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Surgery Shelf > Devirgilio IV > Flashcards

Devirgilio IV Flashcards

1
Q

Neck Mass: Ddx of neck mass, congenital causes?

A

KITTENS: Kongenital, Infectious, Toxins, Trauma, Endocrine, Systemic

Thyroglossal duct cyst, branchial cleft cyst, dermoid cyst, sebaceous cyst, laryngocele, lymphangoima, thymic cyst

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2
Q

Neck Mass: Ddx of neck mass, Infectious/Inflammatory causes?

A

KITTENS: Kongenital, Infectious, Toxins, Trauma, Endocrine, Systemic

Lymphadenitis, Tuberculosis, Toxoplasmosis, Cat scratch disease, actinomycosis, Deep neck abscess

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3
Q

Neck Mass: Ddx of neck mass, Toxic causes?

A

KITTENS: Kongenital, Infectious, Toxins, Trauma, Endocrine, Systemic

Metals (typically cause cancers that metastasize to lymph nodes)
Drugs

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4
Q

Neck Mass: Ddx of neck mass, Trauma causes?

A

KITTENS: Kongenital, Infectious, Toxins, Trauma, Endocrine, Systemic

Hematoma
Foreign body
Aneurysm

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5
Q

Neck Mass: Ddx of neck masses, Endocrine causes?

A

KITTENS: Kongenital, Infectious, Toxins, Trauma, Endocrine, Systemic

Thyroid hyperplasia
Ectopic thyroid gland
Ectopic parathyroid gland

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6
Q

Neck Mass: Ddx of neck masses, Neoplastic causes?

A

KITTENS: Kongenital, Infectious, Toxins, Trauma, Endocrine, Systemic

Benign growths
Malignant growths ( Primary neck tumors: lymphoma, thyroid, salivary, schwannoma, paraganglioma, lipomas, few others)
Metastases (Nearly all malignant neck masses are metastases)

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7
Q

Neck Mass: Ddx of neck masses, Systemic causes?

A

KITTENS: Kongenital, Infectious, Toxins, Trauma, Endocrine, Systemic

AIDS (increased infections)
Kawasaki disease

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8
Q

Neck Mass: New onset in a patient over age 40?

A

Should be considered malignant until proven otherwise. Malignant neck masses represent a metastasis from an unknown primary tumor, only 15% are primary neck tumors.

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9
Q

Neck Mass: Premalignant lesions to look for on physical exam?

A

Leukoplakia (white patch or plaque on buccal, alveolar mucosa and lower lip)

Erythroplakia (Red patch or lesion on floor of mouth, tongue, and soft palate)

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10
Q

Neck Mass: Symptoms associated with head and neck cancers?

A

Otalgia, dysphagia odynophagia, dysphonia, dyspnea, trismus, stridor, hemoptysus

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11
Q

Neck Mass: What are the most common benign and malignant salivary tumors?

A

Benign: Pleomorphic adenoma

Malignant: Mucoepidermoid carcinoma

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12
Q

Neck Mass: What is the most common site of a malignant salivary tumor? How do locations and malignancy correlate in salivary tumors?

A

Most common site of malignant tumor: Parotid gland

Otherwise, larger salivary glands tend to have benign tumors and small glands have malignant

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13
Q

What is Virchow’s node? Why is it concerning?

A

Virchow’s node is an enlarged, left supraclavicular node where the cisterna chyli empties into the subclavian vein. It suggests the presence of metastatic lung or GI malignancies.

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14
Q

Neck Mass: Most common sites of head and neck cancers?

A

Oral cavity - 44%
Larynx - 31%
Pharynx - 25%

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15
Q

Neck Mass: Most common type of head and neck cancer?

A

Squamous cell carcinoma

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16
Q

Neck Mass: Work up?

A

1) Observation and reassessment if mass is less than 3 weeks old
2) Flexible nasopharyngoscopy
3) Imaging (x-ray, CT), tissue biopsy and labs all simultaneously (CBC, coags, liver enzymes, chemistry, TSH)

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17
Q

Neck Mass: What imaging should be used?

A

CT with contrast: Head and neck

Chest Xray

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18
Q

Neck Mass: If tissue biopsy reveals a metastatic mass, what are the next steps?

A

Panendoscopy (triple endoscopy): laryngoscopy, esophagoscopy, ani bronchoscopy. Allows for biopsy of the upper aerodigestive tract.

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19
Q

Ddx for a child presenting with hearing loss, +/- otalgia, +/- fever?

