By S. Topork. Knox College.

Congenital short frenum of the upper lip may be seen with a wide gap between the permanent incisor teeth buy fluconazole 200mg with visa. Fractures of facial bones are not quite common and do not come in the domain of such book proven fluconazole 200 mg. Such haematoma usually occurs in either in the second connective tissue layer of the scalp or in the 4th layer which consists of loose areolar tissue of the scalp proven 50 mg fluconazole. Cephal haematoma (subpericranial haematoma) occurs due to accumulation of blood beneath the pericranium. It forms a localized swelling being limited to the affected bone bounded by its suture lines. Acute localized pain, localized tenderness and swelling over the affected bone are the clinical features of this condition. Boils, carbuncles, cellulitis and erysipelas are quite common in the head and face. The infection spreads (i) along the angular vein to the ophthalmic vein — a tributary of the cavernous sinus or (ii) along the deep facial vein which communicates with the cavernous sinus through the pterygoid plexus of veins passing through the foramen ovale and foramen lacerum. Diagnosis of such complication is made by noting severe constitutional disturbances, proptosis, squint and paralysis of the ocular muscles, especially the rectus lateralis which is supplied by the abducent nerve. Rodent ulcer is commonly found in the face particularly above the line joining the angle of the mouth to the tragus of the ear. Actinomycosis rarely affects the lower jaw and may cause multiple sinuses of the face with surrounding induration discharging pus with sulphur granules. Extragenital chancre or mucous patches or condylomas (manifestations of syphilis) may be seen in the lip. Plexiform haemangioma or arterial haemangioma or cirsoid aneurysm is almost only seen in the face particularly in the forehead. It is nothing but a network of a dilated interwoven arteries commonly affecting the superficial temporal artery and its branches. Occasionally there may be ulceration of skin over this haemangioma which may lead to serious haemorrhage. X- ray of the skull almost always shows erosion and occasionally there may be perforations in the skull due to intracranial extension of such haemangioma being connected with dilated tortuous vessels in the extradural space. Osteoma particularly sessile type (compact osteoma or ivory exostosis) is a tumour commonly seen affecting the outer table of the skull. Very occasionally this tumour may originate from the inner surface of the skull when it may give rise to focal epilepsy. The adolescents or young adults are the common victims and the presenting symptom is the hard painless lump. Among malignant tumours squamous cell carcinoma, malignant melanoma, osteosarcoma and secondary carcinoma in the skull may occur. Ectopic salivary tumour may be rarely seen particularly in the lip of a young adult male. A tumour arising from the skin or subcutaneous tissue can be moved freely over the bone. Skin can be moved freely over the tumour which is arising from subcutaneous tissue or bone. It is considered to be a type of basal cell carcinoma, though a few pathologists are of the opinion that it is an endothelioma. In the first figure note the ‘kiss lesion’ affecting the upper tumour of the skull. Soft and very vascular metastases often show pulsation presenting as pulsatile swelling. This condition almost always affects the skull and the skull enlarges so that the patient often requires a bigger hat after certain time interval. This disease usually affects old individuals above 40 years and males are more often affected. The thickened cranial bones are sometimes quite vascular so as to produce systolic bruit on auscultation. Mucous cysts are often found on the mucous surface of the lip and cheek (these are recognized by their blue colour and translucency). It is in fact due to dehydration rather than peritonitis that the appearance of sharp nose, hollow eyes and collapsed temples are produced. But when this facial appearance is combined with thready pulse and a grossly distended abdomen, the condition is nothing but an advanced case of diffuse peritonitis. There is also presence of spider naevi and all these indicate a moderately advanced case of hepatic cirrhosis. However this concept has been challenged nowadays and these features are not considered to be pathognomonic of enlarged adenoids. This condition produces characteristic facial flushing, which is known as carcinoid facies. In the last figure the patient has been asked to breathe through the naris of the affected side while his other naris and mouth are kept closed. The inferior orbital margins of both sides are palpated and note any difference in sharpness and level. One may have a glance at each profile of the patient in order to consider relative protuberance of the eyeball. If the nostril on the affected side is not blocked, it is obvious that the medial wall of the maxilla is not bulging to any great extent. The patient should be asked if any discharge is coming out through the nostril of the affected side. Constant overflow of tears from the eye (epiphora) indicates obstruction of the nasolacrimal duct. Only extension of the growth from this surface may firstly be felt in the infratemporal region. So this region must be palpated before completion of the palpation of the surfaces of the maxilla. While examining these surfaces, if any swelling or ulcer is discovered, examine it in the usual way. If there is any tenderness in the maxillary antrum without any distension of its wall, it may suggest empyema of the antrum.

