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Medical student surgery osce

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Medical student surgery osce

  1. 1. OSCE SAMPLE Dr Bashir BnYunus Surgery Resident AKTH bbinyunus2002@gmail.com 1
  2. 2. Picture 1 bbinyunus2002@gmail.com 2
  3. 3. Questions  Describe and give differential diagnose  Classify and treat if the swelling brilliantly transilluminate and cannot be felt separate from the testis bbinyunus2002@gmail.com 3
  4. 4. Answers  Steps in describing an inguinoscrotal swelling  Differential  Hernia  Hydrocele  Other differentials;  Lipoma of the cord  Lymphangiectasis of the cord  Varicocele  Funiculitis bbinyunus2002@gmail.com 4
  5. 5.  Hydrocele  Abnormal collection of fluid within the tunica vaginalis of the testis.  Classification as; Communicating and non-communicating Or Congenital acquired; primary or secondary bbinyunus2002@gmail.com 5
  6. 6.  Primary/idiopathic  Congenital  Infantile  Funicular  Encysted hydrocele of the cord  Hydrocele of canal of nuck  Vaginal hydrocele  Secondary  Trauma  Inflammation- epididymoorchitis  Lymphatic obstruction-filariasis  Tumour bbinyunus2002@gmail.com 6
  7. 7.  Treatment  Paeditrics ; herniotomy  Adult; hydrocelectomy bbinyunus2002@gmail.com 7
  8. 8. Picture 2 bbinyunus2002@gmail.com 8
  9. 9. Questions  Describe the pathology  What are the types  What is the timetable of testicular descent  What factor affect testicular descent  How is it treated  What are the complications bbinyunus2002@gmail.com 9
  10. 10. Answers  Left undescended testes  True undescended or retractile  Timetable;  3rd month intrauterine- iliac fossa  7th month of fetal life- deep inguinal ring  Later part of 7th month travels down the inguinal canal  8th month IU- superficial ring  9th month shortly before birth drop into the scrotum  Right testis descends before left bbinyunus2002@gmail.com 10
  11. 11. Factors affecting descent  Favours;  Shorting of gubernaculum  Differential body growth in relation to gubernaculum  Raise intraabdoinal pressure  Higher body temperature inside the abdomen  Development and maturation of epididymis  Hormones; hCG, testosterone and DHT bbinyunus2002@gmail.com 11
  12. 12.  Factors interfering  Retroperitoneal adhesion  Obstruction at the deep ring  Short vas deferens  Short testicular vessels  Short pampiniform plexus  Insufficient pull by the gubernaculum testis  Deficient hormonal stimulation  Prune belly  External exposure to estrogen during the 1st trimester bbinyunus2002@gmail.com 12
  13. 13.  Treatment  Orchidopexy ;before 2year  Orchiectomy ;  Atrophic testis  Adolescence and adult ; risk of malignant transformation  Intra-abdominal that cannot be brought down  Complication  Infertility  Trauma/torsion/tomour  Hernia  inflammation bbinyunus2002@gmail.com 13
  14. 14. bbinyunus2002@gmail.com 14
  15. 15. 1. identify this pathology 2. how is it classify 3. mention two diagnostic clinical features in this photo. 4. what could be two major problems if unrepaired? 5. what will you advise the parents against? 6. list three components of surgical repair. bbinyunus2002@gmail.com 15
  16. 16. 1. hypospadias 2. Classify as; glandular, coronal, penile, penoscrotal, scrotal, perineal. 3. ventral urethral meatus, hoody, chordee,median grooving of the glans, spatulation of the glans 4. (a) body wetting during urination, (b) psychological problems, (c) sexual problems, (d) social stigmatization 5. advise against circumcision 6. (a) orthoplasty, (b) urethroplasty, (c) glanduloplasty (d) meatoplasty, (e) scrotoplasy, (f) skin cover bbinyunus2002@gmail.com 16
  17. 17. bbinyunus2002@gmail.com 17
  18. 18.  Identify and give differentials  How is it classified  How is it treated  What are the complication  What syndromes could be associated with it bbinyunus2002@gmail.com 18
  19. 19.  Capillary hemangioma  Strawberry hemangioma  Portwine stain(naevus flammeus)  Salmon patch  Hemangioma are classified as  Capillary, cavernous or mixed  Treatment  Reassure and observe lesion regresses spontaneously (during this period, cosmetic creams can be used to camoflage)  Corticosteroids; intralesional triamsinolone or oral prednisolone  Sclerotherapy  Embolization  Laser therapy  Surgical excision  Radiotherapy bbinyunus2002@gmail.com 19
  20. 20.  Complications of hemangioma  Atrophy of overlying skin  Ulceration  Haemorrhage  Calcification  Thrombosis  Infection  Recurrence  Pressure effect especially in skeletal hemangioma; osteoporosis or bony erosion  Limb overgrowth  Huge hemangioma can cause congestive cardiac failure  Complications related to syndromes bbinyunus2002@gmail.com 20
  21. 21.  Syndromes associated with hemangioma;  Kassabach Merritt syndrome; haemangioma assiociated with thrombocytopenia  Maffucci’s syndrome; haemangioma associated with dyschondroplasia  Von Hippel-Ladau syndrome; hemangioma of the face associated with cerebellar hemangioma, glaucoma and pancreatic disease  Sturge-Weber syndrome; hemangioma associated with ipsilateral glaucoma, intracranial hemangioma and focal epilepsy  Osler Rendu-Weber syndrome; hemangioma of GI, Urinary tract, liver, spleen and brain  Klippel Trenauny- Weber syndrome ; associated osteohypertrophy of the extremities and AV fistula bbinyunus2002@gmail.com 21
  22. 22. bbinyunus2002@gmail.com 22
  23. 23.  What is the common name of this lesion?  What is the other name that it is also called that depicts its pathogenesis?  What is the pathogenesis?  List two (2) other sites of occurrence, though less frequent  Name a striking lesion, though infrequent, that may be associated  List 2 diagnostic clinical signs of this lesion.  List two (2) effective modalities of treatment.  Complications bbinyunus2002@gmail.com 23
  24. 24.  Cystic hygroma  Lymphangioma or hydrocele of the neck  Types; capillary, cavernous lymphangioma and cystic hygroma  Pathogenesis; benign proliferation of the lymphatic tissue that donot communicates freely with the lymphatic system.  Sites  1. Posterior triangle of the neck—75%—most common site.  Eventually may extend upwards in the neck  2. Axilla—20%  3. Cheek  4. Tongue—lymphangiogenetic macroglossia  5. Groin  6. Mediastinum  7. Often multiple sites bbinyunus2002@gmail.com 24
  25. 25.  May be associated with macroglosia  Swelling is smooth, soft, fluctuant (cystic), not compressible, brilliantly transilluminant. It is not reducible completely.  Treatment  Surgical excision  Sclerotherapy ; for recurrent lesion. Scelosant ; bleomycin,sodium tetradecyl sulphate and glucose, Ok-432  External beam radiation  Complications ;  Airway obstruction, infection, hemorrhage into cyst, insinuation into major structures, obstructed labour bbinyunus2002@gmail.com 25
