1 Cellulitis: a non-suppurative inflammation of subcutaneous tissue, extending along connective tissue planes and across intercellular spaces.

Spreading inflammation in the tissue planes is called cellulitis. There is wide spread swelling, redness and pain without definite localization.

Caused by Streptococcus pyogenes.. If general condition of the patient is undermined, as in diabetes, cellulitis spreads rapidly and leads to Septicemia (infection in the blood).Redness, itching and stiffness is present in the site of inoculation (where the bacteria enter the skin), local Gangrene (death of the tissue) may occur. The appearance of skin creases or wrinkles, indicates resolution (healing).

Treatment

1. Rest , Appropriate antibiotics.

Cellulitis of the neck: Is a complication of wounds tonsillitis or mastoiditis Ludwig’s angina is the term applied to sub-maxillary cellulitis. The two dangers of cervical cellulitis are:

1. Oedema of glottis - with possible asphyxia (respiratory obstructon )

2. Mediastinitis - In ludwig’s angina the floor of the mouth become oedematous. The tongue can be seen displaced, turned upwards by swelling and oedema. The patient is unable to close the mouth owing to oedema of the tongue and the floor of the mouth. This can also CCC when the tongue is bitten by a wasp.

Ludwig’s angina: Ludwig - characterized by a brawny (non pitting) swelling of the sub-mandibular region, corn with inflammatory oedema of the mouth. It is the combined cervical and intrabuccal signs that constitute the characteristic feature of the lesion. The cause of the condition is virulent, usually streptococcal infection of the cellular tissue surrounding the sub-mandibular salivary gland.

Clinical features

 The swollen tongue is pushed towards the palate and forwards through the open mouth, while the cellulitis extends down the neck.

The most dangerous plane, is deep to the deep fascia.

Ludwig’s angina is an infection of closed fascial space and if .untreated, the inflammatory exudate often passes via, the tunnel occupied by stylohyhoid to the submucosa of glottis, in which event the patient is in immediate danger of death from oedema of the glottis.

Treatment

1. antibiotics on Early Diagnosis

2. In cases where the swelling, both cervical and intrabuccal, does not subside rapidly with such treatment, a curved incision, beneath the jaw is made and this decompresses the closed fascial space. The incision is deepened and after displacing the superficial lobe of the sub-mandibular salivary gland, the mylohyoid muscle are divided. This decompresses the closed fascjal space referred to. The wound is lightly sutured and drained. The operation can be conducted with greatest safety under local anaesthesia.

Bacteraemia and  Septicemia

Bacteraemia and septicaemia means the organisms are present in the blood. Clinical features are those of severe infection and shock: , Pyrexia is intermittent , Rigors ,  Jaundice is due to liver damage,  Acute renal failure may occur , Peripheral circulatory failure,  lntravascular coagulation indicates a fatal outcome

 causative focus found and treated surgically .g., Appendicetomy in perforated appendix

2. Blood culture taken

3. Broad spectrum antibiotic is given

4. Blood transfusion is given.

5. Injection hydrocortisone is given.

Pyaemia

Pyaemia is due to infected emboli circulating in blood stream. Pyaemia is characterized by: -

1. Rigors

2. Intermittent fever

3. Formation of abscess in vital organs like heart or brain.

Treatment

1. Is to prevent emboli reaching the blood stream

2. Broad spectrum antibiotic is given.

3. Abscess are incised and drained

If not treated portal pyaemia with multiple abscesses in liver occur, which is a dangerous condition.

Acute Abscess :  An abscess a collection of pus.

Bacteria which cause pus formation is called pyogenic organisms. Bacteria reach the infected area by:

1. Direct route: eg. Penetrating wound

Local extension: From adjacent focus of infection

2 Lymphatics

4. Blood stream

Pyogenic membrane surrounds the abscess and is infiltration with (leukocytes and bacteria.

Pus: Pus contains dead leukocytes and bacteria. It reaches the surface of the body or is discharged into a hollow viscous.

