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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 lymph- adenopathy
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
LUMPS IN THE NECKLUMPS IN THE NECKCAUSESCAUSES
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)
LUMPS IN THE NECKLUMPS IN THE NECKCAUSESCAUSES
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
LUMPS IN THE NECKLUMPS IN THE NECKCAUSESCAUSES
2. CONGENITAL CYST:2. CONGENITAL CYST:
c. CYSTIC HYGROMAc. CYSTIC HYGROMA
LUMPS IN THE NECKLUMPS IN THE NECKCAUSESCAUSES
2. CONGENITAL CYST:2. CONGENITAL CYST:
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
LUMPS IN THE NECKLUMPS IN THE NECKCAUSESCAUSES
2. CONGENITAL CYST:2. CONGENITAL CYST:
b. BRANCHIAL CYSTb. BRANCHIAL CYST
LUMPS IN THE NECKLUMPS IN THE NECKCAUSESCAUSES
3.LUMPS IN THE SKIN:3.LUMPS IN THE SKIN:
a. LIPOMAa. LIPOMA
LUMPS IN THE NECKLUMPS IN THE NECKCAUSESCAUSES
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
LUMPS IN THE NECKLUMPS IN THE NECKCAUSESCAUSES
4.RARE TUMORS:4.RARE TUMORS:
CAROTID BODY TUMORSCAROTID BODY TUMORS
LUMPS IN THE NECKLUMPS IN THE NECKCAUSESCAUSES
Multinodular goitre
LUMPS IN THE NECKLUMPS IN THE NECKCAUSESCAUSES
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
INFECTIONS IN THE NECKINFECTIONS IN THE NECK
RETROPHARYNGEAL ABSCESSRETROPHARYNGEAL ABSCESS
INFECTIONS IN THE NECKINFECTIONS IN THE NECK
PARAPHARYNGEAL ABSCESSPARAPHARYNGEAL ABSCESS
INFECTIONS IN THE NECKINFECTIONS IN THE NECK
SUBMANDIBULAR SPACE INFECTIONS (LUDWIGS ANGINA)SUBMANDIBULAR SPACE INFECTIONS (LUDWIGS ANGINA)