  26. 26. bbinyunus2002@gmail.com 26
  27. 27. bbinyunus2002@gmail.com 27 • Identify this abnormality • How is it classified • What is the aetio-pathology? • List 2 clinical conditions that may be associated. • List 3 complications of this condition. • State the timing and type of a corrective operative technique for this condition. • State another specialist, apart from a plastic surgeon, that should be involved in management of this boy
  28. 28.  Cleft lip  Classification;  Central cleft- rare  Lateral cleft  Unilateral or bilateral  Complete(extend into the nostril) or incomplete  Simple or compound(associated with cleft of alveolus)  Complicated(associated with cleft palate) or uncomplicated  Aetio-pathology  Both genetic and environmental factor  15% are familial through male sex-linked recessive gene bbinyunus2002@gmail.com 28
  29. 29.  Nutritional deficiency; Vit B, Vit A folic acid.  Rubella infection  Drugs; steroid, phenytoin,diazepam  Anoxia  Radiation  Stress  Advance maternal age  Diabetic  Consanguineous marriage  In association with other syndrome; bbinyunus2002@gmail.com 29
  30. 30.  Cleft palate and VACTARL abnormality  Complications of cleft lip;  Cosmetically ugly  Defective suction during breast feeding  Dental irregularity  Defective speech with particularly with labial letters ; B,F,M,P,V,W  Timing for corrective operation  Millard rule of 10; child should fulfil  ≥ 10weeks  10lbs (4.6kg)  Hb 10g bbinyunus2002@gmail.com 30
  31. 31.  So the operation is performed when the child is 2.5- 3month  Patient’s nutrition is accepted for GA and operation  Lips element are larger and repair is precise and easy  Dropper feed is easier post operatively to facilitate healing  Operative technique  Millard’s rotation advancement flap  Tennison- Randall triangular flap  Multidisiplinary ; plastic surgeon, orthodontist, paedo- dentist, paediatrcian, speech therapist, ENT surgeons bbinyunus2002@gmail.com 31
  32. 32. bbinyunus2002@gmail.com 32
  33. 33.  Identify the pathology  Classify  What are problems associated with it  How is it corrected  What is the optimum time for repair bbinyunus2002@gmail.com 33
  34. 34.  Cleft lip and palate  Classification of cleft palate Incomplete  Bifida uvula  Cleft of soft palate along its entire length  Cleft of the whole length of the soft palate and the posterior part of the hard palate.(intra-maxillary) Complete  Cleft soft palate and whole length of the had palate bbinyunus2002@gmail.com 34
  35. 35.  Problems associated with cleft palate;  Defective suction  Defective speech consonant like; B,D,K,P,T  Defective smell  Defective hearing and chronic otitis media  Repeated respiratory tract infection  Chances of aspiration bronchopneumonia  Defective dentition because of irregular development of alveolus  Cosmetically ugly look particularly when associated with cleft lip bbinyunus2002@gmail.com 35
  36. 36.  Treatment of cleft palate  Von Langenbeck palatoplasty  V-Y pushback palatoplasty  Furlow  Others  The optimum time for repair  14-18month ie before the child can speak (however current trend 9month -1year because child start making effort to produce understandable sounds ) bbinyunus2002@gmail.com 36
  37. 37. bbinyunus2002@gmail.com 37
  38. 38.  List there (3) differential diagnosis of this lesion  What is the definitive diagnosis of these swellings that are soft (but not cystic) and tender on examination ?  What is the other name the condition is known as which is based on its features?  How is it classify  Complications bbinyunus2002@gmail.com 38
  39. 39.  Differentials;  Lipoma  Neurofibroma  Cystic swellings  Dercum’s disease(adipose dolorosa) – multiple neurolipomatosis  Lipoma  Classification of lipoma;  Encapsulated or diffuse (in relation to capsule)  Fibrolipoma, neavolipoma or neurolipoma (histological) bbinyunus2002@gmail.com 39
  40. 40.  Classification  Solitary or multiple (number)  Sessile or pednculated (shape)  Anatomical  Subcuteneous  Sub-fascial  Intermuscular  Intramuscular  Subperisteal  Subsynovial  Intra-articular  Submucous  Subserosal  Subdural or extradural bbinyunus2002@gmail.com 40
  41. 41.  Complications of lipoma;  Cosmetically urgly  Necrosis due to repeated trauma  Calcification  Haemorrhage  Infection  Lipomatosis may cause huge enlarment and deformity  Liposarcoma  Myxomatous degeneration  Ulceration bbinyunus2002@gmail.com 41
  42. 42. bbinyunus2002@gmail.com 42
  43. 43.  What investigation is shown  What are the indications  How is it reported  What are mammographic findings of malignancy bbinyunus2002@gmail.com 43
  44. 44.  Mammography  Indications;  Screening ; women >50year or >35years with risk factors  Diagnostic mammography to evaluate existing feature of breast disease  Obese patient  Whenever breast conservation is planned  To rule out tumour in the contralateral breast  Mammography guided biopsy  Follow up of benign breast disease with malignant potential  Follow up after conservative breast surgery  mastalgia bbinyunus2002@gmail.com 44
  45. 45.  BIRADS- breast imaging reporting and data system  Grade - features  0- need for further imaging  1- negative  2- benign (repeat mammography in 1year)  3- probably benign (mammography in 6month)  4- suspicious as carcinoma (biopsy)  5- highly suggestive of carcinoma(biopsy)  6- known carcinoma bbinyunus2002@gmail.com 45
  46. 46.  Mammographic findings of malignancy;  Microcalcification  Branching calcification  Spiculations  Ductal distortion  Mass effect  Loss of symmetry  Clustering bbinyunus2002@gmail.com 46
  47. 47. bbinyunus2002@gmail.com 47
  48. 48.  Spot diagnosis  How is pathology classified  How would this patient be treated bbinyunus2002@gmail.com 48
  49. 49. Ans;  Double-bubble sign- duodenal atresia  Types of atresia;  Type1-mucosal defect with continuity of the wall-20%  Type 2- lumen atretic with fibrous cord btw proximal and distal lumen  Type 3a – complete atresia with V shape mesenteric defect  Type 3b- apple peel or chrismas tree deformity  Type 4 – multiple atresia  Adequate resuscitation  N-G tube decompression  Iv fluid, fluid and electrolyte correction  Antibiotic prophylaxis  Vit K prophylaxis  Doudenoduodenostomy bbinyunus2002@gmail.com 49
  50. 50. bbinyunus2002@gmail.com 50 a) What is the spot diagnosis (b) State 3 other parts of the body that may have this type of abnormality. (c)List 4 Aetiologic/Risk factors that may predispose to this condition. (d)List 4 complications of this condition. (e)List 2 surgical treatment options.