Symptoms: patient feels ill., Throbbing pain is characteristic of suppuration. Pain becomes more severe in the dependent position. E.g. infected finger,

Classical signs

Temperature is elevated , Rigors, inflammation

Fluctuation: Present in the later stages, and reveals the presence of pus. Prevention

1. An abscess can sometimes be aborted by antibiotics in the early stage.,. Rest,  Elevation of the affected part.

Treatment

Is incision and drainage of abscess

Hilton’s method of opening an abscess:

It is used where important anatomical structures like the blood vessels and nerves are preesnt, as in the neck, axilla and groin. The skin and superficial fascia is incised. A sinus forceps is thrust into the abscess  cavity. The blades are opened and the pus is drained. A gloved finger is introduced and loculi are broken. A ribbon gauze is lightly packed and antibiotics are given. This is done under surface anaesthesia i.e., ethyl chloride spray.

Antibioma

 If antibiotic is given the pus in the abscess frequently becomes sterile and a large brawny edematous swelling remains which takes many weeks to resolve.

Treatment: explore the mass with a wide-bore aspirating needle

 Most antibiornas are due to late, inadequate, and ineffective antibiotics.

CANCRUM ORIS

Is an infective gangrene of cheek and lip.

may occur as a complication of kala azar, enteric fever and  children with poor oral hygiene.

The lesion starts as an acute inflammatory patch on oral mucosa which is seen ulcerated.

The affected part of the cheek or the lip gradually becomes gangrenous.

Focal vascular thrombosis and sepesis occur.

When slough separates, a part of the cheek or lip sloughs out to form a buccal fistula with ugly deformity. The adjacent jaw may be infected too.

Various organisms are found - specially Fusiform bacillus and_Borrellia vincenti.

The foetid odour, gangrenous patch of cheek or lip, purulent discharge from the mouth, fever and toxaemia are the characteristic features. The patient is unable to open the mouth properly.

Treatment

1. Antibiotics, multivitamins and repeated mouth washes

2 Neostibamine in kala-azar. Sequestrectomy in chronic osteomyelitis of the mandible.

4. Plastic reconstruction of the lip or cheek for unsightly deformity undertaken.

CARBUNCLE

Is an infective gangrene of the subcutaneous tissue. It is due to staphylococcal aureus infection. It is uncommon before the age of 40. Males are the usual sufferers. Diabetes may be present. It often occurs on the nape of the neck.

Clinical features

Subcutaneous tissue becomes painful and indurated. Ove skin is red. Unless treated promptly, extension will occur and late softening. The skin gives way and thick pus and slough are discharged.

Usually, there is one central large slough, surrounded by smaller areas of necrosis. Infection extends widely and fresh openings appear

Treatment

1. Many carbuncles are aborted, if penicillin is used adequately in the early stage.

2. Local treatment consists of hygroscopic dressings being given ie. magsulph-glycerin dressing Later the carbuncle is excised with a cruciate incision.

3. If the gap is large and when the granulation tissue comes to the surface, skin grafting is done.

Types of Head Injury

1. Extradural Hematoma (EDH)

Overview

• Demographics: Most common in young male patients.
• Association: Always associated with skull fractures.
• Injured Vessel: Middle meningeal artery.
• Common Site of Injury: Temporal bone at the pterion (the thinnest part of the skull), which overlies the middle meningeal artery.
• Location of Hematoma: Between the bone and the dura mater.

Other Common Sites

1. Frontal fossa
2. Posterior fossa
3. May occur following disruption of major dural venous sinus.

Classical Presentation

• Initial Injury: Followed by a lucid interval where the patient may only complain of a headache.
• Deterioration: After minutes to hours, rapid deterioration occurs, leading to:
  • Contralateral hemiparesis
  • Reduced consciousness level
  • Ipsilateral pupillary dilatation (due to herniation)

Imaging

• CT Scan: Shows a lentiform (lens-shaped or biconvex) hyperdense lesion between the brain and skull.

Treatment

• Surgical Intervention: Immediate surgical evacuation via craniotomy.
• Mortality Rate: Overall mortality is 18% for all cases of EDH, but only 2% for isolated EDH.

2. Acute Subdural Hematoma (ASDH)

Overview

• Location: Accumulates in the space between the dura and arachnoid.
• Injury Mechanism: Associated with cortical vessel disruption and brain laceration.
• Primary Brain Injury: Often associated with primary brain injury.

