ࡱ> npklm5@ bjbj22 "dXX]HS$$$8\LJ2XX"zzz'J)J)J)J)J)J)J$KR,N>MJMJzzbJAAA zz'JA'JAAU?`@IzL o$B\'JxJ0JSChjN+jNIjNIl&Aի6MJMJD % SPECIALTY : SURGERY CASE : NECK MASSES NAME OF THE EXPERT : Dr. A.K. Gupta, Principal & Controller, R.N.T. Medical College &Associated Group of Hospitals, UDAIPUR 313001, Rajasthan. AN APPROACH FOR NECK MASSES 1. HISTORY : A. Age Group: When examining a patient with a neck mass the first consideration should be the patients age group: pediatric (upto 15 yrs), young adult (16 to 45 yrs) or old adult (more than 40 yrs). Within each group, the incidence of congenital, inflammatory and neoplastic diseases fit into one of these three categories. Pediatric patient generally exhibits inflammatory neck masses more frequently than congenital ones and developmental more than neoplastic masses. This incidence is similar to that found in younger adults. In contrast, the first consideration in older adults should always be neoplasia with a smaller emphasis on inflammatory masses and even less emphasis on congenital masses. B. Location of Mass: The next consideration should be the location of the neck mass. This is particularly important in the differentiation of congenital and development masses because they usually occur in consistent locations. The location of a mass is both diagnostically and prognostically significant. The spread of head and neck carcinoma is similar to inflammatory diseases, generally following an orderly lymphatic spread. The appearance and location of a metastatic neck mass may be the key to identifying the primary tumour or source of infection. As age group and location, duration, consistency, associated complaints, progressive status of neck mass, all these add to reach on provisional diagnosis. 2. CLINICAL EXAMINATION : The most important diagnostic step is the physical examination of head and neck. Visualization and palpation are the most important components of the clinical evaluation. There help determine the location of mass according to anatomic lymphatic drainage area, the size of lesions and its relationship (fixation or displacement) to surrounding structures, the consistency of mass, presume of any pulsations or thrills. The physician should perform an indirect mirror of flexible endoscopics examination of all mucosal surface of the upper aerodigestive tract. These areas should also be palpated even when no lesion can be seen specifically the primarily site for lymphatic drainage to the location area of the mass is question. Often, even the most thorough physical examination only gives a general impression of the derivation of mass vascular, salivary, nodal; inflammatory, congenital or neoplastic and not a firm diagnosis. At this point a battery of test are available for help. 3. INVESTIGATION A. Physical Examination:- Repeated, Most important; B. Ultrasonography:- To differentiate solid from cystic masses, especially useful in congenital and development cysts : useful non-invasive technique for vascular lesions. C. Needle Biopsy:- Gold standard in diagnosis of a neck mass; use small gauge needle; obtain flow cytometry of lymphoid population. D. Endoscopy and Biopsy:- To identify primary tumor as source of metastatic node, use in all patients suspected of having neck neoplasia. E. Open Biopsy:- Use only after workup is complete and if diagnosis is not evident; specimen for histologic frozen section, be prepared to do simultaneous neck dissection. F. CT & MRI:- Single most informative test; differentiates cyst from solid lesions; locates mass within or outside the gland or within a nodal chain mucosal disease enhancement, provides anatomic relationships. G. Arteriography:- Arteriography:- For vascular lesions and tumor fixed to the carotid artery. H. Sialography:- To diagnosis diffuse sialoadenopathies or to locate mass within or outside a salivery gland. I. Radionucleotide scanning:- Obtain in lesions of ant. neck compartment, helpful in thyroid lesions and in localizing a lesion to be within a salivary gland, PET scan may be helpful in differentiating tumor from post irradiation changes, and identifying distant metastasis. J. X-Ray, Plain:- Rarely of help in differentiating neck masses. K. Culture and Sensitivites:- Inflammatory tissue at open biopsy. L. Skin Tests:- Used when chronic and granulomatous inflammatory lesion is suspected. M. Antibiotic Course:- Clinical test for suspected inflammatory bacterial lymaphadenopathy, must pursue workup if unsoloved after course of antibiotics. Micro amounts of tissue obtained by fine needle aspiration have been studied by flow cytometry for lymphoma diagnosis and polymerase chain reaction (PCR) to identify the Epstein Barr Virus (EBV) diagnosis of primary nasopharyngeal carcinoma. FNA biopsy is needed for staging and planning purpose in a patient of distant metastasis, to make a tissue diagnosis to initiate non-surgical therapy and in a patient with unknown mass. If the nature of mass or the source of metastasis identified by FNA remains elusive, the aerodigestive tract should be examined endoscopically especially in the area from which primary lymphatic drainage to mass occurs. An obvious lesion should be biopsied; when no lesion is seen or palpated, guided (not blind) biopsies should be performed of the most logical areas for the silent primary tumor based on known lymphatic drainage. These areas are usually the nasopharynx around. Roseonmullers fossa, the tonsil, the base of tongue and pyriform sinus. The rationale for the guided biopsy when an obvious lesion is not present is that the primary tumor is often submucosal or arises deep in the cysts of the palative tonsil or the fold of the lingual lymphoid tissue. Main indication for open excisional biopsy or incisional biopsy are; Progressively enlarging nodes: A single asymmetric nodal mass A persistant nodal moss without antecedent active signs of infection. Actively infectious conditions that do not respond to conventional antibiotics. Asymmetric enlargement of one or more cervical lymphnodes in an adult is almost always cancerous and usually is due to metastasis from a primary lesions from upper aerodigestive tract. Another principle regarding unknown primary lesions is that the immediate removal of an enlarged lymphnode for diagnosis is disservice to the patient with metastatic cervical carcinoma. Distant metastasis and late regional recurrences and wound necrosis are more frequent in patients who have pretreatment biopsies than in those with same stage of disease who have not. These findings suggests that disruption of lymphatic drainage and manipulation of a metastasis decreases the chances for clean surgical excision and cure. In a patient who present with a neck mass and in whom prior routine physical examination of head and neck is negative, an independent second survey of the less visible areas of upper aerodiagnostic tracts is the most cost effective diagnostic tool. Direct endoscopic examination should be performed after T2-weighted MRI because of its better delineation of submucosal disease. Enlarged node high in the neck or in post triangle suggest a nasopharyngeal lesion, whereas enlarged jugulodiagastric node points to the tonsil, base of tongue and the supraglottic larynx. The ipsilateral tonsil should be removed and examined for upper jugular adenopathy. When the enlarged nodes are in the supraclavicular area or the lower third of the neck, the surgeon must consider the whole length of the digestive tract, tracheobronchial tree, breast, genitourinary tract, thyroid gland as potential site for lesions. 