Clinical Surgery Pearls R Dayananda Babu
INDEX
Page numbers followed by f refer to figure, and fc refer to flowchart
A
ABCDE system 371
Abdomen 478, 555
acute 1
computed tomography scan 532, 533f
general fullness of 246
nine areas of 100f
plain
radiograph 263, 478f
skiagram 487f
ultrasonography 509, 526, 527f, 528, 529f
Abdominal wall, anterior 458
Abram's needle 123
Abscess 1, 142, 325
pancreatic 11, 221
pericolic 521
Absorbable meshes 443
Accoucheur's hand 33
Achalasia 506
cardia 505507
Achlorhydria 102
Acid poisoning 100
Acquired phimosis, management of 394
Acrocyanosis 187
Adenocarcinoma 279
extracolonic 129
metastasis 485
treatment of 286
Adenoid 272
cystic carcinoma 310
Adenoma
carcinoma sequence 131
follicular 39
Adenomatous polyps, types of 130
Adenosine deaminase 123
Adiposis dolorosa 352
Adjuvant therapy 136
Adriamycin 232, 343
Adson's test 181, 500
Adventitious bursae 4
Agenesis 1, 233f
Agranulocytosis 26
Airway
control 544
obstruction 544
techniques, advanced 544
Albumin-bound total calcium 34
Alcohol, action of 292
Alkaline
phosphatase 148, 152
urine 513
Alkalosis, hypochloremic 513
Allen's test 182
Allergic disorders 567
Alvarado score 142, 559
Ambulatory venous
hypertension 162
pressure study 169
Amelanotic melanoma 371
Amenorrhea 16
American College of Surgeons Committee on Trauma 544
American Joint Committee on Cancer 9, 103
American National Pressure Ulcer Advisory Panel 564
American Venous Forum Classification 167
Amputation 343
complications of 568
neuroma 346
role of 190, 342
stump 570
Amyand's hernia 430
Amylase 2
Amyloid stroma 57
Anal
canal 376
fissures 571
fistula 570
Anaplastic carcinoma 48, 49
Anastrozole 80
Anderson-Hynes pyeloplasty 504
Anemia 102, 122, 365
Anesthesia, types of 119
Aneurysm 324
Angiosarcoma 339
Angular stomatitis 555
Ankle
brachial pressure index 182, 183, 563
edema 164
flare, malleolar of 164
Ankyloglossia 2, 11, 289
Ann-Arbor staging 200
Anomalous pancreatobiliary ductal junction 562
Anorexia 144
Anthropometry 540
Antibiotic prophylaxis, role of 132
Antiestrogens 465
Antiseptic solutions 366
Antithyroglobulin antibody 22
Antithyroid drugs 25, 26, 30
Antituberculous drugs 125
Aorta 487
Apex beat 494
Apoplexy, abdominal 1
Appendicectomy
interval 142
rate 142
Appendicitis
acute 142
building 143f
Appendicular abscess 140
classification of 141
complications of 141
management of 141
Appendicular mass 139142
management of 140
Appendix
epiploicae, torsion of 143
positions of 559
Apple-jelly granulation 363
Aqueductal stenosis 348
Arc of Riolan 2, 10, 133
Arch vein 162f
Arecoline 292
Arm stress test 500
Aromatase inhibitors 79, 465
Artefact ulcer 363
Arterial
embolism, peripheral 191
occlusion, chronic 188
revascularization 185
ulcer 361, 363
Arteriogram, complications of 184
Arteriography 178, 184
Arteriosclerotic lesion 1
Arteriovenous fistula 360, 407
congenital 400
Arteriovenous malformation 160, 566
Artery 516, 532
major 343
meandering 133
of Drummond, marginal 10, 133
Arytenoidopexy 35
Ascites 98f, 101, 246
complications of 259
pancreatic 11, 12
signs of 247
Ascitic fluid
study 123
types of 246
Aseptic ulceration 10
Asthenia 102
Atherosclerosis 178
Athyreosis 327
Atresia 1
Atrophie blanche 168
Atrophy 105
Attack, hypoglycemic 115
Autoimmune disorders 394
Axilla 92, 570
Axillary
dissection 77
lymph nodes
level of 91
palpation of 69
node 541
sampling 81
swelling 196
tail of Spence 67, 67f
Azzopardi and Savadori criteria 470
B
Bacteremia 2
Bacteria, multiplication of 15
Bacterial sialadenitis, acute 305, 306
Bacteroides 490
fusiformis 364
Bad prognostic sign 288
Baker's cyst 569
Balanitis 393
xerotica obliterance 394
Balanoposthitis 393
Balloon tamponade, rate of 256
Banti's syndrome 253
Barium
meal examination 102
sulfate 511, 512
swallow 505, 506f, 507, 508f, 511
Barrett's esophagus 2
Basal cell
carcinoma 380, 380f, 381, 382
multiple 382
origin of 380
types of 381, 382
papilloma 381
Basaloid carcinoma 397
Bashful bladder 13
Basic airway techniques 544
Bassini's herniorrhaphy 436
Bassini's repair 435
Batson's plexus 90, 91
Bayley's symptom complex 35
Bazin's disease 364
B-cell neoplasms, mature 199
Beck's triad 494
Bed sore, prevention of 365
Beger procedure 488
Bendavid classification 434
Benjamin classification 149
Berry's sign 19, 46
Bethesda system of reporting thyroid cytology 40
Bevacizumab 94, 138
Bile duct
cystadenocarcinoma 115
distal extrahepatic tumors of 156
strictures, Bismuth classification of 557
tumors, management of 156
Bile pigment metabolism 146f
Biliary drainage, external 525
Bilirubin 145
glucuronide 145
Billiard ball testis 236
Bilocular hydrocele 420
Biological mesh 443
Biopsy 102, 274
endometrial 102
forceps 102
incision 268f
non-diagnostic 53
open 319
surveillance 278
types of 12, 373, 388
Bird's beak appearance 505
Bisphosphonates 97
Bite duct 7
Black-Colored granulation tissue 367
Bladder, painless 13
Bleeding 49
ulceration 12
Bleomycin 398
Blind biopsy 278
Blood 307
brain barrier 208
pressure 344, 494
staining 127
transfusion, massive 10
Bloom Richardson combined scores 553
Blowout syndrome 162
Blue liver 138
Blue nevus 369
Blumer's shelf 100, 101
B-mode ultrasound 527
Bodansky units 148
Body moles 369
Body scan, total 56
Boil 2
Bone 56
complications 568
destruction 47f
graft, microvascular 302
marrow
biopsy 203
involvement 202
metastases 91, 96
common sites of 90
treatment of isolated 59
Borrmann classification 105
Bowen's disease 386, 387
Brachytherapy, role of 343
Brain
computed tomography 529, 530f
cyst 5
metastases 91
treatment of 56
Branchial arch 330
pathology 330f
Branchial cyst 325, 329, 329f, 330333
origin of 330
Branchial fistula 329, 331333
lining of 331
Breast 75, 464, 467, 533, 552
biopsy 72
cancer 96, 464
advanced 87, 88f
bilateral 84
biological markers of 82
early 67, 78, 97
locally advanced 88f, 89f
male 70, 460, 466
management 77fc, 94fc
carcinoma of 2, 83, 84
common malignancy of 73
conservation therapy 76
cyst 467, 471, 472
excision of 472
management of 471
disease, benign 73, 468
lesion, benign 471
lymphatic drainage of 91
massive enlargement of 468
origin of carcinoma 75
Paget's disease of 82
pathological type of carcinoma 75
recurrence in 536
subtypes of carcinoma 76
surveillance of 534
treatment of carcinoma 79, 84
tuberculosis 88f
Breastfeeding 70
Breslow's thickness 372
Brodie-Trendelenburg test 165
Bronchoscopy 278, 509
Brown pigment stones 489
Browse, fibrin-cuff theory 163
Brugia malayi 414
Bruit 3, 182
Brunner's grading 412
Brush biopsy 102
Buccal mucosa 11, 301
Budd-Chiari syndrome 252
treatment of 252
Buerger's disease 185, 191
Buerger's vascular angle 180
Bulky disease 204, 205, 243
Bunion 3, 4
Bupivacaine 540
Burkitt's lymphoma 207
Burns 3, 548
classification of 548
complications of 549
resuscitation of 549
types of 549
Bursae 3
Buschke-Loewenstein tumor 395
Bypass graft 189
Bystander lesion 81
C
Cabana's node 398
Cachexia 102
Café-au-lait macules 344
Café-au-lait spot 347
Calcification
peripheral 214
types of 46
Calcitonin 57, 58
Calcitriol 34
Calcium
carbonate 34
gluconate 34
Callous ulcer 360
Campbell de Morgan spot 405
Canal of Nuck, hydrocele of 421
Cancer
colonic 136
colorectal 130, 136
endometrial 282
family syndrome 129
head and neck 9
laboratory 50
male breast 460f
microscopic 50
Candidal infection 294
Cannon ball 214
lesion 484
Capillary filling time 180
Carbimazole
action of 26
side effects of 26
Carbon dioxide laser, role of 383
Carbuncle 2, 4
Carcinoembryonic antigen 126, 135
Carcinoma 43, 46, 53, 54, 105, 115, 153, 472, 552, 555
adenosquamous 115
adrenocortical 542
advanced 87, 98f
branchiogenic 332
breast 67, 67f, 68, 68f, 69, 70, 72, 73, 76, 80, 82, 84, 88f, 89, 90, 92, 95, 97, 470, 533, 534f, 554
Bloom Richardson grading of 552
diagnosis of 69
lobular 82
modes of spread of 91
staging of 73
cecum 122, 127, 516
diagnosis of 132
colon 127, 131, 137
destroying glans 392f
development of 464
esophagus 507, 509, 511
ex-pleomorphic adenoma 310
extensive secondary 114
fibrolamellar 117
follicular 39, 43, 47f, 4851
gingivobuccal complex 299, 299f
hepatocellular 115, 116, 532
in situ 386, 552
lobular 81, 82
insular 59
male breast 461f, 466
microscopic 55
nasopharynx 281
parotid 310
penis 392, 393, 393f, 394, 396, 398, 399
staging of 395
periampullary 282
retromolar trigone 301
secondary 114
stomach 100, 101, 103106, 108, 110, 511, 512
prognosis of 109
spread of 106
thyroid 43, 45f, 46, 46f, 47, 50, 54, 56, 551
diagnosis of 47
recurrent 46f
tongue 289, 290, 290f, 295, 298
surgical management of 296
Cardiac tamponade 494, 544
Cardioesophageal junction 108
Cardiovascular depression 540
Carney's triad 111
Caroli's disease 150, 156
Carotid artery 31, 288, 334
external 313, 334
internal 334
syndrome 334
tumor 329, 332, 334, 335, 564
Carotid pulse 19
Carpal ligament 567
Carpopedal spasm 33
Catheter drainage 224
Cattell's operation 447
Cattell Braasch maneuver 154
Cauda eqina 357
Cauliflower-like proliferation 385
Cavity, abdominal 246
Cecum 519f
carcinoma of 126, 127, 518
Ceftuximab 138
Cell
benign 552
cycle 540
