Lectures: Surgery C Flashcards
Pathogens which may lead to otitis externa
PSEUDOMONAS AERUGINOSIA
Staph aureus
E-Coli
Candida
Aspergillus
Otitis externa management
- Topical acidifiers
- acetic acid (ear calm spray)
- aluminium acetate drops
- Topical Abx
- Ciprofloxacin drops
- Gentamicin + hydrocortisone
- Oral Abx
- flucloxacillin
- ciprofloxacin
- metronidazole (if anaerobic)
In malignant otitis externa, how long will patient be treated with Abx:
6 weeks of IV ABx
Two forms of chronic suppurative otitis media:
1. Active
- perforated eardrum with infection
+/- cholesteatoma
2. Inactive
- perforated eardrum WITHOUT infection
Management of chronic suppurative otitis media:
Active
- may respond with topical Abx
- ciprofloxacin drops
- gentamicin + hydrocortisone drops
Surgery
- stop infection spreading to brain
- TYMPANOPLASTY (closing hole in ear drum)
How might you confirm diagnosis of BPPV:
Dix-Hallpike manoeuvre
- patient sits with head turned at 45 degrees and eyes wide open
- lies with one ear pointed to ground (1-2 mins)
- check for nystagmus
How might you treat BPPV:
Epley manoeuvre
- will make patient feel dizzy 20 mins after
Or Brandt Darroff
Management of Meniere’s disease
- Prochlorperazine (not long term)
- Trans tympanic steroids
- Chemical labyrinthectomy (gentamicin ablation)
- majority of patients may lose hearing
Give example of a vestibular rehabilitation exercise
Cooksey-Cawthorne exercises
Key features of labrinthitis?
- tinnitus
- hearing loss
- vertigo
- post URTI
What medication may you give to aim to prevent vestibular migraine:
- beta blockers
- calcium channel blockers
- anti-epileptic’s
- tricyclic antidepressants
Grading system for facial palsy
House-Brackman grade 1-6
What causes Ramsay Hunt syndrome:
Herpes Zoster oticus
Management of facial palsy
- Prednisolone 1mg/kg (up to 60mg) daily for 1 week, then taper by 10mg ever 3 days thereafter
- PPI
- Viscotears
- Anti-virals if Ramsay Hunt (valacyclovir)
Sounds getting jumbled up making it difficult to hear is known as:
auditory processing disorder
What is Rhino-sinusitis characterised by?
Definition
- inflammation of nose and paranasal sinuses
Characterised by 2 or more symptoms
One should be: nasal blockage, obstruction, congestion
Or nasal discharge
Endoscopic findings:
- nasal polyps / recurrent and chronic rhinosinusitis
Differences between acute, recurrent and chronic rhino sinusitis:
- Acute: less than 12 weeks
- Recurrent: > 3 episodes throughout year
- Chronic: more than 12 weeks
Medical management for Chronic rhino-sinusitis with and without nasal polyps
WITHOUT NASAL POLYPS
- saline nasal douching BD
- Fluticasone propionate nasules 400mcg (1/2 in each nostril, 3 weeks)
- clarithromycin 250mg BD 3 weeks
WITH NASAL POLYPS
- prednisolone 0.5mg/kg 30-40mg OD 1 week
- saline nasal douching BD
- Fluticasone propionate nasules 400mcg
- Doxycycline 100mg OD 3 weeks
SFC
Polyp = P = Pred
What cells produce mucus in the ear
goblet cells
Adenoids and tonsils produce what:
B-cells (IgG and IgA)
- therefore adenoidectomy might affect serum IgG but not reduce immunity significantly
Tonsils drain into what two nodes:
- Jugulodigastric nodes
- Midcervical nodes
Inflammation of what commonly leads to croup:
Cricoid ring
- narrowest part of airway in babies
Common bacterial causes of acute otitis media:
- H influenza
- S pneumoniae
- M catarrhalis
Recurrent tonsillitis is how many episodes:
5 per year for 2 years , 10 episodes over 2 years
small changes in airway diameter cause big changes in resistance is what law
Poiseuille’s law
What condition is the commonest cause of congenital stridor:
Laryngomalacia
- floppy larynx
Croup caused by what pathogen:
parainfluenza virus (4 months - 2 years)
Epiglottitis caused by what pathogen
haemophilus influenza (2-5 years) drooling
What gene mutation is present in 50% of all severe or profound hearing loss
GJB2
Group of fractures affecting the midface of skull are known as:
Le Fort Fractures
Type 1 - swelling of upper lip, loosening of teeth
Type 2 - midface deformity, upper jaw and nose
Type 3 - orbital, flattening of face
What is pulpitis:
- causes SEVERE acute tooth pain
- may be tooth with hole or filling
CT: What is the black eyebrow sign?
- indicates air in superior part of orbit
- indicates orbital fracture
Key features of retrobulbar haemorrhage?