  51. 51. Answers (a) Varicose veins (b) Oesophageal varices; haemorrhoidal venous plexus; pampiniform venous plexus, (c) Occupation (Prolonged standing), congenital absence or incompetence of valves, obstruction to venous return eg intra abdominal tumour or pregnancy, recurrent thrombophlebitis, A-V malformations, iliac vein thrombosis (d) lipodermatosclerosis, venous ulcer, eczema and dermatitis, haemorrhage; periostitis, ankylosis of joints, thrombophlebitis, calcification, equinovarus deformity. (e) Tredenlenberg operation, Venous stripping, Subfascial ligation of Cocket and Dodd, Subfascial endoscopic perforator ligation surgery, Endoluminal laser ablation bbinyunus2002@gmail.com 51
  52. 52. bbinyunus2002@gmail.com 52
  53. 53. (a)What is the condition in this picture called? (b)Mention 4 deformities present? (c)What are the pathological lesions causing these deformities ? (d)Mention 2 congenital conditions that may be associated with this condition. (e)Mention 2 acquired causes of the condition. (f)What are the treatment modalities bbinyunus2002@gmail.com 53
  54. 54. Answers (a)Congenital talipes equinovarus deformity (b)-Fore foot adduction and supination (varus) -Hind foot adduction and supination(inversion) -Equinus deformity. -High arched dorsal surface of the foot -Plantar cavus (c)-Dorsolateral subluxation of the navicular -Medial displacement at the subtalar joint -Soft tissue contractures (d)-Congenital constriction band syndrome -Spinal dysraphism -Myelodylpasia -Arthrogryposis (e)-Post polio paralysis -Cerebral palsybbinyunus2002@gmail.com 54
  55. 55. TREATMENT OF TALIPIS EQUINOVARUS  Goals  To correct early  To correct fully  To maintain in the corrected position until growth stops  Timing  Within 1st week of birth  Non-operative  Steps  First correct the forefoot adduction  Secondly correct the inversion  Finally the equinus bbinyunus2002@gmail.com 55
  56. 56.  Operative treatment;  Indications;  when plateau have reach in non operative treatment  Response not obtained after 6month  Resistant cases declares themselves after 8-12weeks of serial manipulation and strpping  Relapsed cases  Rigid club foot  Late presentation after 6months of age  Complementary to conservative treatment  Treatment is soft tissue release on the medial side of the foot and lenghting of tendoachillis bbinyunus2002@gmail.com 56
  57. 57.  How age roughly guide the choice of treatment;  Less than 5years; soft tissue release(posterior medial). Incisions; Cincinatti, Turco and Caroll  More than 5years; requires bone releasing e.g dorso- lateral wedge excision of the calcaneo cuboid joint(Evans procedure). Osteotomy of the calcaneum to correct the varus (Dwyer)  More than 10years ; lateral wedge tarsectomy or triple arthrodesis recommended after skeletal maturity  Ilizarov method can be used as a primary procedure but is normally reserved for recurrent CTEV bbinyunus2002@gmail.com 57
  58. 58. bbinyunus2002@gmail.com 58
  59. 59.  Defined the above image  Classify  What are the indications  What are the complications bbinyunus2002@gmail.com 59
  60. 60.  Colostomy; an artificial colo-cutaneous fistula on the anterior abdominal wall for the purpose of discharging faeces and flatus.  Types;  According to duration  Temporal  Permanent  According to anatomical location;  Sigmoid colostomy  Transverse colostomy  Caecostomy  Desending colostomy bbinyunus2002@gmail.com 60
  61. 61.  According to appearance;  End colostomy  Loop colostomy  Double- barreled colostomy  According to function  Diverting or defuntioning  Decompression colostomy bbinyunus2002@gmail.com 61
  62. 62. Indications for colostomy Congenital malformations  Anal atresia  Hirschsprung’s disease Neoplasm  Colon carcinoma  Rectal carcinoma Inflammatory - intrinsic and extrinsic  Chronic diverticular disease  Crohn’s disease  Lymphogranuoma venesum  Radiation injury to colon  Endometriosis of the colon or rectum bbinyunus2002@gmail.com 62
  63. 63. Colorectal Fistulas  Colocutaneous  Rectovaginal  Vesicocolic Trauma  Large colonic injuries with faecal contamination  Rectal injury bbinyunus2002@gmail.com 63
  64. 64. Surgical Operation  Distal anastomosis (FAP)  Low rectal excision Miscellaneous  Volvulus of sigmoid colon or caecum  Severe or persistent colonic hypomotility  Anal incontinence from repeated operation for inflammatory perianal disease  Paraplegia, extensive decubitus ulcer/severe burns or infection of the perineum. bbinyunus2002@gmail.com 64
  65. 65. complications  Immediates  Bleeding  Necrosis of distal end of stoma  Electrolyte derangement  Intermediate  Retraction  Prolapse  Stenosis  Intestinal obstruction  Fistula  Abscess  Stricture  Parastomal cellulitis- skin excoriation  Intraperitoneal abscess bbinyunus2002@gmail.com 65
  66. 66.  Late  Colostomy hernia  Colostomy diarrhea  Recurrence of malignancy  Psychological trauma bbinyunus2002@gmail.com 66
  67. 67. bbinyunus2002@gmail.com 67
  68. 68.  a)What is the function of this tube in this picture?  (b)State 3 indications  (c)State 4 complications/problems associated with the use  (d)State 2 contraindications to use of this tube  What are the types bbinyunus2002@gmail.com 68
  69. 69.  Gastrostomy feeding tube  Severe malnutrition, major surgeries, severe sepsis, trauma, head and neck surgeries, oesophageal obstruction. It is done if feeding is required for more than one month.  Leak-gastric fistula, displacement, blockage of tube, tube migration, diarrhea, bloating, abdominal cramp, wound infection.  Previous gastric surgeries, intestinal obstruction, gastric outlet obstruction. bbinyunus2002@gmail.com 69
  70. 70. Types of gastrostomy  Base on technique;  Stamm temporary gastrostomy  Kader-Senn temporary gastrostomy  Percutaneous endoscopic gastrostomy  Janeway’s mucus lined permanent gastrostomy  Base on duration;  Temporal  Permanent  Base on lining;  Mucus lined (permanent )  Serosal lined (temporal) bbinyunus2002@gmail.com 70
  71. 71. bbinyunus2002@gmail.com 71