Presentation

• Consciousness: Impaired consciousness from the time of impact.

Imaging

• CT Scan: Appears hyperdense, with hematoma spreading diffusely and having a concavo-convex appearance.

Treatment

• Surgical Intervention: Evacuation via craniotomy.
• Mortality Rate: Approximately 40%.

3. Chronic Subdural Hematoma (CSDH)

Overview

• Demographics: Most common in patients on anticoagulants and antiplatelet agents.
• History: Often follows a minor head injury weeks to months prior.
• Pathology: Due to the tear of bridging veins leading to ASDH, which is clinically silent. As the hematoma breaks down, it increases in volume, causing mass effect on the underlying brain.

Clinical Features

• Symptoms may include:
  • Headache
  • Cognitive decline
  • Focal neurological deficits (FND)
  • Seizures
• Important to exclude endocrine, hypoxic, and metabolic causes in this group.

Imaging

• CT Scan Appearance:
  • Acute blood (0–10 days): Hyperdense
  • Subacute blood (10 days to 2 weeks): Isodense
  • Chronic (> 2 weeks): Hypodense

Treatment

• Surgical Intervention: Bur hole evacuation rather than craniotomy.
• Anesthesia: Elderly patients can often undergo surgery under local anesthesia, despite comorbidities.

4. Subarachnoid Hemorrhage (SAH)

Overview

• Causes: Most commonly due to aneurysms for spontaneous SAH, but trauma is the most common cause overall.
• Management: Conservative treatment is often employed for trauma cases.

5. Cerebral Contusions

Overview

• Definition: Bruising of the brain tissue due to trauma.
• Mechanism: Often occurs at the site of impact (coup) and the opposite side (contrecoup).
• Symptoms: Can range from mild confusion to severe neurological deficits depending on the extent of the injury.

Imaging

• CT Scan: May show areas of low attenuation (hypodense) or high attenuation (hyperdense) depending on the age of the contusion.

Treatment

• Management: Depends on the severity and associated injuries; may require surgical intervention if there is significant mass effect.

Tracheostomy

Tracheostomy is a surgical procedure that involves creating an opening in the trachea (windpipe) to facilitate breathing. This procedure is typically performed when there is a need for prolonged airway access, especially in cases where the upper airway is obstructed or compromised. The incision is usually made between the 2nd and 4th tracheal rings, as entry through the 1st ring can lead to complications such as tracheal stenosis.

Indications

Tracheostomy may be indicated in various clinical scenarios, including:

1. Acute Upper Airway Obstruction: Conditions such as severe allergic reactions, infections (e.g., epiglottitis), or trauma that obstruct the airway.
2. Major Surgery: Procedures involving the mouth, pharynx, or larynx that may compromise the airway.
3. Prolonged Mechanical Ventilation: Patients requiring artificial ventilation for an extended period, such as those with respiratory failure.
4. Unconscious Patients: Situations involving head injuries, tetanus, or bulbar poliomyelitis where airway protection is necessary.

Procedure

Technique

• Incision: A horizontal incision is made in the skin over the trachea, typically between the 2nd and 4th tracheal rings.
• Dissection: The subcutaneous tissue and muscles are dissected to expose the trachea.
• Tracheal Entry: An incision is made in the trachea, and a tracheostomy tube is inserted to maintain the airway.

Complications of Tracheostomy

Tracheostomy can be associated with several complications, which can be categorized into intraoperative, early postoperative, and late postoperative complications.

1. Intraoperative Complications

• Hemorrhage: Bleeding can occur during the procedure, particularly if major blood vessels are inadvertently injured.
• Injury to Paratracheal Structures:
  • Carotid Artery: Injury can lead to significant hemorrhage and potential airway compromise.
  • Recurrent Laryngeal Nerve: Damage can result in vocal cord paralysis and hoarseness.
  • Esophagus: Injury can lead to tracheoesophageal fistula formation.
  • Trachea: Improper technique can cause tracheal injury.