- pain behind eye
- eye sticks out more than usual
- opthalmoplegia
Management of retrobulbar haemorrhage:
- Steroids IV
- Acetazolamide (reduces IOP)
- Mannitol (osmotic diuretic)
After clinical diagnosis
- surgical decompression
- lateral canthotomy
What is a white eye blow out fracture:
Signs
- eye will not look up or down
- requires urgent treatment
OFTEN in younger patients
Summary of pre-malignant conditions
1. Fanconi anaemia: increased risk of AML
–> short, strabismus, bird like facies, macrocytic anaemia
2. Ataxia telangiectasia
–> DNA repair disorder, high AFP, ARecessive, trouble walking, slurred speech, muscle twitching, infections
3. Blooms syndrome
–> Arecessive, distinctic craniofacial features
–> photosensitive
–> cafe-au-lait spots
4. Li-Fraumeni syndrome
–> p53 issue, may dispose to sarcoma, breast, leukaemia and adrenals
What is Kaposi sarcoma?
- cancer cells found in skin
- or mucous membranes than line GI tract, from mouth to anus including stomach and intestines
- purple patches or nodules on skin / mucous membranes
- can spread to lymph nodes and lungs
What is Kaposi sarcoma?
- cancer cells found in skin
- or mucous membranes than line GI tract, from mouth to anus including stomach and intestines
- purple patches or nodules on skin / mucous membranes
- can spread to lymph nodes and lungs
Side effect profile for radiotherapy: ACUTE
- Mucositis
- Skin erythema or ulceration
- Loss of taste
- impaired nutrition
- Bleeding
- Infection
- Lymphoedema
Side effect profile for radiotherapy: ACUTE
- Mucositis
- Skin erythema or ulceration
- Loss of taste
- impaired nutrition
- Bleeding
- Infection
- Lymphoedema
Side effect profile for radiotherapy: LATE
- Impaired healing
- osteoradionecrosis
- impaired swallow / speech / taste
- xerostomia (oral dryness)
- dental caries (tooth decay)
- loss of hair
- radiation induced tumours
- cataracts
Heterochromic cyclitis is
Chronic uveitis
What is Kaposi sarcoma?
- cancer cells found in skin
- or mucous membranes than line GI tract, from mouth to anus including stomach and intestines
- purple patches or nodules on skin / mucous membranes
- can spread to lymph nodes and lungs
Kearns-Sayre syndrome
rare neuromuscular disorder
Kearns-Sayre syndrome
rare neuromuscular disorder
Triad
1. symptoms before age 20
2. pigmentary retinopathy (salt and pepper pigmentation)
3. Progressive external opthalmoplegia
Sturge Weber syndrome
- abnormal blood vessels on skin leading to reddish colour on one side of face (port-wine birthmark)
- may be abnormal vessels on eye –> high eye pressure –> glaucoma
Von Hippel Lindau disease
- genetic disease that affects people of all ethnicities
- characterised by tumour development
–> CNS
–> kidneys
–> adrenal glands
–> pancreas
Summary of conditions affecting the eye:
1. Endocrine
2. Inflammatory and autoimmune
3. Infective
4. Congenital
5. Blood
6. Skin
- ENDOCRINE
- DM, HTN, thyroid, hyperlipidaemia, acromegaly - Inflammatory and autoimmune
- rheumatoid arthritis
- ankylosing spondylitis (anterior uveitis)
- behcet’s (eye inflammation, mouth ulcers, genital ulcers)
Summary of conditions affecting the eye:
Inflammatory and autoimmune
–> rheumatoid arthritis
–> ankylosing spondylitis (anterior uveitis)
–> Behcet’s (eye inflammation, mouth ulcers, genital ulcers)
–> sarcoidosis
–> Sjogren’s (autoimmune, tear and salivary glands)
–> GCA (swollen pale optic disc, flame haemorrhages)
–> multiple sclerosis (optic neuritis)
–> myasthenia gravis ( ptosis, diplopia)
–> pemphigoid (blistering lesions affecting mucous membranes)
Summary of conditions affecting the eye: INFECTIVE
- Toxoplasmosis
- Fungal
- HIV / AIDs
- Lyme disease (ticks)
- Syphilis
- TB
- Herpes simplex
Skin condition which could affect eye
Rosacea
What is the classification of diabetic retinopathy
Background DR
–> Microaneurysms , dot and blot haemorrhages
MILD
–> Retinal haemorrhage, cotton wool spots
MODERATE
–> > 6 cotton wool spots, small intra-retinal microvascular abnormalities, dense HMA in 1-3 quadrants
SEVERE
–> Dense HMA 4 quadrants.
–> Multiple or large IRMAs, venous beading in 2 quadrants.
PROLIFERATIVE
–> new vessels on disc or elsewhere in fundus
Background retinopathy key features on ophthalmoscopy
- microaneurysms
- retinal haemorrhages (dot and blot)
- exudates (lipid and protein)
- venous beading
Cotton wool spots are a sign of:
Ischaemia
What is Kaposi sarcoma?
