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CVSOH 4 > Surgery > Flashcards

Surgery Flashcards

1
Q

Define cholesteatoma.

A

An epidermoid cyst within the middle ear

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2
Q

Define myringotomy.

A

Making a hole in a membrane, like the tympanic membrane

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3
Q

Define neuropraxia.

A

Injury to a peripheral nerve

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4
Q

How is the structure of the ear all connected?

A
  • EEC is made up of vertical and horizontal canals
  • EEC is connected to ME via EAM, which is where ear drum sits
  • ME is where the bulla and ossicles (tiny bones that conduct sound waves from EEC)
  • ME connected to pharynx via auditory tube
  • ME is connected to IE which sound waves connect to cochlea via cochlea window
  • Another window in the IE called vestibular window that connects to vestibular apparatus
  • IE connected to the brain via cochlea and vestibular nerves
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5
Q

What are the causes and site of autoimmune ear diseases?

A

Allergic skin disease
Discoid lupus erythematosus
Pemphigus

External ear canal, pinna

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6
Q

What are the primary anatomical causes of ear diseases?

A

Congenital ear canal stenosis
Pendulous ears
Hair ear canals

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7
Q

What are the secondary anatomical causes of ear diseases?

A

Secondary ear canal stenosis
Cauliflower ear
Other traumatic deformity

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8
Q

What are the sites of anatomical ear diseases?

A

Pinna – post injury. Puncture/laceration/aural haematoma

External ear canal – commonly secondary changes due to scarring with chronic otitis externa, which is usually due to underlying allergic skin disease

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9
Q

What are the neoplastic causes of ear disease?

A

Benign – ceruminous gland adenomas, papillomas, inflammatory polyps

Malignant – squamous cell carcinoma, ceruminous gland adenocarcinoma

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10
Q

What are the sites of neoplasia causing ear disease?

A

Pinna, external ear canal, middle ear, inner ear, para-aural

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11
Q

What are the infectious causes of ear disease?

A

Bacterial – staphylococcus, streptococcus, pseudomonas

Parasitic – mites (otodectes, demodex, sarcoptes, harvest mites)

Fungal – Malassezia, ringworm

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12
Q

What are the causes and sites of inflammatory ear disease?

A

Cholesteatoma
Foreign bodies
Inflammatory polyps
Solar dermatitis
Viral (distemper)

Pinna, external ear canal, middle ear, inner ear, para-aural

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13
Q

What are the causes and sites of traumatic ear disease?

A

Self-inflicted secondary to pruritic
Surgical
Accident
Fighting

Pinna, external ear canal

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14
Q

What is ear canal avulsion and what is the consequence of this?

A

Separation between the auricular and annular cartilage or at the level of the external acoustic meatus. Fluid, cerumen and debris will accumulate in the proximal portion of the ear canal. Likely to become infected causing a para-aural abscess.

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15
Q

Where are inflammatory polyps found?

A

Auditory tube, external ear canal, middle ear, nasopharynx

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16
Q

What are the possible causes of aural haematomas?

A

Trauma
Immune-mediated or coagulopathy

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17
Q

What are the clinical signs of aural haematomas?

A

Head shaking
Ear scratching
With/without underlying dermatopathy
With/without trauma
Pain
Swollen pinna
Reason for pruritus

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18
Q

What factors may determine whether an aural haematoma is medically or surgically treated?

A
  • Haematoma size and how long has it been there
  • Patient co-morbidities
  • Patient temperament
  • Owner finances
  • Owner practicalities
  • Surgeon preference
  • Cosmetic appearance
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19
Q

How are aural haematomas surgically treated?

A
  1. Skin incision – position and length depends on where on the pinna the haematoma is
  2. Evacuate – flush with saline to remove fibrinous material that will prevent the medial skin and cartilage coming into close apposition
  3. Bring incision edges together – the medial skin will be stretched so there will be excess skin. So start right by/close to your incision and work laterally or you will end up with a raised bit of skin in the middle.
  4. Sutures to close dead space
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20
Q

Where is a lateral wall resection done?