2. Early Postoperative Complications

• Apnea: Temporary cessation of breathing may occur, especially in patients with pre-existing respiratory issues.
• Hemorrhage: Postoperative bleeding can occur, requiring surgical intervention.
• Subcutaneous Emphysema: Air can escape into the subcutaneous tissue, leading to swelling and discomfort.
• Pneumomediastinum and Pneumothorax: Air can enter the mediastinum or pleural space, leading to respiratory distress.
• Infection: Risk of infection at the incision site or within the tracheostomy tube.

3. Late Postoperative Complications

• Difficult Decannulation: Challenges in removing the tracheostomy tube due to airway swelling or other factors.
• Tracheocutaneous Fistula: An abnormal connection between the trachea and the skin, which may require surgical repair.
• Tracheoesophageal Fistula: An abnormal connection between the trachea and esophagus, leading to aspiration and feeding difficulties.
• Tracheoinnominate Arterial Fistula: A rare but life-threatening complication where the trachea erodes into the innominate artery, resulting in severe hemorrhage.
• Tracheal Stenosis: Narrowing of the trachea due to scar tissue formation, which can lead to breathing difficulties.

Zygomatic Bone Reduction

When performing a reduction of the zygomatic bone, particularly in the context of maxillary arch fractures, several key checkpoints are used to assess the success of the procedure. Here’s a detailed overview of the important checkpoints for both zygomatic bone and zygomatic arch reduction.

Zygomatic Bone Reduction

1. Alignment at the Sphenozygomatic Suture:

   • While this is considered the best checkpoint for assessing the reduction of the zygomatic bone, it may not always be the most practical or available option in certain clinical scenarios.

2. Symmetry of the Zygomatic Arch:

   • Importance: This is the second-best checkpoint and serves multiple purposes:
     • Maintains Interzygomatic Distance: Ensures that the distance between the zygomatic bones is preserved, which is crucial for facial symmetry.
     • Maintains Facial Symmetry and Aesthetic Balance: A symmetrical zygomatic arch contributes to the overall aesthetic appearance of the face.
     • Preserves the Dome Effect: The prominence of the zygomatic arch creates a natural contour that is important for facial aesthetics.

3. Continuity of the Infraorbital Rim:

   • A critical checkpoint indicating that the reduction is complete. The infraorbital rim should show no step-off, indicating proper alignment and continuity.

4. Continuity at the Frontozygomatic Suture:

   • Ensures that the junction between the frontal bone and the zygomatic bone is intact and properly aligned.

5. Continuity at the Zygomatic Buttress Region:

   • The zygomatic buttress is an important structural component that provides support and stability to the zygomatic bone.

Zygomatic Arch Reduction

1. Click Sound:

   • The presence of a click sound during manipulation can indicate proper alignment and reduction of the zygomatic arch.

2. Symmetry of the Arches:

   • Assessing the symmetry of the zygomatic arches on both sides of the face is crucial for ensuring that the reduction has been successful and that the facial aesthetics are preserved.

Cardiovascular Effects of Sevoflurane, Halothane, and Isoflurane

• Sevoflurane:

  • Maintains cardiac index and heart rate effectively.

  • Exhibits less hypotensive and negative inotropic effects compared to halothane.

  • Cardiac output is greater than that observed with halothane.

  • Recovery from sevoflurane anesthesia is smooth and comparable to isoflurane, with a shorter time to standing than halothane.

• Halothane:

  • Causes significant decreases in mean arterial pressure, ejection fraction, and cardiac index.

  • Heart rate remains at baseline levels, but overall cardiovascular function is depressed.

  • Recovery from halothane is less favorable compared to sevoflurane and isoflurane.

• Isoflurane:

  • Preserves cardiac index and ejection fraction better than halothane.

  • Increases heart rate while having less suppression of mean arterial pressure compared to halothane.

  • Cardiac output during isoflurane anesthesia is similar to that of sevoflurane, indicating a favorable cardiovascular profile.

An ulcer is a break in the continuity of the skin or the mucous membrane.

Mode of onset:  Traumatic ulcers heal when the traumatic agent is removed., If it persists it becomes chronic as in the case of dental ulcer of the tongue. Ulcers may develop spontaneously as in the case of gumma (syphilitic ulcer). It may develop with varicose veins called varicose ulcer, which develops in the lower third of the leg.

