SURGICAL DISEASES DIAGNOSIS

SURGICAL DISEASESSURGICAL DISEASESDIAGNOSISDIAGNOSIS

HYSTORY HYSTORY

CLINICAL EXAMINATIONCLINICAL EXAMINATION

LAB.TESTSLAB.TESTS

IMAGISTIC IMAGISTIC INVESTIGATIONSINVESTIGATIONS

TREATMENT MODALITIESTREATMENT MODALITIES

SURGERY - CLASIC ORSURGERY - CLASIC OR

MINIMALLY INVASIVE (LAPAROSCOPIC)MINIMALLY INVASIVE (LAPAROSCOPIC)

MEDICAL- COMORBIDITIES, DEFFICITS MEDICAL- COMORBIDITIES, DEFFICITS CORRECTION: SEVERE ANEMIA CORRECTION: SEVERE ANEMIA HYPOVOLEMIA, DISELECTROLYTEMIA, HYPOVOLEMIA, DISELECTROLYTEMIA, ANTIBIOTICS, ANTICOAGULANTSANTIBIOTICS, ANTICOAGULANTS

ADJUVANT, NEOADJUVANT:ADJUVANT, NEOADJUVANT:

RADIOTHERAPY, CHEMOTHERAPYRADIOTHERAPY, CHEMOTHERAPY

SURGICAL TREATMENTSURGICAL TREATMENT

THE RIGHT OPERATION PERFORMED WELLTHE RIGHT OPERATION PERFORMED WELL

THE RIGHT OPERATION PERFORMED BADLYTHE RIGHT OPERATION PERFORMED BADLY

THE WRONG OPERATION PERFORMED WELLTHE WRONG OPERATION PERFORMED WELL

THE WRONG OPERATION PERFORMED THE WRONG OPERATION PERFORMED BADLYBADLY

In only one case the patient will have the best resultIn only one case the patient will have the best result

SURGERY OF THE NECKSURGERY OF THE NECKANATOMYANATOMY

DEFINITIONDEFINITION

STRUCTURES:STRUCTURES:– SKIN, SUPERFICIAL FASCIA, VEINS, NODESSKIN, SUPERFICIAL FASCIA, VEINS, NODES– DEEP CERVICAL FASCIADEEP CERVICAL FASCIA– MAIN ARTERIES, VEINS, NERVESMAIN ARTERIES, VEINS, NERVES– VISCERA OF THE NECKVISCERA OF THE NECK

– THE ROOT OF THE NECKTHE ROOT OF THE NECK

NECK SURGERYNECK SURGERY

LUMPS IN THE NECKLUMPS IN THE NECK

WOUNDS OF THE NECKWOUNDS OF THE NECK

SURGICAL INFECTIONS IN THE NECKSURGICAL INFECTIONS IN THE NECK

LUMPS IN THE NECKLUMPS IN THE NECKHISTORY AND EXAMINATIONHISTORY AND EXAMINATION

HISTORY:- rate of growth of the lump, HISTORY:- rate of growth of the lump, - symptoms:pain, discharge - symptoms:pain, discharge

EXAMINATION- characteristics of the lump- EXAMINATION- characteristics of the lump- site, shape, size, surface, tenderness, site, shape, size, surface, tenderness, fixation, consistency, fluctuence, pulsatility, fixation, consistency, fluctuence, pulsatility, associated lymph- adenopathyassociated lymphadenopathy

Clinical diagnosis- benign or malignant Clinical diagnosis- benign or malignant

-cystic or solid lump -cystic or solid lump

LUMPS IN THE NECKLUMPS IN THE NECKCAUSESCAUSES

1. Lymph node enlargement:1. Lymph node enlargement:-lymphomas,-lymphomas,-lymph node metastases,-lymph node metastases,-inflammatory lymphadenopathy from acute or -inflammatory lymphadenopathy from acute or chronic infections in the neck,chronic infections in the neck,-AIDS related lymphadenopathy-AIDS related lymphadenopathy

2. Congenital cysts: thyroglossal, branchial, cystic 2. Congenital cysts: thyroglossal, branchial, cystic hygromahygroma

3. Lumps in the skin: lipoma, epidermal cyst3. Lumps in the skin: lipoma, epidermal cyst4. Rare tumors: carotid body tumors4. Rare tumors: carotid body tumors5. Thyroid and parathyroid nodules5. Thyroid and parathyroid nodules

LYMPH NODE ENLARGEMENTLYMPH NODE ENLARGEMENT

CERVICAL TUBERCULOSISCERVICAL TUBERCULOSIS

Synonims: tuberculous cervical adenitisSynonims: tuberculous cervical adenitis

:cervical tuberculous :cervical tuberculous lymphadenopathylymphadenopathy

:mycobacterial lymphadenitis:mycobacterial lymphadenitis

:extrapulmonary tuberculosis:extrapulmonary tuberculosis

CERVICAL TUBERCULOSISCERVICAL TUBERCULOSIS

Acquired chronic infection of the nodesAcquired chronic infection of the nodes

Acquired by drinking milk infected cattleAcquired by drinking milk infected cattle

The primary infection occurs in the tonsilsThe primary infection occurs in the tonsils

Secondary involvement of the cervical Secondary involvement of the cervical nodes- enlarged, matted togethernodes- enlarged, matted together

The incidence of coexisting pulmonary TB The incidence of coexisting pulmonary TB is less 5%.is less 5%.