To divide adhesions in these cases discount fluconazole 50 mg with visa, many of the loops of Extensive damage requires bowel resection with anastomo- bowel can be separated by inserting the index finger between sis by sutures or stapling buy 150 mg fluconazole with amex. By elevating the finger buy line fluconazole, If a segment of bowel is of questionable viability, replace the adhesion can be stretched between the bowel segments. Reevaluation in 10–15 min often reveals that the 44 Enterolysis for Intestinal Obstruction 407 bowel has regained some color, tone, and peristalsis In the very rare situation when a Baker tube must remain indicative of recovering perfusion. Our policy is to avoid filling both After decompressing the bowel, replace it in the abdominal nostrils with intestinal tubes. If there has been any spillage, thoroughly irrigate the cases to insert the long Baker tube through a newly con- abdominal cavity with large volumes of warm saline solution. Postoperative Care Complications Nasogastric suction may be required postoperatively until evi- dence of bowel function returns. This is manifested by active Recurrent intestinal obstruction bowel sounds or the passage of flatus or stool per rectum. Intestinal fistula or peritonitis Baker Tube Stitchless Plication: 4 5 Surgical Legacy Technique Carol E. Chassin† Indications The Baker tube may be passed through a Stamm gastrostomy (preferred), a jejunostomy, or under rare Operations for intestinal obstruction due to extensive adhe- circumstances retrograde through a cecostomy. It is not sions, when the patient has already undergone numerous advisable to pass the tube via the nasogastric route, as the similar operations tube must remain in place for at least 10 days. A naso- Extensive serosal damage following division of many gastric tube may be required to decompress the stomach adhesions postoperatively. Pitfalls and Danger Points Trauma to the bowel while passing the Baker tube Reverse intussusception when the tube is removed Operative Strategy Adhesions tend to form again after enterolysis. Plication attempts to prevent multiple recurrent adhesions by holding the bowel in a prearranged orderly fashion (Fig. In this manner, any adhe- sions that develop presumably form between loops of intes- tine that are held in gentle curves, minimizing the chances of recurrent adhesive obstruction. Suction all the bowel contents through the Baker tube and deflate the Enterolysis of the entire small bowel should be performed as balloon. Postoperative Care Pass the sterile Baker tube into the gastrostomy and then through the pylorus; partially inflate the balloon. Deflate the milking the balloon along the intestinal tract, the tube balloon at the end of the Baker tube on the second postopera- may be drawn through the entire length of the intestine. We cut off the port after balloon deflation to ensure Supply intermittent suction to the tube to evacuate gas and that the balloon is not inadvertently reinflated. Pass the balloon through the ileocecal must stay in place for 14–21 days if a stitchless plication is valve and inflate it to 5 ml. An additional nasogastric tube may be Distribute the length of the intestine evenly over the required for several days. Then, arrange the intestine in the shape of tive obstruction or the manipulation of bowel required to multiple gentle S-curves as shown in Fig. When bowel function returns, remove the Baker tube If there has been any spillage of bowel contents during the from the suction and allow the patient to eat. Simply dissection, if gangrenous bowel has been resected, or if an clamp the tube and leave it in place as a stent. When it enterotomy has been performed for intestinal decompres- is time to remove the Baker tube, do so gradually, with sion, do not close the skin incision, as the incidence of wound the balloon deflated to avoid creating (reverse) infection is extremely high. When local factors contraindicate a gastrostomy, a poten- Antibiotics are given postoperatively to patients who have tial “bailout” maneuver is to pass the Baker tube through a had an intraoperative spill of intestinal contents. Postoperative Complications Make a puncture wound in the center of the purse-string suture, insert the Baker tube, and hold the purse-string suture Wound infection taut. To pass the Baker tube through the ileocecal valve, make a 3- to 4-mm puncture wound in the distal ileum. Then, insert a Kelly hemostat into the wound and pass the hemostat Further Reading into the cecum. Experience with intestinal plication and a pro- Inflate the balloon of the Baker tube and milk the balloon posed modification. Incision Interval appendectomy following conservative treatment of appendiceal abscess. The healed scar with this inci- right colon resection in addition to appendectomy, espe- sion is usually quite strong, and the cosmetic result is good. Preoperative Preparation Recognize, however, that the cecum and appendix can vary considerably in location. Use any available informa- Diagnostic studies: ultrasonography and computed tomogra- tion to guide incision placement. Gently palpate the abdomen once the patient is Perioperative antibiotics under anesthesia, and place the incision over any mass that Nasogastric tube if ileus is present might be found. If in doubt, remember that it is easier to pull the cecum and appendix up out of the pelvis into the incision than to pull a high-lying retrocecal appendix down into a low Pitfalls and Danger Points incision. Adequate exposure of a true retrocecal appendix will require mobilization of the cecum; plan accordingly. Inadvertent laceration of inflamed cecum during blunt If the exposure proves inadequate, the incision may be car- dissection ried in a medial direction by dividing the rectus sheath and Inadequate control of blood vessels in edematous retracting the muscle laterally. If necessary, the right rectus mus- mesoappendix cle itself may be transected to expose the pelvic organs. Indication for Drainage The presence of inflammation or even generalized peritonitis due to a perforated appendix is not an indication for external drainage. Close the abdominal wall without drainage after thoroughly irrigating the abdominal cavity and pelvis. If an abscess with rigid walls is encountered, drain the cavity with a closed-suction drain. At a point 3–4 cm medial to the anterior spine, draw a line perpendicular to this line Fig. About one-third of the incision should be above the imaginary line between the iliac spine and umbi- licus and two-thirds below this line.