5. NON SURGICAL V/s SURGICAL MANAGEMENTS For a patient with an unknown primary metastatic squamous cell carcinoma, postoperative irradiation of the nasopharynx, ipsilateral tonsil, base of tongue and the contralateral side of neck is frequently advocated after radical neck dissection. The best candidates for postoperative irradiation to control recurrence in the neck are patient whose nodal mass is staged N1, with nodal capsular penetration, N2 or N3. Controversy exists over how to manage patient with N1 disease not extending through the nodal capsule. These are advocates for surgery to the neck only, for local nodal excision plus irradiation and for complete neck dissection plus radiotherapy. Regardless of whether postoperative irradiation therapy is used, patient with malignant metastatic cervical nodes and unknown primary lesions, must be re-examined frequently. The neck mass in a patient with a known primary neoplasm of the head and neck should be managed according to the principles for each primary site. In general clinically positive cervical lymphnode metastasis are present, a complete cervical lymphadenectomy should be done alongwith removal of primary tumour. MANAGEMENT OF INDIVIDUAL CASES OF NECK MASSES Thyroid neoplasm, both benign and malignant, are a leading cause of anterior compartment neck masses in all age groups. In the pediatric group, thyroid-neoplasm frequently show a male predominance as well as increased incidence of malignant disease. In contrast, the young adult and older groups show a greater incidence of benign conditions and a female preponderance. Ultrasound, thyroid function tests, thyroid scans can be considered for patients having an anterior compartment neck mass. Cystic lesions of thyroid found on ultrasound should be aspirated. Solid lesion should be managed according to there activity on nuclear scan. Functioning nodules should be managed by suppression and all non-functioning cold nodules should be explored with appropriate concomitant therapeutic measure being taken on the basis of histology and extent of disease. Lymphomas, Hodgkins disease and lymphosarcoma occurs commonly in pediatric and young adult age groups. Except for progressive enlargement of lymphnode tissue, local head and neck symptoms are usually absent. Lymphomas are usually discrete, rubbery and non tender. Extranodal lymphomas can be associated with gastrointestinal or central nervous system involvement and require appropriate evaluation. Salivary neoplasm must be considered whenever an enlarging solid mass lies in front of and below the ear, at the angle of mandible, submandibular triangle. Pain, rapid growth, cranial nerve (VII) symptoms or skin fixation suggest malignancy. The diagnostic test of preference is open biopsy in the form of complete submandibular gland removal of superficial parotidectomy. The surgeon planning to a open node biopsy must be prepared to perform an immediate neck dissection, the surgeon approaching masses in and around the ear should be prepared to do a total partidectomy and facial nerve dissection. Carotid body tumours or glomus tumors or paraganglioma classically occur in the upper anterior triangle around the carotid bifurcation and are pulsatile, compressible masses that rapidly refill on the release of pressure. Carotid body tumor can be moved side to side but not up or down a Positive Fontaine Sign. Both a bruit and thrill are present and with glomus vagale tumor, the ipsilateral tonsil may pulsate and be deviated towards midline. The diagnosis is made angiographically. Small tumor in young patient should be resected. In elderly patient or for extensive tumors in patients who are at high risk for functional disability from cranial nerve damage by resection, management by irradiation to arrest the growth with a good long term outcome is permissible. Schwannomas or neurilemomas are solid, neurogenic tumors that occur most commonly in parapharyngeal space and will usually cause medical tonsillar displacement. There origion from vagus nerve can cause hoarseness, or Horners syndrome when arise from the sympathetic chain. Surgical exploration and excision is indicated after routine evaluatio. Lipomas are ill defined soft masses that occurs in various neck locations in patient older than 35 yrs. These are asymptomatic and on CT scan a lipoma appears as a fat air density. Surgical excision is advised. Branchial cleft cyst most commonly occur in late childhood or early adulthood. They frequently follow an upper respiratory tract infection, and they persist as soft, doughy, variable size masses in anterior triangle of neck, after a course of antibiotic therapy. Ultrasound scan can be helpful in identifying the lesions as cystic. Aspiration of the content yields a milky, mucoid, brownish fluid which often contains cholesterol crystals. Management involves initial control of local infection followed by surgical excision of cyst and its entire tract. Thyroglossal duct cyst are anterior neck, midline structure often appear after an upper respiratory tract infection. USG can be used to differentiate the persistant mass from a lymphnode, a dermoid cyst, or thyroid tissue. A pathognomic sign is vertical motion of the mass with swallowing and tongue protrusism. Radionucleotide scanning being reserved for cyst in the tongue base, which must be differentiated from undescended lingual thyroid tissue. The cyst tract should be completely removed, alongwith the mid portion of the hyoid bone. Lymphangiomas usually occur at birth or evident within first year of life, located commonly in posterior triangle of neck. The cervical lymphangioma is a fluctuant, diffuse, soft, spongy mass, often having indiscrete margin. Its extent is often much greater than apparent. Transillumination is diagnostic. The lesion should be excised if it is easily accessible or is affecting vital functions. Sclerotherapy represents as option in extensive lesions with a high risk of recurrence or complication. Hemangiomas are usually considered congenital are bluish purple colouration, increased warmth compressibility