcers

13. Triangles of neck

14. Lumps in the neck Anterior Triangle Posterior Triangle Lymph nodes Cervical rib Cystic hygroma Pancoast’s tumour Subclavian artery aneurysm • Pulsatile • Carotid artery aneurysm • Tortuous carotid artery • Carotid body tumour (Chemodectoma) • Non-Pulsatile • Thyroglossal cyst • Dermoid cyst • Ectopic thyroid tissue • Branchial cyst

18. EXAMINATION • Introduction - ?obvious swelling ?scars • HANDS: • Thyroid acropachy and palmarerythema • Temperature and pulse • Fine tremor • EYES: • Exophthalmos • Eye movements ?lid lag • Proptosis (stand behind patient) • Stand in front: ask to swallow • Protrude tongue • Stand behind: palpate each lobe separately; does it move on swallowing? • Palpate for local lymph nodes • ?Tracheal deviation • Percuss sternum ?Retrosternal thyroid • Listen for bruit (Grave’s disease) • Ask patient to stand – proximal myopathy

19. Focused history • Symptoms of hyper/hypo – thyroidism: • Weight, Appetite, Sweating, Tremor, Palpitations, Menstrual irregularities, Irritability, Diarrhoea • Have they noticed a lump • Change in size over time? • Change in voice? • Any pressure symptoms? • Dyspnoea, Dysphagia • Diet (deficient in Iodine) • Any history of radiation exposure? • Family history

20. INVESTIGATIONS • Biochemistry: • Thyroid status: T3, T4 and TSH • FBC, U+Es, Ca2+, LFTs and ESR • Radiology: • CXR • Ultrasound (solid, cystic masses) • CT scan • Special: • Fine needle aspirate (not reliable for follicular adenoma/carcinoma) • Tru-cut biopsy • Radioisotope scan (Tc99) • Laryngoscopy (?paralysis of vocal chords pre-operatively)

21. Management of Thyrotoxicosis • MEDICAL • Pharmacological: • Carbimazole; Propylthiouracil; Propanolol • Radioiodine (nb: teratogenic) • >50yrs old, recurrent episodes or post surgery • SURGERY • Once medical therapy failed or pressure symptoms • Sub-total thyroidectomy (after antithyroid drugs)

25. Dermoid cysts • Inclusion dermoids: • At site of embryological fusion: midline neck, angle of orbit • Firm, not attached to skin • Rx = excise • Implantation dermoids: • Subcutaneous swellings after penetrating injury • Epidermal tissue introduced beneath skin

29. Complications

33. HOW WOULD YOU TREAT?

34. WHAT WOULD YOU DO???

35. WHAT WOULD YOU DO????

36. WHAT WOULD YOU DO???

37. Summary • Covered common presentations for Finals • Examination methods • Presenting your findings • Typical XRs in shorts • Google pathology • Questions?