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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5233_Библиотеки_им_академика_М_И_Перельмана.pdf
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A. Farag et al.
Acute: Hematoma, Abscess and infected sebaceous cyst.
Chronic: Sebaceous cyst, Haemangioma, Lipoma, or Neurobroma.
2. Less Common tumors:
Bone Secondaries, Meningocele, Osteoma, Lymphoma and Multiple
Myeloma, Encephalocele and hernia Cerebri.
3. Pulsating Tumors:
Cersoid Aneurysm, Meningocele “Positive trans illumination”,
Encephalocele and Hernia Cerebri.
4. Ulcers or Ulcerating Masses:
Ulcerating Sebaceous cyst “Cock’s Peculiar Tumor”, Malignant Ulcer
including Squamous Cell Carcinoma, Basal Cell carcinoma or Rodent Ulcer,
Sebaceous Carcinoma or Melanoma, Leishmanial ulcer, Lupus Vulgaris, and
Keratoacanthoma.
The Forehead andFace
• Acute diffuse Swelling: Infections including osteomyelitis, and Allergies like
Angioneurotic edema.
• Chronic diffuse Swelling: Diffuse Haemangioma and Plexiform neuroma
“Pacchydermatocele”.
• Chronic Localized: Sebaceous Cyst, dermoid cyst, Haemangioma,
Lymphangioma, Neurobroma, Lipoma, Melanoma, Keloid, Mucocele of the
Nasolacrimal duct, mucous retention cyst from the buccal surface of the Cheek,
Tumors of the Maxilla.
• Ulcer: Rodent Ulcer, Squamous Cell carcinoma, Molluscum Sebaceum and
Keratoacanthoma. Lupus Vulgaris, Tuberculous Ulcer and Leishmanial Ulcer.
The Lips
• Diffuse Swellings: Lymphangioma, Lymphatic obstruction due to repeated
infections and Diffuse Tertiary Syphilis “Rare nowadays”.
• Localized Swelling: Mucous Cyst, Haemangioma, Lymphangioma Papilloma
Squamous cell carcinoma.
• Ulcers: Central Cracks due to prolonged dryness of the Lips, Angular Cracks due
to riboavin deciency, Squamous cell Carcinoma, Syphilis “Rare” and
Dyspeptic ulcers “Mucous membranes:
• N.B. Dark muco-cutaneous pigmentations are indicative of peutz jeghers
syndrome.
24 Examination ofaMass intheHead andFace
The Tongue
Swellings
• Localized: 1. Haemangioma. 2. Mixed salivary tumor. 3. Lingual Thyroid.
• Diffuse: 1. Haemangioma. 2. Lymphangioma. 3. Cretinism.
• Ulcers: 1. Traumatic. 2. Dental. 3. Dyspeptic ulcers.
• 4. Malignant. 5. Frenal ulcers. 6. Tuberculous.
• Fissures: 1. Congenital ssures. 2. Chronic supercial.
• Glossitis. 3. Median Rhomboid Glossitis.
• Pain: 1. Trauma “Biting the tongue”. 2. Leukoplakia.
• 3. Supercial glossitis. 4. Cancer. 5. T.B. ulcers.
The Palate
Swellings: Mucous Cysts. Mixed salivary tumors.
Ulcers: Dyspeptic, Malignant and Syphilitic “rare”.
Perforations: Congenital Cleft Palate, Traumatic and malignant.
237
Floor oftheMouth
Swellings: Ranula, Dermoid Cyst, Mucous retention cyst, Submandibular Salivary
gland stone, Sialadenitis or tumor.
Ulcers: Dyspeptic or Malignant.
Cheek
Ulcers: Dyspeptic or Malignant ulcers.
Swellings: Mucous retention cyst, Mixed Salivary tumor, Haemangioma,
Lymphangioma and Lipoma.
Swellings fromtheJaw
Bone swellings:
• Acute inammatory: Osteomyelitis: Dental caries, Periodontal abscess or post
traumatic.
• Chronic inammatory: From Carious tooth.
• Cysts and Neoplasms:
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A. Farag et al.
1. Dental Cyst.
2. Dentigerous Cyst.
3. Adamantinomas are locally invasive, highly destructive tumors of the jaw and
commonly arise in the molar area. They are odontogenic tumors derived from
tooth formation tissues.
4. Osteoclastoma: They are distinctive neoplasms characterized by a profuse
multinucleate giant cells scattered throughout the stroma of mononuclear
cells. These giant cells have some similarity with osteoclasts, and so are
called Osteoclastoma
5. Benign tumors: Chondroma and Osteoma.
6. Carcinoma of the Maxillary Sinus.
Swellings from the Gum “Epulides’:
1. Fibrous epulis.
2. Myeloid epulis.
3. Granulomatous epulis.
4. Carcinomatous epulis.
5. Sarcomatous epulis.
Swellings fromtheParotid Area
Skin
• Benign tumors e.g. papilloma.
• Malignant tumors e.g. squamous cell carcinoma, basal cell carcinoma, malignant
melanoma.
• Cyst e.g. sebaceous cyst.