followed by refilling, bruit and thrill help to distinguish them. Traditional management of hemangioma has consisted of observation only unless rapid growth, thrombocytopenia or involvement of vital structures. Most of these resolve spontaneously. Newer Pulse dye lasers management is being advocated. Local resection of some lesions is also advocated for better end result cosmesis. Dermoid cysts occurs most commonly in pediatric patient and young adults, slowly enlarge because of accumulation of sebaceous content unlike sebaceoun cyst they lie deep to cervical facia and skin moves freely over them. These cysts are curved by simple complete excision. Lymphadenitis, occurs in nearly every person at some point in life, especially during the first decade of life. Lymphadenopathy caused by bacterial or viral infection of the upper respiratory tract, is so common that it is an expected sign. Granulomatous inflammatory diseases affects specific age group and locations like tuberculosis, atypical tuberculosis and actinomycosis common in pediatric group. Excisional biopsy is usually diagnostic and curative. Incisional biopsy should be avoided due to the sequalate of a chronic draining fistula. Cervical lymphnode hyperplasia is ubiquitous in human immunodeficiency virus(HIV) positive patient. Tender enlarging nodes should make one suspicious of tuberculosis or nocardia species infection, whereas non tender enlarging head and neck nodes often indicates Kaposis sarcoma or Burkitts lymphoma. Sequelae of trauma occasionally present as a neck mass. In pediatric patients. Haematoma, due to forcep delivery, can result a mass in anterior neck within the sternomasthoid muscle, which organized later on. Heat massage and observation are often associated with resolution. Continued growth or increasing torticollis indicate surgical explorations. Pseudoaneurysm of major vessels are occasionally associated with blunt trauma neck. Neuromas are small neck mass that found after surgery, especially radical neck dissection commonly in post triangle of neck. They occur from sensory nerve ending commonly from great anvicular nerve (C2 3). Neuromas are tender, associated with sharp shooting pain on palpation, quite slow in growth and require excision. SPECIALTY : SURGERY CASE : ASCITES NAME OF THE EXPERT : Dr. Satinder Singh Kaushal, Prof. & Head, Medicine, IG Medical College, Shimla. ASCITES Ascites is pathological accumulation of fluid in the peritoneal/ abdominal cavity. Healthy men have no intra-peritoneal fluid but woman may normally have as much as 20ml depending on phase of the menstrual cycle.  DISTENSION ABDOMEN: Duration of distension. Progression-slow, or rapid. Distension painful malignant condition. Painless cirrhosis liver Distension abdomen along with swelling feet more likely liver disease/cirrhosis. Disteusion abd with generalized anasarca Cardiac or renal causes need evaluation. JAUNDICE Present or past History of Jaundice. H/O intravenous drug abuse, blood transfusions, ear piercing, tattooing Post necrotic cirrhosis. CONSTITUTIONAL SYMPTOMS- Anorexia, lethargy easy fatigueability point to malignant cirrhosis. UPPER G.I. BEED (HEMETAMESIS AND MELENA) indicate portal Hypentension/variceal blood. ALTERED SENSORIUM (Recurrent indicate chronic hepatic encephalopathy. PERSONAL H/O ALCHOHOL INTAKE Duration, amount, type of alcohol, frequency, dependency. H/O withdrawal symptoms. H/O Sexual Promiscuity. OBESITY, HYPERCHOLESTEROLEMIA & TYPE 2 DIABETES MELLITUS Non alcoholic steatohepatitis cirrhosis.  GENERAL PHYSICAL EXAMINATION LEVEL OF CONSCIOUSNESS Drowsy, Stuprosed or Comatosed. ORIENTAION Time, place, person. - JAUNDICE - SIGN OF LIVER CELL FAILURE Palmar erythema, Spider Angioma, Gynecomastia, testicular atrophy, white nails. LYMPH NODES Virchows Lymph node, (Left Supra-clavicular node) BLEEDING Purpura - EDEMA Pedal, Sacral, Puffiness face. - JVP for cardiac cause. SYSTEMIC EXAMINATION ABDOMEN- INSPECTION - Distension fullness in flanks. UMBLICUS everted or transversaly stretched, umblical NODULE firm immobile mass at umbilicus peritoneal carcinomatosis also knows as SISTER MARY JOSEPHS NODULE Periumblical radiating veins (Caput madusae) PALPATION - Liver Size Shrunken or enlarged. Tenderness for Spontaneous bacterial peritonitis. PUDDLE SIGN - 120 ml of fluid. SHIFTING DULLNESS - 500 ml of fluid. FLUID THRILL SPLEEN Enlargement by dipping method for portal Hypertension.  ABDOMINAL X-RAYS:- Diffuse abdominal haziness is seen. However X-Rays are insensitive and non-specific for diagnosis of ascites. ULTRASOUND ABDOMEN:- Most sensitive technique to detect ascites. Volumes as small as 5-10 ml can routinely be visualized Morphology of liver, portal and Splenic vein diameter assessed. Multiple septae, loculation, matting of bowel loops on sonography indicate tubercular peritonitis. Tethering of bowel loops along posterior abdominal wall plastered to the liver or other organs is suggestive of malignant ascites. C T SCAN- Ascites well demonstrated on CT images. Hepatic, adrenal, Splenic or Lymphnodes lesions associated with masses arising from the gut, ovary or pancreas are suggestive of malignant ascites. ABDOMINAL PARACENTESIS & ASCITIC FLUID ANALYSIS GROSS APPEARANCE Clear, Straw Colored Cirrhosis, tuberculosis. Blood Malignancy, tuberculosis. Cloudy infection, Spontaneous bacterial peritonitis Chylous, Milky Lymphatic obstruction. CYTOLOGY- Normal ascitic fluid has less than 500 leukocytes/ml and less than 250 Polymorphs / ml. Neutrophils more than 250 Cells/ml Bacterial peritonitis. Predominance of lymphocytes suggest tubercular or malignancy. Malignant Cells indicate some malignancy (58-75% sensitive to detect malignant ascites). CULTURE/GRAM STAIN OF Ascitic fluid indicate presence of bacterial growth. TOTAL PROTEIN- SAAG- SERUM ASCITIS ALBUMIN GRADIENT Calculated by subtracting the ascitic fluid albumin value from serum albumim value. Specimens should be obtained relatively simultaneously. SAAG (>1.1 g/dl). High albumin gradient is suggestive of portal hypertensive cause e.g Cirrhosis, Cardiac SAAG (<1.1 g/dl). Low albumin gradient is suggestive of non portal hypertensive causes e.g tuberculosis, malignancy, pancreatic ascites. Earlier terminology of Transudative (Protein < 3 g/dl) and exudative (Protien > 3 g/dl) has been completely replaced by SAAG. LAPAROSCOPY - is valuable in detecting peritoneal disease esp. tubercular, malignancy. LIVER BIOPSY, UPPER G.I ENDOSCOPY, COLONOSCOPY BARIUM STUDIES, TUMOUR MARKERS, HIV ELISA are some other investigations to rule out specific causes of Ascites.  