follicular 51
neoplasms 199
Cellulitis 4, 415
Central compartment dissection 53
Cerebral edema 549
Cerebrovascular accidents 571
Cervical
lymph node 60, 269, 270, 274, 297
classification of 270fc
deep 48
examination 269f
level of 284
palpation of 270
tuberculosis 272, 275
metastatic lymph node 277
node 276
extracapsular invasion of 551
tuberculosis 272
rib 498, 499, 500
etiopathology of 500
pathology of 500
symptoms of 500
treatment of 501
types of 498
scan 56
sinus of His 330
sympathetic involvement 551
Chagas’ disease 506, 571
Chalky plaques 294
Champagne bottle leg 168
Charcot's triad 145, 155, 490
Charles procedure 417
Cheilosis 555
Chemical sympathectomy 190
Chemodectoma 332
Chemoradiation 107, 110
advantage of 303
disadvantage of 303
role of 510
Chemosis 20
Chemotherapy 78, 79, 93, 108, 204, 243, 244, 303, 343
adjuvant systemic 466
anterior 553
preoperative 343
role of 155
selection of 96
side effects of 93
Chernobyl nuclear disaster 50
Chest
drain 498
injury 544
metastases 244
types of 90
radiography 509
skiagram of 482f, 491, 493f, 495f, 496f, 491, 506f
trauma
result of 494
skiagram of 492
tube
insertion of 497
removal of 498
wall 74, 497
infiltration 3
swellings 349
X-ray of 62
Chevassu maneuver 242
Chiba needle 526
Chilaiditi's syndrome 483
Child's classification 251
Child-Pugh classification 118
Child-Pugh grading, role of 118
Child-Turcotte-Pugh classification 251, 557
Chills 151
Chimney sweeps cancer 387
Chines university prognostic index 119
Chlamydia trachomatis 139
Cholangioadenoma 115
Cholangiocarcinoma 115, 117, 156
Bismuth classification of 157
Cholangiogram, percutaneous transhepatic 525, 526f
Cholangiohepatitis 149
Cholangiopancreatography, endoscopic retrograde 151
Cholangitis 155
pathology of 155
Cholecystectomy, laparoscopic 156
Cholecystitis 2, 143, 491
Cholecystojejunostomy 154
Choledochal cyst 149, 150
treatment of 150, 262
types of 150
Choledocholithotomy 523, 525
Choledochotomy 523, 525
Cholesterol crystals 332
Cholestyramine 153
Choroid, diagnosis of melanoma of 376
Choudary Millis criteria 84
Chromoendoscopy 102
Chvostek sign 33
Chylocele 418, 422
Cirrhosis 117, 252, 258, 462
background of 117
Cirsoid aneurysm 406
Clamping T-tube before removal 524
Clark's level 373
Claudication 4, 178
Boyd's grading of 179
pain 178
sites of 178
types of 178
Clergyman's knee 3, 4
Clodronate 97
Clonorchis sinensis 117
Cloquet's hernia 442
Cloquet's node 441
Clostridial septicemia 143
Clostridium tetani 549
Clot colic 213
Clubbing 115
Clutton's joint 237
Cock's peculiar tumor 355
Cockett's perforators 161
Coffee
bean sign 480
ground vomitus 248
Cogwheel limb rigidity 115
Cold abscess 1, 4, 268f, 272, 272f, 273, 276, 332, 445
sites of 273
treatment of 276
Cold nodule 41, 41f
Colectomy
subtotal 136
total 136
Colicky abdominal pain 121
Collagen deficiency 445
Collar-stud abscess 273
stage of 273
Colon 477
ascending 518
cancer 132
ligaments attaching hepatic flexure of 134
lymphatic drainage of 134
management of carcinoma 135
regions of 136
Colonic cancer, acute manifestations of 132
Colonoscopy, virtual 130
Colorectal cancer, types of 129
Colostomy 137, 445
Commando operation 297
Compression 63
principle of 174
role of 174
Computed tomography scan, advantages of 530
Congestion, intraorbital 20
Conley's pointer 313
Conservative parotidectomy, total 312
Constipation 5, 52, 132, 571, 480
Contralateral kidney, function of 214
Convulsions 540
Cooper's ligament 91
Cope's needle 123
Cord, medialization of 35
Cordectomy 35
Core biopsy 49, 71, 338
Core nodal regions 206
Corona phlebectasia 164
Corpora, lymphatic drainage of 398
Correa cycle 105
Corticosteroids 407
Corynebacterium diphtheriae 364
Costello syndrome 228
Cotton wool, pad of 289
Cough impulse 5
Countryman's lip 387
Courvoisier's law 145, 149
Courvoisier's sign 151
Cowden syndrome 50
Cranial nerves 318
Crepitus 5, 495
Cresent sign 482
Cricoid cartilage 283, 325
Cricothyroid muscle, 35
Cricothyroidotomy 544
Crigler-Najjar disease 147
Crile incision, modified 287f
Critical limb ischemia 187
Crohn's disease 555, 560, 571
Cruveilhier's sign 441
Cryosurgery 391
complications of 383
role of 383
Cryptorchid testis 236
Curling's ulcer 549
Curving osteophytes 487
Cushing's syndrome 115
Cyst 5, 332
acquired 325
chylolymphatic 262
classification of 325
complications of 262, 325
congenital 325
content of 355
epidermoid 353, 418, 422
false 5
true 5
Cystadenoma 325
Cystic
hygroma, complications of 333
lymphangioma, abdominal 232
swelling, central abdominal 261
Cystogastrostomy 224
postoperative complication of 225
Cystojejunostomy 224
Cystosarcoma 467, 467f
phyllodes 469
Cytokines 208
D
Dacarbazine 343, 377
Daily living, activities of 1
Death, causes of 229, 288, 298
Decubitus ulcer 365, 549
Deep venous
insufficiency, treatment of 174
obstruction 174
surgery 174
system 161
thrombosis 169, 363, 564
Degidio and Schein classification 225
Dental
cyst 5
pores 297
sockets 297
Dercum's disease 352
Dermal
leishmaniasis 411, 567
lymphatics 78
Dermatolymphangioadenitis, acute 413
Dermis 369
Dermoid
classification of 541
cyst 5, 320f, 325, 332, 353, 356, 357
congenital 356
Desmoid tumor
diagnosis of 457
incidence of 457
management of 458
staging of 562
surgical management of 458
types of 457
Dexamethasone 27
Diabetes mellitus 151, 358, 365
Diabetic foot 358f, 359f, 365, 563
Diabetic ulcer 365
Diarrhea 5, 16, 57, 58, 122, 132, 521
intermittent 121
Diethylenetriaminepenta-acetic acid 503
Dietl's crisis 5, 8, 218, 504
Digastric muscle 313
Digital subtraction angiography 185
Dihydrotachysterol 34
Dihydrotestosterone 465
Diphtheritic desert sore 364
Distant metastasis, management of 398
Diverticular disease 571
Diverticulitis, acute 559
Diverticulosis 5
Diverticulum 5
false 5
true 5
Dome sign 483
Dominant nodule 38f, 39
Doppler wave appearance 183
Dormia basket 525
Double contrast barium enema 123, 516, 517
Double duct sign 151
Double wall sign 483
Dry gangrene 186
Dual hernia 433
Dubin Johnson's familial conjugated hyperbilirubinemia 144, 147
Ducrey's ulcer 361
Ductal carcinoma in situ 81
Dumbbell tumor 347
Duodenal
cap 515
nonvisualization of 516
deformity 515
obstruction 155
ulcer 100, 515, 549, 556
complications of 516
perforation 483
treatment of 516
turn malignant 516
Duodenum 549, 556
Duplex ultrasound imaging 168
Dupuytren's contracture 115
Dupuytren's fibromatosis 457
Dyshormonogenesis 62
Dyskeratosis congenita 295
Dysmenorrhea 139
Dysphagia 509, 555
lusoria 555
Dysplasia 105
Dyspnea, acute 494
E
Echelon lymph node 374
Echosclerotherapy 170
Ectopic
gastric epithelium 516
hormones 213
lobe 319
testis 235
thyroid 323, 327
Eczema 83
Edema 3, 6, 89, 121, 411
Elephantiasis neuromatosa 346
Elliptical incision 355
Elston-Ellis modification 76
Embolectomy 192
Embolic lung phenomena 549
Emphysema
subcutaneous 495
surgical 5, 494, 395
Empyema 6
Encephalopathy 115
management of 259
Endarterectomy 189
Endocrine
neoplasia, multiple 57
therapy, selection of 96
Endotoxin 6
Endotracheal tube 63, 65
Enterogenous cyst 262, 325
treatment of 262
Epidermal growth factor receptor 92
Epidermis 369
Epididymis 240, 424
tuberculosis of 422
Epigastric
hernia 450, 451
complications of 451
repair 451
surgical management of 451
mass 100f
vein, superficial 398
Epithelial cells 552
Epithelioid sarcoma 339
Epithelioma 385
Epitrochlear nodes 541
Epstein-Barr virus 203
Erysipelas 4, 6
Erythrocyanosis frigida 364
Erythrocytosis 115, 212
Erythroplakia 6, 293, 387
management of 293
of Queyrat 394
Escherichia coli 490
Esophageal
diverticulum 555
transection 257
varices 249, 250, 556
endoscopic grading of 249
Esophagitis
acute 555
chronic 555
Esophagogastric junction tumors 106
Esophagojejunostomy, palliative 108
Esophagoscopy 278
Esophagus 376, 506f, 510
carcinoma of 507, 508
lower 510
lumen of 555
Estrogen
producing tumors 463
receptor 280
source of 80
Ethambutol 275
European Hernia Society Classification 434
Excision
biopsy 71, 375
marginal 342
Exomphalos 455
Exophthalmos 18, 20, 37
management of 37
severe 20, 37
Exotoxin 6
Extensive retroperitoneal nodes, treatment of 244
External drainage, complications of 224
Extracapsular dissection 314
Extranodal metastasis, sites of 239
Eye
melanoma of 376
opening 545
signs 20
F
Facial artery 319
Facial nerve 33, 304, 312, 313
branch of 318
injury, management of 312
sectioning of 313
Facial palsy 305f, 308, 312
management of 312, 314
types of 308
Familial adenomatous polyposis 127, 337
Fascia
deep 269, 362
lata 398
superficial 341
Fascial repair 447
Fast track surgery 137
Fat
burn 3
cell, adult 10
Fatty hilus, loss of 59
Febrile 194
Feeding vessel 335
Fegan's test 165, 166, 167
Felty's syndrome 360
Femoral canal, boundaries of 441
Femoral hernia 426, 427f, 429, 430, 440, 441
enlargement of 430
favor of 440
stages of 440
Femoral nerve resection 343
Fertility 235
Fever 151
Fibroadenoma 467, 469471
complex 471
excision of 471
favor of 467
incidence of 469
intracanalicular 469
juvenile 469, 471
pericanalicular 469
turn malignant 470
types of 469
Fibroadenosis 467
management of 473
