Clinical

Hernia

Introduction-

                      A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the wall of its containing cavity. The external abdominal hernia is the most common form, the most frequent varieties being the inguin

Figure:Hernia

Aetiology

                 Any condition that rises the intra-abdominal pressure such as powerful muscular efforts, may produce a hernia. Whooping cough is a predisposing cause in childhood, whereas chronic cough, straining on micturation or straining on defaecation may precipitate a hernia in adult. Hernias are more common in smokers, intra-abdominal malignancy can be a cause of hernia. Stretching of the abdominal musculature because of an increase in contents as in obesity can be another factor. Fat acts to separate muscle bundles and layers, weaken aponeuroses and favour the appearance of para-umbilical, direct inguinal and hiatus hernia. An indirect inguinal hernia may occur in a congenital preformed sac- the remains of the processus vaginalis.

Composition of hernia

                                      A hernia consists of three parts- the sac, the covering of the sac, and the contents of sac.

The sac- The sac is a diverticulum of peritoneum consisting of mouth, neck, body and fundus.

  The neck is usually well defined but in some direct inguinal hernia and many incisional hernias, there is no actual neck.

   The body of the sac varies greatly in size and is not necessarily occupied. In long standing case the wall of the sac may be comparatively thick.

The coverings of the sac-Coverings are derived from the layers of the abdominal wall through which the sac passes. In longstanding cases they become atrophied from stretching and so amalgamated that they are indistinguishable from each others.

Contents

                These can be-

• Omentum- Omentocele
• Intestine-   Enterocele
• A portion of circumference of the intestine- Richter’s hernia
• A portion of bladder may constitute part of or sole content of direct inguinal, a sliding inguinal or a femoral
• Ovary with or without the corresponding fallopian tube.
• A meckle’s diverticulum- a little’s hernia.
• Fluid as a part of ascites or residuum there of.

Classification- Irrespective of site, a hernia can be classified into five different types-

·         Reducible hernia- The hernia either reduces itself when the patient lies down or can be reduced by the patients or the surgeon. The intestine usually gurgles on reduction and the first portion is more difficult to reduce than the last. Omentum in contrast is described as doughy and the last portion is more difficult to reduce than the first. A reducible hernia imparts an expansile impulse on coughing.

·         Irreducible hernia- In this case the contents cannot be return to the abdomen but there is no evidence of other complications. It is usually due to adhesions between the sac and its contents or overcrowding with in the sac.

·         Obstructed hernia- This is an irreducible hernia containing intestine that is obstructed from without or within but there is no interference to the blood supply to the bowel. The symptoms are less severe and the onset more gradual than in strangulated hernia (colicky abdominal pain).

·         Incarcerated hernia- The term incarceration is often used loosely as an alternative to obstruction or strangulation but is correctly employed only when it is considered that the lumen of that portion of the colon occupying hernial sac is loaded with feces.

·         Strangulated hernia- A hernia becomes strangulated when the blood supply of its contents is seriously impaired, rendering the contents are ischaemic. Gangrene may occur as early as 5-6 hours after the onset of first symptoms. Although inguinal hernia may be 10 times more common than femoral hernia, a femoral is more likely to strangulate.

Pathology-

                 The intestine is obstructed and its blood supply impaired. Initially only the venous return is impeded; the wall of intestine becomes congested and bright red with the transudation of serous fluid into the sac. As congestion increases the wall of the intestine becomes purple in color. The intestinal pressure increase, distending the intestinal loop and impairing the venous return further. As venous stasis increase, the arterial supply becomes more and more impaired. Blood is extravasated under the serosa and is effused into the lumen. The fluid in the sac becomes blood stained and the shining serosa dull because of a fibrinous, sticky exudate. At this stage the walls of the intestine have lost their tone and becomes friable. Bacterial transudation   occurs secondary  to the lowered intestinal viability and the sac fluid becomes infected. Gangrene appears at the rings of constriction, which become deeply indented and grey in color. The gangrene then develops in the anti mesenteric border. The mesentery involved by the strangulation also becomes gangrenous. If the strangulation is unrelieved perforation of wall of the intestine occurs.

Clinical features

                            Sudden pain, at first situated over the hernia, is followed by generalized abdominal pain, colicky in nature and often located mainly at the umbilicus. Nausea and subsequently vomiting ensue. The patient may complain of an increase in hernia size. On examination, the hernia is tense, extremely tender and irreducible, and there is no expansile cough impulse.

Strangulated hernias

·         Present with local then general abdominal pain and vomiting.

·         A normal hernia can strangulate at any time.

·         Most common in hernias with narrow necks such as femoral hernias.

·         Require urgent surgery.

                          

Types of hernia

·         Reducible- Contents can be return to abdomen

·         Irreducible- Contents cannot be returned but there are no other complications.

·         Obstructed- bowel in the hernia has good blood supply but bowel is obstructed.

·         Strangulated- blood supply of bowel is obstructed.

·         Inflamed- contents of the sac have become inflamed.

  Natural history of hernias

·         Irreducible hernias-there is a risk of strangulation at any time

·         Obstructed hernias- usually go on to strangulation

·         Strangulated hernias-Gangrene can occur within 6 hours.

Richter’s hernia

                            Richter’s hernia is a hernia in which the sac contains only a portion of the circumference of the intestine (usually small intestine). It usually complicates femoral and rarely, obturator hernias.

Inflamed hernia

                           Inflammation can occur from inflammation of the contents of the sac, e.g. acute appendicitis or salphingitis, or from external cause, e.g. the tropic ulcers that develop in the dependent area of large umbilical or incisional hernias. The hernia is usually tender but not tense and the overlying skin red and edematous. Treatment is based on treatment of underlying cause.