A

Disease isolated to vertical ear canal’s lateral wall

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21
Q

How is a lateral wall resection done?

A
  1. Surgical preparation
  2. Incision - U shaped over later ear canal, with U ventral to level of horizontal canal
  3. Expose lateral wall of vertical canal
  4. 2 parallel cartilage incisions
  5. Remove excess cartilage and its overlying skin to leave a 2-3cm drainage board, ventral to the opening to the horizontal canal. Board must not obstruct the opening
  6. Close
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22
Q

Where is a vertical ear canal ablation done?

A

Disease isolated to vertical ear canal. Taking both lateral and medial wall of the ear canal and leaving the horizontal behind.

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23
Q

How is a vertical ear canal ablation done?

A
  1. Surgical preparation
  2. Skin incision – T-shaped incisions that extends below level of horizontal canal
  3. Expose the vertical canal
  4. 2 cartilage incisions to create a dorsal and ventral flap from the residual vertical canal – 1 incision cranially and the other caudally
  5. Close – reflect the dorsal and ventral cartilage flaps into place
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24
Q

Where is a total ear canal ablation and lateral bulla osteotomy done?

A

Taking horizontal and vertical ear canals and taking lateral wall of the bulla

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25
Q

How is a total ear canal ablation and lateral bulla osteotomy?

A
  1. Skin incision – T-shaped incisions that extends below level of horizontal canal, around the inside of the pinna to include the whole opening to the vertical ear canal.
  2. Exposure the vertical canal
  3. Perform a lateral bulla osteotomy
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26
Q

Where is a ventral bulla osteotomy done?

A

When external ear canal is unaffected and/or disease is confined to the middle ear or if has had external ear canal surgery but residual disease in bulla.

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27
Q

What are the reasons for a pinnectomy?

A
  • Neoplasia - curative or palliative
  • Neutering status – feral cats
  • Trauma – if very severe damage
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28
Q

How is a pinnectomy done?

A
  1. Excise tip
  2. Undermine the lateral skin with/without excise a further 2mm cartilage
  3. Find a tissue plane between skin and cartilage
  4. Elevate the lateral skin enough to allow it come over the top of the cartilage
  5. Suture skin closed medially
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29
Q

What are the possible complications of ear surgery?

A
  • Failure to cure
  • Healing tissue
  • Anatomical complication
  • Infection
  • Haemorrhage
  • Neurological complication
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30
Q

When might ear surgery cause failure to cure? How is this treated?

A

Wrong procedure
Neoplasia

Treatment – more surgery, palliation

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31
Q

When might healing tissue be problematic after ear surgery? How is this treated?

A
  • Residual infected tissue causing para-aural abscess
  • Residual cartilage
  • Patient interference
  • Poor technique

Treatment – conservative management or more surgery

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32
Q

What are the possible anatomical complications of ear surgery and how is this treated?

A
  • Cauliflower ear
  • Stenosis
  • Traumatic ear canal avulsion causing para-aural abscess

Treatment – conservative management or more surgery

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33
Q

When might ear surgery cause infection and how is this treated?

A
  • Recurrence of primary condition
  • Secondary infection

Treatment – culture and targeted antibiosis, more surgery

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34
Q

When might ear surgery cause haemorrhage and how is this treated?

A
  • External to ear canal – branches of jugular and carotid
  • Within bulla – retroglenoid vein

Treatment – avoid, ligatures, electrosurgery, pressure, bone wax

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35
Q

What are the consequences of neurological complications of ear surgery?

A

Temporary neuropraxia or permanent dysfunction

Externally vulnerable branches of cranial nerves – facial nerve runs around horizontal canal from caudal to cranial

Internal branches of cranial nerves
- Sympathetic branches within middle ear > Horner’s syndrome
- Vestibular nerves > balance issues
- Cochlear nerves > hearing issues

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36
Q

How are neurological complications from ear surgery treated?

A

Conservative management, more surgery, palliation

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37
Q

Define an pharyngeal mucocele.

A

Salivary mucocele within the pharynx formed due to damage to mandibular or parotid salivary ducts

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38
Q

Define ranula.