Sometimes a malignant ulcer develops in a scar called Marjolin’s ulcer. Special features are:

 No pain - as there are no nerves. It does not spread - as there is scar tissue. No metastases - as there are no lymphatics Treatment:- Wide excision.

Classification of Ulcer

A) Pathologically

I. Non-specific ulcers:

a. Due to infected wound after trauma, that is physical or chemical agents.

b. Due to local infection example dental ulcer, pressure sore

 Specific ulcers: Caused by specific infection

a. Syphilitic ulcers (Hunterian chancre)

b. Tubercular  ulcers, actinomycosis

Trophic ulcer:- Caused by two factors:

Diminished nutrition due to inadequate blood supply to the tissues

Eg. Ulcers in Buerger’s Disease, Artherosclerosis

b. Diminished or absence of sensation of the skin leading to perforating ulcer of the foot

iv. Malignant ulcer: Due to squamous cell carcinoma, rodent ulcers and melanoma.

B) Clinical classification of ulcers

1. Acute Ulcer:  The edge is inflamed oedematous and painful with slough in the floor and n o granulation tissue. Profuse purulent Discgarge seen

2. Healing ulcers: edge sloping with bluish margin The floor is covered with a red, healthy granulation tissue.

3. Chronic or callous ulcer (non- healing) There is no tendency to heal by itself, the base is jndurated  unhealthy granulation tissue is present in the floor The edge is rounded and thickened.

Chronic ulcer occur due to:

Chronic infection , Defective circulation , Foreign body, Persistent local oedema , Malignancy , Diabetes , Malnutrition (loss of proteins), Gout

Specific Ulcers

Tubeculous Ulcer

Edge Undermined, floor contains granulation tissue a watery discharge is present. Caseous material is found in the floor of the ulcer. It usually occurs in tubercular lymphadenitis in the neck, axilla or groin.

Syphilitic Ulcer

a) Huntarian Chancre or  primary sore or hard chancre: usuaIly occurs over the genitalia especially on penis. Occurs in the primary stage of syphilis Ulcer is round or oval, it is hard,indurated, elevated and painless It feels like a button, discharges serum containing spirochetes (cork screw) which is highly infective.

b) In the Secondary stage mucous patches and condylomata occurs The ulcers are shallow white patches, of sodden thickness which occur in the mouth and tongue. Condyloma are hypertrophied epithelium with serous discharge occurring in mucocutaneous junction around the anus. The regional lymphnod (inguinal transverse chain) are enlarged.

c) In tertiary stage of syphilis gummatous ulcers occur They have a punched  out edge and wash Ieather floor. They occur on the subcutaneous bones like sternum and tibia. They are painless and refuse to heal.

Soft Sore (chanchroid)

They are painful muitiple ulcers, with copious discharge. They are caused by Bacillus Ducrey  lncubation time is 3 to 4 days. located on glans penis and prepuce is due to venereal infection. They are associated with enlarged called bilateral inguinal lymphnodes

Tropical ulcer:

a) Oriental Sore - due to L. Tropica (lieshmaniasis)

b) Ulcers and sinuses are due to guinea worm abscess

c) Histoplasmosis with multiple ulcers on the tibia.

d) Chronic ulcers due to yaws

e) Amoebic ulcers occur in colon_and rectum , flask shaped ulcers , undermined edge , caused by  Entamoeba Histolytica

Varicose Ulcer:

Associated with varicose veins. Occurs on the inner aspect of the lower third of leg , chronic ulcer The surrounding area is pigmented and eczema is present. The sore is longitudinally oval It does not penetrate the deep fascia and is painless The base is adherent to the periosteum of the tibia

Rodent ulcer

Usually Occurs on the face above a line joining the lobule of the ear to the angle of the mouth. Usually occurs at the inner canthous of the eye . Edge is raised and rolled, Erodes the deeper structures and the bone, the lyrnph nodes are not involved.

Treatment: If small wide excision is done with skin grafting, If large, radiotherapy is given.

Malignant Ulcer

Occurs due to chronic irritation as in the case of malignant ulcer of the tongue. The edge is everted. The floor is covered with slough and tumor tissue The regional lymph nodes are hard.

Initially mobile later becomes hard

Treatment: Wide excision is done.

Marjolin ulcer: Malignant Ulcer occurring on scar of Burns