Inguinal hernia

      Surgical anatomy- The superficial inguinal ring is a triangular aperture in the aponeurosis of the external oblique muscle and lies 1.25cm above the pubic tubercle.

      The deep inguinal ring is a U shaped condensation of the transversalis fascia and lies 1.25cm above the inguinal ligament, midway between the symphysis pubis and the anterior superior iliac spine. The transversalis fascia is the fascial envelope of the abdomen and the competency of the deep inguinal ring depends on the integrity of this fascia.

Figure:Inguinal Hernia

      The inguinal canal

                                      In infant the superficial and deep inguinal rings are superimposed and the obliquity of the canal is slight. In adult the inguinal canal which is about 3.75cm long and directed downwards and medially from the deep to superficial inguinal ring. In male the inguinal canal transmit the spermatic cord, the ilio-inguinal nerve and the genital branch of genito-femoral nerve. In the female the round ligament replaces the spermatic cord. The anterior boundary comprises mainly the external oblique aponeurosis with the conjoined muscle laterally. The posterior boundary is formed by the fascia transversales and the conjoined tendon. The inferior epigastric vessels lie posteriorly and medially to the deep inguinal ring. The superior boundary is formed by the conjoined muscle and the inferior boundary is the inguinal ligament.

         An indirect inguinal hernia travels down the canal on the outer side of the spermatic cord. A direct hernia comes out directly towards directly forwards through the posterior wall of the inguinal canal. The neck of the indirect inguinal hernia is lateral to the inferior epigastric vessels, the direct hernia usually emerges medial to this.

  Natural history of inguinal hernia

• Inguinal hernia in babies are the result of a persistent processus vaginalis.
• Indirect inguinal hernia is the most common hernia of all specially in the young.
• Direct inguinal hernia becomes more common in the elderly.

Indirect (oblique) inguinal hernia

                                                        This is the most common form of hernia. Indirect hernias are most common in the young whereas direct hernias are most common in the old. In the first decade of life, inguinal hernia is more common on the right side in the male. In adult males 65% of the inguinal hernias are indirect and 55% are right sided. The hernia is bilateral in 12% of cases.

Natural history of inguinal hernias

·         Inguinal hernias in babies are the result of a persistent processus vaginalis

·         Indirect inguinal hernia is the most common hernia of all, specially in the young

·         Direct inguinal hernia becomes more common in the elderly.

 Types of indirect inguinal hernia

1)       Bubonocele-The hernia is limited to the inguinal canal.

2)       Funicular -  the processus vaginalis is closed just above the epididymis. The contents of the sac can be felt separately from the testes,which lies below the hernia.

3)       Complete – A complete inguinal hernia is rarely present at birth but is commonly encountered in infancy. It also occurs in the adolescence or in adulthood. The testis appears to lie within the lower part of the hernia.

Differential diagnosis in the male 

• Vaginal hydrocele
• Encysted hydrocele of the cord
• Spermatocele
• Femoral hernia
• Incompletely descended testis in the inguinal canal- an inguinal hernia is often associated with this condition;
• Lipoma of the cord

Differential diagnosis in the female

• Hydrocele of the canal of Nuck
• Femoral hernia.

Treatment

                  Operation is the treatment of choice.

Treatment of hernias

• Surgery is the treatment of choice
• Surgery is either open or laparoscopic
• Any hernia can strangulate.

Direct inguinal hernia

                                      In adult 35% of the inguinal hernia are direct. A direct inguinal hernia is always acquired. The sac passes through a weakness or defect of transversalis fascia in the posterior wall of the inguinal canal. In some cases the defect is small and is represented by a discrete in the transversalis fascia, whereas in others there is a generalized bulge.

    Direct hernias do not often attain a large size or descend into the scrotum. In contrast to an indirect inguinal hernia, a direct inguinal hernia lies behind the spermatic cord. The sac is often smaller than the hernial mass would indicate, the protruding mass mainly consisting of extra-peritoneal fat. As the neck of the sac is wide, direct inguinal hernias do not often strangulate.

Direct inguinal hernias

• All are acquired
• They are most common in older man
•  They rarely strangulate

Operation for direct inguinal hernia

                                                             The principles of repair of direct inguinal hernias are the same as those of indirect hernia, with the exception that the hernia sac can usually be simply inverted after it has been dissected free and the transversalis fascia reconstructed in front of it. The reconstruction of the posterior wall of the inguinal canal should be undertaken by the Shouldice repair or by using a mesh implant according to the Lichtenstein technique. The ‘Bassini’ darn operation is no longer acceptable because of its high recurrence rate and slow rehabilitation.

Sliding hernia ( hernia-en-glissade)

                                                        As a result of  slipping of the posterior parietal peritoneum on the underlying retroperitoneal structures, the posterior wall of the sac is not formed of peritoneum alone, but the sigmoid colon and its mesentery on the left side, the caecum on the right side and sometimes on either side by a portion of the bladder.

  Clinical features

                             A sliding hernia occurs almost exclusively in men. Five out of six sliding hernias are situated on the left side; bilateral sliding hernias are rare. The patient is always over 40 years of age, the incidence rising with age. It should be suspected in a very large globular inguinal hernia descending well into the scrotum.

   Treatment

                      A sliding hernia is impossible to control with a truss and as a rule, the hernia is a cause of considerable discomfort. Consequently, operation is indicated and the result is very good.

                                                               DIPHTHERIA                                            

It is an acute infection caused by Gram positive bacillus, Corynebacterium Diphtheriae.

It spreads by droplet infection.
Incubation period : 2-6 days

Incidence :
The incidence has fallen markedly in the last quarter of a century.
Children are particularly affected , especially those between 2-5 years of age. But any age group can be affected.

Because of widespread and routine childhood DPT immunizations, diphtheria is now rare in many parts of the world.
Risk factors include crowded environments, poor hygiene, and lack of immunization.