  72. 72.  Give differential diagnosis  What are the risk factors for breast ca  Mention 2 syndromes associated with breast ca  What are the pathological types  What are the prognostic factors bbinyunus2002@gmail.com 72
  73. 73.  Differential diagnosis;  Carcinoma of the breast  Tuberculosis of the breast  Traumatic fat necrosis  Chronic breast abscess  Risk factors for breast ca; Very high risk;  Therapeutic radiation  Family history in two 1st degree relative  Family history of breast and ovarian cancer  BRAC 1 and BRAC 2 mutation carrier or first degree relatives with mutation bbinyunus2002@gmail.com 73
  74. 74.  Moderate to high risk;  Age > 60years  History of DCIS,LCIS  Cancer of the contralateral breast  Slight to moderate risk  Nulliparity  Early menarchy, late menarchy  HRT  Obesity  Alcohol  Benign breast disease bbinyunus2002@gmail.com 74
  75. 75.  Syndromes associated with breast ca;  Li Fraumeni syndrome  Cowden’s syndrome  Ataxia telangiectasia  Pathological types  Non invasive  a) Ductalcarcinoma-in-situ  b) Lobularcarcinoma-in-situ bbinyunus2002@gmail.com 75
  76. 76. Invasive a) Invasive ductal carcinoma b) Invasive ductal carcinoma with a predominant intraductal componenl c) Invasive lobular carcinoma d} Mucinou scarcinoma c) Medullary carcinoma f) Papillary carcinoma g) Tubular carcinoma bbinyunus2002@gmail.com 76
  77. 77.  h) Adenoid cystic carcinoma  i) Secretory (juvenile) carcinoma  j) Apocrine ca  k) Carcinoma with metaplasia  i) Squamous type  ii) Spindle - cell type  iii) Cartilaginous and osseous Iype  iv) Mixed type  l) Inflammatory carcinoma  m) Others bbinyunus2002@gmail.com 77
  78. 78.  Prognostic factors  I. Absence or presence of axillary node metastases.  2 Presence or absence of systemic dissemination.  3. Menstrual status of the patient.  4. Biological propensity and grade of the tumour.  5. Size of the tumour at the time of diagnosis.  6. Hormone dependence. bbinyunus2002@gmail.com 78
  79. 79. PREDICTIVE FACTORS;  these predicts the probability of a tumour to respond to certain drugs  ER, PR positive tumours have a good response to hormonal manipulation.  HER-2/neu overexpression. They do not respond to hormonal manipulaton, are resistant to CMF and show partial resistance to anthracyclines. However, they respond to trastuzumab (herceptin)  p53 mutation also shows resistance to anthracyclines but have greater sensitivity to taxanes.  Age below 35 years tend to have high grade tumours with poor response to treatment. bbinyunus2002@gmail.com 79
  80. 80. bbinyunus2002@gmail.com 80
  81. 81.  Identify  Classify  Aetiology  How is it treated  What is thyroid storm and how is it managed Ans  Thyrotoxicosis  Types  Primary (graves disease)  Secondary bbinyunus2002@gmail.com 81
  82. 82.  Aetiology;  Auto- immune  Genetic – autosomal dominant non-autoimmune hereditary familial thyrotoxicosis  Iodine induce – Jod Basedow thyrotoxicosis  Treatment; 3 forms  Antithyroid drug therapy  Radioactive iodine  Surgery bbinyunus2002@gmail.com 82
  83. 83.  Drud therapy;  Indications;  Children  Adolescents  Female patient who is reliable to take drugs and attend follow up  Impalpable thyroid  Heart failure  Recurrence after subtotal thyroidectomy bbinyunus2002@gmail.com 83
  84. 84.  Drugs 1. Carbimazole or metimazole 10-15mg tds. They prevent binding of iodine to tyrosine and MIT and DIT to T3 and T4 2. Proply or methyl- thiouracil 100-200mg tds acts like carbimazole 3. Sodium or potassium perchlorate 800mg daily. They prevent trapping of iodine. Maintenance is 100-200mg daily  Propranolol, a B- adrenergic blocker is added 40mg tds to relieve palpitations  Phenobarbitone or diazepam are give to reduce anxiety bbinyunus2002@gmail.com 84
  85. 85.  Symptoms improve in 7-14days and when patient becomes euthyroid usually in 4weeks, the antithyroids are reduce to maintenance for 12-18months and then stopped. 50% of patients relapse in 1-6months.  Drug toxicity;  Skin rashes, arthralgia, agranulocytosis, and rarely aplastic anaemia. Monthly white cell and red cell counts are done and treatments stopped if leucopenia or sore throat occurs. bbinyunus2002@gmail.com 85
  86. 86.  Radio- active iodine  I¹³¹ taken up irradiates and destroys the thyroid gland.  Patient should be made euthyroid before giving the radioactive iodine since only 50% becomes euthyroid  Not given below 45years for fear of malignancy later and pregnant women  Problems ;  Ophthalmoplegia 15%  Hypothyroidism 10% in one year and at 5years 40-50% bbinyunus2002@gmail.com 86
  87. 87.  Surgery;  Subtotal thyroidectomy is performed after patient is made euthyroid  Leaving about 4g (2g on each lobe), or 1/8 of the gland by visual estimation or by comparative weighing of tissue remove and tissue left behind  Complications;  Early  Respiratory obstruction; hemorrhage, bilateral abductor paralysis of the vocal cord from damage of recurrent laryngeal nerve, tracheal collapse, oedema from intubation  Hypothyroidism  Recurrent laryngeal nerve paralysis  Thyrotoxic crisis  Wound infection  Late ; hypothyroidism, recurrence, keloid bbinyunus2002@gmail.com 87
  88. 88.  Thyroid storm (thyrotoxic crisis);  Acute exacerbation of thyrotoxicosis and occurs in patient who is not euthyroid at the time of operation.  Occurs 6-24hours post surgery, patient is restless, maniacal with profuse sweating, severe dehydration, circulatory collapse, hypotension, hyperpyrexia(40°C), tarchycardia, hyperventilation, tremours, vomiting and diarrhea.  Treatment;  Iv hydrocortisone  Propranolol 20mg 6hourly  Proplythiouracil via N-G tube  Diazepam or phenobarbitone  Lugol’s iodine  IV fluids to correct dehydration  Tepid sponging  IV PCM  Oxygen may also be given bbinyunus2002@gmail.com 88
  89. 89. bbinyunus2002@gmail.com 89
  90. 90.  Identify  What are the sites of predilection  Types  complications  How is it treated  How does it differs from hypertrophic scar bbinyunus2002@gmail.com 90
  91. 91.  Keloid  Genetic predisposition  Preponderance in Africans  Commoner in adolescence, highest incidence is btw 10- 30years  Commoner in females  Persons suffering from TB are more prone  Most common site is the sternum  Does not occur in palms or sole bbinyunus2002@gmail.com 91