SAAG>1.1 g/dl SAAG<1.1 g/dl Cirrhosis liver Fulmimant Hepatic failure Hypoalbuminemia Budd-Chiari Syndrome Nephrotic Syndrome Congestive Heart failure Protein losing enteropathy Constrictive Pericarditis Diseased Peritoneum Portal Vein Thrombosis Infections Hypothyroidism Tuberculosis HIV associated Peritonitis Bacterial Peritonitis Malignant Conditions Hepatocellular Carcinoma  Pseudo myxoma peritonei Miscellaneous Chytous Ascites Pancreatic ascites Familial Mediterranean Fever Vasculitis Biliary ascites. ASCITES at times may be confused with i) Ovarian cyst ii) Gaseous distension iii) Obesity iv) Rarely pregnancy.  SALT RESTRICTION is Cornesstone of therapy. A diet containing 800 mg sodium (2 gm Nacl) is often adequate to induce a negative sodium balance and permit diauersis. Sodium restriction of 500 mg/d (22 mmol/d) is feasible in hospital setting, however it is unrealistic in most out patient settings. Restriction of dietary Sodium to 80 mmol/day (No added salt diet) may be adequate, but restriction to 40 mmol/day is necessary in more severe ascites. Water restriction to (0.5-1 litre/day) is used only if persistent hyponatremia is present i.e. if Sodium drops below 120 mmol/L. Drugs containing relatively large amounts of Sodium e.g. antacids, aspirin, phenytoin, antibiotics like Ampicilin, Pencillin-G, Cefotaxime, Ceftazidime, Piperacillin, Ticarcillin, and those promoting Sodium retention such a non-steroidal analgesic agents, corticosteroids, estrogens, carbenoxolone must be avoided. DIURETIC THERAPY Spironolactone (100-400 mg) is drug of choice, since it is powerful aldosterone antagonist. Some patients may require loop diuretic (Furosemide) starting from 40mg per day to a maximum of 160 mg/day, in stepwise fashion every 4-5 days. The best method of assessing the effectiveness of diuretic therapy is by monitoring body weight and urinary sodium levels. In general the goal of diuretic treatment should be to achieve weight loss of 300-500 g/d in patients without edema and 800-1000g/d in patients with edema. Once ascites has disappeared, diuretic treatment should be adjusted to maintain the patient free of ascites. Diuresis is improved if patients are RESTED IN BED while diuretics are acting, perhaps because renal blood flow in increases in the horizontal positon. An indication of the minimum effective dose of spironolachone may be obtained by monitoring urinary electrolyte concentrations for a rise in sodium and fall in potassium concentration, reflecting effective competitive inhibition of aldosterone. PARACENTASIS Patients with tense ascites esp with respiratory embarrassment require therapeutic paracentesis. The removal of 5 Litres of fluid is considered large volume paracentasis. Recent studies demonstrate that supplementing 5 gm of albumin per each liter over 5 litres decreases complications of paracentasis such as electrolyte imbalances and increases is serum creatinine secondary to large shifts of intravascular volume. Intravenous colloid such as human albumin solution (6-8 gm per litre of ascites removed) or another plasma expander (dextran) can be used in large volume paracentasis. PERITONEO-VENOUS SHUNTS:- In patients with refractory ascites or rapidly reaccumulalting ascites. Surgical implantation of plastic peritoneo-venous Shunt, having pressure sensitive one way value allowing ascitic fluid to flow from abdominal cavity to superior vena cava. However, high rate of complications such as infection, DIC & thrombosis of shunt limit it use. Leveen Shunt is a long tube with non return value running subcutaneously from peritoneum to internal jugular vein in the neck which allows ascitic fluid to pass directly into systematic circulation. Effective in ascites resistant to conventional treatment.. TIPS: (TRANSJUGULAR INTRAHEAPATIC PORTOCAVAL SHUNT)- It is a non-surgical interventional radiological procedure where a side to side porto-systemic shunt is created within the liver. An expandable metallic shunt (8-10 mm diameter) is placed over a guide wire between the hepatic vein and portal vein within the substance of liver through the transjugular approach. TIPS has been used effectively to control diuretic refractory ascites, although portal decompression while mobilizing ascitic fluid has precipitated severe hepatic encephalopathy in some patients. None of the shunts has been shown to extend life expectancy. TIPS has been used as short term measure in patients awaiting liver transplantation. LIVER TRANSPLANTATION: it is the last resort in the management refractory ascitic. COMPLICATION OF ASCITES Spontaneous Bacterial Peritonitis Most common complication Umblical Hernias with long standing ascites Renal failure. Complication of Paracentesis Infection Electrolyte imbalances Bleeding Bowel perforation Large volume paracentesis often results in large intravascular fluid shifts which may rarely precipitate acute hepatic encephalopathy. PROGNOSIS Depends on Underlying liver disorder. - degree of reversibility of disease process - response to treatment. In cirrhosis liver only 10-20% patients survive 5 year from the appearance of ascites. SPECIALITY :- SURGERY CASE :- SALIVARY GLAND TUMOR NAME OF THE EXPERT :- DR VIKRAM KATE D-II/4, JIPMER QUARTERS, JIPMER, PONDICHERRY- 605006 Salivary Gland Tumour History Mode of onset of the swelling, duration, rate of growth, any ulceration if it has occurred. Exact site where it started differentiates a submandibular from a lower pole parotid tumour. If the swelling increases in size with meals and becomes painful-suggestive of sialoithiasis- unlikely to be a tumour. History suggestive of facial nerve involvement- inability to close the eyes tightly, food bolus collecting in the cheek, deviation of the angle of the mouth. History suggestive of trismus indicates infiltration of malignant tumour in the massetter or pterygoid muscles. Any other swellings in the neck if present are suggestive of lymph nodal metastases. 2. Clinical Examination Examination of the ear lobule. Commonly lifted by parotid tumors. Physical examination of the swelling- site, size, surface, consistency, mobility and plane of the swelling. Fixity of submandibular or other salivary tumours to mandible evaluated. Intraoral examination Medial displacement of the lateral oropharyngeal wall and tonsillar bed for enlargement of deep lobe parotid tumours. Examination of Stensens and Whartons duct for inflammation , discharge of fluids or stones. Sialadenitis can mimic salivary gland tumour. Bidigital examination of Stensens ducti and palpation of the Whartons duct in the floor of the mouth. Bidigital examination of the submandibular gland swelling to differentiate from submandibular lymph nodal enlargement. As submandibular swelling enlarges on either side of mylohyoid muscle, it is palpable bidigitally. Examination of the facial, lingual and hupoglossal verves. Facial involved with malignant parotid tumour and lingual / hypoglossal with malignant submandibular gland tumour. Evaluation of trismus if patient has complained in history. Examination of the cervical lymph nodes. 