Symptoms :
Sore throat
Painful swallowing
Neck swelling
Low grade fever, headache, malaise
Vomiting
Sign :
Enlarged and tender cervical lymph nodes.
Sometimes presenting a “bull-neck” appearance.
Patches of false membrane are present on the tonsils, faucial pillars, soft palate and occasionally on the posterior pharyngeal pharyngeal wall. It is usually grey in colour. It is firmly attached and when detached, leaves a bleeding surface on which it tends to re-form. It often has a strong foetor. In atypical cases no false membrane is present and picture resembles a simple streptococcal infection.
Pyrexia : The temperature is rarely above 38.30C(1010F), but the pulse rate is usually raised out of proportion.
Toxaemia is marked.( Patient is ill and toxic but fever seldom rises above 380C)

Complications :
Myocarditis
Cardiac arrythmia
Acute circulatory failure
Paralysis of soft palate, diaphragm and ocular muscles.
Laryngeal diphtheria may cause airway obstruction.

Treatment :
Antitoxin must be given  immediately, without waiting for the bacteriological results of a swab, when the disease is suspected. 20,000 – 100,000 units are injected.
Systemic penicillin : helps to control the primary and any secondary infection.

Other treatments may include:

Fluids by IV
Oxygen
Bed rest
Heart monitoring
Insertion of a breathing tube
Correction of airway blockages

HERNIA

Introduction-

                      A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the wall of its containing cavity. The external abdominal hernia is the most common form, the most frequent varieties being the inguin

Figure:Hernia

Aetiology

                 Any condition that rises the intra-abdominal pressure such as powerful muscular efforts, may produce a hernia. Whooping cough is a predisposing cause in childhood, whereas chronic cough, straining on micturation or straining on defaecation may precipitate a hernia in adult. Hernias are more common in smokers, intra-abdominal malignancy can be a cause of hernia. Stretching of the abdominal musculature because of an increase in contents as in obesity can be another factor. Fat acts to separate muscle bundles and layers, weaken aponeuroses and favour the appearance of para-umbilical, direct inguinal and hiatus hernia. An indirect inguinal hernia may occur in a congenital preformed sac- the remains of the processus vaginalis.

Composition of hernia

                                      A hernia consists of three parts- the sac, the covering of the sac, and the contents of sac.

The sac- The sac is a diverticulum of peritoneum consisting of mouth, neck, body and fundus.

  The neck is usually well defined but in some direct inguinal hernia and many incisional hernias, there is no actual neck.

   The body of the sac varies greatly in size and is not necessarily occupied. In long standing case the wall of the sac may be comparatively thick.

The coverings of the sac-Coverings are derived from the layers of the abdominal wall through which the sac passes. In longstanding cases they become atrophied from stretching and so amalgamated that they are indistinguishable from each others.

Contents

                These can be-

• Omentum- Omentocele
• Intestine-   Enterocele
• A portion of circumference of the intestine- Richter’s hernia
• A portion of bladder may constitute part of or sole content of direct inguinal, a sliding inguinal or a femoral
• Ovary with or without the corresponding fallopian tube.
• A meckle’s diverticulum- a little’s hernia.
• Fluid as a part of ascites or residuum there of.

Classification- Irrespective of site, a hernia can be classified into five different types-

·         Reducible hernia- The hernia either reduces itself when the patient lies down or can be reduced by the patients or the surgeon. The intestine usually gurgles on reduction and the first portion is more difficult to reduce than the last. Omentum in contrast is described as doughy and the last portion is more difficult to reduce than the first. A reducible hernia imparts an expansile impulse on coughing.

·         Irreducible hernia- In this case the contents cannot be return to the abdomen but there is no evidence of other complications. It is usually due to adhesions between the sac and its contents or overcrowding with in the sac.

·         Obstructed hernia- This is an irreducible hernia containing intestine that is obstructed from without or within but there is no interference to the blood supply to the bowel. The symptoms are less severe and the onset more gradual than in strangulated hernia (colicky abdominal pain).

·         Incarcerated hernia- The term incarceration is often used loosely as an alternative to obstruction or strangulation but is correctly employed only when it is considered that the lumen of that portion of the colon occupying hernial sac is loaded with feces.

·         Strangulated hernia- A hernia becomes strangulated when the blood supply of its contents is seriously impaired, rendering the contents are ischaemic. Gangrene may occur as early as 5-6 hours after the onset of first symptoms. Although inguinal hernia may be 10 times more common than femoral hernia, a femoral is more likely to strangulate.

Pathology-

                 The intestine is obstructed and its blood supply impaired. Initially only the venous return is impeded; the wall of intestine becomes congested and bright red with the transudation of serous fluid into the sac. As congestion increases the wall of the intestine becomes purple in color. The intestinal pressure increase, distending the intestinal loop and impairing the venous return further. As venous stasis increase, the arterial supply becomes more and more impaired. Blood is extravasated under the serosa and is effused into the lumen. The fluid in the sac becomes blood stained and the shining serosa dull because of a fibrinous, sticky exudate. At this stage the walls of the intestine have lost their tone and becomes friable. Bacterial transudation   occurs secondary  to the lowered intestinal viability and the sac fluid becomes infected. Gangrene appears at the rings of constriction, which become deeply indented and grey in color. The gangrene then develops in the anti mesenteric border. The mesentery involved by the strangulation also becomes gangrenous. If the strangulation is unrelieved perforation of wall of the intestine occurs.

Clinical features

                            Sudden pain, at first situated over the hernia, is followed by generalized abdominal pain, colicky in nature and often located mainly at the umbilicus. Nausea and subsequently vomiting ensue. The patient may complain of an increase in hernia size. On examination, the hernia is tense, extremely tender and irreducible, and there is no expansile cough impulse.