A

Salivary mucocele under the tongue formed due to damage to mandibular or sublingual salivary ducts

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39
Q

Define sialography.

A

Contrast radiography of salivary ducts

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40
Q

Define sialoliths.

A

Stones formed within salivary glands/saliva

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41
Q

Define subcutaneous emphysema.

A

Free air under the skin

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42
Q

Define trichobezoar.

A

Furball

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43
Q

When approaching the neck surgically, where are the important anatomical landmarks in this region?

A
  • Muscles = combined sternohyoideus and sternothyroideus
  • Oesophagus = dorsal to the trachea and just to the left of midline
  • Larynx = cranial, midline and palpable
  • Trachea = caudal to larynx, midline and palpable
  • Recurrent laryngeal nerves = run from thorax to larynx either side of trachea
  • Thyroids and parathyroid glands = caudal to the larynx, either side of trachea
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44
Q

What is the aetiology of stick injuries?

A
  • History of playing with sticks
  • Owner aware or unaware
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45
Q

What are the oropharyngeal clinical signs of peracute stick injuries?

A
  • Severe impaling injury
  • Severe haemorrhage
  • Dyspnoea due to pneumomediastinum/pneumothorax
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46
Q

What are the oropharyngeal clinical signs of acute stick injuries?

A
  • Nothing
  • Pain – one yelp, pain opening mouth
  • Pawing at mouth, gagging, retching, dysphagia
  • Ptyalism/hypersalivation with/without blood
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47
Q

What are the systemic clinical signs of acute stick injuries?

A

Depression
Pyrexia

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48
Q

What are the oropharyngeal clinical signs of chronic stick injuries?

A
  • Worsening of the acute signs
  • Swelling
  • Draining tract
  • Inflammation/abscessation associated with a foreign body. Not all FBs will introduce an infection and some infections can be worse than others (antibiotic stewardship)
49
Q

How are oral examinations used to diagnose stick injuries?

A
  • Conscious > limited
  • Sedation > rarely a good idea unless confident FB is in the oral cavity only, not further back and is stuck rather than penetrating
  • GA safer – have control of the airway
50
Q

Which imaging modalities can be used to diagnose stick injuries?

A

Laryngoscope/oesophagoscopy
Radiographs
Ultrasonography
CT - best for iceberg injuries

51
Q

How are patients with stick injuries stabilised?

A
  • IVFT if hypovolaemic or shocked
  • Pain relief – opioids initially rather than NSAIDs
  • Antibiotics
52
Q

When is surgical exploration done with stick injuries?

A
  • If unable to retrieve pieces
  • If acute with signs of cervical emphysema/dyspnoea
  • If chronic stick injury
53
Q

Outline stick injury surgeries.

A
  1. Follow the tract
  2. Need a larger incision than you might suspect
  3. Culture and histopathology
  4. Debride and flush
  5. Close
54
Q

Why is debridement and flushing important in stick injury surgery?

A
  • Microscopic FBs can be present
  • Necrotic tissue will make it difficult to clear infection and be a cause of ongoing draining sinus tract without foreign material
55
Q

What is the post-op management for stick injury surgery?

A

Analgesia
IVFT
Antibiotics

56
Q

What is the prognosis of acute and chronic stick injury surgeries?

A

Acute – best handled definitively at time of presentation so no residual foreign material, repair damage as required

Chronic – pre-treatment can complicate investigation, particularly antibiotics (resistance an issue), best to explore when actively draining

57
Q

Where does the cervical oesophagus sit in relation to the trachea?

A

Dorsal and to the left

58
Q

What are the clinical signs of cervical oesophageal foreign bodies?

A

Gagging
Dysphagia
Retching
Regurgitation
Vomiting
Dyspnoea

59
Q

What are the common sites of cervical oesophageal foreign bodies?

A

Heart base
Distal oesophageal sphincter
Near the diaphragm

60
Q

How can cervical oesophageal foreign bodies be diagnosed with imaging?