  92. 92.  Area of predilection; sternum, earlobe, face, neck, lower extremities, breast, chest, back and abdomen.  Types  Progressive(claw-like processes) and non-progressive  Acquired and spontenous  Complications  Ulceration  Infection  Malignant transformation; fibrosarcoma  Itching and tenderness bbinyunus2002@gmail.com 92
  93. 93.  Treatment ; very difficult  Multimodality; occlusive dressing, compression therapy, intralesional steroid injection, cryosurgery, excision, radiotherapy and leser surgery  Excision and radiotherapy  Excision and triamcinolone injection  Triple therapy; surgery, radiotherapy and triamcinolone injection  Compression therapy  Recent involution; intralesional interferon, 5FU, doxorubicine, bleomycin, verapamil,retinoic acid etc bbinyunus2002@gmail.com 93
  94. 94. DIFFERENCE BETWEEN KELOID AND HYPERTROPHIC SCAR KELOID HYPRETROPHIC SCARS Genetic predisposition yes no Site of occurrence chest wall, upper arm anywhere in the body, ears, lower neck common in flexure areas Growth continues to grow without growth limits for 6 month time limit, goes beyond scar limit to scar tissue only. and extends to normal skin. Treatment poor response good response to steroid Recurrence very high uncommon Collagen synthesis 20 times more than normal 6 times than normal skin skin,(type III thick ) (type III fine collagen) Age adolescence and middle children age Sex commoner in females equal in both sex Race more in blacks (15 times) no racial relation Structure Thick collagen with increased Fine collagen with epidermal hyaluronic acid increased alpha actin Size of injury no relation, small healed scar related to size of injury and can form large keloid duration of healing. bbinyunus2002@gmail.com 94
  95. 95. bbinyunus2002@gmail.com 95
  96. 96.  Identify and how is it prevented  What are the complications  How is it treated bbinyunus2002@gmail.com 96
  97. 97.  Complications;  Keloid or hypertrophic scar  Deformity and limitation of movement  False ankylosis  Marjolin’s ulcer  Cosmetically ugly  Treatment;  Timing ; 6month -1year when scar has matured  Contracture release and grafting  Method of release; single or multiple Z-plasty at the point of maximum tension bbinyunus2002@gmail.com 97
  98. 98.  Post burns contracture  From full thickness burns  Neglected Superficial burns which undergoes infection and ulceration  Prevention  Proper treatment of superficial burns  Adequate splintage of part in extension during healing  Prevention of infection  Early skin grafting  Early physiotherapy bbinyunus2002@gmail.com 98
  99. 99. bbinyunus2002@gmail.com 99
  100. 100.  Differential diagnosis  What are the various types of malignant melanoma  Which has the worst prognosis  What are other site lesion could be found  What features make a lesion suspicious  How is it staged  Treatment options  Prognosis bbinyunus2002@gmail.com 100
  101. 101.  Differential diagnosis;  Malignant melanoma  Squamous cell ca  Basal cell ca  Seborrhoeic keratosis  Cuteneous agiomata  Pyogenic granuloma  Kaposi sarcoma bbinyunus2002@gmail.com 101
  102. 102. Types of malignant melanoma  Superficial spreading (55%)  Nodular (15-30%)  Lentigo maligna(10%)  Acral lentiginous (29-72% in blacks and 2-8% in whites)  The nodular melanoma has the worse prognosis, then the acral lentigenous type. The lentigo maligna has the best prognosis  Common sites; skin, uveal coat of the eye, GI tract, leptomeninges, perianal skin. bbinyunus2002@gmail.com 102
  103. 103.  Origin  De novo 10%  Pre-existing naevus 90%  Signs of malignant changes in a benign naevus;  Pain  Itching  Satellitism  >6mm  Deepening of pigmentation  Crust formation  Inflammatory changes  ulceration  Bleeding  Irregularities of edges  Lymph node metastesis bbinyunus2002@gmail.com 103
  104. 104.  Staging  TNM – see text  Treatment;  Excision  Excision + elective lymph node dissection (ELND)  ELND is recommended only in patient with palpable or proven lymphadenopathy  Immunotherapy; cytokine and interferon as adjuvant  New immune and gene therapies; vaccine and gene therapy  Melanoma are radio and chemo- resistant bbinyunus2002@gmail.com 104
  105. 105. Prognosis  Clinical indicators  Sex ; better in females  Age ; better in younger < 60years  Site; worse in scalp, feet, hands and trunk  Pre-existing naevus ; better prognosis  Skin colour ; non- white poorer prognosis  Pathological indicators;  Tumour thickness (Breslow’s level); < 0.7mm good,>1.5mm likelihood to metastesis, >3.5mm greater tendency to met.  Ulceration; poor prognosis  Nodular, acral lentigenous and genital; unfavorable prognosis  Clark’s level (invasion)  Size of tumour; <2cm without spread good  Type of melanoma; lentigo maligna good prognosis bbinyunus2002@gmail.com 105
  106. 106. Breslow’s classification (1970): Based on thickness of invasion measured by optical micrometer—most important prognostic indicator until nodal spread  I: Less than 0.75 mm  II: Between 0.76 to 1.5 mm  III: 1.51 mm to 4 mm  IV: more than 4 mm bbinyunus2002@gmail.com 106
  107. 107. Clark’s levels  Level 1: Only in epidermis  Level 2: Extension into papillary dermis  Level 3: Filling of papillary dermis completely  Level 4: Extension into reticular dermis  Level 5: Extension into subcutaneous tissue bbinyunus2002@gmail.com 107
  108. 108.  Relation of Tumour Thickness to Nodal Spread—Based on AJCC Classification  Lesion Tumour thickness Nodal spread  Thin < 1 mm < 10%  Intermediate 1-4 mm 20-25%  Thick > 4 mm 60% bbinyunus2002@gmail.com 108
  109. 109. bbinyunus2002@gmail.com 109
  110. 110.  Defined  Classify  What are the causes  What abnormalities may be associated with it  How is it treated  Differential diagnosis  How does OFC changes with age bbinyunus2002@gmail.com 110