3. INVESTIGATIONS Fine needle aspiration cytology is the investigation of choice to confirm diagnosis CT and MRI are the most useful imaging techniques to evaluate the extent of the spread of the salivary gland tumours. It also helps in identifying deep lobe enlargement of the parotid tumours. Open and true cut needle biopsy is contraindicated as it leads to tumour seeding. Open biopsy can be done if the tumour has ulcerated. 4. DIFFERENTIAL DIAGNOSIS Enlarge lymph nodes, soft tissue tumours and sialadenitis are common conditions which can simulate the clinical picture of a salivary gland tumour. DD of salivary gland tumours : Pleomorphic adenoma is the commonest benign tumour. Mucoepidermoid carcinoma is the commonest malignant tumour. Other benign tumours include Warthins tumour (papillary cystadenoma lymphomatosum) and rarely oncocytoma, lipoma, hemagioma, Other malignant tumours include acinic cell adenocarcinoma, adenoid cystic carcinoma, squamous cll carcinoma, carcinoma ex-pleomorphic adenoma. 5. NON-SURGICAL MANAGEMENT Surgery is the mainstay of treatment for salivary gland tumours. Radiotherapy (RT) is indicated for the treatment of malignant salivary gland tumours. Indications for RT in malignancy include Extraglandular disease Perineural invasion Direct invasion of regional structures Regional metastases High grade malignancy RT may be indicated following excision of recurrent pleomorphic adenoma to reduce the possibility of further recurrence. 6. SURGICAL MANAGEMENT Specific parotidectomy is the treatment of choice for bengin parotid gland tumours of the superficial lobe. Total parotidectomy is done when deep lobe is involved. Excision of the submandibular gland, sublingual or minor salivary gland is the treatment of choice for benign tumours of these organs. Incisions for the excision of the parotid and submandibular gland- Parotid- lazy S incision, modified Blair incision, Sistrunks incision. Submandibular- Incision is 3-4 cm below and parallel to the lower border of the horizontal ramus of the mandible. The nerves at risk during salivary gland surgery- Facial with parotid gland surgery. Identification aids for facial nerve on operation table: Conleys tragal pointer, posterior belly of digastric nerve stimulator, retrograde dissection. Marginal mandibular, lingual and hypoglossal with suybmandibular gland surgery. Malignant tumours of the parotid- When facial nerve is not infiltrated, superficial parotidectomy for a superficial lobe tumour and total conservative parotidectomy is performed when the tumour extends into the deep lobe. Facial nerve is conserved. With high grade tumoursinfitrating the facial nerve, radical parotidectomy with elective excision of the facial nerve is done. If metastases in lymph nodes are present, a modified radical neck dissection from Level I to Level V is done. Malignant tumors of other salivary glands- Radicial excision with en-bloc removal of lymph nodes if involves When frank infiltration of the lingual or hypoglossal nerve present, excision of these nerves is done. Complications of surgery for salivary glands Temporary/permanent facial weakness. Frey,s syndrome. Sialocele. Marginal mandibular/lingual/ hypoglossal nerve injury. 7. Any other SPECIALITY: SURGERY CASE: INGUINO-SCROTAL SWELLINGS EXPERT: DR. P SAMPATH KUMAR Inguino-Scrotal Swellings Conditions presenting as Inguino-scrotal swellings are: Inguinal Hernia Indirect Inguinal Hernia Direct Inguinal Hernia (uncommonly) Congentital hydrocoele Infantile Hydrocoele 1. HISTORY Swelling: Whether swellings appears on standing or straining like coughing Swelling disappears on lying down An existing swelling increases in size on straining Change in size over a day: Least size early in the morning and maximum size at the end of day (congenital hydrocoele) Reducibility: Reducible either spontaneously or manually by the patient Reducible easily on lying down (Direct inguinal hernia) Swelling initially reducible but now-a-days not (Irreducible or obstructed) Swelling was never reducible Pain: Pain associated with abdominal distension, vomiting and constipation: Obstructed or Strangulated hernia. Fever: Strangulated hernia Precipitating factors: Cough, attacks of breathlessness: Brochial asthma, Chronic bronchitis Straining during micturition Constipation 2. CLINICAL EXAMINATION Inspection: Extent : Inguino-Scrotal swelling Cough impulse Reducibility on lying down Palpation: Inflammatory signs like tenderness, local warmth Getting above the swelling: Whether able to get above the swelling (Should be negative) Expansile cough impulse Reducibility Reduces with gurgle (Enterocoele) Relation to pubic tubercle (differentiate form a femoral hernia) Internal ring occlusion test Location of internal inguinal ring Fluctuation Transillumination (only if fluctuation is positive) Testis whether separately felt Testis enlarged Tenderness of testis and epididymis Spermatic cord: Thickening of Spermatic cord Opposite side scrotal and groin examination Abdominal examination: Abdominal wall tone and Malgaignes bulges Ascitis Loaded colon Distended urinary bladder Genitalia examination: Phimosis, urethral stricture Per rectal examination: Prostate enlargement Respiratory and Cardiovascular examination 3. INVESTIGATIONS Ultrasound examination: Scrotal ultrasound if there is doubt about testicular tumour X-Ray Chest P.A. 4. DIFFERENTIAL DIAGNOSIS If cough impulse and reducibility positive Indirect inguinal hernia Special types and their significance: Sliding hernia Maydls hernia Pantaloons hernia Richters hernia Litters hernia Direct inguinal hernia If cough impulse is negative and swelling fluctuant Congenital hydrocoele Infantile hydrocoele If cough impulse is negative and fluctuation is negative Irreducible inguinal hernia 5. NON-SURGICAL TREATMENT Inguinal hernia: No non-surgical treatment Technique of reduction (taxis), complications Hydrocoele; No non-surgical treatment 6. SURGICAL TREATMENT Congenital hydrocoele: Herniotomy (reason for herniotomy) Inguinal hernia: Any of the accepted hernia surgeries Herniotomy: Indications Herniorrhaphy: Types Hernioplasty: Indications, techniques 7. ANY OTHER Complications of inguinal hernia: Irreducibility Obstruction Strangulation How to diagnose each of them Treatment: Pre-operative treatment Difference in surgical technique in strangulated hernia SPECIALITY: SURGERY CASE:GENERALISED LYMPHADENOPATHY EXPERT:DR. V PARI GENERALISED LYMPHADENOPATHY (MUST KNOW) I. HISTORY Primary focus of the node & drainage Loss of appetite, weight and fever Pressure effects - Local, Infiltration - Neuro vascular 4) Personal History - Tobacco, smoking, alcohol, eating habits II. CLINICAL EXAMINATION 1) General Exam - Nutritional Status Performance status in malignancy Local exam Examination from behind, front & sides Sequence of nodal examination