Fibrocystic disease 467, 472
Fibroelastic transformation 294
Fibrofatty tissue 566
Fibroid uterus, favor of 140
Fibrolipoma 352
Fibromatosis 341
aggressive 457
Fibrosarcoma 542
Fibrous tissue 221
Filarial lymphedema, pathogenesis of 413
Filariasis
attacks 422
lymphatic 566
rule out 422
surgical complications of 415
Fine needle aspiration cytology 25, 39, 44, 47, 58, 62, 90, 102, 156, 280, 338, 552
Fingers, lymphatic drainage of 541
First rib, resection of 501
First-bite syndrome 335
Fistula 6, 331
intersphincteric 570
Fistula-in-ano 7
Fistulogram 333
Flail chest 7, 491, 492, 544
consequence of 492
first aid treatment of 492
treatment of 492
Flail sternum 7
Flaps, types of 390
Fleischner sign 123, 519
Flexor digitorum superficialis 567
Fluctuation 4
Fluid
collection, acute 11
levels, number of 479
thrill 247
Foam sclerotherapy 170
Focal nodular hyperplasia 115, 532
Foley's catheter 545, 546
Follicular
Carcinoma
diagnosis of 50
types of 51
neoplasia, meaning of 43
Folliculitis 2, 7
Fontain sign 334
Foot
dorsum of 359f
gangrene, partial 563
Football sign 483
Footballer's ulcer 361
Foramen cecum 326
Foreign body granuloma 445
Forrest's classification 557
Foul smelling discharge 385
Fournier's gangrene 364f
Fracture rib
complications of 491
consequence of 491
role for strapping of 492
signs of 491
treatment of pain of 492
Frey's procedure 488
Frey's syndrome 314
management of 314
Frimann Dahl sign 480
Funicular direct inguinal hernia 433
Furuncle 2
Furunculosis 2
G
Galactocele 472
Gallbladder 490
cancer 557
Gallstone 146, 488490, 528
asymptomatic 490
complications of 490
formation 490
incidence of 490
pancreatitis 558
types of 489
Ganglion 7
Gangrene 7, 177, 185, 186
clinical types of 186
treatment of 186
Gangrenous patches 563
Gardner's syndrome 128, 337
Gastrectomy 107
palliative 108
total 106109
Gastric
adenocarcinoma, surgical treatment of 106
atrophy 105
cancer 105, 110
advanced 105
diffuse 105
distal 106
early 7, 101, 109
fundal varices, treatment of 255
lavage 102
malignancy 108
distal 100
outlet obstruction 100, 513
benign 513
causes of 556
metabolic abnormalities of benign 513
peristalsis, visible 100
polyps 105
resection, extent of 106
ulcer 549, 556
classification of 556
Gastrinoma 7
triangle 7
Gastrointestinal
bleed
lower 10
upper 10, 15, 102
endoscopy, upper 557
stromal tumor 110, 561
Gastrojejunostomy 155
palliative 108, 512
Gastroschisis 456
incidence of 456
Gaur's sign 441
Genital
tract, female 376
warts 394
Genitalia 100, 570
examination 213
male 392
Geographic tongue 295
Gerota's fascia 215
Giant fibroadenoma 469
Gibbon's hernia 430
Gilbert's disease 147
Gilbert's familial non-hemolytic hyperbilirubinemia 144
Gingiva 296
Gingivobuccal complex, advanced 302
Gland, removal of 31
Glansectomy 397
Glasgow coma scale 545
Glasgow scoring system 558
Glasgow seven point 371
Globus hystericus 555
Glossitis 294
Goiter 7, 16, 19, 18, 486
grading of 7
large 8
longstanding 486
plunging 19
recurrent 60f
retrosternal extension of 61f
small 25
WHO grading of 18
Golden tumor 212
Golfer's elbow 3, 4
Gorlin's syndrome 380
Granulation tissue 1
layer of 10
Granuloma 8
Graves’ disease 21
Great auricular nerve 313
Griffith's point 134
Gynecomastia 115, 238, 460463, 463f, 464, 465
benign 466
bilateral 461, 461f, 464
drug-induced 462
incidence of 461
management of 464
physiological 461
unilateral 461f
H
Haemophilus ducreyi 393
Hairy leukoplakia 293
Hairy tongue 294
Halitosis 139
Hamartoma 8
Hamburg classification 404
Hands, tremor of 17
Hansen's disease 358, 411, 567
stigmata of 362
Hard mobile lymph node 144
Hard palate 11
Hard thyroid nodule 42, 46
causes of 42
Hartley-Dunhill procedure 28, 29, 29f
Hartmann's procedure 137
Hashimoto's disease 206
Hashitoxicosis 37
Helicobacter pylori 105
Heller's myotomy 507
complication of 507
Helman spectrum theory 69
Hemangioma 115, 332, 400, 402404, 532, 542
capillary 402
classification of 402
complications of 403
sites of 403
treatment of 407
Hemangiopericytoma 229, 230, 542
Hematemesis 8, 102, 248, 251
Hematocele 418, 423
Hematochezia 8, 248
Hematocrit 33
Hematological toxicity, chemotherapy-induced 94
Hematoma 325, 439, 445
extradural 529, 531
type of 531
Hemicolectomy 125
left 136, 521
right 133, 136
Hemiglossectomy 296
Hemithyroidectomy 29, 43, 50, 53
Hemobilia 150
treatment of 150
triad of 150
Hemochromatosis 117
Hemodilution 33
Hemolytic crisis 148
Hemopneumothorax 496, 497
management of 497
radiological signs of 496
Hemorrhage 1, 62, 516, 531
extradural 532
Hemorrhoids 571
degree of 570
Hemothorax 496
management of 497
massive 10, 496, 544
Henoch-Schönlein purpura 143
Hepatic
adenoma 115, 116, 532
duct stump 557
resection, major 119
Hepaticojejunostomy 156
Hepatitis
B virus 117
C virus 117
Hepatocellular carcinoma
complications of 115
diagnosis of 116
macroscopic types of 117
types of 117
Hepatoma 542
Hepatorenal syndrome 259
Hereditary nonpolyposis colorectal cancer 128
Hernia 8, 428, 432f, 433
complications of 433
direct 430, 432
etiology of 430
formation, stages of 450
incidence of 433
interparietal 457
interstitial 458
large 446
management of dual 438
obstructed 433
parts of 428
postoperative 444
recurrent 439, 449
repair 436
laparoscopic 437
right side 429f
sliding 429
strangulated 433
surgery 434, 438
complications of 439
types of 432
Hernial orifices 99
Hernial sac, hydrocele of 420, 422
Hernioplasty 436
Herniorrhaphy 439
Herniotomy 435
Heterogeneity, functional 61f
High dose estrogen therapy 565
Hilar lymph nodes 214
Hirschsprung's disease 506, 517, 571
Hoarseness 34
Hodgkin's disease 201, 203205
classic cell of 198
early stage 204
favor of 199
pathological types of 200
treatment of 204
unfavorable types of 202
Hodgkin's lymphoma 196, 200, 201
lymphocyte predominant 201
staging of 200
Hormone 208
insensitive 64
replacement therapy 70
therapy 79, 81
role of 95
timing of 80
Horner's syndrome 551
Hot nodule 41, 41f
Hounsfield unit 529
Housemaid's knee 3, 4
Hughes technique 445
Human melanoma black 280
Human papilloma virus 292, 394
Hurthle cell
neoplasm 51
tumor 8
Hutchinson's halo 370
Hutchinson's lentigo 370
Hutchinson's pupil 532
Hydatid cyst 114
Hydatid of Morgagni 325
Hydrocele 392f, 414, 421, 422
acute 421
complications of 423
en bissac 418f, 419f, 420
encysted 420
etiology of 421
filarial 422
fluid 423
color of 421
constituents of 421
funicular 420
operation 423
secondary 422
treatment of 423
types of 421
Hydronephrosis 8, 211, 218, 219, 504
bilateral 211
intermittent 5
unilateral 211, 504
Hygroma, cystic 325, 329, 332, 333, 405
Hyoglossus muscle 318
Hyoid bone 283, 284
Hypercalcemia 115
treatment of 97
Hypercalciuria 9
Hyperemia 10, 293
Hyperesthesia 10
Hypernephroma 212
Hyperparathyroidism 8
Hyperplasia
congenital 567
diffuse 62
distal 567
Hyperplastic candidiasis, chronic 294
Hypersplenism 197
Hypertension 58, 212
Hyperthermia 542
Hyperthyroid thyrotoxicosis 22
Hyperthyroidism 21, 463
apathetic 2, 25
histopathological appearance of 37
postpartum 36
treatment of 36
Hypertrophic pyloric stenosis
adult type of 100
congenital 100
Hypertrophic scar 549, 550
Hypertrophy, benign 471
Hypochondrial lump, right 113
Hypogastric mass 234f
Hypoglossal nerve 296, 318
Hypoglycemia 542
Hypogonadism, causes of 462
Hypokalemia 514
Hyponatremia 514
Hypoparathyroidism 33, 34
low incidence of 53
management of 34
treatment of 34
Hypopharynx 376
Hypothermia 546
produces 546
Hypothyroidism 18, 33
I
Idiopathic pelviureteric junction obstruction 218
surgical treatment of 504
Ifosfamide 343, 398
Ileocecal mesenteric adenitis, acute nonspecific 263
Ileocecal tuberculosis 121, 122, 519
favor of 123
Ileostomy 445
Iliac
fossa
mass, right 121, 121f, 122, 139
pain, right 143
nodes 121
vein occlusion 159
Iliocecal tuberculosis, complications of 124
Immunotherapy, role of 217
Incidentaloma 59
Incisional biopsy 72, 290, 338, 375
Incisional hernia 444, 444f, 445447
complications of 446, 449
favor of 444
repair of 447
Indian oral cancer 299
Indwelling stents, pnsertion of 525
Infarction 7, 9
Infection 325, 490
Inflammation 12
carcinoma 78
breast 3
types of 317
Infraclavicular nodes 91, 201
Infraumbilical hernia 452
Infusion pyelogram 503
Inguinal
block dissection, complications of 398
canal 9, 430, 438
anatomy of 431f
dissection
superficial 398
types of 398
hernia 426, 427f, 428, 429, 430, 432, 434
bilateral 429f
direct 428, 429
indirect 428
management of 435fc
types of 430
ligament, point of 431
lymph node 195
node
enlarged 390
metastasis 239, 385f
orchidectomy 241
ring, external 431
Inguinoscrotal swelling, right 427f
Inherited syndrome, part of 457
Injection sclerotherapy, technique of 170
Insomnia 16
Insulinoma 542
Intercostal veins 90
Intermuscular lipoma 351
International prognostic index 208
Internodular tissue 63
Interstitial hernia
complications of 459
treatment of 459
Intestinal obstruction 477480
causes of 479
treatment of 477
Intestinal tuberculosis
hyperplastic types of 561
types of 124
Intra-abdominal bleeding, rule out 546
Intracapsular dissection 318
Intracranial pressure 288