  111. 111.  Excessive accumulation of cerebrospinal fluid (CSF) in the ventricles and subarachnoid spaces due to disturbance in its formation, flow or absorption  Classification; 1. Communicating(non-obstructive) or non-communicating(obstructive) 2. Congenital or acquired 3. Hydrocephalus with increased ICP or Normal pressure Hydrocephalus  Causes ;  Increase CSF production; choroid plexus papilloma and choroid plexus carcinoma  CSF flow obstruction; aqueductal stenosis, brain lesion and tumour, infections, intraventricular bleeds, Dandy Walker cyst  Reduce CSF absorption; obstruction at the arachnoid granulations, otitic hydrocephalus, sinus thrombosis, arachnoiditis  Familial causes; Bicker’s Adam syndrome, an X-linked recessive abnormality bbinyunus2002@gmail.com 111
  112. 112. Associated abnormalities  Dandy-Walker syndrome  Arnold-Chiari malformation  Spina bifida  Aqueductal stenosis bbinyunus2002@gmail.com 112
  113. 113.  Treatment;  Medical; pre-operatively is commenced;  Acetazolamide- a carbonic anhydrase inhibitor  Furosemide- has synergistic action with acetazolamide  Surgery Shunting procedure ;  Ventriculo-peritonel  Ventriculo-pleural  Ventriculo-atrial  Lumboperitoneal  Torchedsen shunt bbinyunus2002@gmail.com 113
  114. 114.  Differential diagnosis;  Hydrocephalus ex-vacuo  Hydrancephaly  Familial big head  OFC- occipito-frontal circumference  At birth average 35cm  1st year it increase by 12cm to 47cm  In the 1st 3months, increase by 2cm/month (gain of 6cm)  In the next 3months increase by 1cm/month (gain of 3cm)  In the last 6months increase by 0.5cm/month (gain of 3cm) bbinyunus2002@gmail.com 114
  115. 115. bbinyunus2002@gmail.com 115
  116. 116.  What are the type  Risk factors  Prenatal diagnosis  What problems may be associated with it  How is it treated bbinyunus2002@gmail.com 116
  117. 117. Types ;  Spinal bifida occulta  Spinal bifida aperta (cystica) Risks factors;  Pre-conception maternal folic acid deficiency  Maternal exposure to excessive heat during time of fetal embryogenesis  Use of valproic acid (an anticonvulsant) during pregnancy  Previous birth of a child with NTD  Maternal cocaine abuse bbinyunus2002@gmail.com 117
  118. 118.  Prenatal diagnosis;  Maternal serum alpha-fetoprotein at 15-20weeks is more than twice for that gestational age  Prenatal ultrasound detects 90-95% of spinal bifida  Amniotic fluid alpha-fetoprotein is very high  Extreme maternal age  Complicated pregnancies e.g toxemia, hydramnois, malpresentations  Associated anomalies  Hydrocephalus  Club foot  Fecal incontinence  Urine incontinence bbinyunus2002@gmail.com 118
  119. 119.  Treatment;  Multidisiplinary  Myelomeningocele excision and repair  Serial manipulation of club foot  Incontinence at an older age  Complications of surgery  Wound infection and meningitis  CSF leak  Hydrocephalus  Nerve or spinal cord injury bbinyunus2002@gmail.com 119
  120. 120. bbinyunus2002@gmail.com 120
  121. 121. (a)State 3 descriptive features of the bowel in this picture (b) What is the likely diagnosis (c) State 3 investigation necessary to confirm this diagnosis (d) What surgery was being carried out (e) State 2 complications of this surgery bbinyunus2002@gmail.com 121
  122. 122. (a)Megacolon, transition zone and collapsed bowel segament (b)Hirschsprung’s disease (c)Unprepared Barium enema, rectal biopsy, anorectal manometry (d)Pull through surgery (e)Rectal prolapsed/retraction, gangrene, bowel perforation bbinyunus2002@gmail.com 122
  123. 123. PIX 4 bbinyunus2002@gmail.com 123
  124. 124. (a)What is the spot diagnosis? (b)State 2 differential diagnosis (c)What is the embryologic origin of this condition? (d)State 3 possible complications (e)Classify this condition bbinyunus2002@gmail.com 124
  125. 125. (a)Sacrococcygeal teratoma (b)Spinal bifida; Lipoma (c)Primitive streak (d)Infection, Ulceration, malignant transformation (e) -Type I predominantly external with minimal presacral component -Type II external with a significant intrapelvic component -Type III external with predominant pelvic mass with intra abdominal extension -Type IV entirely presacral without external or pelvic extension bbinyunus2002@gmail.com 125
  126. 126. bbinyunus2002@gmail.com 126
  127. 127.  Defined  Classify  Modalities of treatment  Lymphoedema; is interstitial oedema of lymphatic origin resulting in protein-rich fluid accumulation in the interstitial compartment.  Classification ;  Primary  Secondary bbinyunus2002@gmail.com 127
  128. 128.  Primary ; developmental defects of subcutaneous lymphatic channels. There are 3 types;  Lymphoedema congenital(10%) ; aplasia  < 2year of age  10-25% of all primary lymphedema  When Sporadic or familial (Milroy's disease)  More common in males  Lower extremity is involved 2 times more frequently than the upper extremity  2/3 patients have bilateral lymphedema bbinyunus2002@gmail.com 128
  129. 129.  Lymphedema praecox (75%) : hypoplasia (reduced number and caliber)  Evident after birth and before age 35 years  Most often arises during puberty  65-80% of all primary lymphedema cases  Females are affected 4 times  70% of cases are unilateral, with the left lower extremity being involved bbinyunus2002@gmail.com 129
  130. 130.  Lymphoedema tarda (15%);  not evident until 35 years or older  Rarest form of primary lymphedema  Only 10-15% of cases  Hyperplasic pattern, with tortuous lymphatics increased in caliber and number  Absent or incompetent valves bbinyunus2002@gmail.com 130
  131. 131. Secondary lymphedema;  Trauma  Surgery—inguinal block or axillary block dissection/postmastectomy with axillary clearance  Filarial lymphoedema due to Wuchereria bancrofti—common cause in coastal region  Tuberculosis  Syphilis  Fungal infection  Advanced malignancy—hard, fixed lymph nodes in axilla orin inguinal region  Postradiotherapy lymphoedema  Bacterial infection  Rare causes: Rheumatoid arthritis, snake, and insect bite, DVT, chronic venous insufficiency bbinyunus2002@gmail.com 131
  132. 132. Brunner’s grading bbinyunus2002@gmail.com 132
  133. 133. Treatment Modalities  Conservative;  Hygiene of affected limb  Limb elevation  Compression stockings once swelling is reduced  Physiotherapy  External pneumatic compression  Surgery Debulking operations ;  Homan’s procedure  Charlse procedure  Sistrunk procedure  Thompson’s procedure bbinyunus2002@gmail.com 133
