Jonny Lenihan Surgical CT1 NWTD Surgical Short Cases Jonny Lenihan Surgical CT1 NWTD

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

Hypertrophic scar

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

Keloid Scar

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

Hypertrophic scars Keloid Scars Appearance Confined to wound margins Extend beyond wound margins Site Flexor surfaces and skin creases Earlobes, chin, neck, shoulder, chest Age Any age (commonly 8-20) Puberty to 30 Gender M=F F>M Race Any Black and Hispanic Pathology Normal rate of collagen synthesis, but increased rate of collagen breakdown Increased rate of collagen synthesis and increased rate of collagen breakdown

Ulcer = interruptions in the continuity of an epithelial or endothelial surface Neuropathic ulcers: Repeated injury to a pressure area. Underlying conditions = diabetes, alcoholic peripheral neuropathy, tabes dorsalis

Venous ulcer: Increased pressure within venous system forces blood out causing lipodermatosclerosis and poor oxygenation of the tissues. Presisposes to ulcers. Commonly on medial side of leg as this is site of GSV.

Pyoderma gangrenosum: Associated with inflammatory bowel disease

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

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

Triangles of neck

Lumps in the neck Anterior Triangle Posterior Triangle Pulsatile Carotid artery aneurysm Tortuous carotid artery Carotid body tumour (Chemodectoma) Non-Pulsatile Thyroglossal cyst Dermoid cyst Ectopic thyroid tissue Branchial cyst Lymph nodes Cervical rib Cystic hygroma Pancoast’s tumour Subclavian artery aneurysm BC = embryological remnant of 2nd pharyngeal cleft; upper 2/3 of the anterior border of sternomastoid; soft, fluctuant and transilluminates. Classically contains cholesterol crystals.

Thyroglossal cyst: Moves up on swallowingand protrusion of the tongue

Multinodular goitre: Most common type of goitre in the UK

EXAMINATION Introduction - ?obvious swelling ?scars HANDS: EYES: Thyroid acropachy and palmar erythema 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 If you find a lump describe it as you would any other, using previous descriptions

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

INVESTIGATIONS Biochemistry: Radiology: Special: 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) Not reliable because need to know as requires knowing if cancer has invaded through the capsule.

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) Collar incision

Soft, fluctuant, transilluminates Cholesterol crystals on fna

Branchial cyst

Dermoid cysts Inclusion dermoids: Implantation 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

Ileostomy: Spouted to avoid excoriation Digitate lumen for patency Check contents of bag: urine vs faeces

End colostomy: Check patency of anus – patent: Hartmanns Non-patent: AP resection What operation could they have had this for: UC/ diverticulitis/ Malignancy

Complications

Prolapse

Retraction

Necrosis

HOW WOULD YOU TREAT?

WHAT WOULD YOU DO???

WHAT WOULD YOU DO????

WHAT WOULD YOU DO???

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