Strangulated hernias

·         Present with local then general abdominal pain and vomiting.

·         A normal hernia can strangulate at any time.

·         Most common in hernias with narrow necks such as femoral hernias.

·         Require urgent surgery.

                          

Types of hernia

·         Reducible- Contents can be return to abdomen

·         Irreducible- Contents cannot be returned but there are no other complications.

·         Obstructed- bowel in the hernia has good blood supply but bowel is obstructed.

·         Strangulated- blood supply of bowel is obstructed.

·         Inflamed- contents of the sac have become inflamed.

  Natural history of hernias

·         Irreducible hernias-there is a risk of strangulation at any time

·         Obstructed hernias- usually go on to strangulation

·         Strangulated hernias-Gangrene can occur within 6 hours.

Richter’s hernia

                            Richter’s hernia is a hernia in which the sac contains only a portion of the circumference of the intestine (usually small intestine). It usually complicates femoral and rarely, obturator hernias.

Inflamed hernia

                           Inflammation can occur from inflammation of the contents of the sac, e.g. acute appendicitis or salphingitis, or from external cause, e.g. the tropic ulcers that develop in the dependent area of large umbilical or incisional hernias. The hernia is usually tender but not tense and the overlying skin red and edematous. Treatment is based on treatment of underlying cause.

Inguinal hernia

      Surgical anatomy- The superficial inguinal ring is a triangular aperture in the aponeurosis of the external oblique muscle and lies 1.25cm above the pubic tubercle.

      The deep inguinal ring is a U shaped condensation of the transversalis fascia and lies 1.25cm above the inguinal ligament, midway between the symphysis pubis and the anterior superior iliac spine. The transversalis fascia is the fascial envelope of the abdomen and the competency of the deep inguinal ring depends on the integrity of this fascia.

Figure:Inguinal Hernia

      The inguinal canal

                                      In infant the superficial and deep inguinal rings are superimposed and the obliquity of the canal is slight. In adult the inguinal canal which is about 3.75cm long and directed downwards and medially from the deep to superficial inguinal ring. In male the inguinal canal transmit the spermatic cord, the ilio-inguinal nerve and the genital branch of genito-femoral nerve. In the female the round ligament replaces the spermatic cord. The anterior boundary comprises mainly the external oblique aponeurosis with the conjoined muscle laterally. The posterior boundary is formed by the fascia transversales and the conjoined tendon. The inferior epigastric vessels lie posteriorly and medially to the deep inguinal ring. The superior boundary is formed by the conjoined muscle and the inferior boundary is the inguinal ligament.

         An indirect inguinal hernia travels down the canal on the outer side of the spermatic cord. A direct hernia comes out directly towards directly forwards through the posterior wall of the inguinal canal. The neck of the indirect inguinal hernia is lateral to the inferior epigastric vessels, the direct hernia usually emerges medial to this.

  Natural history of inguinal hernia

• Inguinal hernia in babies are the result of a persistent processus vaginalis.
• Indirect inguinal hernia is the most common hernia of all specially in the young.
• Direct inguinal hernia becomes more common in the elderly.

Indirect (oblique) inguinal hernia

                                                        This is the most common form of hernia. Indirect hernias are most common in the young whereas direct hernias are most common in the old. In the first decade of life, inguinal hernia is more common on the right side in the male. In adult males 65% of the inguinal hernias are indirect and 55% are right sided. The hernia is bilateral in 12% of cases.

Natural history of inguinal hernias

·         Inguinal hernias in babies are the result of a persistent processus vaginalis

·         Indirect inguinal hernia is the most common hernia of all, specially in the young

·         Direct inguinal hernia becomes more common in the elderly.

 Types of indirect inguinal hernia

1)       Bubonocele-The hernia is limited to the inguinal canal.

2)       Funicular -  the processus vaginalis is closed just above the epididymis. The contents of the sac can be felt separately from the testes,which lies below the hernia.

3)       Complete – A complete inguinal hernia is rarely present at birth but is commonly encountered in infancy. It also occurs in the adolescence or in adulthood. The testis appears to lie within the lower part of the hernia.

Differential diagnosis in the male 

• Vaginal hydrocele
• Encysted hydrocele of the cord
• Spermatocele
• Femoral hernia
• Incompletely descended testis in the inguinal canal- an inguinal hernia is often associated with this condition;
• Lipoma of the cord

Differential diagnosis in the female

• Hydrocele of the canal of Nuck
• Femoral hernia.

Treatment

                  Operation is the treatment of choice.

Treatment of hernias

• Surgery is the treatment of choice
• Surgery is either open or laparoscopic
• Any hernia can strangulate.

Direct inguinal hernia

                                      In adult 35% of the inguinal hernia are direct. A direct inguinal hernia is always acquired. The sac passes through a weakness or defect of transversalis fascia in the posterior wall of the inguinal canal. In some cases the defect is small and is represented by a discrete in the transversalis fascia, whereas in others there is a generalized bulge.

    Direct hernias do not often attain a large size or descend into the scrotum. In contrast to an indirect inguinal hernia, a direct inguinal hernia lies behind the spermatic cord. The sac is often smaller than the hernial mass would indicate, the protruding mass mainly consisting of extra-peritoneal fat. As the neck of the sac is wide, direct inguinal hernias do not often strangulate.

Direct inguinal hernias

• All are acquired
• They are most common in older man
•  They rarely strangulate

Operation for direct inguinal hernia

                                                             The principles of repair of direct inguinal hernias are the same as those of indirect hernia, with the exception that the hernia sac can usually be simply inverted after it has been dissected free and the transversalis fascia reconstructed in front of it. The reconstruction of the posterior wall of the inguinal canal should be undertaken by the Shouldice repair or by using a mesh implant according to the Lichtenstein technique. The ‘Bassini’ darn operation is no longer acceptable because of its high recurrence rate and slow rehabilitation.