A
  • Radiographs – may need contrast to highlight radiolucent FBs, plain radiography may not identify perforations, avoid barium in case there is a perforation
  • Ultrasound
  • CT
  • Fluoroscopy
  • Endoscopy - ideal, allows for easier, safer less traumatic removal, assessment of damage
61
Q

How can oesophageal foreign bodies be retrieved non-surgically?

A

Oesophageal foreign body forceps – blind retrieval, can be traumatic, bring foreign body out of mouth if can be done with minimal trauma.

Can use a Foley catheter pushed beyond the FB and bulb inflated and advance into stomach

62
Q

Outline surgical retrieval of cervical oesophageal foreign bodies?

A
  • Ventral, midline skin incision
  • Split the paired strap muscles
  • Avoid damage to neurovascular/thyroids
  • Gentle retractors to expose
  • Longitudinal incision following the oesophageal striations
  • They have no serosal layer means that dehiscence is more likely than for small intestinal surgery
63
Q

What are the possible complications of surgical retrieval oesophageal foreign bodies?

A
  • Oesophagitis
  • Oesophageal perforation – sharp edged FBs
  • Oesophageal necrosis
  • Mediastinitis/pneumomediastinum – fascial planes of the neck communicate with the mediastinum
  • Aspiration pneumonia secondary to dysphagia
64
Q

How is oesophagitis from surgical oesophageal foreign body removal treated?

A

Mild = antacids/Sucralfate

Severe = feeding tube

65
Q

How does oesophageal necrosis form from surgical oesophageal foreign body removal?

A
  • Severe oesophagitis > inflammatory necrosis
  • Delayed diagnosis > pressure necrosis
  • Necrosis can be partial or full thickness
  • May lead to late breakdown > perforation
  • May lead to stricture formation
66
Q

If cost if not an issue, what is the best imaging modality for penetrating stick injury?

A

CT

67
Q

How do salivary mucoceles form?

A
  • Salivary duct leakage – idiopathic, trauma, sialoliths
  • Inflammation – salivary gland, ducts and oral mucosa all adapted to contact with saliva, marked response to the saliva being in the subcutaneous tissues, a form of autodigestion
68
Q

What are the clinical signs of salivary mucoceles?

A

Localised swelling in subcutaneous or submucosal tissues:

  • Pharyngeal swelling – respiratory distress, dysphagia
  • Sublingual ranula causes a saliva-filled, cyst-like swelling under the tongue
  • Zygomatic can cause proptosis
69
Q

How are salivary mucoceles diagnosed?

A
  • Aspiration – characteristic stringy fluid, low cell numbers
  • Imaging
  • Glands involved
70
Q

How are salivary mucoceles treated?

A

Salivary drainage
- Reasonable for traumatic mucoceles
- Futile as saliva will continue to form
- Marsupialisation for ranula is a possibility as can get the leaking saliva to drain into the mouth

Gland removal

70
Q

What does the position of mucoceles suggest?

A
  • Cervical = sublingual or mandibular
  • Pharyngeal = mandibular
  • Ranula = sublingual
  • Under eye = zygomatic
  • Base of ear/side of head = parotid
  • Mandibular/sublingual most common
71
Q

How can marsupialisation treat salivary mucocele?

A
  • Incise the ranula and suture the inner aspect to the outer mucosal layer of the tongue
  • Saliva drains into the mouth directly
72
Q

What are the complications of surgical treatment of salivary mucoceles?

A

Iatrogenic damage
Seroma formation
Infection
Recurrence

73
Q

Which salivary gland is most commonly affected by a salivary mucocele and where does the mucocele sit?

A

Mandibular, cervical

74
Q

What are the differential diagnoses of neck masses?

A
  • Foreign body-induced abscess or sinus tract
  • Salivary mucoceles
  • Oesophageal foreign body
  • Thyroid and parathyroid diseases
  • Neoplasia (skin, subcutaneous)
  • Congenital neck cysts
  • Lymphadenopathy
  • Cervical expanding hematoma
  • Postoperative seroma
75
Q

Distinguish stertor and stridor.

A

Stertor = abnormal. Low breathing noise created above the level of the larynx

Stridor = abnormal, high-pitched noise, typically created within the larynx or below

76
Q

Define oronasal fistulae.