CERVICAL TUBERCULOSISCERVICAL TUBERCULOSISClinical featuresClinical features

Long history of a lump in the neckLong history of a lump in the neck

Medical advise- the lump has become Medical advise- the lump has become painfulpainful

Presentation: - just lump in the neckPresentation: - just lump in the neck

- discharging sinus- discharging sinus

- cold abscess- cold abscess

- lump adherent to the skin- lump adherent to the skin

CERVICAL TUBERCULOSISCERVICAL TUBERCULOSISClinical featuresClinical features

90% unilateral90% unilateral

90% involve only one node group90% involve only one node group

The commonest- deep jugular veinThe commonest- deep jugular vein

- submandibular- submandibular

- in the posterior triangle- in the posterior triangle

CERVICAL TUBERCULOSISCERVICAL TUBERCULOSISDiagnosisDiagnosis

HistoryHistory

Physical examination: characteristics of an Physical examination: characteristics of an inflammatory lump inflammatory lump

Specific investigations:Specific investigations:– Positive tuberculin testPositive tuberculin test– Excisional biopsy of the lumpExcisional biopsy of the lump– Culture of Mycobacterium tuberculosis Culture of Mycobacterium tuberculosis

CERVICAL TUBERCULOSISCERVICAL TUBERCULOSISTreatmentTreatment

Excisional biopsyExcisional biopsyAntituberculous chemotherapy Antituberculous chemotherapy

for 9-12 monthsfor 9-12 monthsMatted nodes attached to the internal jugular Matted nodes attached to the internal jugular vein- functional neck dissectionvein- functional neck dissection(preservation of the SCM, accessory nerve, jugular vein (preservation of the SCM, accessory nerve, jugular vein

if possible)if possible)

*In a kid- remove and examine histologically the *In a kid- remove and examine histologically the tonsils before removing the lymph nodestonsils before removing the lymph nodes

*Surgery not followed by chemotherapy- a *Surgery not followed by chemotherapy- a persistent discharging sinus will form and later persistent discharging sinus will form and later ugly scarugly scar


1.LYMPH NODE ENLARGEMENT:1.LYMPH NODE ENLARGEMENT:

c. ACUTE INFECTIONS d. CHRONIC INFECTIONSc. ACUTE INFECTIONS d. CHRONIC INFECTIONS

CERVICAL LYMPH NODESCERVICAL LYMPH NODESCLINICAL ENTITIES CLINICAL ENTITIES

Lymphomas= neoplastic disorders of Lymphomas= neoplastic disorders of lymphoid cellslymphoid cells– Solid tumorsSolid tumors– Involve the lymphoid tissueInvolve the lymphoid tissue– Hodgkin’s disease=malignant neoplasm Hodgkin’s disease=malignant neoplasm

originating in lymphoid tissueoriginating in lymphoid tissue– Characteristic Reed-Sternberg cellsCharacteristic Reed-Sternberg cells

CERVICAL LYMPH NODESCERVICAL LYMPH NODESCLINICAL ENTITIESCLINICAL ENTITIES

Cervical lymph nodes metastasesCervical lymph nodes metastases– Primary tumors located in the head neck, Primary tumors located in the head neck,

chest or abdomenchest or abdomen– Tumors of the head and neck, send Tumors of the head and neck, send

metastases to nodes- submandibular region metastases to nodes- submandibular region and upper part of the anterior triangleand upper part of the anterior triangle

– Tumors of the chest and abdomen send Tumors of the chest and abdomen send metastases to nodes- lower part of the metastases to nodes- lower part of the posterior triangle (Virchow’s node) posterior triangle (Virchow’s node)


1.LYMPH NODE ENLARGEMENT:1.LYMPH NODE ENLARGEMENT: a. PRIMARY TUMORS b. SECONDARY TUMORSa. PRIMARY TUMORS b. SECONDARY TUMORS -lymphomas- -lymph node metastases--lymphomas- -lymph node metastases-