Sliding hernia ( hernia-en-glissade)

                                                        As a result of  slipping of the posterior parietal peritoneum on the underlying retroperitoneal structures, the posterior wall of the sac is not formed of peritoneum alone, but the sigmoid colon and its mesentery on the left side, the caecum on the right side and sometimes on either side by a portion of the bladder.

  Clinical features

                             A sliding hernia occurs almost exclusively in men. Five out of six sliding hernias are situated on the left side; bilateral sliding hernias are rare. The patient is always over 40 years of age, the incidence rising with age. It should be suspected in a very large globular inguinal hernia descending well into the scrotum.

   Treatment

                      A sliding hernia is impossible to control with a truss and as a rule, the hernia is a cause of considerable discomfort. Consequently, operation is indicated and the result is very good.

Adenoid

Definition : Hypertrophy of the nasopharyngeal tonsil sufficient enough to obstruct the airway.

Age incidence : Usually 3-7 years
Regress : From 10 years
Complete regress : Within 20 years


Clinical features are due to –
Hypertrophy of the adenoid causing mechanical obstruction

Fig:Enlarge adenoid

Inflammation
Generalized symptoms

Symptoms due to nasal obstruction --    Mouth breathing
     Dryness of throat
     Dribbling of saliva
     Sore throat due to associated pharyngitis
     Deafness, earache( Due to blockage of Eustachian tube)
    
 Due to inflammation :
     I.  Nasal discharge
     II. Post-nasal drip
     III. Recurrent acute suppurative otitis 
          media
      IV. Persistence of chronic suppurative
          otitis media
       V. Rhinitis/Sinusitis

Generalized disturbances :
Mental apathy
Mental dullness
Nocturnal enuresis
Night terror

In long standing cases patient may develop adenoid facies.

Adenoid facies :
Open mouth
Pinched nose
Retraction of upper lip
Prominent upper incisor
High arched palate
Flat chest and rounded shoulder

Sign :
Mouth breath
Digital examination
Posterior rhinoscopy

Diagnosis :
By symptoms and Xray nasopharynx lateral view


Differential diagnosis :
Deviated nasal septum
Hypertrophied posterior end of inferior turbinate
Antrochoanal polyp
Congenital chonal atresia

Complications :
Pharyngitis
Tonsillitis
Secretory otitis media
Recurrent acute suppurative otitis media
Persistance of chronic suppurative otitis media
Sleep apnoea
Mental dullness

Treatment :
When symptoms are mild-
Nasal decongestants
Antihistamine

When there is recurrent symptoms and/or complications- Adenoidectomy
In secretory otitis media, myringotomy and possibly insertion of ventilation tube(Grommet) are done together with adenoidectomy.

DIPHTHERIA

It is an acute infection caused by Gram positive bacillus, Corynebacterium Diphtheriae.
It spreads by droplet infection.
Incubation period : 2-6 days

Incidence :
The incidence has fallen markedly in the last quarter of a century.
Children are particularly affected , especially those between 2-5 years of age. But any age group can be affected.

Because of widespread and routine childhood DPT immunizations, diphtheria is now rare in many parts of the world.
Risk factors include crowded environments, poor hygiene, and lack of immunization.

Symptoms :
Sore throat
Painful swallowing
Neck swelling
Low grade fever, headache, malaise
Vomiting
Sign :
Enlarged and tender cervical lymph nodes.
Sometimes presenting a “bull-neck” appearance.
Patches of false membrane are present on the tonsils, faucial pillars, soft palate and occasionally on the posterior pharyngeal pharyngeal wall. It is usually grey in colour. It is firmly attached and when detached, leaves a bleeding surface on which it tends to re-form. It often has a strong foetor. In atypical cases no false membrane is present and picture resembles a simple streptococcal infection.
Pyrexia : The temperature is rarely above 38.30C(1010F), but the pulse rate is usually raised out of proportion.
Toxaemia is marked.( Patient is ill and toxic but fever seldom rises above 380C)

Complications :
Myocarditis
Cardiac arrythmia
Acute circulatory failure
Paralysis of soft palate, diaphragm and ocular muscles.
Laryngeal diphtheria may cause airway obstruction.

Treatment :
Antitoxin must be given  immediately, without waiting for the bacteriological results of a swab, when the disease is suspected. 20,000 – 100,000 units are injected.
Systemic penicillin : helps to control the primary and any secondary infection.

Other treatments may include:

Fluids by IV
Oxygen
Bed rest
Heart monitoring
Insertion of a breathing tube
Correction of airway blockages

STOMAS(Colostomy)

                  A colostomy is an artificial opening made in the large bowel to divert faeces and flatus to the exterior, where it can be collected in an external appliance. Depending on the purpose for which the diversion has been necessary, a colostomy may be temporary or permanent.

Figure:Colostomy bag

     SUMMRY

     Stomas

·         May be colostomy or ileostomy

·         May be temporary or permanent

·         Temporary or defunctioning stomas are usually fashioned as loop stomas

·         An ileostomy is spouted; a colostomy is flush

·         Ileostomy effluent is usually liquid whereas colostomy effluent is usually solid

·         Ileostomy patients are more likely to develop fluid and electrolyte problems

·         An ileostomy is usually sited in the right iliac fossa

·          A temporary colostomy may be transverse and sited in the right upper quadrant

·         End colostomy is usually sited in the left iliac fossa

·         All patients should be counselled by a stoma care nurse before operation

·         Complications include skin irritation, prolapse, retraction, necrosis, stenosis, parastromal hernia, bleeding and fistulation.

