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Observation by an assistant and notation of facial switching and motion and its location generlly are more helpful than the use of a facial nerve stimulator.
8- Aciod making the posterior portion of the flap in the infraauricular area too thin or too long to prevent skin necrosis.
9- infection after parotidectomy is rare: preoperatively, anitibiotics are only needed with a pre-existing history of sialadenitis. 1- Use of a facial nerve stimulator is unnecessary except in reoperations.
2-Reoperating in the parotid bed should with the aid of intraperative faical nerve monitoring.
3- Key landmarks for identifying the facial nerve include the cartilaginous pointer, the mastiod tip, and the posterior belly of the digstric muscle. Observation by an assistant and notation of facial switching and motion and its location generlly are more helpful than the use of a facial nerve stimulator.
8- Aciod making the posterior portion of the flap in the infraauricular area too thin or too long to prevent skin necrosis.
9- infection after parotidectomy is rare: preoperatively, anitibiotics are only needed with a pre-existing history of sialadenitis.
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2. INTRODUCTION
⢠Congenital syphilis is infection of fetus in utero as a
result of syphilitic infected mother and refers to all
outcome of pregnancy ( spontaneous abortion, still birth,
live syphilitic child)
3. INCIDENCE
⢠Occurrence of cong. syphilis â indication of STD in a
given population
⢠Sub-SaharanAfrica- 10% pregnant women are affected by
syphilis
⢠Decline in incidence after the introduction of penincillin
⢠In India - <1/1000 of childhood STDâs
5. Early congenital syphilis
Early cong.
syphilis
⢠Primary stage â absent (blood borne)
⢠Baby â Preterm/full term
Lack
manifestations -
birth
rhinitis,
pneumonia,
failure to thrive
Classical
presentation -
birth
Wizened, pot
belly, hoarse baby
looking like old
man, withered
brown skin &
runny fissured
nose.
More prone for
intercurrent
infection
6. Skin Lesions
⢠Vesicobullous rash, symetrically , palms and soles-
earliest & specific sign.
⢠Also known as Pemphigus syphiliticus
⢠Lesions are contagious, also seen around oral cavity,
trunk, buttocks, and genitilia.
⢠Few weeks later, a papulosquamous rash may appear.
Usually involve the face, mouth, anterior nares, buttocks,
palms & soles.
10. ⢠Condylomata lata- flat topped, hypertrophic, moist
papules which are greyish white.
ďś Present- angle of mouth, nose, perianal, vulvar.
⢠Rhagades- healed linear scar of radiating fissures
produced due to movement of lips.
⢠Nail- syphilitic paronychia(due to nail bed involvement)
ď atrophic nail, claw nail deformity.
⢠Hair-brittle and sparseď patchy alopecia
16. Lymph Nodes
⢠Generalized lymphadenopathy seen in 50% of the cases.
⢠Nodes are multiple , discrete & non tender
⢠Epitrochlear lymphnodes are considered pathognomonic
17. Bone lesions
⢠During first six months â osteochondritis of long bones
(upp. end of tibia, distal end of radius & ulna)
⢠Child presents with severe pain, tenderness while
handling with consequent loss of movements ď syphilitic
pseudo paralysis.
⢠Wimbergerâs sign- loss of density on the medial side of
upper end of tibia .
⢠Syphilitic dactilitis- painless fusiform swellings of the
digits, osteochondritis of phalanges occur in the second
year of life.
18.
19.
20. Eyes
⢠Choroidoretinits, glaucoma, uveitis .
⢠Choroidoretinitis in later life is seen as salt & pepper
fundus showing black pigment & white atrophic patches.
21.
22. Centralnervous system
Asymptomatic
No clinical disease
Abnormal CSF
findings
Symptomatic
Meningeal or
meningoencephalitis
involvement
Convulsions, bulging
fontanelles, stiffness of
neck, hydrocephalus &
CSF findings
23. Other organ systems
⢠Liver & spleen â hepatosplenomegaly & ascites ď
protuberant abdomen. It may be associated with jaundice
& hypoproteinaemia
⢠Kidneys- presence of hyaline , albumin & granular casts
in urine.
ďśProliferative / membraneous glomerulonephritis may be
seen.
⢠Lungs- infiltration of lungs is known as
âwhite pneumonia or pneumonia albaâ.
⢠Pancreas & intestines â syphilitic diarrhoea
⢠Heart- myocarditis
25. Stigmata
⢠They are scars & deformity resulting from cong. Syphilis
⢠Few are characteristic & remain as permanent evidence of
infection. Eg:
1. âHot cross bunâ look of the cranium.
bossing due to chondritis & focal osteitis)
2. Olympian brow
3. Saddle nose
4. Short maxilla
5. High arched palate
(frontal & parietal
1. âBull dog jawâ (prominent mandible)
2. â Sabre tibiaâ
3. Scaphoid shape of the scapula
4. âHigoumenakisâ signâ â thickening of the medial third of
clavicle
26.
27.
28.