CONGENITAL NECK LUMPSCONGENITAL NECK LUMPS CYSTIC HYGROMA CYSTIC HYGROMA

Synonim- cystic lymphangiomaSynonim- cystic lymphangioma

Tumor of lymph vessels which forms Tumor of lymph vessels which forms multilocular cyst- like spacesmultilocular cyst- like spaces

Painless lump just below the angle of the Painless lump just below the angle of the mandible, soft, fluctuant, transilluminablemandible, soft, fluctuant, transilluminable

Surgical excision- the best option in fit Surgical excision- the best option in fit patientspatients

Incision and drainage when infected Incision and drainage when infected


2. CONGENITAL CYST:2. CONGENITAL CYST:

c. CYSTIC HYGROMAc. CYSTIC HYGROMA



a. THYROGLOSSAL CYSTSa. THYROGLOSSAL CYSTS

CONGENITAL NECK LUMPSCONGENITAL NECK LUMPSTHYROGLOSSAL DUCT CYSTTHYROGLOSSAL DUCT CYSTThe commonest midline neck cystThe commonest midline neck cystRemnant of the thyroglossal duct- incomplete Remnant of the thyroglossal duct- incomplete regression may result in a cystregression may result in a cystIt is attached to the base of the tongue and It is attached to the base of the tongue and hyoid bonehyoid bonePainless cystic neck lump, moving up with Painless cystic neck lump, moving up with tongue protrusion, mobile, transilluminabletongue protrusion, mobile, transilluminableTenderness when infectedTenderness when infectedMay drain spontaneouslly with fistula formationMay drain spontaneouslly with fistula formationSurgical excision with central part of the hyoid Surgical excision with central part of the hyoid bonebone

CONGENITAL NECK LUMPSCONGENITAL NECK LUMPSBRANCHIAL CYSTBRANCHIAL CYST

Remnant of the 2Remnant of the 2ndnd pharyngeal pouch pharyngeal pouchPainless lump in the side of the neck, Painless lump in the side of the neck, deep to the SCM, 1/3-2/3, anterior triangledeep to the SCM, 1/3-2/3, anterior trianglePainful lump if infected, soft, fluctuantPainful lump if infected, soft, fluctuantComplete surgical excision or incision and Complete surgical excision or incision and drainage if infected, preventing injuries to drainage if infected, preventing injuries to the ICA-ECA.the ICA-ECA.Branchial fistula discharges a glairy Branchial fistula discharges a glairy mucinous substancemucinous substance



b. BRANCHIAL CYSTb. BRANCHIAL CYST


3.LUMPS IN THE SKIN:3.LUMPS IN THE SKIN:

a. LIPOMAa. LIPOMA


3.LUMPS IN THE SKIN:3.LUMPS IN THE SKIN: b. EPIDERMAL CYSTb. EPIDERMAL CYST

CAROTID BODY TUMORCAROTID BODY TUMOR

Synonim=chemodectomasSynonim=chemodectomas

High incidence in Peru, high altitudeHigh incidence in Peru, high altitude

Chronic hypoxia at high altitudes leads to Chronic hypoxia at high altitudes leads to carotid body hyperplasiacarotid body hyperplasia

Firm ovoid tumor, firmly adherent to the Firm ovoid tumor, firmly adherent to the bifurcation of the CCAbifurcation of the CCA

Painless palpable lumpPainless palpable lump

Seldom grows to more than 4-5 cm.Seldom grows to more than 4-5 cm.

CAROTID BODY TUMORCAROTID BODY TUMORDIAGNOSIS AND TREATMENTDIAGNOSIS AND TREATMENTLong history of a lump in the neckLong history of a lump in the neckPhysical examination- characteristics of a solid Physical examination- characteristics of a solid tumortumorInvestigations- carotid angiogram, doppler Investigations- carotid angiogram, doppler echographyechographySurgical removal- risk of morbidity and mortalitySurgical removal- risk of morbidity and mortalityIndications limited for malignant resectable Indications limited for malignant resectable tumors, interfering swallowing, speaking, tumors, interfering swallowing, speaking, breathingbreathingRadiotherapy indicated in poor- risc surgical pt. Radiotherapy indicated in poor- risc surgical pt. or metastatic diaseaseor metastatic diasease


4.RARE TUMORS:4.RARE TUMORS:

CAROTID BODY TUMORSCAROTID BODY TUMORS


Multinodular goitre


Parathyroid adenomaParathyroid adenoma

WOUNDS OF THE NECKWOUNDS OF THE NECK

SUICIDAL CUT-THROATSUICIDAL CUT-THROAT

HOMICIDAL CUT-THROATHOMICIDAL CUT-THROAT

OTHER WOUNDS OF THE NECKOTHER WOUNDS OF THE NECK

CUT-THROATCUT-THROAT

Is due to attempted suicideIs due to attempted suicideHead extended- great vessels escape Head extended- great vessels escape injury, the air passages are open- repair, injury, the air passages are open- repair, tracheostomytracheostomyBleeding from thyroid artery- securedBleeding from thyroid artery- securedIJV- ligated above and below the injury IJV- ligated above and below the injury sitesitePharyngeal injury- suture, septic risk Pharyngeal injury- suture, septic risk NG tube for feedingNG tube for feeding