Temporary colostomy

                                        A transverse loop colostomy has in the past been most commonly used to de function an anaestomosis after an anterior resection. It is now less commonly employed as it is fraught with complications and is difficult to manage; a loop ileostomy is preferred.

    A loop left iliac fossa colostomy is still sometimes used to prevent faecal peritonitis developing following traumatic injury to rectum, to facilitate the operative treatment of a high fistula in ano and incontinence.

    A temporary loop colostomy is made bringing a loop of colon to the surface, where it is held in place by a plastic bridge passed through the mesentery. Once the abdomen has been closed, the colostomy is opened, and the edges of the colonic incision are sutured to the adjacent skin margin. When firm adhesion of the colostomy to the abdominal wall has taken place, the bridge can be removed after 7 days.

    Following the surgical cure or healing of the distal lesion for which the temporary stoma was constructed, the colostomy can be closed. It is usual to perform a contrast examination (distal lopogram) to check that there is no distal obstruction or continuing problem at the site of previous surgery. Colostomy closure is most easily and safely accomplished if the stoma is mature i.e. after the colostomy has been established for 2 months. Closure is usually performed by an intra peritoneal technique, which is associated fewer  closure breakdowns with faecal fistulae.

Double barrelled colostomy

                                                This colostomy was designed so that it could be closed by crushing the intervening spur by using an enterotome or a stapling device. It is rarely used now, but occasionally the colon is divided so that both ends can be brought to the surface separately, ensuring that the distal segment is completely defunctioned.

Permanent colostomy

                                      This is usually formed after excision of the rectum for a carcinoma by the abdomino-perineal technique. It is formed by bringing the distal end(end colostomy) of the divided colon to the surface in the left iliac fossa, where it is sutured in place, joining the margin to the surrounding skin. The point at which the colon is brought to the surface must be carefully selected to allow a colostomy bag to be applied without impinging on the bony prominence of the antero superior iliac spine. The best site is usually through the lateral edge of the rectus sheath, 6 cm above and medial to the bony prominence.

Complications of colostomies

                                                  The following complications can occur to any colostomy but are more common after poor technique or siting of the stoma:

• Prolapse
• Retraction;
• Necrosis of the distal end;
• Fistulae formation;
• Stenosis of the orifice
• Colostomy hernia
• Bleeding
• Colostomy diarrhoea; this is usually an infective enteritis and will respond to oral metronidazole 200 mg three times daily.

Many of these complications require revision of the colostomy.

Loop ileostomy

                           An ileostomy is now often used as an alternative to colostomy, particularly for defunctioning a low rectal anaestomosis. The advantages of a loop ileostomy over a loop colostomy are the ease with which the bowel can be brought to the surface and the absence of odour. Care is needed, when the ileostomy is closed, that the suture line obstruction does not occur.

        

Enterocutaneous Fistula

Figure:Enterocutaneous fistula

An external fistula communicating with the gut mucosa to the skin surface. It may occur following an operation for gangrenous appendicitis or the draining of the appendix abscess. A faecal fistula can occur from necrosis of a gangrenous patch of intestine after the relief of a strangulated hernia, or from a leak from an intestinal anaestomosis. The opening of an abscess connected with chronic diverticulitis or carcinoma of the colon frequently results in faecal fistila. Radiation damage is also another cause of faecal fistula. The most common cause of cutaneous fistula is however previous surgery. This happens most often in patients with adhesions following previous operations. Enterocutaneous fistula can be divided into:-

1)       Those with a high output, more than 1 L/day

2)        Those with a low output, less than 1 L/ day.

They can also be describe anatomically as simple, with a direct communication between the gut and the skin, or complex, i.e. those with one or more tracts they are tortuous and sometimes associated with an intervening abscess cavity half way along the tract.

The discharge from a fistula connected with the duodenum or jejunum is bile stained and causes severe excoriation of the skin. When the ileum or caecum is involved is involved, the discharge is fluid faecal matter; when the distal colon is the affected site, it is solid or semisolid faecal matter. The site of the leakage and the length of the fistula can be determined by small bowel enema and Ba-enema, by fistulogram and more importantly, by CT scan of the abdomen will show up any associated abscesses.

Treatment

                     This can be very challenging in patients with a high output fistula. Low output fistula can be expected to heal spontaneously, provided that there is no distal obstruction. Reasons for failure of spontaneous healing also include:

1)        epithelial continuity between the gut and the skin;

2)        the presence of active disease where, for example there is crohn’s disease or carcinoma at the site of anaestomosis or in the tract;

3)        an associated complex abscess.

The abdominal wall must be protected from erosion by the use of appliances. The patients must remain nil by mouth; intravenous nutrition is started and signs of a decrease in fistula output are sought. The higher the fistula in the intestinal tract, the more skin excoriation must be expected, and this is worst in the case of a duodenal fistula. High output fistula cause rapid dehydration and hypo-proteinaemia. Vigorous fluid replacement  and nutritional support is essential. The drainage of an intra-abdominal abscess can be life saving. This can be achieved by either CT guided drainage or occasionally laparotomy. In patients with a complex  fistula, it may be necessary to bring out a de-functioning stoma upstream of the fistula site, even if this result in a high output stoma.    

 Operative treatment  

                                        Operative repair should be attempted only after a trial of conservative management. The surgery can on occasion be extremely technically demanding and an anaestomosis should not be fashioned in the presence of continuing intra-abdominal sepsis or when the patient is hypo proteinaemic.

ABDOMINAL TUBERCULOSIS

Abdominal tuberculosis can be divided into

·         Tuberculous peritonitis and

·         Tuberculosis of the intestine.