A 
Acute otitis media
Chronic otitis media
Otitis media with effusion
Otitis externa
Labrynthitis
Cholesteatoma
Congenital
Misc (cerumen, trauma, foreign body)
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20
Q

Define otitis media with effusion

A

Middle ear effusion without signs of acute infection, may follow AOM or develop in isolation, predominant symptom is hearing loss

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21
Q

Define Chronis otitis media

A

Recurrent or chronic ear infections that result in perforation of the TM +/- otorrhea

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22
Q

What might missing of language milestones or regression in language indicate in a child?

A

Early hearing loss

23
Q

What are the three roles of the eustachian tube?

A

Maintain gas pressure homeostasis within the middle ear
Prevent infection of the middle ear and reflux of contents from the nasopharynx
Clears middle ear secretions

24
Q

What are the most common bacterial species that cause acute otitis media?

A

Streptococcus pneumonia
Haemophilus influenza (non-typable, not covered by HiB vaccine)
Moraxella catarrhalis

25
Q

What are the two main causes of otitis media with effusion?

A

Results from residual fluid from suppurative AOM

Isolated eustachian tube dysfunction

26
Q

What to suspect with unilateral otitis media with effusion in an adult? What is it associated with?

A

Nasopharyngeal carcinoma
Associated with EBV infection
Higher incidence in China

27
Q

Work up for acute otitis media and otitis externa?

A

History and physical exam

Otoscopy to characterize ear canal contents and TM

28
Q

Work up for otitis media with effusion?

A

Pneumatic otoscopy, less invasive than myringotomy

In adults, nasopharyngoscopy to evaluate for tumors obstructing ET

29
Q

Management for acute otitis media?

A

Antibiotics

30
Q

Management for OME

A

Majority of cases do not require medical or surgical intervention. Observe for 3 months, if mild hearing deficits exist move child to front of classroom and keep home environment quieter. Attempt auto-inflation if desired.

Short term oral steroids +/- antibiotics may be effective in relieving OME, but no evidence of long term benefits to hearing or lasting benefits. Abx are not routinely prescribed.

31
Q

Indications for PE tube placement?

A

Symptomatic OME lasting more than 3 months
Recurrent AOM with OME
Bilateral OME with hearing impairment
Any OME with vestibular problems, poor school performance, behavioral problems, otalgia, or reduced quality of life

32
Q

Complications of OME?

A

Most significant complication is conductive hearing loss
Long term complications may include permanent hearing loss, ruptured TM, mastoiditis, temporal bone osteomyelitis, meningitis, sigmoid sinus thrombosis, brain abscess

33
Q

Most common cause of sudden hearing loss? Treatment?

A

Viral infections - herpes simplex and herpes zoster

Tx: High-dose empiric steroid +/- antiviral therapy

34
Q

Most common species in Otitis media with effusion?

A

Same as AOM: Strep pneumo, non-typable H flu, Moraxella catarrhalis

but also Pseudomonas aerugenosa, strep pyogenes, and other anaerobes

35
Q

Why does the HiB vaccine not prevent otitis media?

A

HiB does NOT cover non-typable H flu

36
Q

What is the Weber test and how does it work?

A

Weber up in yo’ grill!!
Weber test places the tuning fork on the top of the head (or forehead/bridge of nose).
Distinguishes between sensorineural hearing loss (SNHL) and conduction hearing loss (CHL).
Unilateral SNHL = tone is heard/louder in unaffected ear (no signal from affected ear)
Unilateral CHL = tone is heard/louder in affected ear (only bone conduction to inner ear)

37
Q

What is the Rinne test and how does it work?

A

Rinne test places tuning fork next to ear until it is unhearable, then moves to mastoid process. If the sound returns after moving to bone conduction (bone louder than air), then the test is negative and there is conductive hearing loss in the ear.

38
Q

What are the most common organisms found in the bile with acute cholecystitis?

A 
E coli
Bacteroides fragilis
Klebsiella
Enterobacter
Enterococcus
Pseudomonas species
39
Q

What are the components of the bile?

A

Bile salts
Cholesterol
Lecithin

Also water, electrolytes, proteins, bile pigments

40
Q

What are the two main types of gallstones? How do they form?

A

Cholesterol 70-80%
Pigment stones

Cholesterol stones form when the concentration of cholesterol exceeds its solubility, i.e. when bile salts and lecithin are decreased

Pigment stones contain calcium bilirubinate and are often associated with hemolytic diseases like hereditary spherocytosis or sickle cell. Hemolysis - inc bili in bile - precipitation and stone formation (black in bladder, brown in bile ducts esp. Asians)

41
Q

Two pathologies that lead to air in the gallbladder on imaging?

A

Gallstone ileus - stone wears a fistula from gall bladder into GI tract, may cause SBO (not technically ileus!!) May not require cholecystectomy.