Intraepidermal growth 370
Intralesional steroid therapy 407
Intraperitoneal chemotherapy, hyperthermic 112
Intrathoracic goiter, management of 30
Intravenous urogram 501, 502f, 505f
Intussusception 521
parts of 521
types of 522
Iodine
containing dye 501
deficiency 50, 62
Irritable bowel syndrome 571
Isotope scanning
role of 22
routine 40
Itching, treatment of 153
J
Japanese Research Society for Gastric Cancer 103
Jaundice 9, 101, 113, 114, 144, 145, 147, 148, 151, 223
acholuric 148
color of 146
hemolytic 147149
hepatic 145
intermittent 150
obstructive 144, 145, 147, 148, 153, 155, 525, 526f
prehepatic 145
surgical 149
types of 146, 148
waning of 145
Jejunojejunostomy 154
Jejunum 476
Jelly, redcurrant 522
Jenkin's formula 445
Jod-Basedow thyrotoxicosis 24, 36
Joffroy's sign 20
Jugular
group
middle 283
upper 283
nodes, sampling of 58
veins, anterior 30
venous pressure 494
Jugulodigastric node 289
enlargement 272
K
Kang cancer 387
Karnofsky performance status 9, 538
Kasabach-Merritt syndrome 403
Keel's operation 447
Keloid 550
Kenawy's sign 196
Keratitis, interstitial 237
Keratoacanthoma 381, 386
Keratosis 12
actinic 386
Kern's rule 541
Khangri cancer 387
Kidney
nonvisualization of 501, 503
signs of enlarged 210
Kissing ulcer 516
Klatskin tumor 156
Klebsiella 490
Klinefelter's syndrome 412, 464
Klippel-Trenaunay syndrome 165, 408
Knee
amputation
above 568
below 568
brace 343
hammer 33
Knobby liver enlargement, generalized 114
Kocher's collar incision 30
Kocher's test 19
Koilonychia 555
Krukenberg's tumor 92, 101, 133
L
Lacrimal gland enlargement 306
Laparoscopic nephrectomy, role of 216
Laparoscopy 103, 509
role of 103, 142
staging of 112
Laparotomy 111f
Laryngeal cancer, extralaryngeal involvement of 551
Laryngeal nerve
damage, recurrent 49
external 35
injury
recurrent 31, 32f
unilateral external 35
non-recurrent 32
recurrent 31
superior 31, 35
Laryngocele 332
Laryngoscopy
indirect 30, 62
routine postoperative indirect 34
Larynx 376
Laser treatment
endoscopic 35
endovenous 175
Lateral neck node dissection 54
Laugier's femoral hernia 441
Lauren's pathological classification 104
Lavage, peritoneal 103, 547
Leather bottle stomach 105, 513
Leg test of Fuchsig 181
Leg ulcers, causes of 173
Leiomyosarcoma 339, 542
Lentigo malignant melanoma 370
Leonardo's vein 161
Leriche's syndrome 179
Lesion
benign 533, 534f, 552
cystic 40
malignant 552
skip 186
small 386
Leukemia 365
Leukemic ileocecal syndrome 143
Leukocyte count, total 264
Leukonychia 115
Leukoplakia 6, 293, 394
management of 293
natural course of 293
types of 293
Levothyroxine 26
Leydig cell tumor 238
Lichen sclerosus atrophicus 394
Lichtenstein tension-free repair 437
Lid
lag sign 20
retraction 20
Ligaments of Cooper 2
Light bulb sign 116
Limb 369, 566
edema, lower 566
ischemia 187
acute 192
chronic 187
fontaine classification of 179
lymphedema of 416
sparing 341
Lindsay tumor 51
Linea alba, fatty hernia of 450
Linear atelectasis 483
Lingual
nerve 318
thyroid 323, 327
manifestation of 327
symptoms of 327
Linitis plastica 513
Lipodermatosclerosis 159, 363
Lipoma 10, 324, 350, 351, 445
back 350f
complications of 352
right arm 351f
signs of 351
symptoms of 352
Liposarcoma 227, 229, 230
origin of 229
pathology of 229
signs of 227
symptoms of 227
Lips 11
Lisch nodule 347
Liver 114
abscess 114
biopsy 117
carcinoma, primary 114
cirrhosis of 114
disease 113, 251, 557
alcoholic 117
functional status of 251
score 118
stigmata of 115, 145
flap 115
function tests 509
mass 116
metastases 114
resection of 562
necrosis 549
overlap sign 480
parenchymal resection of 119
primary malignancy of 114
resection 119
swelling 113f
favor of 113, 114
transplantation 258
tumors, classification of 115
Lobectomy 29, 50, 54
hepatic 156
Local anesthesia, advantages of 435
Long saphenous system, anatomy of 161
Lotheissen's operation 442
Lower limb
edema, unilateral 409
ischemia, acute 190
Lucid interval 532
Ludwig's angina 324
Lugol's iodine 27
Lumbar sympathectomy 190
Lump
abdomen 99f
epigastric 98, 110
painful 467
painless 67, 467
Lumpectomy 81
Lumpy breast, treatment of 473
Lung 56
cancer 551
primary
malignancy of 484
neoplasms of 485
resection 485
treatment of primary in 485
Lupus vulgaris 363
Lymph follicles 272
Lymph node 46, 92, 197, 202, 263, 275, 289, 307, 324, 330, 360, 385
adjacent 271
biopsy 47, 202, 279
cut section of 271
delphic 46
dissection 107, 297
bilateral 398
enlarged 270
submental 324
examination 194, 268
favor of 269
first echelon 291
functions of 270
group of 268, 272, 281
intramammary 92
intraparotid 313
ipsilateral infraclavicular 74
levels of 283
mass, intra-abdominal 198
matting of 199
metastases 42, 45, 47, 51, 59, 291, 338, 509
treatment of 54
pretracheal group of 48
round shape of 59
section 272f
significant 269
spread 388
stations 104
treatment of fixed 285
tuberculosis of 271, 275
Lymph sac, jugular 333
Lymphadenectomy 104, 397
adequate 104
Lymphadenopathy 265, 270, 271fc
Lymphangiectasia, intestinal 412
Lymphangioma 405
Lymphatic drainage 6
simple 416
Lymphedema 410f, 411, 413, 414
bandaging, multilayer 416
congenita 566
conservative management of 416
cutaneous 89
dangerous complication of 415
drug therapy of 416
grading of 567
lymphangiographic patterns of 567
management of 415
praecox 566
primary 412
secondary 413
sites of 414
tarda 566
therapy, decongestive 416
WHO staging of 412
Lymphoepithelial lesion, benign 306
Lymphogranuloma inguinale 566
Lymphoid
irradiation, total 204
neoplasm 197, 198
tissue 333
Lymphoma 49, 194197, 208
malignant 48, 367, 368, 368f, 369, 371, 377379
management of 59
WHO classification of 199
Lymphonodovenous shunt 416
Lyre sign 334
M
MacFee incision 286
Macronodular cirrhosis 114
Maffucci syndrome 408
Magnesium 34
gluconate 34
Magnetic resonance imaging 280
advantages of 536
role of 116
Malignancy
favor of 42
pathological type of 236
secondary signs of 535
signs of 19, 319
types of 310
Malnutrition universal screening tool 540
Mammary nodes, internal 78, 91
Mammogram 470, 533, 534f
presence of carcinoma in 535
Mammography 533, 534
digital 536
disadvantages of 535
evaluation of 534
false-negative rate of 535
radiation dose of 533
Mandibular
canal 297
resection, marginal 296
Mandibulectomy, marginal 297, 302
Mantoux test 274
Marjolin's ulcer 173, 365, 388
Marsupialization, role of 262
Martin incision 287, 287f
Martorell's ulcer 360, 365
Mass
lesions 116
ligation 31
right iliac fossa 122
Masseter muscle 305, 307
Massive midline defects 449
Mastalgia 467
noncyclical 473
Mastectomy 78, 81, 95, 554
Mastitis, chronic 467, 472
Mastopathy 467, 472
Maydl's hernia 429
May-Husni procedure 174
Mayo's repair 453
Mechanical ventilation, action of 492
Meckel's diverticulitis 143
Mediastinal lymph nodes 198
Mediastinum
superior 541
widening of 505, 506f
Medullary cords 272
Medullary thyroid carcinoma 43, 47, 5658
diagnosis of 58
treatment of 58
Meige's disease 411, 566
Melanoblast 369
Melanoma 282, 368, 372, 375, 377, 379
childhood 375
desmoplastic 375
heel, malignant 367f
management of 375
modes of spread of malignant 368
neurotropic 375
origin of 376
types of malignant 370
vaccine 378
Melanophores 369
Melanuria 378
Melemesis 8
Melena 8, 151, 248
Meleney's ulcer 363
Menarche, early 10
Meningeal artery, tearing of 532
Menopause 470
late 10
Mercedes-Benz sign 489
Mesenchymal stem cells 337
Mesenteric
adenitis 264
treatment of nonspecific 264
artery 2
cyst 260262
movement of 261f
sign of 261
desmoids 457
infarction 143
lymph nodes 487
Mesentery, neoplasms of 263
Mesh
complications of 440
types of 442
Mesocaval shunt 257
Mesosigmoid attachment 135f
Metabolic acidosis 546
Metachronous cancer 129
Metal stents, self-expandable 110
Metaplasia 105
Metastasis 532
classification of 115
liver 103, 114
resection of 485
scalp 46f
sites of 378
treatment of 56
Metastatic
adenocarcinoma, treatment of 280
bone involvement, order of 56
breast cancer 85, 96
cervical lymph node 277f, 278
disease, management of 378
emphysema 440
lesion reach vertebrae 90
liver 101
lymph node 278, 278f, 279
node 45f, 305f
ovarian tumor 133
Methimazole 36
Methotrexate 398
Mickey mouse sign 169
Microaerophilic nonhemolytic streptococci 363
Micrometastasis 3
Microsclerotherapy 170
Middle third malignancy 107
Migratory thrombophlebitis 145
Mikulicz's syndrome 306
Milian's ear sign 4, 6
Milk leg 566
Milroy's disease 411
Minimally invasive procedures 109
Minnesota tube 256
Minor salivary gland, distribution of 322
Miscarriage 36
Mitotic activity 339
Möbius's sign 20
Mohs micrographic
surgery 383
technique, role of 391
Molar region, lower 299
Mole 368
compound 369
intradermal 369
junctional 369
juvenile 369
Molecular therapy 110
Monson's zones 547
Morison's aphorism 4
Morrissey's cough impulse test 165, 167
Motility disorders 571
Mouth, floor of 11
Moynihan's aphorism 490
Mucinous cyst adenoma 228
Mucocutaneous junctions 369
Mucoepidermoid carcinoma 310
Mucosal melanomas 376
incidence of 375
sites of 376
treatment of 376
Mucous cyst 320, 321, 325
surgical treatment 321
Mulligan classification 404