TUBERCULOUS PERITONITIS

Acute tuberculous peritonitis

                                                  Tuberculous peritonitis sometimes has an onset that so closely resembles acute peritonitis that the abdomen is opened. Straw coloured fluid escapes and tubercles are seen scattered over the peritoneum and greater omentum. Early tubercles are greyish and translucent. They soon undergo caseation and appear white or yellow and are then less difficult to distinguish from carcinoma. On opening the abdomen and finding tuberculous peritonitis, the fluid is evacuated, some being retained for histological studies. A portion of diseased omentum is removed for histological confirmation of the diagnosis and the wound closed without drainage.

Chronic tuberculous peritonitis

                                                        The condition presents with abdominal pain (90% of cases), fever (60%),          weight loss (60%), ascites(60%), night sweats (37%) and abdominal mass (26%).

Origin of the infection

                                       Infection originate from:

·         tuberculous mesenteric lymph  nodes

·         tuberculosis of the ileocaecal region

·         a tuberculous pyosalphinx

·         blood borne infection from pulmonary tuberculosis usually the miliary.

Varieties of tuberculous peritonitis

 There are four varieties of tuberculous peritonitis:

ascitic, encysted, fibrous and purulent.

Ascitic form

                     The peritoneum is studded with tubercles and the peritoneal cavity becomes filled with pale, straw-coloured fluid. The onset is insidious. There is loss of  energy, facial pallor and some loss of weight. The patient is usually brought for advice because of the distension of the abdomen. Pain is often absent; in other cases there is considerable abdominal discomfort, which may be associated with constipation or diarrhoea. On inspection, dilated veins may be seen coursing beneath the skin of the abdominal wall. Signs of ascites can be elicited readily. Because of raised intra-abdominal pressure, an umbilical hernia commonly occurs. On abdominal palpation, a transverse solid mass can often be detected. This is rolled- up greater omentum infiltrated with tubercles.

  Diagnosis is seldom difficult except when it occurs in an acute form or when it first appears in an adult, in which case it has to be differentiated from other forms of ascites, especially malignancy. Laparoscopy is useful by allowing inspection of the peritoneal cavity, where the appearance is often diagnostic. Areas of caseation an be biopsied for histopathology. The ascitic fluid is pale yellow, usually clear and rich in lymphocytes.

  Once the diagnosis of tuberculous peritonitis has been made, it is always important to look for tuberculous disease elsewhere. A chest radiograph should always be taken before laparoscopy or laparotomy is performed.

 Encysted form

                          The encysted form is similar to the ascitic form except that one part of the abdominal cavity alone is involved. Thus a localized intra-abdominal swelling is produced, which may give rise to difficulty in diagnosis. In the women above the age of puberty when the swelling is in the pelvis an ovarian cyst will probably be diagnosed. In the case of  a child it is sometimes difficult to distinguish the swelling from a mesenteric cyst. Late intestinal obstruction is a possible complication.

Fibrous form

                      The fibrous form is characterized by the production of widespread adhesions, which cause coils of intestine, specially the ileum, to become matted together and distended. This distended coils act as a ‘blind loop’ and give rise to steatorrhoea, wasting and attacks of abdominal pain. On examination the adherent intestine with omentum attached, together with the thickened mesentery, may give rise to palpable swelling. The first intimation of the disease may be sub-acute or acute intestinal obstruction. If the adhesions are accompanied by fibrous strictures of the ileum as well, it is best to excise the affected bowel, provided that not too much of the small intestine need to be sacrificed. Anti-tubercular therapy will often rapidly cure the condition without the need for surgery.

Purulent form

                        The purulent form is rare. When it occurs, usually it is secondary to tuberculous salphingitis. Amidst a mass of adherent intestine and omentum, tuberculous pus is present. Sizeable cold abscess often form and point on the surface, commonly near the umbilicus, or burst into the bowel. In addition to prolonged general treatment, operative treatment may be necessary for the evacuation of cold abscesses and possibly for intestinal obstruction. If a faecal fistula forms, it usually persists because of distal intestinal obstruction. Closure of the fistula must therefore be combined with some form of anaestomosis between the segment of intestine above the fistula and an unobstructed area below. The prognosis of this variety of tuberculous peritonitis is relatively poor.

Tuberculosis of the intestine

                                                        Tuberculosis can affect any part of the gastrointestinal tract from mouth to the anus. The sites affected most often are the ileum, proximal colon and peritoneum. There are two principal types.

 Ulcerative tuberculosis

                                          Ulcerative tuberculosis is secondary to pulmonary tuberculosis and arises as a result of swallowing tubercle bacilli. There are multiple ulcers in the terminal ileum, lying transversely and the overlying serosa is thickened, reddened and covered in tubercles

Clinical features

                             Diarrhoea and weight loss are the predominant symptoms, and the patient  will usually be receiving treatment for pulmonary tuberculosis.

Radiology

                 A barium meal and follow thorough or small bowel enema will show the absence of filling of the lower ileum, caecum and most of the ascending colon as a result of narrowing and hyper motility of the ulcerated segment.

Treatment

                  A course of chemotherapy is given. healing often occurs provided the pulmonary tuberculosis is adequately treated. An operation is only required in the rare event of a perforation or intestinal obstruction.

Hyperplastic tuberculosis

                                            This usually occurs in the ileo-caecal region, although solitary and multiple lesions in the lower ileum are sometimes seen. This is caused by ingestion of Mycobacterium tuberculosis by patients with a high resistance to the organism. The infection establishes itself in lymphoid follicles, and the resulting chronic inflamation causes thickening of the intestinal wall and narrowing of the lumen. There is early involvement of regional lymph nodes, which may caseate. Unlike CD with which it shares many similarities, abscess and fistula formation is rare.

Clinical features

                             Attacks of abdominal pain with intermittent diarrhoea are the usual symptoms. The ileum above the partial obstruction is distended, and the stasis and consequent infection lead to steatorrhoea, anaemia and loss of weight. Sometimes, the presenting picture is  of a mass in the right iliac fossa with vague ill health. The differential diagnosis is that of an appendix mass, carcinoma of the  caecum CD, tuberculosis or actinomycosis of the caecum.