A

Abnormal communication between the oral and nasal cavities

77
Q

What is the aetiology of oronasal fistulae?

A
  • Congenital – cleft lip/palate
  • Acquired
  • Breed disposition – brachycephalic dogs and cats
78
Q

What are the clinical signs of oronasal fistulae?

A
  • Facial deformity
  • Coughing/gagging when drinking water
  • Pneumonia due to aspiration
  • Failure to thrive – not getting enough nutrition due to difficulties swallowing
  • None
79
Q

Distinguish primary and secondary palate defects.

A

Primary – upper lip, rostral part of the maxilla, maxillary alveolus, and the hard palate rostral to the incisive foramen

Secondary – more distal hard palate behind the incisive foramen and soft palate

80
Q

What is causes by congenital oronasal fistulae?

A
  1. Inability to suck
  2. Milk into the nasal cavity
  3. Milk into trachea and out of nose
81
Q

What may cause oronasal fistulae?

A
  • Hereditary
  • Nutritional – deficiency during pregnancy
  • Viral – drugs and other chemical exposure during pregnancy, teratogen
  • Trauma
82
Q

When should treatment of oronasal fistulae be treated?

A

Delay surgery until 3-4 months old

83
Q

How are oronasal fistulae surgically treated?

A

Reconstruct tissues to form a more normal barrier between oral and nasal cavities. Tissue from the mucosa side of the lip to cover hole instead of tissue from the hard palate.

84
Q

What are the possible causes of acquired oronasal fistulae?

A

Trauma – RTA, malicious act, dental or oral procedure/elevator handling

Periodontal disease – severe localised inflammation/infection causing osteomyelitis, particularly in Dachshunds

85
Q

What is the supportive care for acquired oronasal fistulae?

A
  • Adjust feeding – small sized kibble
  • Analgesia
  • Oral rinses to avoid secondary infection
  • Systemic antibiotics best avoided
  • Feeding tube to bypass the area so food stuff doesn’t interfere with healing
  • Avoid chewy treats and toys
86
Q

What are the possible complications of oronasal fistulae surgical treatment?

A

Dehiscence – high failure rates >50%

Repeat surgery
- Friable tissue
- More debridement
- Less and less tissue available
- Progressively harder to get a good outcome

87
Q

What is the most common reason for a pippy to be born with a congenital cleft palate?

A

Inherited a faulty gene from parents

88
Q

Name 3 nasopharyngeal disorders.

A

Nasopharyngeal atresia/stenosis
Nasopharyngeal/BOAS
Nasopharyngeal polyps

89
Q

What is the aetiology of nasopharyngeal atresia/stenosis?

A

Congenital or acquired. Secondary to severe inflammation – rhinitis, foreign body, reflux under GA (silently regurgitating in GA and stomach acid sits in oesophagus or nasopharynx and causes bad inflammation that causes stenosis)

90
Q

What are the clinical signs of nasopharyngeal polyps?

A

Clinical signs will depend on where they pop out from forming in the middle ear

91
Q

What is the conservative treatment for nasopharyngeal polyps?

A
  • Traction – grasp polyp with forceps. Apply gradual, steady traction pressure gently, some are very friable
  • Steroids – prednisolone
92
Q

What is the surgical treatment for nasopharyngeal polyps?

A

VBO or ear canal surgery

93
Q

What are the complications of traction for treatment of nasopharyngeal polyps?

A
  • Bleeding usually self-limiting
  • Neurological signs
  • Infection
  • Recurrence
94
Q

An apparently 10 day old Persian kitten is presenting with milk coming out of its nose. What is the most likely diagnosis?

A

Secondary palate deficit

95
Q

What are the clinical signs of nasopharyngeal disorders?

A

Upper respiratory obstruction
Stertor
Mouth breathing
Sneezing

96
Q

What tissues can be affected by oral masses?

A

Bone – mandible, maxilla, hard palate, nasal bones

Soft – gingiva, mucosa, periodontal ligament, tongue, tonsils

97
Q

What are the clinical signs of oral masses?