  134. 134.  Bypass surgery  Lymphaticovenous anastomosis  Lymphaticolyphatic anastomosis  Enteromesenteric bridges  Omental bridges  Skin and muscle flap bbinyunus2002@gmail.com 134
  135. 135. bbinyunus2002@gmail.com 135
  136. 136. Identify and how is it treated Polydactyly Excision and wound closure bbinyunus2002@gmail.com 136
  137. 137. bbinyunus2002@gmail.com 137
  138. 138.  Identify the lesion in this 24year man  How is it classified  What are the differential diagnosis if unilateral  What are relevant investigation  What are the modalities of treatment bbinyunus2002@gmail.com 138
  139. 139.  Gynaecomastia  Grade;  1- minor breast enlargement with no redundant skin  2a- moderate breast enlargement with no redundant skin  2b-moderate breast enlargement with redundant skin  3- grossly enlarged breast  Unilateral enlargement;  Breast cancer  Fibroadenoma  Fibrocystic changes  Phylloides tumour bbinyunus2002@gmail.com 139
  140. 140.  Investigations  Hormonal assay; testosterone, estrogen, LH, FSH, prolactin, TFT  LFT  Abdominal USS, testicular USS, CXR  Biopsy; FNAC  Treatment; over 80% regress spontenously ;  If the cause found and treated  Subcutenous mastectomy; via an infra-mammary incision or endoscopic with small distant incision to prevent breast scar  Danazol 200mg bd for 3month reduces breast in 50%  Tamoxifen 20mg od cause complete regression in 80% of middle aged bbinyunus2002@gmail.com 140
  141. 141. bbinyunus2002@gmail.com 141
  142. 142.  List 3 differential diagnosis  If the swelling moves with tongue protrusion how is it treated Differential diagnosis;  Thyroglossal cyst  Ectopic thyroid  Pretracheal lymph node  Dermoid cyst  Solitary nodule of thyroid—isthmus  Submental lymph node  collar stud abscess  Subhyoid bursa bbinyunus2002@gmail.com 142
  143. 143. Treatment of thyroglossal cyst Sistrunk operation:  Excision of cyst and also full tract upto the foramen caecum is done along with removal of central part of the hyoid bone, as the tract passes through it. bbinyunus2002@gmail.com 143
  144. 144. bbinyunus2002@gmail.com 144
  145. 145.  Identify  What is the incidence  How is the spectrum of the disease  How is it treated Bladder extrophy (ectopia vesicae) Incidence;1/10,000-50,000. M:F is 2:1 Other associated pathology; widely separated pubic rami, externally rotated femora, epispadia. May be associated with other genital, neuronal or anorectal anomalies,undescended testes, inguinal hernia. Cause of death; ascending pyelonephritis 200 time risks of carcinoma.-adenocarcinoma bbinyunus2002@gmail.com 145
  146. 146. Treatment  Defect is repaired early to prevent metaplasia and malignant changes  Bladder is closed or augumented by ileum  Bladder neck reconstruction  Pubic rami is approximated  Anterior abdominal wall closed  At times, the bladder is excised and continent urinary diversion done and later epispadia repair bbinyunus2002@gmail.com 146
  147. 147.  Spectrum  Covered extrophy (only apical portion of the bladder is involved the anterior abdominal wall muscle is intact)  Epispedia  Ectopia vesicae  Cloacal extrophy bbinyunus2002@gmail.com 147
  148. 148. bbinyunus2002@gmail.com 148
  149. 149.  Spot diagnosis  What are the types  What side is commoner and why  Important signs  How is it graded  How are the types differentiated  An important complication  What are the modalities of treatment bbinyunus2002@gmail.com 149
  150. 150.  Varicocele; dilatation, elongation and tortusity of the vein draining the testis (pampiniform venous plexus)  Types;  Primary or idiopathic  Secondary  Signs; bag of worm feel, cough impulse, disappears on lying, reappears from bottom to top on standing, bow sign.  Grade; 1- are palpable only on valsava maneuver 2- palpable without any maneuver 3- visible to the exerminer’s eye bbinyunus2002@gmail.com 150
  151. 151.  Commoner on the left side because;  Left spermatic vein drains into the left renal vein at rigth angle  Left testicular vein is longer  Absent valve at the termination of left spermatic vein  Left renal vein is crossed by and may be compressed by left colon, may also be obstructed by left renal artery  Metastatic renal tumour may cause obstruction of the vein  Primary varicocele empties as the scrotum is elevated when patient is lying while secondary does not. bbinyunus2002@gmail.com 151
  152. 152.  Complication  Infertility  Treatment  Conservative  Surgery open Open ligation of varicocele – scrotal, inguinal approach(ivanissevitch procedure) and suprainguinal extraperitoneal approach (Palomo approach) Laparoscopic embolisation bbinyunus2002@gmail.com 152
  153. 153. bbinyunus2002@gmail.com 153
  154. 154.  Generalised neurofibromatosis or Von Recklinghausen’s disease  Neurofibroma; a benign tumour containing a mixture of neural(ectodermal) and fibrous(mesodermal) element. It arise not from the nerve proper but from endoneurium which is a supporting connective nerve tissue  Types;  Type 1 and type 2 bbinyunus2002@gmail.com 154
  155. 155.  Type 1  Autosomal dominant with defective gene on chromosome 17  Diagnostic criteria; two or more of;  six or more cafe-au -lait > 5mm in diameter if prepubertal individuals and> 15mm in postpubertal individuals,  Two or more neurofibroma or one plexiform neurofibroma,  freckles in the axilla or groin,  optic glioma,  Two or more iris hamartomas,  a distinctive osseous lesion such as sphenoid dysplasia or thing of long bone cortex with or without pseudoarthrosis ,  A first degree relative with NF-l. bbinyunus2002@gmail.com 155
  156. 156.  Complications of type 1;  Hypertension (6%). Due to renal artey stenosis  scoliosis, bowing of the legs, impaired vision, ptosis, optic atrophy, language or learning disorders , mental retardation, precocious puberty or hypogonadism, GI hemorrhage,  Malignancy(5%) bbinyunus2002@gmail.com 156