Multilaminated basement membrane 542
Multinodular goiter 29, 60, 60f, 61f, 63
recurrent 65
Multiple endocrine neoplasia 57
Multisystem trauma 543
Mumps 306
Murphy's kidney punch 211
Muscle 286
complications 568
fibers 333
flap 288
pain, cramp like 4
twitches 540
Mycetoma 567
Mycobacterium tuberculosis 125, 275
Mycosis fungoides 207
Mycotoxins 117
Myelodysplastic syndromes 347
Myeloid leukemia, juvenile chronic 347
Mylohyoid muscle 316, 318
Myocardial infarction 565
Myoepithelial cells 310
Myopectineal orifice 432f, 437
of Fruchaud 431
Myxoid liposarcoma 339
N
Napkin lesion 519
Narath's femoral hernia 442
Nasogastric tube 546
Nasopharynx 143, 376
Natal cleft 570
Neck 551
dissection 277, 286, 287f
adequate 285
bilateral 288
complications of 288
functional 54, 285, 286
modified 285
types of 285
hydrocele of 421
incision series 287f
lymph node levels of 283f
midline swellings of 267
node 297
metastasis 281, 288
management of 297
skiagram of 486, 499f
swelling 265
triangles of 266, 266f, 266
X-ray of 62, 63f
Necrosing tumors 493
Necrosis 7, 11
central 62
pancreatic 11
Necrotizing fasciitis 569
Needle biopsy 117
role of 116
Neoadjuvant chemotherapy 110
Neonatal thyrotoxicosis 36
Neoplasia, follicular 43
Neoplasm
follicular 42, 51
malignant 555
Nephrectomy 215, 219, 505
partial 216
Nephrogram 501
Nephrone sparing surgery 216
Nerve 286
injury, types of 568
resection 343
Nervous diseases 358
Neurilemmoma 346
Neuritis 388
peripheral 364
Neuroblastoma 282
Neuroectodermalin origin 326
Neurofibroma 344346
treatment of 346
types of 346
Neurofibromatosis
central 347
types of 346
Neuropathic ulcer 361, 365
Neurovascular deficit, distal 336
Nevolipoma 352
Nevus 368
Nipple
discharge 83, 467, 474, 475
Paget's disease of 83f
retraction 2, 89, 554
Nodal metastasis 291, 338
Nodes, tuberculosis of 271
Nodular
goiter 60f, 61, 62, 64
complications of 63
dominant nodule of 39
favor of 61
leukoplakia 293
melanoma 370
Nodule
autonomous 24f
formation 62
hypertrophy of 63
malignant 62
primary 22, 23
secondary 22, 23
Nongastrointestinal disorders 571
Nonhealing heel ulcer 178
Non-Hodgkin's lymphoma 196, 197, 205
Nonprotein bound free calcium 34
Nonseminomatous germ cell tumor 244
management of 243
Nonthyroid neck
masses 265
swelling 265
Non-touch technique of Turnbull 133
Non-tuberculous mycobacterium 275
Noonan syndrome 412
Nottingham prognostic index 92, 553
Nuclear
grooves 50
pleomorphism 553
pseudo-inclusions 50
Nucleating factors 490
Nutritional assessment methods 540
NYHUS classification 434
O
Obesity, postmenopausal 70
Obstetrician's hand 33
Obstipation 5
Obstructive jaundice, management of 156
Obtuse ileocecal angle 519
Occult recurrent laryngeal nerve palsy 62
Octreotide acetate, role of 255
Okuda needle 526
Okuda staging 119
Oligometastatic disease 97
Omental cyst 262
Omphalocele 455, 456
incidence of 455
management of 455
types of 455
Oncocytoma 309
Oncoplastic surgery 81
Ophthalmopathy 28
Ophthalmoplegia 20
Oral
cancer 291, 292, 300, 302
macroscopic types of 291
modes of spread of 291
types of 291
carcinoma 290
cavity 11, 292, 307, 376
contraceptive 457
pills 71
lichen planus, types of 295
melanoma 376
mucosa 294
submucous fibrosis 294
treatment of 294
tongue 11
Orchidectomy, high 241
Orchidopexy 235, 236
Orchitis, ischemic 440
Organ invasion 103
Oropharyngeal cancers 291
Oropharynx 376
Orphan Annie nuclei 50
Osteolytic metastases 91
Otalgia 289
Ovarian cyst 247, 325
favor of 140
torsion of 139
Oxaliplatin 138
Oxyphil 51
Oxyphilic adenoma 309
P
Pachydermatocele 346
Paget's disease 83, 358, 364, 386, 394
extramammary 386
Pain 49
abdominal 262
epigastric 98
Palma operation 174
Palmar
erythema 115
ganglion, compound 4
Palomos operation 425
Pamidronate 97
Pancreas 107
calcification of 488
carcinoma head of 151, 154, 155
pseudocyst of 5, 220
Pancreatic
cancer 155, 562
management of 151fc
head malignancy 155
tumor 153
biopsy of 153
Pancreaticoduodenectomy 154
Pancreaticojejunostomy 154f
Pancreatitis 11, 488
acute 11, 143, 221, 558
chronic 11, 153
classification of 12
nongallstone 558
tropical chronic 487
Panendoscopy 279
Papillary cancer 54
tall cell variety of 54
Papillary carcinoma 43, 4751, 53
thyroid 45, 47
Papillary edema 523
Papillary microcarcinoma 50
Papillary thyroid cancer 43, 46f, 54
pathology of 50
Papilloma 12
benign 12
Para-aortic dissection 108
Parafollicular cells 326
Paraganglioma 228
Paralytic ileus 12, 447
radiological sign of 479
Paramandibular infiltration 302
Paramyxovirus 306
Paranasal sinuses 376
Paraneoplastic syndrome 58, 208, 212, 230
Paraphimosis 12, 393
Parathyroid
autotransplantation of 58
glands 30
hormone 8
Paraumbilical hernia 452, 453
complications of 453
surgery 453
Park's classification 570
Parkes-Weber syndrome 408
Parkland formula 549
Parotid
abscess 306f
carcinoma 311
duct 307
enlargement, bilateral 304f
fascia 305
gland 307, 313
benign tumors of 309
enlargement of 304
surgery 312
malignant 305f
neoplasms, WHO classification of 309
nodes 284
sandwich 308
surgery, complications of 314
swelling 304, 305, 307, 308
bilateral 306
favor of 305
right 308, 309
small 307
tumor 308, 309, 311
bilateral 311
malignant 310
mixed 310
staging of 310
Parotidectomy
complications of 314
superficial 313
Parotitis, acute 306
Passaro's triangle 7
Paterson-Kelly syndrome 295
Patey's mastectomy 95
Peau d'orange appearance 2, 12, 87, 88f, 89
Pectoral muscles 87
Pelvic mass 247
Pelvicalyceal system 502
appearance of 503
Pelvis, brim of 143
Pemberton's test 18, 60
Penile reconstruction 398
Penis
amputation of 397
edema of 393f
lymphatic drainage of 394
partial amputation of 397
types of carcinoma 394
Peptic ulcer 516
common sites of 516
disease 556
Periadenitis 272
Periductal fibrosis 89
Perihilar cholangiocarcinoma, Bismuth classification of 558
Peripheral occlusive vascular disease 176, 177
Peritoneal metastases, peritoneal 103, 153
Peritonitis 483
stages of 483
Pernicious anemia 105
Persistent sinus 275
Perthes’ test 166
modified 165, 167
Pes anserinus 308
Pfannenstiel incision 438
Phantom limb 568
Pharyngeal pouch 555
Pharyngocele 332
Pheochromocytoma 58, 347
Phimosis 12, 393
acquired 394
Phlebography 169
Phlegmasia
alba dolens 415, 566
cerulea dolens 415, 566
Photodynamic therapy 510
Photoplethysmography 185
Phyllodes
breast 468, 468f
tumor 469, 470
Pigmented basal cell carcinoma 368
Pilonidal sinus, sites of 570
Plastic balloons 507
Pleomorphic adenoma 310
treatment of 312
turning malignant 305f
Plethysmography 185
Plexiform neurofibromas 348, 349
types of 346
Plummer's disease 63
Plummer's hydrostatic bag 507
Plummer's sign 20
Plummer-Vinson syndrome 295
Plunging ranula 320, 321
Pluripotential epithelial cell 380
Pneumatic dilatation 507
Pneumoperitoneum 482, 483
demonstration of 482
signs of 483
Pneumothorax 492
open 544
simple 14, 493
skiagram of 492
Poiseuille's law 546
Polycystic disease
gross appearance of 217
manifestations of 217
Polycystic kidney disease 217
autosomal dominant 217
congenital 217
Polyp 12
classification of 12
Polyposis 12
Polytetrafluoroethylene 189
Porcelain 490
Porphyria, abdominal crisis of 143
Port wine stain 401f, 404
Portal hypertension 245, 249251, 258, 259
favor of 246
management of 253fc
Portal vein, peculiarities of 249
Portosystemic anastomosis, sites of 250
Positive end-expiratory pressure 492
Positron emission tomography 280, 509
Postherniorrhaphy hydrocele 422, 439
Post-mastectomy 88f
Postphlebitic syndrome 161, 165
Postsacral dermoid 357
Post-thrombotic ulcer 363
Post-thyroidectomy stridor, causes of 34
Potato tumor 332, 334, 335
Pott's disease 143
Pratt's test 165, 166, 167
Preauricular lymph nodes 307
Prednisolone 35
Prelaryngeal node 47
Preoperative radiotherapy
advantages of 343
disadvantages of 343
Pressure sores, staging of 564
Pretibial myxedema 21
Pretracheal fascia 30
Prevertebral fascia 286
Prevesical hernia 433
Profundaplasty 190
Progesterone receptor 280
Prophylactic
lymph node dissection 391
mastectomy 82
sclerotherapy 255
therapy 258
thyroidectomy 58
Propranolol 26
action of 26, 258
Propylthiouracil
action of 25
dose of 25
Prosthetic mesh repair 458
Proximal gastric cancer 106
surgical treatment of 108
Proximal growth 108
Pruritus 549
Psammoma bodies 50
Pseudoachalasia 507
Pseudoarthrosis 344, 348
Pseudocapsule 342, 342f
Pseudocyst 11, 221225
acute 221, 222
chronic 221
complications of 222
diagnosis of 222
locations of 221
management of 223
multiple 221
pancreatic 224
recurrence of 224
types of 221
Pseudodiverticula 555
Pseudofluctuation 350, 351
Pseudogynecomastia 463
Pseudomesenteric cyst 263
Pseudomonas septicemia 549
Pseudothyrotoxicosis 12
Puberty, precocious 348
Puddle sign 247
Pulmonary function test 63
Pulmonary metastasis 484, 484f
surgical removal of 485
Pulsatile bony swelling 47, 354
Pulsating exophthalmos 20
Pulse, grading of 539
Punch biopsy 102
Punctum 354
Pus 307
Pyelolysis, endoscopic 219
Pyemia 2
Pyloric
edema 514
stenosis 100, 513
Pylorus preserving gastrectomy 109
Pyrazinamide 125
Q
Quadruple assessment 47
R
Radial forearm flap 296
Radiation
ionizing 50