A
  • Mass
  • Dysphagia – gagging, messy eating, rubbing at mouth when food lodged uncomfortably
  • Halitosis
  • Bleeding
98
Q

How are oral masses investigated?

A
  • Cytology - impression smear/scrapings/FNA. SCC can be friable so smears/scrapings may be helpful
  • Histopathology
  • Staging
99
Q

What are the treatment options for oral masses?

A
  • Local – for benign masses
  • Wide - getting more than 1cm margin likely to be very challenging with a malignancy with/without bone depending on cell type and site
  • Lymph node – if local metastasis present, particularly important for melanoma
  • Melanoma vaccine
  • Radiation
  • Chemotherapy
  • Photodynamic therapy
100
Q

What are the possible intraoperative complications of oral mass surgery?

A

Bleeding
Nerve damage
Fracture
Damage to salivary ducts

101
Q

What are the short term post-operative complications of oral mass surgery?

A

Dysphagia, drooling, inappetence
Dehiscence
Swelling

102
Q

What are the long term post-operative complications of oral mass surgery?

A

Recurrence
Metastasis
Anorexia
Fistulation
Malocclusion, ulceration
Chronic pain
Mandibular drift

103
Q

What is the best treatment option for a nasopharyngeal inflammatory polyp?

A

Traction followed by steroids

104
Q

How are patients with oral cavity trauma triaged?

A
  • Treat shock
  • Pain relief
  • With/without antibiotics if infection present
  • Preliminary clinical exam to assess severity of injuries
105
Q

What is done to manage patients with oral cavity trauma post stabilisation?

A
  • Complete clinical exam to check for other external/internal injuries
  • Check for co-morbidities that could complicate healing
  • Imaging
  • Wound management
106
Q

What are in the indications for a glossectomy?

A
  • Trauma – bites, laceration, burn
  • Neoplasia
  • Lingual abscess
107
Q

What are the complications of glossectomy?

A
  • Haemorrhage – intra or post operative
  • Failure to cure – recurrence
  • Failure to heal – dehiscence, tongue necrosis
  • Tongue function
108
Q

What are the consequences of impaired tongue function as a complication of glossectomy?

A
  • Dysphagia/ptyalism = aspiration pneumonia
  • Prehension = messy eating and drinking
  • Grooming = poor coat care
  • Panting = heat stress
109
Q

What are the indications for a tonsillectomy?

A

BOAS or neoplasia

110
Q

What is the technique for a tonsillectomy?

A
  • Grasp the tonsil firmly
  • Exteriorise tonsil from crypt
  • Electrosurgery/sutures to prevent bleeding from the tonsillar vessels
  • Transect at base
  • Close tonsillar crypt with simple continuous suture pattern to reduce bleeding
111
Q

What are the complications of a tonsillectomy?

A
  • Intra-operative/post-operative haemorrhage
  • Failure to cure/recurrence
112
Q

How would you confirm your diagnosis of a nasopharyngeal polyp?

A

Otoscope and endoscopy

113
Q

Which plain radiographic views of the skull would be most helpful for diagnosing nasopharyngeal polyps?

A

Open mouthed, rostro-caudal – as there is so much bone in the skull so only view, MRI and CT are better for visualising the head. Sould be soft tissue density in the middle ear and if not there is something in there.

114
Q

What is the most common complications following treatment with traction alone with nasopharyngeal polyps?

A

Polyp regrowth

115
Q

What are the most common complications following treatment with traction and VBO for nasopharyngeal polyps?

A

Horner’s syndrome and vestibular disturbances

116
Q

What are the possible complications after a partial maxillectomy?

A

Difficulty eating
Wound dehiscence
Altered appearance
Buccal ulcer
Chronic pain

117
Q

How do complications after maxillectomy differ from complications following mandibulectomy?

A

Potential penetration of the nasal cavity performing max – formation of oronasal fistula. Cosmetic appearance with mandibulectomy. More issues with post op inappetence with maxillectomy and more chronic pain associated with maxillectomy. Cosmetic results following maxillectomy and mandibulectomy vary between location.

CVSOH 4 (13 decks)

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