  157. 157.  Type 2  Autosomal dominant with defect on chromosome 22  Diagnostic criteria are;  Bilateral 8th nerve masses seen with appropriate imaging techniques (e.g. CT, MRl) or One 8th nerve mass With two of the following: neurofibroma, meningioma., glioma, Schwannomas or posterior lenticular opacity.  Complications;  hearing loss. tinnitus, dizziness, loss of balance, headaches, fits.  There may be a first-degree relative with NF-2. bbinyunus2002@gmail.com 157
  158. 158. bbinyunus2002@gmail.com 158
  159. 159. bbinyunus2002@gmail.com 159
  160. 160. treatment  All patients must be reviewed yearly .  Surgery is employed only when there is severe cosmetic deformity , increase in. size, Evidence of malignant change, functional disturbance or pain  A progressive 8th nerve tumour that causes tinnitus or vertigo is removed while bilateral hearing remains.  Any signs of epilepsy should be investigated and responsible tumours removed.  Genetic counselling should also be given bbinyunus2002@gmail.com 160
  161. 161. bbinyunus2002@gmail.com 161
  162. 162.  Differential diagnosis  If histology shows cell-nest,  what is the likely diagnosis  what are likely pre-existing skin lesions  What are the types  Risk factors  What are the modalities of treatments bbinyunus2002@gmail.com 162
  163. 163.  Differentials;  Squamous cell carcinoma  Basal cell carcinoma  Keratoacantoma  Amelanotic melanoma  Nest cells is characteristic of squamous cell ca  Pre-existing lesions;  Senile(or solar) keratosis  Bowen’s disease- erythroplasia of Queyrat  Leukoplekia  Lupus vulgaris  Xeroderma pigmentosis  Radiodermatitis  Chronic ulcer  Chronic skin irritation; ‘chimney sweep ca’- scrotal, kangri ca of Kashmir, etc bbinyunus2002@gmail.com 163
  164. 164.  Types;  Proliferative or cauliflower  Ulcerative - common  Risk factors;  UV light exposure  Ionizing radiation  Immunosuppression  Chronic inflammation  Arsenic exposure  Inherited disorders; albinism, xerodma pigmentosis  Smoking bbinyunus2002@gmail.com 164
  165. 165.  Treatment options;  Surgical excision  Radiotherapy  Topical treatment(5-FU, phytodynamic therapy)  Electrosurgery (curettage and electrodessication)  Cryotherapy  Moh’s surgery bbinyunus2002@gmail.com 165
  166. 166. bbinyunus2002@gmail.com 166
  167. 167.  Identify  Differential diagnosis  What are radiological findings in infantile blount’s disease and angles of radiological importance  Treatment bbinyunus2002@gmail.com 167
  168. 168.  Genu varum Differential diagnosis;  Physiologic genu varum  Pathologic conditions  Metabolic bone disease – rickets, hypophosphatemia  Asymmetrical bone arrest or retardation- blount disease, trauma near the growth epiphysis of femur, osteomyelitis, tumour affecting the lower end of femur and upper tibia.  Bone dysplasia; metaphysical chrondrodysplasia  Congenital; deficient tibia relative to long fibula  Neuromuscular; in adult, degenerative disorders(osteoarthritis of the knee) and paget’s disease are important causes. bbinyunus2002@gmail.com 168
  169. 169.  AP and lateral Xray ;  Flattening or disappearance of the medial aspect of the epiphysis and apparent increase in the height of the lateral aspect of the epiphyseal plate  Breaking of the proximal medial tibial metaphysis  Fragmentation with a protuberant step deformity  Angles of radiological importance;  Metaphysial- diaphyseal angle  Tibiofemoral angle  Metaphyseal- epiphyseal angle bbinyunus2002@gmail.com 169
  170. 170.  Metaphyseal-diaphyseal angle is important in differentiating Blount’s disease from physiological bowing in a child less than 2years  MDA< 11° normalphysiologic bowing  MDA 11-15° equivocal  MDA> 15° blount disease bbinyunus2002@gmail.com 170
  171. 171. Treatment Non-surgical;  Observation and trial of bracing (2-5years) Surgical  Corrective osteotomy aiming at 6-10° of valgus  Others;  Hemiepiphysiodesis  Asymmetric physeal extraction  External fixation with distraction osteogenesis bbinyunus2002@gmail.com 171
  172. 172. bbinyunus2002@gmail.com 172
  173. 173.  Identify  What are the causes  Treatment Genu valgum (knock knee) Causes;  Idiopathic  Bone softening; rickets, osteomalecia, paget disease  Laxity of ligament; medial collateral ligament  Trauma; lateral tibial condyle  Ostheoathritis  Muscle weakness NB; intermalleola distance > 10cm bbinyunus2002@gmail.com 173
  174. 174. Treatment Non-operative  Idopathic- ignored <7years  Raising inner side of the heel by 3-4mm  Using splint Operative;  For > 10years  Risk factor corrected  Stapling innerside of epiphysis to stop growing  Supracondylar osteotomy, after growth is completed bbinyunus2002@gmail.com 174
  175. 175. bbinyunus2002@gmail.com 175
  176. 176.  State two (2) differential diagnoses.  Give one major reason why Burkitt’s tumour is not a likely differential diagnosis of this particular lesion.  State (a) types of Surgical treatment that may be offered and (b) for which types of cases?  List two major complications that may follow surgical treatment in this specific case. bbinyunus2002@gmail.com 176
  177. 177.  Differentials  1. Benign Parotid tumour  a. Pleomorphic adenoma (mixed parotid tumour) – 60%  b. Monomorphic adenoma (Adenolymphoma - Warthin's Tumour) – 10%  2. Malignant Parotid tumour  a. Mucoepidermoid tumour )  b.Acinic cell tumour ) – 4%  c. Adenoid cystic carcinoma )  Investigations  1. FNAC helps to diagnose most cases of malignancies but it is not always reliable. Frozen section also gives some false-positive results.  2. CT is the most accurate investigation. It helps to determine the local and regional extent of the disease.  Treatment  Superficial/total Parotidectomy  1. Benign mixed tumors arising in the lateral lobe. Wide excision to prevent recurrence.  a. Identify the facial nerve and branches  b. Facial nerve may be excised if involved in malignancy  c. Medial lobe involvement may require a total parotidectomy bbinyunus2002@gmail.com 177
  178. 178.  BARAKALLAHU FI bbinyunus2002@gmail.com 178
  179. 179. Test questions bbinyunus2002@gmail.com 179
  180. 180. bbinyunus2002@gmail.com 180
  181. 181. bbinyunus2002@gmail.com 181
  182. 182. bbinyunus2002@gmail.com 182
  183. 183. bbinyunus2002@gmail.com 183

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