therapy, postoperative 302
Radical gastrectomy
distal 108
subtotal 107
Radical neck dissection 285, 286, 303
modified 280, 286, 302
Radical nephrectomy 215, 216
Radical parotidectomy 313
Radicular cyst 5
Radioactive remnant ablation 55
Radiofrequency ablation 175
Radioiodine 23, 27, 36, 56
dose of 56
therapy 25, 27, 37, 64
contraindications of 27
treatment, method of 27
Radiotherapy 59, 298
adjuvant 314
complications of 298
disadvantages of 384
dose of 298
preoperative 302
role of 216, 231, 383
types of 396
Raju's test 165, 169
Raloxifene 80
Ramstedt's pyloromyotomy 513
Randomized controlled trials 6
Ranson's prognostic signs 558
Ranula 320, 321
complications of 321
diagnosis of 321
surgical treatment of 321
Raynaud's disease 187
manifestations of 187
treatment of 187
Raynaud's syndrome 187
treatment of 187
Reactive hyperemia test 182
Rectum 376
Reed-Sternberg cells 198
Refeeding gynecomastia 462
Regional lymph node 18, 102, 242, 284, 340, 367, 372, 380, 389, 396
Regression, pathological types of 378
Renal
angle 13, 100, 210
ballottement 210
cell carcinoma 212
triad of 211
failure 463
mass 211
pain 211
parenchyma in hydronephrosis 504
stones 501, 488, 489
bilateral 503
percentage of 503
types of 503
swelling 209
tumors 212, 213
Residual neuralgia, chronic 440
Respiratory
depression 540
epithelium 387
Rest pain 4, 13
Retention, chronic 13
Reticular veins 164
Retractile testis 235
Retrograde pyelogram 218
Retromolar trigone 11, 14, 301
Retroperitoneal
cystic lesions 232
fibrosis 567
hematoma, classification of 547
liposarcoma, treatment of 231
malignancy 229
neurilemmomas 228
nodes 239
organs 228
sarcoma 229
structures 143
tumor 226, 228, 230
classification 228
favor of 227
malignant 229
origin of malignant 229
Retroperitoneoscopy, role of 230
Retroperitoneum 227
cystic lesion of 232
Retropharyngeal lymph nodes 281
Retrosternal extension 30, 63f, 65f
signs of 19
Retrosternal goiter 555
Revised European-American classification of lymphoid neoplasms 199
Reynold's pentad 155, 490
Rhabdomyosarcoma, embryonal 228
Rheumatoid arthritis 358, 364
Rhomboid glossitis, median 294
Ribs, fracture of 491
Riddle's triangle 31
Riedel's lobe 114
Rifampicin 125, 275
Rituximab 208
Robson's staging 214
Rodent ulcer 361, 380, 382
Roger's phenomenon 110
Roos test 500
Rotter's nodes 91
Routine indirect laryngoscopy, early 34
Rutherford classification 179
Rutkow and Robbins modification of Gilbert's classification 433
S
Sac, content of 429
Sacroiliac joint 122
Saint's triad 489
Saline load test 100, 514
Salivary gland 306, 316
tumors
major 311
minor 311
Salmonella typhimurium 490
Sandblom's triad 150
Saphena varix 441
Saphenofemoral incompetence, surgical treatment of 171
Sapheno-popliteal junction, peculiarity of 171
Saphenous system, varicosity of long 159
Saphenous vein 171
long 162f, 171
short 162f
Sarcoidosis 306
Sarcoma
growth of 342
types of 339, 340
Satellite lesion 371
Sausage-shaped mass 522
Scabbard trachea 63
Scald 3
Scalp metastasis 47f
Scanty benign cells 552
Scarff Bloom-Richardson grading system 76
Schechter incision 286
Schimmelbusch's disease 473
Schistosomiasis 252
Schwannoma 346
treatment of 346
Schwartz's test 165167
Sciatic nerve resection 343
Scirrhous carcinoma 106
Sclerotherapy 169, 254, 333
advantage of 170
complications of 170, 255
mechanism of 254
Scoliosis 14, 348
Scrofuloderma 274
Scrotal edema 439
Scrotal swellings 419fc
Scrotum, cellulitis of 4
Seagull sign 489
Sebaceous cyst 325, 332, 353356
complications of 355
edematous 355
plane of 354
surgical treatment of 355
Sebaceous horn 355
Seborrheic
keratosis 381
wart 381
Seddon's classification 568
Seldinger technique 184
Semen banking 243
Semimembranosus bursa 569
Seminoma 234, 238, 243
management of 243
Sengstaken-Blakemore tube, role of 256
Senile
keratosis 381
wart 381
Sentinel lymph node biopsy 80, 374, 375, 398
Septic ulceration 10, 186
Septicemia 2
Serocystic disease of Brodie 469
Serum
albumin 94, 557
calcium 62
glutamic
oxaloacetic transaminase 94
pyruvic transaminase 94
human binding globulin 462
thyroglobulin 55
transaminase 152
tumor markers 240
Sexually transmitted disease 394
Shamblin classification 334f, 335, 564
Shock therapy 545
Short saphenous system, anatomy of 162
Shouldice's repair 435
Shunt surgery
principle of 256
types of 256
Sialadenectomy 318
complications of 319
Sialadenitis 305, 317
bacterial 317
chronic 305, 306, 317
granulomatous 306
types of 317
Sialadenosis 306
Sialolithiasis 317
Sickening sensation 422
Sickle cell anemia 358
Sideropenic dysphagia 295
Siewert classification 106
Sigmoid
cancer 136
mesentery of 10
volvulus 481
Sigmoidectomy 481
Signet ring carcinoma 115
Silver's sign 483
Simon's classification of gynecomastia 463
Sinuses 6, 7, 14, 301
multiple 195
stage of 273
Sipple's syndrome 57
Sister Mary Joseph's nodule 99, 101
Sistrunk's operation 326, 327
Sjogren's syndrome 206, 304f, 306
pathology of 307
treatment of 307
Skeletal
metastases 55, 96f
survey 90
Skin 265, 386
breast 3
cheek 299
damage 387
fixity 2, 89
fold freckling 347
graft 366, 390, 541
incision 497
involvement 3
layers of 369
malignancy, types of 380
melanoma of 376
nodule 89
part of 369
precancerous lesions of 386
tethering 2, 67, 67f, 89
ulceration 87f, 460f
vermilion junction 11
Skull, thinnest part of 532
Slip sign 351
Slow transit constipation 571
Small bite technique 446
Small bowel obstruction, diagnosis of 479
Small intestinal
obstruction 476
tuberculosis, types of 519
Small intestine 261f
mesentery of 10
Soft
chancre 361
sarcoma 337f
sore 361
swelling, superficial 273
tissue sarcoma 336, 336f, 337, 337f, 338, 340, 341f, 342
management of 341
pathogenesis of 338
recurrent 337f
staging of 340
treatment of 342
warning signs of 337
tissue shadows, abnormal 476
Solar keratosis 386
Solitary
metastasis, treatment of 56
pulmonary metastasis 216
thyroid nodule 29, 38, 38f, 39
favor of 38
management of 44fc
Space of Bogros 431
Speech
slurring of 289
therapy 35
Spermatic cord 438
Spermatocele 418, 422
Spermatogenesis 424
Spherocytosis, hereditary 145, 148, 157
Sphincterotomy 156
endoscopic 156, 525
Sphygmomanometer 33
Spider nevus 405
Spigelian hernia 457, 459
diagnosis of 459
treatment of 459
Spinal deformity 345f
Spine, examination of 344
Spitz nevus 369
Spleen 107
physical signs of enlarged 196
Splenectomy of Hassab 258
Splenic artery 487
aneurysm 1
Splenorenal shunt, central 257
Spontaneous
bleeding, sites of 250
hemorrhage 1
mutation 348
regression 378
Spurious hypocalcemia 33
Squamous cell carcinoma 280, 281, 290, 294, 295, 365, 385, 385f, 485
metastasis 286
types of 291, 388
Squamous epithelium 324
Stafne bone cyst 319
Staghorn calculus 503
treatment of 503
Staphylococcus aureus 363
Stapled transection 257
Stauffer's syndrome 213
Stellwag's sign 20
Stenosis 14, 100
Stensen's duct 307
Stercobilinogen 145
Sterlin sign 519
Steroids 35
Stierlin sign 123
Stoma, creation of 445
Stomach 98f, 101, 102, 111f, 549
divisions of 107
laparoscopic wedge resection of 109
lump 100
middle third of 109
normal emptying time of 514
operable cancers of 107
Stomal ulcer 516
Stones, pancreatic 488
Stool, incontinence of 9
Strap muscles 30
Strawberry hemangioma 403
Streptococcal infection 549
Streptococcus
faecalis 106
pyogenes 4, 6
Streptomycin 125
Struma ovarii 24, 37, 328
Students elbow 3, 4
Stylomastoid artery 313
Subcapsular sinus 271
Subcutaneous emphysema 5, 494, 495
Subcutaneous tissue 265
scarring of 279
Subdural hematoma 529, 531
Subfascial endoscopic perforator surgery 174
Subhyoid 325
bursa 323
diagnosis of 328
treatment of 328
Sublingual dermoid 320
cyst 321, 322
complications of 322
median 322
types of 322
Sublingual papillae 317
Sublingual salivary gland 322
Submandibular
duct 319
gland 317, 318
lymph node 289, 299
salivary gland 317319
tumors of 319
sialadenectomy, complications of 319
sialadenitis 316, 316f
swelling, right 316
Submucous fibrosis 294
Subperitoneal plexus 91
Subphrenic abscess 483
Subplatysmal plane 318
Subtotal thyroidectomy, bilateral 29
Sucking wound 494
treatment of 494
Sudek's point 134
Sugiura procedure 258
Sun exposure 379
Sunderland's classification 568
Suppression therapy, disadvantages of 64
Suppressive levothyroxine therapy, role of 64
Suppurative cholangitis 155
Supraclavicular lymph nodes 88f, 91, 100, 509
Suprahyoid 325
neck dissection 318
thyroglossal cyst 325f
Suprasternal notch 284
Supraumbilical hernia 452
Surgery 425, 465
advantages of 28
colonic 132
complications of 465
Surgical emphysema
physical sign of 495
treatment of 495
Surgical oophorectomy, role of 80
Suspensory ligament of Berry 31, 32
Swelling 16, 305, 316
beneath chin 322
compressible 400, 401
cystic 320f, 332, 422, 468
goiter 18
inguinoscrotal 419fc, 421
malignant 114
multiple 196, 345f
solid 236, 332
Swiss roll operation 417
Symptomatic gallstones, treatment of 490
Synchronous carcinoma 129
Synergistic ulcer 363
Synthetic mesh 442
Syphilis
attacks testis 422
primary 360
secondary 361
stigmata of 362
Syphilitic glossitis 294
Systemic antibiotics, role of 174