Emphysematous cholecystitis - gas forming organism (like clostridia) colonizes gall bladder. Emergent cholecystectomy!!!

42
Q

When is a HIDA scan called for and how is it read?

A

HIDA scans may be used if there are clinical signs of biliary disease but no visible gall stones on US. Cholescintigraphy (HIDA scan) uses radio labeled IV hepatic iminodiacetic acid which is absorbed by the hepatocytes and excreted into the bile in 30-60 minutes. It is visible in the common bile duct, gallbladder, and small bowel. If the cystic duct or bladder is obstructed, it will not visible in the gall bladder, the test is positive.

Useful in acalculus cholecystitis, which has high morbidity and mortality and must be treated emergently with either cholecystectomy or cholecystostomy tube for decompression.

43
Q

Management of patients with acute cholecystitis?

A 
Admit to hospital
NPO 
IV fluids
IV antibiotics (gram negative and anaerobes)
URGENT: Lap chole within 48 hours
44
Q

Antibiotics for acute cholecystitis (classes and names)

A

Second generation cephalosporins - cefoxitin

Broad spectrum penicillins w/ B-lactmase inhibitors
- Piperacillin/tazobactam; ampicillin/sulbactam

for severe cases:
Third and fourth gen cephalosporins

45
Q

What is the Roux-en-Y hepaticojejunostomy and when is it used in cholecystectomies?

A

Roux-en-Y is a connection of the common bile duct to the jejunum. It is used in cases where the CBD is cut through more than 50% of its circumference. Attempting to repair the CBD with that much damage would result in an ischemic stricture. CBD strictures lead to recurrent cholangitis, eventually cirrhosis and liver failure requiring transplant.

DO NOT CUT THE CBD!!!

46
Q

What are the symptoms of a CBD injury? Treatment?

A

Post-op abdominal pain, bloating, anorexia, elevated LFTs. US or CT will show intraperitoneal fluid collection, either blood or bile. HIDA scan will then show whether bile is entering the duodenum or leaking. If leaking or not in duodenum, ERCP used to determine if major ductal injury exists or if the cystic duct stump is leaking. Cystic duct stump leak is fixed with stunting the CBD (increased flow), major ductal injury = likely Roux-en-Y

47
Q

What is postcholecystectomy syndrome? Work up?

A

RUQ pain starting weeks after surgery. Causes include residual stone in CBD or cystic duct stump, dysfunction of the biliary tree (sphincter of Oddi), or gastritis/PUD.

Work up: CBC, LFT, US
Last test is ERCP

48
Q

Tx of acute cholecystitis in a patient with prohibitive surgical risks?

A

Admit and manage with antibiotics,
monitor
If no improvement then place a percutaneous cholecystostomy tube (as is used for acalculus cholecystitis) and drain the infection. this may be a permanent fix or may allow for later surgery.

49
Q

Clinical presentation of cholangitis?

A

Presents with Charcot’s triad (RUQ pain, jaundice, fever, 40% have all 3) or Reynolds Pentad (triad plus hypotension and AMS, only in 5%)

AMS and hypothermia in elderly, always get LFTs in AMS patients!!!

SIRS criteria are often met

50
Q

Pathophysiology of cholangitis?

A

Cholangitis occurs in the setting of obstructed CBD allowing for ascending infection of the biliary tree.
Most often choledocholithiasis, also neoplasms, biliary strictures, parasites, or Primary Sclerosing Cholangitis from UC (less often Crohn’s)
Bacteria enter via blood stream in portal vein or retrograde through CBD.

51
Q

What is suppurative cholangitis?

A

Cholangitis complicated by septic shock

52
Q

How is cholangitis diagnosed?

A

Elevated WBC on CBC
Alk Phos, GGT rise = obstructive pattern (AST and ALT may rise later or with micro abscess formation in liver)
US shows dilated CBD ( only sign is dilation, likely will not show stone because gas in the duodenum/CBD obstructs the view)

53
Q

What is the management for a patient with cholangitis?

A

Aggressive IV fluids, blood cultures, broad spectrum antibiotics
Admit to ICU (pressers, CV catheter monitoring, IV antibiotics)
Urgent biliary decompression via ERCP
Percutaneous Transhepatic drainage (PTC) if ERCP fails
Open surgery to insert T-tube into CBD if PTC fails
Cholecystectomy AFTER SEPSIS RESOLVES to prevent further complications

54
Q

Two situations that may cloud the diagnosis of cholangitis?

A

Often missed in the elderly or those on steroids/immunosuppression

Surgery Shelf (9 decks)

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