Radiology

                 A barium follow thorough or small bowel enema will show a long narrow filling defect in the terminal ileum.

 

Treatment

                  When the diagnosis is certain and the patient has not yet developed obstructive symptoms, treatment with chemotherapy is advised and may cure the condition. When obstruction is present, operative treatment is required and ileocaecal resection is best.

Tuesday, January 31, 2012

TONSILLECTOMY

METHODS :

1. Guillotine method
2. Dissection method
3. Laser tonsillectomy
4. Electro coagulation method
5. Harmonic scalpel tonsillectomy
6. Cryosurgery
7. Electro frequency coagulation

Figure:Tonsillectomy operation

Indications of Tonsillectomy :

1. Repeated attack of acute tonsillitis more that 3 times per year for consecutive two years, every time causing 3 days or more work loss.
2. Chronic tonsillitis.
3. Hugely enlarged tonsils causing mechanical obstruction- difficulty in swallowing/ difficulty in respiration.
4. Single attack of peritonsillar abscess or Quinsy (operation is indicated  6 weeks after recovery)
5. Unilateral enlargement of tonsil when malignancy is suspected.

    6. Persistant carriers of streptococcus or diphtheria bacilli.

    7. In case of remote complications eg. Rheumatic fever or Acute Nephritis

    8. As an approach of some operations-

     - eg. Avulsion of glossophayngeal neuralgia, avulsion of elongated styloid process

    9. As a part of other operation e.g. Uvulopharyngopalatoplasty.

Contraindications :

Absolute : Some bleeding disorders

Relative contraindications :

1. Acute upper respiratory infections
2. Bleeding disorders (specially trait)
3. Epidemic of polio around the vicinity of hospitals
4. Uncontrolled Diabetes Mellitus
5. Uncontrolled Hypertension
6. Pregnancy
7. Menstruation
8. Systemic diseases
9. Debilitated conditions of patient

Complications of tonsillectomy :

Anaesthetic complications :

1. Injury to different structures :

              - Lip, teeth, gum, cheek, palate, posterior pharyngeal wall, larynx up to trachea.

2. Cardiac arrest

3. Respiratory arrest

Surgical complications :

1. Injury to different structures : Lip, teeth, angle of mouth, palate
2. Hemorrhage – primary, reactionary and secondary.
3. Laryngeal oedema
4. Parapharyngeal abscess, retropharyngeal abscess , Cellulitis of neck
5. Pulmonary complications- aspiration of blood or vomitus, lung collapse, lung abscess.

Primary haemorrhage : Bleeding during operation.

 Due to -

1. Hurried operation
2. Extensive fibrosis
3. Acute upper respiratory infection
4. Bleeding disorder

Management :

1. Ligate/cauterize all the bleeding vessels
2. Pillar to pillar ligation if failed
3. Blood transfusion if there is bleeding disorder

Reactionary haemorrhage :

Bleeding within 24 hours after operation.

Patient is usually admitted in the hospital.

How to confirm?

1. Increase pulse rate
2. Decrease blood pressure
3. Repeated swallowing( we will suspect blood)
4. Rattling noise during respiration or noisy respiration
5. Examination of throat- Blood clot is seen

Causes : The bleeding results from :

•         Failure to ligate all bleeding vessels

•         Oozing from the vessels after relaxation of the stretched faucial tissues

•         Failure of a vessel to contract and retract after crushing or cutting

•         Postoperative rise of blood pressure. Coughing and straining dislodge a clot

•         Slipping of a ligature

Management :

1. Examine the throat under good illumination. If there is any blood clot remove it.
2. Hydrogen per oxide gargling.
3. If failed then apply wet gauge (with hydrogen per oxide) pressure over the tonsillar fossa for 10 minutes.
4. If failed then to open IV channel, start IV fluid, send blood for grouping & cross matching and arrange blood for transfusion.
5. Take the patient to operation theatre and call senior/experienced anaesthetist.
6. Under general anaesthesia, ligate all the bleeding vessels. If failed then pillar to pillar ligation.

Anaethesia for reactionary haemorrhage is always dangerous as throat is full of blood clot and blind intubation may require.

Secondary haemorrhage :

Bleeding from 24 hours after operation up to 10 day. Usually occurs after 5-6 days.

Cause : Infection.

Management :

1. Admit the patient in the hospital.
2. Pressure over the tonsils by hydrogen soaked gauge piece.
3. Send tonsil swab for culture and sensitivity and start IV antibiotics, IV fluid, Start hydrogen per oxide & antiseptic gargling, keep patient nothing by mouth.

      4.After C/S report comes, change antibiotics

      5. To relieve anxiety : Sedative

      6. If bleeding does not stop then under general anaesthesia, try for haemostasis. If      failed then pillar to pillar ligation.

Secondary haemorrahge usually stops after IV antibiotics and gargling Posoperative care :

1. Keep the patient in tonsillar position.
2. Check whether any bleeding from nose or mouth
3. Record vital signs, pulse, blood pressure and respiration
4. Diet – 2 hours after operation and when patient is fully recovered, then liquid diet and ice cream.

      Usually 1^st day – liquid diet

                    2^nd to 5^th day – Semisolid diet

                    5^th day onwards – Normal diet

        Plenty of water by mouth

5. Maintain oral hygiene : with hydrogen per oxide/ povidone Iodine mouth wash.

6. Antibiotic : Broad spectrum antibiotic for 10 days

7. Analgesic – Tab Diclofenac sodium or Paracetamol 1 tab 3 times daily after food till necessary if not contraindicated.

Patient is usually discharged 24 hours after operation.