All nodes are deep to deep fascia Group of nodes involved and its character Involvement of adjacent structures Nerves Cranial, Cervical Sympathetic Vascular Other-Trachea, Esophagus Drainage area for focal site Examination of oral cavity, ENT, Salivary glands, Cervical spine and thyroid if need be Others Examination of other lymph nodes groups (generalized) Breast if need be Abdomen for spleen, liver, nodes, lump, free fluid PV & PR for pelvic deposits & nodes. Respiratory system for Tb, secondaries, mediastinum III. DIFFERENTIAL DIAGNOSIS 1) Pathological causes of nodal swelling a) Infective - Especially tuberculosis b) Malignancy - Primary Secondary 2) Swelling other than the nodes (if need be) Carotid body tumor Branchial cyst Neurofibroma Lipoma subfascial Schwanoma Salivary gland swelling IV. INVESTIGATIONS Routine baseline blood investigations For tuberculous nodes Chest X-ray USG abdomen FNAC Biopsy For lymphomas Chest x-ray and CT chest USG abdomen and CT abdomen Biopsy BM Biopsy for stage IIA onwards For secondaries with unknown primary Pan endoscopy to visualize upper aerodigestive tracts and biopsy if lesion is visualized. Colonoscopy and biopsy if lesion found for lower neck (Lt) & Supraclavicular (Lt) nodes if need be. If lesion not found FNAC of the node Positive for squamous cell ca (SCC). Further CT of head & Neck for evaluation. FNAC positive for adeno carcinoma CT Head & Neck for thyroid and salivary glands Chest for bronchus Abdomen & Pelvis for GI tract FNAC Negative for malignancy, do biopsy of the node Secondaries with known primary Biopsy of focal lesion (Primary) CT head and neck CXR (Ct scan chest-SOS) V. MANAGEMENT 1. Non surgical a) Acute lymphadenitis - appropriate antibiotics & drainage SOS b) Tb adenitis ATT & Drainage SOS c) Lymphoma-Stage la, IIa- Radiotherapy (RT) d) Secondaries with unknown primary Stage. N1, N2a, 2b curative comprehensive RT Stage. N2C and N3 SCC Palliative RT Adeno Ca. Palliative Chemo e) Secondaries with known primary Early disease - Comprehensive Curative RT to Both local & Nodal disease Advanced disease-Palliative RT/Chemo Surgical: Neck secondaries with known primary Early diseae aggressive surgery for local & node RND (equally effective is RT) Node with unknown (occult) primary N1, N2, a, b RND (Consider post op RT) VI. OTHERS 1) Anatomy of neck a) triangles b) Oral cavity c) Drainage sites 2) Tuberculosis a) Cold abscess stages (Pathology) b) Microbiology (Ziehl Neelsons) c) Collar stud abscess (Tb & Pyogenic) 3) Lymphoma a) Clinical staging (Ann Arbor) Principles in cervical node biopsy a) Anaesthesia b) Incision c) Node- Incision Biopsy Excision Biopsy d) Imprint cytology SPECIALITY: SURGERY CASE: HEPATOSPLENOMEGALY EXPERT: DR. H. S. BHANUSHALI Hepatosplenomegaly 1. HISTORY Chief complaints :- Duration of Complaints Of Swelling in abdomen H/o fever with rigors Pain in and (L) hypochondrium Duration of presence of Ascites Past History :- H/o alcoholism H/o Jaundice H/o haematemesis H/o fever with rigors Loss of appetite H/o visits to endemic areas (Bihar etc) Personal History :- Loss of appetite/Weight H/o Smoking Visits to Kala azar area (like Bihar) H/o Treatment with drugs 2. GENERAL EXAMINATION Palpable Lymph nodes Anaemia Evidence of Abdominal swelling with enlarged umbilical veins. JVP Jaundice Abdominal Examination :- Supine Position Inspection :- Swelling or distention of Abdomen Any umbilical veins Swelling if present moves with respiration Hernial Orifices Testes Palpation :- Liver (Enlarged), can not insinuate fingers between costal margins and liver surface Moves with respiration (confirmed) Smooth or nodular surface Spleen :- It palpable with notch, cannot insinuate fingers below costal margin. Surface smooth or nodular moves with respiration Direction of Enlargement (Towards umbilicus) Percussion :- Grade of Enlargement To R/o Ascites Shifting dullness Examination in knee elbow position Liver span for upward enlargement Auscultation :- Any Bruie over the umbilical engorged veins PR/Proctoscopy 4. INVESTIGATIONS Routine CBC Abnormal cells, with Blood for malaria parasites and kala azar Urine Blood sugar Liver Function tests S. Bilirubin Alb. S. Protein Globulin S. Alkaline Phosphotase SGPT/SGOT/SGGT Protbrombin time and Index Specific :- Hbs Ag HCV USG for Liver, Spleen, Ascites, any other gland or mass CT Scan with contrast to know any other mass, portal and splenic veins size Gastroscopy for oesophageal varices, to R/o any malignancy in oesophagus Stomach, duodenum Spleno portovenogram (Non Invasive) for splenic vein and portal vein morphology Bone marrow Ascitic fluid examination 5. DIFFERENTIAL DIAGNOSIS Cirrhosis with or without portal hypertention Chronic malaria/kala azar Lymphoma/Hodgkins Leukemia Idiopathic Thrombocytopenic Purpura Ca upper GI 6. NON-SURGICAL MANAGEMENT Ascites in chronic liver disease Beta blockers Salt restriction Diuretics Abdominal paracentesis Rx of anaemia with haematenics and /or blood transfusion Lymphoma/Hodgkins/Leukemia-chemotherapy 7. SURGICAL TREATMENT I. Cirrhosis with portal hypertention For oesophageal bleed Vasopresin Stengstaken G.E. Baloon temponade Banding of varices Surgical Devascularation Elective-shunt for Child gr. A & B II. Splenectomy for Idopathic Thrombocytopenic Purpure III. Resection of Ca upper GI, if operable SPECIALITY : SURGERY CASE : BREAST NODULE NAME OF EXPERT : DR. B.S. GEDAM 127, SUYOGNAGAR NAGPUR History - Patients Name - Age - Duration of lump - H/o Pain Nature, Severity, whether associated with menstruation. - Fever - Increase in size - Cough, expectoration - Whether received any treatment Family history H/o Such nodule in mother or sister, treatment received. Past history H/o Previous operation. Personal history Menstrual history. Clinical examination :- - General examination - Pallor - Jaundice - Local - Location quadrant of the breast - Size - Overbuying skin - Prominent veins - Tethering - Peau de arange - Uleration - Nodule on the skin Nipple wheter retracted - Whether recent retraction - Areola Surface of the hump Smooth Irregular Local temp Tenderness Consistency Fixity to - Overbuying skin - Underlying muscle Lymph nodes Ipsilateral - Axillary - Supraclaviulan - Contrateral - Axillary Examination of other breast Systemic examinaton - Chest - Abdomen - Hepatomegaly - Ascites Investigations:- - FNAC - Biopsy if FNAC in not conclusive. If Bemign nodule Pre operative investigations If Malignant - X Ray chest - Liver function tests - USG abdomen - Liver - Ascites - Pelvis - ovaries X-Ray of bones, if bony pains - Bone scan if suspicion of Secondaries. ER and PR receptor study Pre operative investigations, if operable - Urine - Hb% - Blood sugar - ECG - Blood urea - Sr. Creatinine Differential Diagnosis Fibroadenoma Carcinoma of Breast Simple Cyst Tuberculosis of breast Chronic breast abscess