The wound should be explored layer by layer buy 200mg fluconazole mastercard, followed by primary suturing if it has come within 6 hours of injury order 50mg fluconazole with amex. When the oedema and tension have subsided and the tissues within the wounds are viable 150 mg fluconazole otc, delayed primary suture should be performed. Although all wounds heal by the same basic processes, yet their application is different in closed wounds and open wounds. Platelets become adherent and with clotting factors form a haemostatic plug to stop bleeding from the small vessels. Histamine is considered to be the primary mediator of inflammatory vascular responses. Histamine produces local vasodilatation and increases permeability of small vessels. However the action of histamine is short lasting and local sources are depleted rapidly. Kallikrein, an enzyme found in plasma and in granulocytes, releases bradykinin and kallidin. These prostaglandins seem to be the final mediators of acute inflammation and may play a chemotactic role for white cells and fibroblasts. Aspirin and indomethacin are potent inhibitors of prostaglandin biosynthesis and the antiinflammatory action of these drugs actually result from their effects on prostaglandin metabolism. In the early stages of inflammation, actively motile white cells migrate into the wound and start engulfing and removing cellular debris and injured tissue fragments. Leukotaxine, a peptide formed in damaged tissues by the enzymatic destruction of albumin, is thought to be the chemotactic agent — attracting leucocytes into the wound. As the transient phase of white cell migration ends, the granulocytes with shorter life die and release acid hydrolases into the local environment. As the granulocytes are dying, the proportion of monocytes increases significantly and these monocytes continue their scavenging activity for weeks. It has been found out experimentally that wound healing may proceed normally in the absence of granulocytes and lymphocytes, but monocyte must be present to create normal fibroblasts production. Only recently however, the mechanisms responsible for K)ound contraction have been investigated extensively. This wound contraction does not begin immediately and that about 3 to 4 days elapse before movement of the edges become measurable. After this period, there is a period of rapid contraction, which is completed by the 14th day. The magnitude of contraction varies with the species of animal and with the shape, size and site of the wound. So wound contraction is limited in these places, whereas in cervical region or face of old people wound contraction may be more and effective due to lax skin around. When loss of skin occurs over an area such as the malleolar surface of the lower leg and ankle, wound contraction simply cannot occur because there is not enough extra skin around the defect. The first step in studying the mechanism of wound contraction is to try to define precisely where the fundamental process is located. It should be determined whether a centripetal movement occurs because an energy or power source located outside the defect is pushing the skin edges inwards or whether a centrally located power source is pulling the skin edges to the centre of the defect. Removal of fluid by drying has been suggested as a cause of diminution in the size of wound. But this has not been substantiated, as water content of central wound tissue at the beginning of wound contraction has not changed significantly as at the end of contraction. Contraction of collagen has also been incriminated as the cause of wound contraction. Although collagen increases markedly between the 5th and 8th day of healing, yet the total collagen in the wound falls significantly after this period, so it does not correlate with the period of wound contraction. Moreover the rate of wound contraction is not affected by suppressing collagen synthesis. In scorbutic animals, although granulation tissue is formed, collagen production is inhibited and yet wound contraction proceeds normally. But curiously excision of central granulation tissue did not affect the rate of wound contraction. It was further noticed that although wound contraction was not inhibited by excising the central mass of granulation tissue, it could be stopped decisively by excising a very limited zone of tissue just beneath the advancing dermal edge. This area is the strategic location of cells which appear to constitute the machinery for wound contraction. These cells show characteristics of fibroblasts and smooth muscle cells including a rough endoplasmic reticulum and microfilament bundles similar to smooth muscles. In fact colchicine is presently used in the control of fibrous contractures in human beings. Marginal basal cells lose their firm attachment to the underlying dermis, enlarge and begin to migrate into the wound. The fixed basal cells in a zone near the wound edge undergo rapid mitotic divisions (proliferate) and the daughter cells migrate. After bridging the wound defect, the migrating epithelial cells lose their flattened appearance and become more columnar in shape. Subsequent epithelial thickening and keratinization may produce marked foreign body reaction and formation of sterile abscess. In one sentence epithelialization of the wound mainly occurs by proliferation and migration of the marginal basal cells lying close to the wound margin. When there is skin loss, dermal pits which are left behind act as islands for regenerating epithelium. But there is no regeneration of hair follicles, sweat and sebaceous glands in the new epidermis. This formation of granulation is preceded by two phases — (i) phase of traumatic inflammation and (ii) phase of demolition. The mononuclear cells alongwith large phagocytic macrophages infiltrate and ingest particulate matters. It is in fact composed of in the first instance by capillary loops and fibroblasts with a variable number of inflammatory cells.

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