- cancer cells found in skin
- or mucous membranes than line GI tract, from mouth to anus including stomach and intestines
- purple patches or nodules on skin / mucous membranes
- can spread to lymph nodes and lungs
Diabetic retinopathy vs maculopathy
Retinopathy –> damage to retina as a whole
Maculopathy –> leakage of blood vessels at macula
Management of pre-proliferative and proliferative DR
- retinal laser photocoagulation
- reduces VEGF secretion
- reducing tendency to grow new vessels
Management of diabetic maculopathy
- Macular laser (to try and help preserve function of macula)
-
Intravitreal anti-VEGF
- Ranibizumab
- Aflibercept
-
Intravitreal steroid
- dexamethasone implant
- fluocinolone implant
What is malignant hypertension?
sudden spike in blood pressure leading to end organ damage.
What causes a macular star?
Hypertensive retinopathy
- hard exudates can deposit on macula casing appearance of star
- optic disc can also be seen
Treatment of anterior uveitis
- Steroid drops with tapering
a) PredForte, Maxidex - Dilating drops
a) cyclopentolate, atropine - Peri-orbital steroid injections
a) sub-conjunctival dexamethasone
Posterior uveitis - infectious cause
Toxoplasmosis
Ethambutol and associated eye problem
optic neuropathy
Hydroxochloroquine and associated eye problem
bulls eye maculopathy
COCP, tetracycline and associated eye problem
Idiopathic intracranial HTN
Anti-cholinergic’s and associated eye problems
acute closure glaucoma
Tamsulosin and associated eye problem
causes floppy iris
Amiodarone and associated eye problem
corneal verticillate
Name an organism that can cross an intact epithelium leading to corneal infection
Neisseria Gonococcus
Acanthamoeba (protozoal) may be found in corneal infections in what demographic of patients:
contact lens wearers
main symptoms of acanthamoeba keratitis
- red eyes
- sensitivity to light
- extreme eye pain
- blurred vision
- excessive earing
- feeling of something in eye
Management of corneal infection
Dilate pupils with cyclopentolate to help with pain relief
- Antibiotics
- Ciprofloxacin
- +/- teicoplanin
What might be seen in the eye in herpetic disease:
dendritic ulcer
Emergency management of acute (angle closure) glaucoma
1. Pilocarpine –> drops to constrict the pupil
2% Blue
4% Brown
2. Intravenous acetazolamide
- reduction in aqueous humour
3. Timolol eye drops
- beta blocker
4. Steroid eye drops
LASER IRIDITOMY + removal of lense
Management of retinal detachment
Use scars to weld retina in place so it doesn’t detach
Jackson’s burn zones
Zone of coagulation –> irreversible
Zone of stasis –> decreased tissue perfusion
Zone of hyperaemia –> increased tissue perfusion, tissue usually recovers
Superficial burns
- no blistering
- pink and painful
- e.g. sunburn
Partial thickness burns: superficial
- salmon pink
- blanch
- blister
- very painful
Partial thickness burns: deep
- mottled changes
- no blanch
- less painful
Full thickness burns
- dry
- leathery
- waxy
- does not blanch
- white
- painless
Mx of Burns
ABCDE
–> urine output
–> first aid
–> TBSA%
–> tetanus
–> vascular compromise
1. Escharotomy
2. Fasciotomy
Describe components of the reconstructive ladder
- dressing
- primary closure
- delayed closure
- split-thickness
- full thickness
- tissue expansion
- pedicled flap
- free flap
The reconstructive ladder: dressings
Allowing wounds to heal by secondary intention
The reconstructive ladder: Primary closure
Suturing/ closing wound
The reconstructive ladder: Delayed closure
Allow wound to remain open
(vac dressing applying negative pressure)
The reconstructive ladder: Split-thickness graft
Thin layer of shaved skin taken from one area, usually thigh and placed elsewhere
The reconstructive ladder: Full thickness graft
Contain full epidermis and dermis
The reconstructive ladder: Tissue expansion
Stretching skin to enable it to cover complex wounds
The reconstructive ladder: Pedicled flap
flap still attached to original blood supply
The reconstructive ladder: Free flap
Microscopically anastomosed
Autograft
coming from patient themselves
Allograft
same species as patient
Xenograft
different species to patient
What dressing may be used in a full thickness skin graft (FTSG)
Bolster dressing
- prevents sheer forces and haematoma formation
Plasmatic imbibition
- occurs within 24-48hrs
- process in which nutrients and oxygen infiltrate through the capillaries <1mm away (thus the limitation on thickness)
- FIBRIN BRIDGES CREATED
- need a compressive dressing
Inosculation
36-48 hours later
- capillary buds sprout through the skin graft and connect to pre-existing vascular channel and create a new one
- collagen bridges created
Neurotization
nerve buds from bed grow into graft
Summarise steps of graft healing
- plasmatic imbibition
- inosculation
- neurotization