Subcutaneous Tissue
• Benign tumors e.g. Lipoma, broma, Haemangioma, Neurobroma.
• Malignant tumors e.g. sarcoma.
• Cyst e.g. dermoid cyst.
Parotid Lymph Node
• Chronic nonspecic lymphadenitis.
• Chronic specic lymphadenitis e.g. TB.
• Malignancy e.g. lymphoma
24 Examination ofaMass intheHead andFace
Parotid Gland
– Chronic parotitis.
– Parotid cyst.
– Tumors
• Adenomas pleomorphic, Warthin tumor
• Carcinomas Mucoepidermoid Carcinoma, Adenoid Cystic Carcinoma, Acinic
cell carcinoma, Polymorphous low-grade adenocarcinoma
– Autoimmune diseases Mikulicz, Sjögren’s syndromes.
Masseter Muscle
• Fibrosarcoma
• Rhabdomyosarcoma
• Myxoma
• Hypertrophid muscle
Ramus oftheMandible
239
• Osteomyelitis
• Osteoclastoma
• Secondaries
• Cyst
• Winged mandible
Mucosa oftheCheek
• Squamous cell carcinoma.
Others
• Branchial cyst.
• Neuroma.
• Fascial vein thrombosis.
• Temporal artery aneurysm.
• Mastoiditis.
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A. Farag et al.
Clinical Classication
A swelling in the parotid area in history either acute or chronic, on examination it is
either glandular origin or extraglandular.
Acute Swelling
– Parotid
Septic parotitis, mumps.
– Extra parotid
Hematoma, abscess, acute lymphadenitis or osteomyelitis.
Chronic Swelling
• Parotid
• Unilateral
A. Cystic:
Parotid cyst or Adenolymphoma.
B. Solid:
Chronic parotitis, tumors.
• Bilateral
• Adenolymphoma, autoimmune disease
• Extraparotid
• Skin, SC tissue, masseter, etc.
Acute Swellings
Mumps
Young child, usually bilateral, inuenza like symptoms, low grade fever, painful,
tender, edema in the face, difcult mastication, self-limited.
24 Examination ofaMass intheHead andFace
241
Acute Parotitis
Middle age, unilateral, fever, painful, tender, pus emerged through the duct, enlarged
tender and hot cervical lymph nodes.
Chronic Swellings
Parotid Cyst
Translucent, aspiration clear, duct examination shows stone.
Adenolymphoma (WARTHIN TUMOR)
Men more than women, bilateral in 10–15%- soft or cystic- usually at lower part of
the parotid, spherical, smooth surface, well dened edge-mobile.
In pathology has true capsule- full of B lymphocytes.
Pleomorphic Adenoma
75% of parotid tumors, unilateral, equal male to female ratio, ant. & sup to the jaw
angle, spherical when small and lobulated when large, it is smooth and mobile “not
attached to skin or deeper structures” and rm in consistency. Don’t forget parotid
tumors mostly raises lobule of the ear.
Pathology incomplete capsule- mixed cellularity.
Malignant Parotid Tumors
– Criteria of malignancy
• Rapid growth (short history)
• Hard in consistency
• Fixation may attached to skin or deeper structures
• Fascial nerve affection (mouth angel deviation- eye incomplete closure)
• Pain in 30% may referred to ear (auriculotemporal nerve affection)
• Enlarged regional lymph nodes
Autoimmune Diseases
• MIKULIKZ syndrome
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• Bilateral enlargement of all salivary glands and lacrimal glands- dryness of the
eye and mouth
• SJOGRIN syndrome
• Same as Miculikz in addition to keratoconjunctivitis, polyarthritis, other manifestations of Systemic lupus erythematosus (SLE).
A. Farag et al.
Present History
• Onset: Acute onset associated with pain suggest inammatory pathology and if
associated with trauma it may indicate traumatic pathology. Insidious pathology
indicates benign or malignant tumors.
• Course: In cases with insidious onset a rapid progression “Weeks or months”
indicates benign pathology, while slow progression indicates benign pathology.
And regressive course indicates inammatory lesion and intermittent course
indicates an autoimmune disease and salivary gland stone.
• Duration: As mentioned above.
• Analysis of the complaint:
Pain:
• Type “A submandibular salivary stone may cause a colicky like pain during meal
or immediately after it especially after Citrus uids (Lemon Test)”.
• Site: indicates the site of pathology.
• Radiation: may refer to the tip of the tongue “Submandibular sialadenitis” or the
Tempro mandibular Joint “Parotitis”
• What brings pain: Eating especially citrus fruits.
• What relieves pain: Sometimes by milking of the parotid by the palm of the hand
towards the mouth.
Associated Symptoms
• Enlargement of the lacrimal glands with or without Xerostomia and Dry eye
“Mikulicz Syndrome or Sjögren syndrome”.
• Bilateral affection of the salivary glands: Mumps, Autoimmune parotitis,
Whartin’s Tumor.
Past Medical history: For:
• Diseases of Medical importance.
• Previous history of the same condition.
• Surgical History.
• Allergies.