Treatment Depending upon the final diagnosis. SPECIALITY : SURGERY CASE : VARICOSE VEINS & PERIPHERAL VASCULAR DISEASE OF LOWER LIMB NAME OF EXPERT : N.S. HADKE PROFESSOR OF SURGERY MAULNA AZAD MEDICAL COLLEGE, NEW DELHI. Guidelines for Resource persons/facilitators They should ensure that the following key issues are demonstrated/discussed during long and short case presentation Name of the Case: Varicose veins Aims: Must understand anatomy and physiology of venous system of lower limb. Must be able to differentiate between primary varicose veins and secondary varicose veins especially postphlebitic limb. Decide management protocol. History Must be able to differentiate pain of venous origin from pain of vascular Insufficiency and other types of pain such as osteoarthritis. Must include history suggestive of secondary varicose veins, especially history suggestive of deep venous thrombosis. Clinical examination Must be able to perform Trendlenbergs test and interpret the results. Must be able to perform three tourniquet test and interpret the results. Must be able to perform Modified Perths test and interpret the results. Investigations Must know the role of Doppler/Duplex scan indications, advantages and limitations. Must know the types of venographies and their current status in management of varicose veins. Nonopereative Management Must know the indications and various aspects of nonoperative management such as elastic stockings. Must know the indications and contraindications of various operative procedure such as Trendlenbergs flush ligation, stripping, Radical perforator ligations (Open and endoscopic) Must know role of sclerothterapy. Should know principle of management of Postphlebitic limb with chronic venous insufficiency. Guidelines for Resource persons/facilitators They should ensure that the following key issues are demonstrated/discussed during long and short case presentation. Name of the Case: Peripheral vascular disease of lower limb Aim: The postgraduate students must be able to differentiate between Atherosclerosis and thromboangitis obliterans (TAO) as a cause of ischemia. Reasons for differentiating the two. Decide management protocol. History: Must include all the differentiating features of atherosclerosis and TAO. Must mention the progression of the disease. Risk factors for the particular disease must be included. Clinical examination Must be able to identify the type of Gangrene. Must be able to evaluate the evidence of ischemia to skin and subcutaneous tissue and its proximal extent. Must be able to evaluate ischemia to muscle and its proximal extent. Must be able to evaluate all peripheral pulsations and compare with opposite side. Investigations: Must know relevance of ankle brachial pressure index. Must know about Duplex scan/Doppler evaluation, their advantages and limitations. Should know about indication for arteriography both invasive and MR angiography. Their advantages and limitations. Non Surgical Management: Must know role of stoppage of tobacco in all forms. Must know about Haemorheological manipulations. Must know about Buergers exercise. Should know about current status of medical management. Surgical Management Must know the indications for amputations Must know indications for sympathectomy Should know indications of other surgical modalities to augment vascularity Must know role of direct arterial manipulations endovascular/Surgical. SPECIALITY : SURGERY CASE : SOFT TISSUE TUMOURS OF THE TRUNK NAME OF EXPERT : DR. Y.E. MISTRY, JUBILEE MISSION MEDICAL COLLEGE& RESEARCH INSTITUTE, P.B. NO.737,THRISSUR 680 005 HISTORY : Site, mode of onset associated with pain, rate of growth Previous surgery or injury Genetic basis Family History Pigmented lesion Chronic lymph oedema. Infection eg. Kaposis sarcoma Single or multiple Von Reckling hausen. CLINICAL : Usually mass painless gradually increasing with or without rapid growth size of mass. Anatomical location causing associated symptoms, neurovascular or Bursitis. Superficial/deep solid or cystic pigmented lesion with or without sudden growth + ulceration. Adherent to underlying structures. Regional lymph node examination Neurovascular examination. Evaluate for distant metastasis. INVESTIGATIONS : Histology and Cytogenetic tests. Histology (1) FNA minimally invasive and relatively a traumatic. Diagnostic accuracy is high. Needle track seeding is rare. (2) Core needle biopsy has larger sample than FNA. (3) Incisional biopsy - for all large tumours exceeding 5cms. Generous wedge of tissue with minimal manipulation. Along long axis, skin not mobilized. (4) Excisional Biopsy Tumours 5cms or smaller entire lesion with margin of clear tissue excised. (5) Frozen Section + intra operated cytology. Not suitable in fatty lesions. IMAGING : MRI Best for soft tissue masses difficult in oedema. CT larger deeper tumours to assess character extent of tumour and involvement of adjacent tissue. Both are complementary. DIFFERENTIAL DIAGNOSIS: Benign (1) Seborrheic keratosis (2) Nevi (3) Epidermal cysts (4) Benign Neurofibroma (5) Lipoma (6) Dermato fibroma protuberance (7) Dermoid tumours Malignant (1) Melanoma Squamous cell carcinoma eg. Marjolin ulcer Sarcomas Malignant fibrous histocytomas Liposarcoma Fibrosarcoma Neurofibrosarcoma Mixed tumours MANAGEMENT (1) Surgery Local excision Local excision with wide margins Local excision with lymph node dissection Local excision with reconstruction free flaps Post OP compression dressing Suction drains to prevent seromas which hamper institution of radiotherapy (2) Radiation pre op or post op external beam and radiation, Brachy therapy. (3) Radiation along with surgery gives better control. (4) Only radiation in patients who refuse surgery effective in certain sarcomas. Chemotherapy Not very much of value except in melanomas 2 drugs commonly used are Ifosfamide and Doxorubicin. Complications Before therapy completion. Related to tumour site, anatomical location ulceration and haemorrhage and thrombocytopenia. Related to surgery eg. Infection, wound breakdown. After completion of therapy. Related to tumour local recurrence - Distant metastases Related to therapy CT or RT Immuno suppression SPECIALITY : SURGERY CASE : INGUINOSCROTAL SWELLINGS NAME OF EXPERT : DR. DILIP P. AMENKAR,PROFESSOR & HEAD, DEPARTMENT OF SURGERY, GOA MEDICAL COLLEGE, BAMBOLIM GOA. Write in details about the swelling in first paragraph, details about the pain in the second paragraph and in the next paragraph write about any straining factor and any systemic symptoms. * Patinet was apparently well before he had noticed the swelling in groin.months/year back. * Mode of onset- gradual or acute. * How did the swelling appear first following straining or spontaneously. * Where did the swelling appear first in the groin or in the scrotum. * Progress of