29. ⢠Hutchinsonsâ teeth
ďś Seen at 6yrs / later
ďś Permanent upper central incisors are shorter than the lateral
incisors
ďś Widely spaced
ďś Have a notch in the bitting edge
ďś Due to defective enamel formation
ďś Assume a peg / cork screw driver shape
ďś Other incisors may also be effected
30.
31. ⢠Mulberry / Moonâs molars:
ďśFirst lower molars â commonly effected
ďśUnder developed & poorly enameled
ďśBitting surface - dome shaped with small projections of ill
developed cusps
ďśMore prone to caries
ďśUsually lost in early life
33. Interstitial keratitis
⢠Itâs the most common late manifestation of syphilis
⢠Age : 5 â 15yrs.
⢠Symptoms : unilateral photophobia, pain, excessive
watering of eyes & blurred vision.
⢠Usually starts in one eye, the other eye is likely to be
involved in a matter of 2 weeks
34. Neuraldeafness
⢠Hypersensitivity reaction to treponemes.
⢠Due to involvement of cochlear part of VIII nerve
⢠Symptoms :
ďśTinnitis
ďśVertigo
ďśHearing loss
ďśCochlear degeneration (osteochondritis of otic capsule)
ďśSensorineural deafness (ossicles involvment)
35. Nervoussystem
⢠Clinical manifestations may be symptomatic /
asymptomatic
⢠Juvenile paresis is more common than juvenile tabes
⢠Dementia may occur
⢠Ass. with optic atrophy
36. Skin & mucous membrane lesions
⢠Gummas â usual presenting features .
⢠They may manifest as nodules, nodulo ulcerative &
subcutaneous lesions
nasal septal & palatal perforation
nasal twang & regurgitation of food
37. Bone lesions
⢠Gummas may involve long & flat bones
⢠Manifest as diffuse / localized
osteoperiostitis
⢠Bones- thickened , tender
⢠Tibia is most frequently involved, thickening of middle
third causes anterior bowing âSabre tibiaâ
⢠Localized osteoperiostitis of the skull bones causes the
formation of rounded, bony swelling âParrot nodesâ
⢠Thickening of the inner
âHigoumenakis signâ
⢠Dactilitis â rarely occurs.
third of the clavicle
38. Cluttonâsjoint
⢠Perisynovitis of the knee joint
⢠Age: 8 â 15yrs
⢠Leads â hydroarthrosis
⢠Itâs a painless swelling, insidious in onset & chronic in
course
⢠Usually B/L knees are involved
⢠Mobility is preserved (no impairment of function)
⢠X-ray âenlargement of joint spaces with no bone change
⢠Occasionally elbow joint is involved
39.
40. Other organs
⢠Liver is occasionally involved
⢠Cardiovascular syphilis is quite rare
41. Paroxysmal cold
haemoglobinuria
⢠Present in both congenital & acquired syphilis
⢠Due to the presence of thermolabile haemolysin in blood
⢠This test can be performed in vitro as a diagnostic test.
This
antibody
sensitizes
RBC
Hemolyses
them in the
presence of
complement
Donath
Landsteiner
reaction
43. Diagnosis
1. Demonstration of T. pallidum by direct examination â
nasal discharge/ early lesions of congenital syphilis.
1. A positive non-treponemal test in a titre higher than the
mother / rising titre in serial monthly tests.
⢠(but these results do not necessarily indicate infection of the
infant & may be due to the presence of reagin & specific
antibodies which has passed from the maternal to fetal
circulation)
2. An active infection can be ruled out by performing
FTAâ ABS test
3. Western blot supplementing FTA-ABS tests on serum
4. PCR on CSF fluid.
44. Recommended Evaluation
⢠CSF analysis for VDRL , cell count and protein
⢠CBC , differential & platelet count
⢠Other tests as clinically indicated ( long bone radiographs,
chest radiograph, liver function tests, cranial ultasound,
opthamologic examination and auditory brainstem
response)
46. Recommended Regimens
1. Aqueous crystalline penincillin G-
⢠1,00,000 â 1,50,000 units/kg/day
⢠Administered as 50,000 units/kg/dose IV
ďś First 7 days- 12th hourly
ďś Next 10 days â 8th hourly
OR
1. Procaine penincillin G-
⢠5,00,000 units/kg/dose IM in a single daily dose â 10days
⢠If more than 1 day therapy is missed , the entire course
should be restarted.
47. Evaluation & treatment of older infants
and children
⢠Any child at risk for congenital syphilis should receive a
full evaluation and testing for HIV infection.
⢠Recommended evaluation:
ďśCSF analysis for VDRL , cell count and protein
ďśCBC , differential & platelet count
ďśOther tests as clinically indicated ( long bone radiographs,
chest radiograph, liver function tests, cranial ultasound,
opthamologic examination and auditory brainstem response)
48. ⢠Recommended regimen:
1. Aquoeus crystalline penincillin G â
⢠2,00,000 â 3,00,000 units/kg/day IV
⢠Every 4 to 6 hours- 50,000 units/kg
2. If child has no clinical symptoms and CSF is normal,
CSF VDRL is negative â
⢠50,000 units/kg IM upto 3 weekly doses.