Systemic inflammatory response syndrome 542
Systolic bruit 16
T
Tabetic crisis 143
Tachycardia 16, 542
Tachypnea 544
Taj Mahal resection 157
Tamoxifen 79, 377, 466
action of 79
side effects of 79
Tap sign 166
Targeted therapy 120
Technetium scanning 23
Temozolmide 377
Temporalis muscle 311
Temporomandibular joint involvement 311
Tennis elbow 3, 4
Tennis score classification of hemorrhage 545
Tension pneumothorax 14, 493, 494, 544
radiological signs of 14
treatment of 494
Teratoma 8, 238, 325
classification of 237
Test biceps reflex 18
Testicular
artery 439
atrophy 115
malignancy 233, 233f
sensation 240
tumor 237241, 485
bilateral 239
management of 243
modes of spread of 238
vein 424
Testis 424
descent of 234, 235
gumma of 236
lymphatic drainage of 238
palpation of 420
venous drainage of 424
Therapeutic abortion, role of 84
Therapeutic central compartment dissection 53
Thompson procedure 417
Thoracic
esophagus, upper 510
outlet syndrome 182, 498
Thoracotomy 497
Thorax 143
Thrombolytic therapy 192, 193
Thrombophlebitis, superficial 172
Thrombosis, acute 191
Thymic swellings 324
Thyrocytes 64
Thyroglobulin, normal level of 55
Thyroglossal cyst 323327, 331
complications of 325
positions of 324f
Thyroglossal fistula 325, 326, 331
discharge of 326
lining of 326
surgical treatment of 326
Thyroid 18, 19, 22, 23, 26, 3941, 49
acropachy 21
anaplastic carcinoma of 45f, 58
artery, inferior 30, 31
associated ophthalmopathy 37
binding globulins 24
bruit 19
cancer 5053, 59
carcinoma 52
cartilage 325
cysts 42
cytology 40
development of 326
diagnostic scanning of 23
diffuse enlargement of 16
examination of 17
function test 22
gland 18, 24, 30, 206
lymphatic drainage of 47, 48f
lymphoma of 45f, 47
malignancy 47
malignant tumors of 48
neoplasm 48
classification of 48, 49fc
nodule, calcification of 46
normal 18
occur, agenesis of 328
peroxidase 22
scintigraphy 63
stimulating
hormone 21, 44
immunoglobulins 21
storm 25, 33, 35
treatment of 36
suppression 327
surgery 30
swelling 46, 486, 555
types of carcinoma 47
vein, middle 30
vessels, superior 31
Thyroidectomy 28, 30, 58, 65, 327
adequate 64
bilateral 28
completion 43, 53
complications of 32, 33
near total 29, 53
routine 327
subtotal 28, 29f, 64
total 29, 53, 54, 64
Thyroiditis 23, 24, 46
autoimmune 37, 47, 50
Thyrotoxic
crisis 33, 35
periodic paralysis 37
Thyrotoxicosis 21, 25, 28
eye signs of 20
factitious 24
management of 27
non-hyperthyroid 22
postpartum 24
primary 21, 22, 28
recurrent 34
secondary 22, 28
treatment of 25, 36
Thyroxine therapy, complications of 55
Tibial dysplasia 348
Tietze syndrome 473
Tinel test 500
Tissue, pancreatic 11
TNM staging 215, 230, 242
Todani classification 150
Toilet mastectomy 97
Tongue 295
cancer 297
common malignancy of 290
deviation of 289
devoid of papillae 555
lymphatic drainage of 295
Toxic
adenoma 24
cholangitis, acute 155, 156
nodular goiter 16, 25
nodule 22, 23, 24f, 28
autonomous 22
Toxicity 19, 26, 28
diagnosis of 22
recurrent 30
signs of 20
symptoms of 20
types of 21, 63
Toxicosis 21
primary 23f
secondary 24f
Trachea 60
narrowing of 19
position of 19
Tracheal
compression 61f
deviation 63, 63f
injury 49
obstruction, relieve 59
rings
collapse of 65
weakness of 63
Tracheomalacia 63
management of 65
Tracheostomy 35, 65
Traction diverticulum 5
Transarterial
chemoembolization 120
radioembolization 120
Transcutaneous oximetry 185
Transhiatal esophagectomy 510
Transjugular intrahepatic portosystemic stent shunt 252
Trans-scrotal incision 241
Trans-sphincteric fistula 570
Transversalis fascia 432
Transverse rectus abdominis myocutaneous flap 95
Trauma 543
life support system, advanced 4544
prevention of 543
Traumatic cyst 325
Traumatic ulcer 361
Trefoil deformity 515
Trendelenburg's operation 171
Trismus 11, 300
grading of 301
Troisier's sign 101
Trophic ulcers 361, 362
Trophoblastic thyrotoxicosis 37
Tropical chronic pancreatitis
etiology of 488
treatment of 488
Trousseau's sign 33
Trucut biopsy 40, 49
complications of 49
True papillae, demonstration of 50
Trypanosomiasis 571
T-tube
cholangiogram 523, 524, 524f
purpose of 523
removed 525
technique of removal of 525
Tube thoracostomy 496
complications of 498
steps of 497
Tubercle 14
bacilli 1, 273
Tuberculosis 47, 122, 123, 199, 358, 361
abdominal 124, 125
attacks epididymis 422
categories 275
diagnosis of 274
favor of 123
hypertrophic type of 124
intestinal 125
lymphadenitis stages 273f
pulmonary 272
Tuberculous
cervical
lymph node 268
lymphadenitis 269f
infection 1
lymph node 268f, 272
lymphadenitis 263, 273, 274
types of 273
pus 15, 275
sinus 326
ulcer 273, 361, 363
Tubo-ovarian mass 139
Tumor 1
benign 228, 555
cells, isolated 3
cystic degeneration of 5
desmoid 445, 457, 458
grading of 76
growth 370
malignant 308
marker 57, 240
masses 342
primary 297
solid 9
suppressor gene 214, 338
testis 237
thickness 102
tubule formation 552
universal 10, 350, 351
Tunica vaginalis sac 423
hydrocele of 418, 419f
Turcot's syndrome 128
Turner syndrome 412
Tyrosine kinase inhibitor 111
Tyrosinemia, hereditary 117
U
Ubiquitous tumor 351
Ulcer 15, 358, 359, 361, 364
automutilation 363
benign 512
big toe 359f
care of 366
classification of 359
complicating blood diseases 360
edge of 361, 389
etiology of 366
examination of 358
excision of 366
factitious 360, 363
gravitational 363
gummatous 361
healing 359, 360
hypertensive 365
ischemic 179, 180
management of 173, 365
neurotrophic 362
nonspecific 360
spreading 360
stage of 273
tropical 360, 364
types of 360, 361
Ulcerative colitis 136, 560
severity of 559
Ulceroproliferative lesion 388f, 392
Ultrasonography 39, 42, 62, 527
uses of 528
Ultrasound
advantages of 528
disadvantages of 528
endoscopic 102, 509
role of 116
Umbilical hernia 452
adult 454, 455
congenital 454
repair 454
Umbilical nodule formation 101
Umbilicus 143
Undescended testis 233f, 234, 236
complications of 235
Upper limb 500
Upper molar tooth, second 307
Urachal cyst 325
Ureteric stones 501
treatment of 503
Ureteroscopic stone removal 503
Urinary catheter, size of 13
Urine
examination 275
incontinence of 9
retention of 13
Urogram, types of 501
Uveal tract, malignant melanoma of 368
V
Valve less system 424
Valvulae conniventes 476
Variceal bleeding, management of 253
Varicocele 418, 424
grading of 424
incidence of 423
recur after surgery 425
symptoms of 424
Varicose veins 15, 158161, 165, 167169
complications of 172
location of 164
management of 170fc
symptoms of 164
Vas, sign of 234
Vascular
defects, congenital 404
disease
peripheral 188, 189
symptoms of 563
malformation 402, 403, 406
congenital 402, 404, 542
ring 555
Vasopressin
complications of 255
dose of 255
role of 255
Veins 286
anatomy of 161
collapse 180
functions of 162
jugular 60
Venacaval tumor thrombus 214
Venography 169
Venous leg ulcers, management of 173
Venous ulcer 159, 160, 163, 172174, 359f, 361, 363
multiple 173
pathophysiology of 163
precursors of 363
Ventral hernia 444, 446
Verruca senilis 381
Verrucous carcinoma 395, 397
peculiarities of 291
Vessels, ligation of 31
Video laryngoscopy 30
Villous adenoma 130
Vincent's organism 364
Vincristine 205
Virchows sign 101
Visceral malignancy 101
Vitamin
D 34
K 152
Vocal cord, tensor of 35
Voice, hoarseness of 46
Volvulus 15, 480
compound 481
sigmoid, radiological signs of 480
von Graefe's sign 20
von Hippel Lindau disease 111
von Recklinghausen's disease 344, 344f, 345, 345f, 347, 348
management of 348
W
Wagner's classification 563
Warm nodule 41, 41f
Warthin's tumor 306, 309
Wash-leather appearance 362
Weight loss 15, 16, 113, 144
Weil's disease 197
Wharton's duct 305, 317
Whipple's operation 154
Whipple's procedure 154
Whipple's resection 153
Whitaker test 218, 504
White cell count 542
White leg 566
Whole body scanning, role of 55
Wolffian body 234
Wound infection 445
Wuchereria bancrofti 414, 422
X
Xylocaine 540
complications of 540
Y
Yellow liver 138
Yellow nail syndrome 412
Yersinia infection 263
Z
Zieman's test 428
Zuckerkandl's tubercle 31
×
Chapter Notes

Save Clear


16Long Cases

Toxic GoiterCase 1

 
Case Capsule
A 30-year-old female patient with a thin build has presented with diffuse enlargement of the thyroid and palpitation of 6 months duration. She complains of increased appetite and loss of weight. She is apparently irritable and says, she is intolerant to hot weather with excessive sweating. She has a preference for cold weather. She also complains of insomnia and loss of concentration ability. She has diarrhea in addition. She is married and has a baby of 6 months old. She complains of amenorrhea for the last 3 months. On examination, patient is agitated and nervous. Examination of the palms revealed that they are moist and sweaty. She has tachycardia, fine and fast tremor and protruded eyeballs. There is visible diffuse enlargement of the thyroid. On auscultation, there is a systolic bruit heard in the upper pole of the thyroid. The carotids are felt in the normal position. The trachea is central. There is no evidence of retrosternal extension. The cervical lymph nodes are not enlarged.