the swelling-size and extent of the swelling at onset-whether the swelling descended from groin to the scrotum or from scrotum to the groin. * What happens to the swelling when the patient stands up, walks about the strains. * What happens to the swelling when the patient lies down. * Any period of irreducibility of the swelling and abdominal pain. * Any inguinoscrotal swelling on the opposite side. In the next paragraph write about the history of pain. * Site of pain, in the groin or ever the swelling, abdomen. * Any radiation of pain. * Character of pain-usually dull aching. * Relation of pain with straining-usually pain increases with straining. * How is the pain relieved-usually relieved on lying down. In 3rd paragraph write about any straining factor. * History of chronic cough, breathlessness, any histor of chronic bronchial asthma. * Bowel habits-whether normal or there is any history of constipation or straining at stools. Write in details the usual bowel habit. * Bladder habit-write in details about bladder habit to exclude any prostatic enlargement or Urethral stricture. - Any dysuria. - Hesitancy/Urgency/Precipitancy. - Narrowing of stream. - Frequency of Micturition, during daytime and nocturnal (ask whether patient has to wake up at night to micturate). - Any history of acute retention of uring/Haematuria-left renal tumor (Vasicocoele). - Mention about any other important systemic symptom. - H/o fever (filariasis). Past History Any history of operation. (Inguinal region/Appendix). Personal history Type of occupation/smoking habits, Urinary/Bowel. Treatment history Whether using truss or net. CLINICAL EXAMINATION Local Examination: C) Inspection:- Examination in standing/lying down position. Standing:- Side/size/shape and extent in relation to Inguinal canal/scrotum. Impulse on cough. Scar of surgery Inguinal/Scrotal area Engurged Veins/Pigmentation. Visible peristalsis. Position of penis. Swelling in relation to testis. Palpation:- Deviation of Penis. Tenderness/Temperature over swelling. Reducible/Non Reducible. To get above swelling consistency. Relation of swelling to public tubercle. Relation of swelling to testis. Invagination test. Deep Ring invagination, test and its fallacy. Percussion- Resonant/Dull. Auscultation:- Bowel Sounds. Mention about normal side of inguinoscrotal region. SYSTEMIC EXAMINATION: a) Per Abdomen (P/A) Tone of Abdominal wall Muscles. - Palpable lump of kidney (Tumour with varicocoele) - Palpable Urinary Bladder (Chronic Bladder Outlet Obstruction) - Scar of surgery (Appendix) b) Per rectal Examination:- Prostatic Examination. c) Palpation of Anterior Urethra Stricture. d) Respiratory Tract Obstructive Pulmonary Diseases. e) Cardia Vascular System:- Cardiac failure. DIFFERENT DIAGNOSIS: 1. Inguinal Hernia. Varicocoels. Funiculitis. Lipema of Cord. Infantile/Congenital Hydrocoele/Funicular. LYMPH VARIX. Candidate must know minimum two clinical signs of each of these above conditions. INVESTIGATION:- Hb, TC, DC, ESR, X Ray, Chest. - Abdominal/Pelvic USG. - Fasting Blood Sugar. - B.Urea/ S.Creatinine. - Urine Routine/Microscopic. - ECG. MANAGEMENT:- * Anatomy of Inguinal Canal must be know. * Broad knowledge whether swelling is elective case/emergency case. * Complications of Inguinoscrotal swelling must he known. * Principles of Hernia Surgery. * Types of Hernia repair commonly done. * Types of Meshes available. * Open Surgery/Laparoscopic. * Approach to Obstructed/Strangulated Hernia and their management. * Surgical treatment of other inguinal scrotal swelling varicocoele, hydrocoele, etc. SPECIALITY : SURGERY CASE : INGUINO-SCROTAL SWELLINGS NAME OF EXPERT : DR. P. SAMPATH KUMAR, PROF. OF SURGERY, KASTURBA MEDICAL COLLEGE, MANIPAL. Inguino-Scrotal Swellings: Conditions presenting as Inguino-scrotal swelling are: Inguinal Hernia Indirect Inguinal Hernia Direct Inguinal Hernia (uncommoly) Congentital Hydrocoele Infantile Hydrocoele HISTORY Swelling: Whether swelling appears on standing or straining like coughing Swelling disappears on lying down An existing swelling increases in size on straining Change in size over a day: Least size early in the morning and maximum size at the end of day (congenital hydrocoele) Reducibility: Reducible either spontaneously or manually by the patient Reducible easily on lying down (Direct inguinal hernia) Swelling initially reducible but now-a-days not (Irreducible or obstructed) Swelling was never reducible Infantile hydrocoele Pain: Pain associated with abdominal distension, vomiting and constipation: Obstructed or Strangulated hernia Fever: Strangulated hernia Precipitating factors: Cough, attacks of breathlessness: Brochial asthma, Chronic bronchitis Straining during micturition Constipation CLINICAL EXAMINATION: Inspection: Extent: Inguino-Scrotal swelling Cough impulse Reducibility on lying down Palpation: Inflammatory sign like tenderness, local warmth Getting above the swelling: Whether able to get above the swelling (Should be negative) Expansile cough impulse Reducibility Reduces with gurgle (Enterocoele) Relation to pubic tubercle (differentiate form a femoral hernia) Internal ring occlusion test Location of internal inguinal ring Fluctuation Transillumination (only if fluctuation is positive) Testis whether separately felt Testis enlarged Tenderness of testis and epididymis Spermatic cord: Thickening of Spermatic cord Opposite side scrotal and groin examination Abdominal examination: Abdominal wall tone and Malgaignes bulges Ascitis Loaded colon Distended urinary bladder Genitalia examination: Phimosis, urethral stricture Pre rectal examination: Prostate enlargement Respiratory and Cardiovascular examination INVESTIGATIONS: Ultrasound examination: Scrotal ultrasound if there is doubt about testicular tumour X-Ray Chest P.A. DIFFERENTIAL DIAGNOSIS: If cough impulse and reducibility positive Indirect inguinal hernia Special types and their significance: Sliding hernia Maydls hernia Pantaloons hernia Richters hernia Litters hernia Direct Inguinal hernia If cough impulse is negative and swelling fluctuant Congenital hydrocoele Infantile hydrocoele If cough impulse is negative and fluctuation is negative Irreducible inguinal hernia NON-SURGICAL TREATMENT: Inguinal hernia: No non-surgical treatment Technique of reduction(taxis), complications Hydrocoele; No non-surgical treatment SURGICAL TREATMENT: Congenital hydrocoele: Herniotomy (reason for herniotomy) Inguinal hernia: Any of the accepted hernia surgeries Herniotomy: Indications Herniorrhaphy: Types Hernioplasty: Indications, techniques ANY OTHER: Complications of inguinal hernia: Irreducibility Obstruction Strangulation How to diagnose each of them Treatment: Pre-operative treatment Difference in surgical technique in strangulated hernia PAGE  PAGE 3 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