HOMICIDAL CUT-THROATHOMICIDAL CUT-THROAT

The wound is in the lower part of the neckThe wound is in the lower part of the neck

Great vessels injured- is fatalGreat vessels injured- is fatal

Treatment:Treatment:

- proper exploration, - proper exploration,

- debridement of ischemic tissue,- debridement of ischemic tissue,

- repair of damaged structures,- repair of damaged structures,

- suture with drainage- suture with drainage

OTHER WOUNDS OF THE OTHER WOUNDS OF THE NECKNECK

STABSSTABS

GUNSHOT WOUNDSGUNSHOT WOUNDS

WHEN VITAL STRUCTURES ESCAPE, WHEN VITAL STRUCTURES ESCAPE, REMAINS SEPTIC RISKREMAINS SEPTIC RISK

TREATMENT:TREATMENT:

- ENLARGEMENT OF THE WOUND- ENLARGEMENT OF THE WOUND

- DEBRIDEMENT- DEBRIDEMENT

- REPAIR- REPAIR

NECK INJURIESNECK INJURIES

Anatomically, the neck can be divided into Anatomically, the neck can be divided into 3 major zones, in order to aid in the 3 major zones, in order to aid in the decision making- diagnostic tests,-timing decision making- diagnostic tests,-timing of surgeryof surgeryZone I- below the cricoidZone I- below the cricoidZone III- above the angle of the mandibleZone III- above the angle of the mandibleZone II- the most frequently involved Zone II- the most frequently involved region region

Neck injuries- signs and symptomsNeck injuries- signs and symptoms

Vascular injury- shock, hematoma, hemorrhage, Vascular injury- shock, hematoma, hemorrhage, pulse deficit, neurologic deficit, bruits in neckpulse deficit, neurologic deficit, bruits in neck

Laryngo/tracheal injury- subcutaneous Laryngo/tracheal injury- subcutaneous emphysema, airway obstruction, sucking wound, emphysema, airway obstruction, sucking wound, hemoptysis, dyspnea, stridor, dysphoniahemoptysis, dyspnea, stridor, dysphonia

Pharyngo/esophageal injury- Pharyngo/esophageal injury- subcut.emphysema, dysphagia, odinophagiasubcut.emphysema, dysphagia, odinophagia

NECK INJURY- NECK INJURY- MANAGEMENTMANAGEMENT

Patients with refractory shock, Patients with refractory shock, uncontrolable hemorrhage should undergo uncontrolable hemorrhage should undergo immediat neck explorationimmediat neck exploration

Patients who are stable, should undergo Patients who are stable, should undergo directed explorations with subsequent directed explorations with subsequent repair of injured structuresrepair of injured structures

ZONE I INJURY-ZONE I INJURY-MANAGEMENTMANAGEMENT

Penetrating injuries are potentially fatalPenetrating injuries are potentially fatal

Angiography for suspected vascular injuryAngiography for suspected vascular injury

Esophageal examination- a missed Esophageal examination- a missed esophageal injury- mediastinitisesophageal injury- mediastinitis

ZONE II INJURY- ZONE II INJURY- MANAGEMENTMANAGEMENT

Symptomatic- penetrating injury- neck Symptomatic- penetrating injury- neck explorationexploration

Asymptomatic- mandatory neck Asymptomatic- mandatory neck exploration or directed evaluation and exploration or directed evaluation and serial examinations serial examinations

ZONE III INJURY- MANAGEMENTZONE III INJURY- MANAGEMENT

Potential for injury to major blood vessels Potential for injury to major blood vessels and the cranial nerves near the skull baseand the cranial nerves near the skull base

Surgical exposure – difficultSurgical exposure – difficult

Angiogram- interventional radiologyAngiogram- interventional radiology

INFECTIONS IN THE NECKINFECTIONS IN THE NECK

1. Retropharyngeal abscess1. Retropharyngeal abscess

2. Parapharyngeal abscess2. Parapharyngeal abscess

3. Submandibular abscess3. Submandibular abscess


RETROPHARYNGEAL ABSCESSRETROPHARYNGEAL ABSCESS


PARAPHARYNGEAL ABSCESSPARAPHARYNGEAL ABSCESS


SUBMANDIBULAR SPACE INFECTIONS (LUDWIGS ANGINA)SUBMANDIBULAR SPACE INFECTIONS (LUDWIGS ANGINA)

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SURGICAL DISEASES DIAGNOSIS