24 Examination ofaMass intheHead andFace
243
Family History
Past Medical History of importance.
General Examination
• Associated diseases of medical importance.
• Stage of the disease in cases of malignant tumors of the Head and Face.
• Stigmata of autoimmune disease such as SLE.
Local Examination
See the Sheet of Swelling and sheet of Ulcers according to the affected site as mentioned above.
Trauma Examination Sheet
NicholasJohnson
The trauma examinations are a reproducible, reliable, and systematic set of clinical
examinations of a patient separated into three distinct phases: primary survey, secondary survey, and tertiary survey.
The primary survey is used to identify and correct immediate life-threatening
complications from trauma and is therefore a combination of assessment and treatment to stabilize the patient.
The secondary survey is a methodical head to toe examination of the stable
patient in the acute setting, combined with radiology as indicated, to accurately
dene prioritize and direct management of the patient.
The tertiary survey is a complete re-examination of the patient following treat-
ment and is usually completed 24 to 48 h after injury. It is designed to pick up
missed injuries following initial assessment and management or those which have
developed as part of a progressive evolution of injury.
These examinations while simple, need to be protocolized and planed as a team
orientated activity. Ideally in a trauma setting, you will have separate clinicians
performing the various parts of the primary and secondary survey simultaneously,
with a team leader overseeing the process and not getting task focused on any specic part of the examination itself.
244
A good trauma examination however involves more than just a head to toe exam-
ination of the patient. It begins by gathering as much information as possible before
the patient arrives so planning can be activated, the team assembled, and tasks prioritized. While this is not always possible, information from the rst responders
about the nature of the incident, injuries identied what has been done and the
response to these actions is invaluable in planning reception. If this information is
not available, understanding the mechanism of the injury, the patient’s potential
fragility (frailty score) and the result of the primary survey and response to critical
interventions directs a good trauma clinician to identify patterns of injury, and
expected outcome. Combined with the secondary survey this will identify injuries
and direct on-going management. Sudden unexpected deterioration should initiate a
return to a primary survey.
A. Farag et al.
History
An understanding of the mechanism of injury and patient comorbidities is essential
for an effective and thorough clinical examination. Unlike most clinical histories
that a physician takes, a trauma history is focused only on pertinent information
relating to the trauma the patient has experienced and the relevant medical conditions that may impact the patient’s imminent clinical course or surgical needs. There
are several acronyms which aid in gathering this information.
Mechanism ofInjury
All trauma involves a transfer of energy, resulting in tissue damage and injury. In
low velocity blunt and penetrating injuries, the trauma is localized to the path of
transit of the knife or projectile or to the site where the trauma was sustained.
However, in high velocity penetrating trauma and in blast injuries the injury is
unpredictable and atypical. This is important information when determining what
injuries, it is expected that a patient may have. While information may be elicited
from the patient’s themselves, often the information is relayed from rst responders
as patients may be incapacitated on arrival or under the inuence of drugs (alcohol,
opiates).
Blunt Trauma
Blunt trauma has a wide range of potential mechanisms (fall from height, being hit
by a car or bat). What struck the patient, at what speed, where on their body and how
many times is what determines their injuries.
24 Examination ofaMass intheHead andFace
**Trauma Pearl: Patients who have had a delayed arrival to hospital can self-
select out some major injuries (major cardiac or vessel transections have a high
fatality rate even when immediately transferred to hospital) but also include new
unexpected injuries (a patient who has fallen at home, and been left lying for 24h
has a high likelihood of rhabdomyolysis and dehydration).
245
Falls
When assessing a fall: knowledge of the height they fell from, what they landed on
(concrete or a car cushioning their landing, and water introduces the consideration
of a drowning and what body part sustained the impact will greatly change the
injury pattern you are looking at (a 2m fall onto their feet may result in a broken
ankle, whereas a fall onto the head can result in death.
Motor Vehicle Accidents
In a motor vehicle accident knowing what speed the vehicle was travelling at, where
the patient was in the vehicle, how it was hit (a driver hit from behind is different to
being impacted on the passenger side which is different to an impact on the driver
side or head on), if the patient was restrained/ejected (which changes the prole of
the mechanism of injury), and if any other occupants were injured or killed is useful
information when considering what injuries the patient may have. A lower speed
accident will have less energy transfer and therefore usually less signicant injuries.
High speed accidents can have large forces exerted on the body, and more catastrophic injuries for example a transected thoracic aorta in a high speed head on
collision with a restrained driver.
For pedestrians struck by a vehicle, knowing the speed of the vehicle, whether
the windscreen damaged and how far they were thrown is essential. Patients are
often hit in the legs (which can fracture), land on the bonnet (often with their head
onto or through the windscreen resulting in cranial and spinal injuries) and are
thrown to the ground (traumatizing the torso and long bones further). This mechanism is seldom trivial.
Alleged Assault
In the setting of assaults, knowing what the patient was hit with and how many
times will direct you to where you are expecting to nd injuries, knowing if it was
witnessed or unwitnessed can give important information regarding secondary possible injuries (such as a hidden stab wound, or head strike when falling or the