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Question 1

299. What are the clinical features of cancer of the testis, and how should it be investigated?

Answer 1

Clinical features of testicular cancer include:

• Painless testicular nodule or swelling
• Negative transillumination test
• Dull lower abdominal or scrotal discomfort
• If metastatic → lower back or bone pain
  Cough, shortness of breath, chest pain → pulmonary, mediastinal metastases
• Gynaecomastia → from excess HCG or oestrogen produced by tumor
• Paraneoplastic hyperthyroidism → alpha subunits of HCG and TSH are identical → weak stimulation of TSH
  receptor in tumours with HCG overproduction

Question 2

300. What are the clinical features of a fractured maxilla?

Answer 2

Midface fractures are characterised by:

• symmetrical facial swelling,
• bilateral periorbital ecchymosis AND
• bilateral subconjunctival or periorbital haemorrhages (raccoon signs) with flattening and elongation of the midface.

Can be classified as:
Le Fort 1 fracture (horizontal) – aka floating palette fracture – horizontal fracture between hard palette and maxillary bone causing floating palette.

Le Fort 2 fracture (pyramidal) – fractured area includes nose with fracture line extending to infraorbital margins and can potentially damage infraorbital nerve

Le Fort 3 fracture – transverse fracture –craniofacial dislocation where the entirety of facial bones separate from cranial bones. Worst prognosis and involves intraocular orbit and haemorrhage can be catastrophic

Question 3

301. What are the clinical features of a blowout fracture of the orbit and what investigation is most useful?

Answer 3

In a blow out fracture the orbital contents are typically forced through a fractured orbital floor.

Clinical features can include:
- unilateral periorbital pain, oedema and ecchymoisis

• enophthalmos- which is the posterior displacement of the eye ball in the posterior compartment.
• proptosis- which is the anterior displacement. In this case due to haemorrhage behind the eye ball
• diplopia due to restricted ocular movement
• palpable misalignment of the bone at the fracture line (orbital rim “step off”)
• If the infraorbital nerve is trapped or injured then pt could also lose sensitivity to the midface from the lower eyeloid to the upper lip
• epistaxis

CT or Xray would be most useful. This would be done after visual inspection and after ruling out other life threatening injuries,
Can see:
- bleeding into sinuses, muscle entrapment and edema.
- tear drop sign on xray- sign showing soft tissue herniation into maxillary antrum

Question 4

302.Refer to Photograph - This man was assaulted.

Q1. What do the images show?
Q2. Who would manage him?

Answer 4

1. CT RECONSTRUCTION MODEL=
   - BILATERAL ZYGOMATIC FRACTURE
   - TRANSVERSE MAXILLA FRACTURE
   - NASAL FRACTURE
   - ORBITAL FRACTURE
   - INFERIOR RECTUS ENTRAPMENT

CT shows a mid-face fracture. Image depicts pt with swollen face, open mouth and periorbital bruising

2. Maxilofacial surgeon
   POTENTIALLY ENT FOR NASAL