In all goiters or swelling in the neck assess the following:
  1. What is the anatomical diagnosis—by assessing the plane—deep to the deep fascia and deep to the sternomastoid?
  2. What is the pathological diagnosis, e.g. nodular goiter, solitary thyroid nodule, carcinoma, etc.
  3. What is the functional diagnosis—whether the patient is euthyroid, hyperthyroid, hypothyroid?
zoom view
Early exophthalmos
zoom view
Exophthalmos of Graves
zoom view
Goiter with staring look
zoom view
Multinodular goiter with toxicity
zoom view
Recurrent laryngeal nerve
zoom view
Diffuse toxic goiter
zoom view
Primary thyrotoxicosis with staring look
Q 1. Why is the swelling a goiter?
The points in favor of goiter are:
  1. The plane of the swelling is deep-to-deep fascia and deep to sternocleidomastoid (the deep fascia of the neck is stretched by extending the neck and see whether the swelling is becoming less prominent or not, similarly contracts the sternomastoid muscles.
  2. The swelling moves up and down with deglutition.
  3. It occupies the normal position of thyroid.
  4. It is having the shape of thyroid.
Q 2. Why does the thyroid gland move up and down with deglutition?
The inferior constrictor muscle has two parts namely, thyropharyngeus and cricopharyngeus and they are attached respectively to thyroid cartilage and cricoid cartilage. Therefore, when the patient swallows this muscle will contract and the thyroid and cricoid cartilage will move up. The thyroid gland is attached to the cricoid by means of the suspensory ligament of Berry that is nothing but a condensation of pretracheal fascia. Therefore, the thyroid gland will move up and down with deglutition.
Q 3. What is goiter?
Any enlargement of thyroid gland is called goiter. Even though for neoplasms we call it malignancy and for inflammation we call it thyroiditis.
Q 4. Can the normal thyroid be felt on palpation?
In a reasonably slender person it can be felt as a smooth firm structure that moves upwards during deglutition.
Q 5. How do you grade a goiter?
19
Q 6. What are the signs of retrosternal extension?
  • Cannot ‘get below’ the swelling.
  • Pemberton's test positive (arm raising test)—when both arms are elevated so as to touch the sides of the face, after a few moments, there will be congestion of face, some cyanosis and distress. This is due to the narrowing of the thoracic inlet and when the arms are elevated this results in obstruction of great veins of the neck.
  • On percussion over the manubrium sterni, there will be dullness (normally this is resonant).
  • Radiological assessment.
Q 7. How will you assess the position of trachea?
The position of trachea can be assessed by:
  • Palpation of trachea by three finger test (this will be difficult in case of large goiter).
  • Auscultation to detect the position of trachea.
  • Radiological.
Q 8. In which position you normally palpate a patient with thyroid?
The examiner stands behind the patient and will do the palpation.
Q 9. What is Kocher's test?
Slight compression on the lateral lobes of thyroid produces stridor. If this test is positive, it signifies that the patient has an obstructed trachea.
Q 10. What are the conditions in which you get narrowing of the trachea?
Narrowing of trachea is found in:
  • Carcinoma of the thyroid
  • Retrosternal goiters
  • “Scabbard” trachea of long standing multinodular goiter
  • Riedel's thyroiditis.
Q 11. What is plunging goiter?
In this condition, the whole of the enlarged thyroid lies in the superior mediastinum and there is no palpable thyroid gland in the neck. When the intrathoracic pressure rises as in coughing, the goiter will be seen in the neck, this is called plunging goiter.
Q 12. What is Berry's sign?
In goiter, the carotid artery may be pushed posteriorly by the enlarging thyroid and this is called displacement. When there is infiltration of the carotid by tumor the carotid pulse on that side will be absent. This absent carotid pulse is called Berry's sign.
Q 13. What are the signs of malignancy in a goiter?
Q 14. Where will you auscultate for thyroid bruit?
The usual position to look for thyroid bruit is at the upper pole where the superior thyroid artery enters the thyroid gland.
Q 15. What are your points in favor of toxicity in this patient?
The toxicity is diagnosed on the basis of symptoms and signs in this patient. The symptoms of toxicity are:20
Q 16. What are the eye signs of thyrotoxicosis?
21
Q 17. What is pretibial myxedema?
This is a misnomer and it is seen in primary toxicosis (In Graves’ disease with exophthalmos only). It is usually symmetrical. The earliest stage is a shiny red plaque of thickened skin with coarse hair, which may be cyanotic when cold. In severe cases, the skin of the whole leg below knee is involved, together with that of foot and the ankle and there may be clubbing of the fingers and toes (Thyroid acropachy).
Q 18. What are the three most important clinical types of toxicity?
Q 19. What is the difference between thyrotoxicosis and hyperthyroidism?
Thyrotoxicosis refers to the biochemical and physiological manifestations of excessive thyroid hormone. Hyperthyroidism is a term reserved for disorders that result in the over production of hormone by the thyroid gland. Thyrotoxicosis need not be due to hyperthyroidism. In short in hyperthyroidism, the pathology is in the thyroid gland itself. The causes for hyperthyroidism and toxicosis without hyperthyroidism are shown below.
Hyperthyroidism
Toxicosis without hyperthyroidism
  • Graves's disease
  • Subacute thyroiditis*
  • Toxic nodular
  • Ectopic functioning thyroid goiter tissue
  • Toxic adenoma
  • Silent thyroiditis
  • Jod-Basedow's disease
  • Struma ovarii
  • Metastatic follicular carcinoma (functioning)
  • Trophoblastic tumors
  • Postpartum thyroiditis
  • Thyrotoxicosis factitia
*Note: In thyroiditis, inflammation of thyroid causes release of already formed thyroid hormones into the circulation, resulting in toxicosis. In other conditions such as struma ovarii, trophoblastic tumors, etc., there is extrathyroid production of thyroxin from these tissues.
Q 20. What is Graves’ disease?
The essential components of Graves’ disease are:
  • Diffuse goiter
  • Thyrotoxicosis
  • Autoimmune manifestations like:
    • Infiltrative ophthalmopathy
    • Dermatopathy
    • Myopathy.
Q 21. What is the essential etiology of Graves’ disease?
Graves’ disease is an autoimmune disorder caused by thyroid stimulating immunoglobulins (TSIs) that have been produced against an antigen in the thyroid. This is directed to the thyroid stimulating hormone receptors (TSHR-Ab). This acts like TSH agonist. TSH-Ab is found only in Graves’ disease.
Q 22. What are the precipitating factors for primary thyrotoxicosis?
Remember 3S
  • Sex (puberty, pregnancy)
  • Sepsis
  • Psyche (sudden emotional upset).
22
Q 23. What are the differences between primary thyrotoxicosis and secondary thyrotoxicosis?
Primary thyrotoxicosis
Secondary thyrotoxicosis
  • Etiology—autoimmune
Not autoimmune
  • Enlargement of goiter is diffuse, firm or soft
Bosselated or nodular not uniform
  • Onset is abrupt
Insidious
  • Hyperthyroidism is usually severe
Hyperthyroidism usually mild
  • Cardiac failure is rare
Cardiac failure or multiple extrasystole, paroxysmal atrial tachycardia, paroxysmal atrial fibrillation, or persistent atrial fibrillation
  • Eye signs common
Except lid lag and retraction other eye signs are not seen
  • No pre-existing goiter
Pre-existing nodular goiter for a long duration
  • Usually younger women
Usually middle aged or elderly
  • The entire gland is overactive
Internodular thyroid tissue is overactive, rarely one or more nodules also may be overactive
  • Presence of bruit
Bruit need not be present
  • It is due to abnormal thyroid stimulating antibodies (TSAb)
No such antibodies (it is due to over activity of nodules)
  • Can be managed by, drugs, radioiodine, and surgery
Surgery is the treatment of choice after control of the toxicity
  • Manifestations not due to hyperthyroidism pretibial myxedema may occur
Not seen
Q 24. How will you confirm your diagnosis of toxicity?
Confirmation by:
  • Thyroid function test (TSH)T3, T4 and TSH (immunochemiluminometric assay is the current method).
  • Free T3, T4 are more significant and meaningful. The T3 and T4 are raised and TSH is lowered in hyperthyroidism.
    Normal values are total
    Free T3
    3.5 – 7.5 mol/L
    Free T4
    10 – 30 nmol/L
    TSH
    0.3 – 3.3 mU/L
Note: The total T3 and T4 hormone level will vary depending upon the amount of thyroid binding globulin (TBG).
Q 25. What are the other investigations required?
  • Antithyroglobulin antibody: More than 1:100.
  • Thyroid peroxidase (TPO): >25 units (TPO and TSH antibodies are increased in autoimmune thyroiditis).
  • TSH receptor antibodies are difficult to estimate.
  • Radioisotope scintigraphy (radionuclide scan).
Q 26. What is the role of isotope scanning in thyroid?
  • The only absolute indication in thyrotoxicosis for isotope scanning is for the diagnosis of autonomous toxic nodules.
  • Toxicity with nodularity is an indication. It can identify hypofunctioning nodule (cold). Cold nodule in Graves’ is likely to be malignant.
  • It is the only method by which one can definitely differentiate primary, secondary and toxic nodules.
  • Isotope scan can also differentiate hyper- thyroidism from toxicosis due to other causes. (To differentiate hyperthyroid thyrotoxicosis from non-hyperthyroid thyrotoxicosis). The radioactive iodine uptake (RAIU) is increased in hyperthyroidism whereas toxicosis because23 of extrathyroidal causes the RAIU is decreased (e.g. thyroiditis).
Other indications for isotope scan are:
  • To identify ectopic thyroid tissue.
  • To identify recurrence and metastases in thyroid carcinoma.
Q 27. What is the isotope of choice for diagnostic scanning of the thyroid?
  • 99mTc is the isotope of choice for diagnostic purposes. It is cheap and the radiation is less than radioiodine. Twenty minutes after intravenous injection of 99mTc, scanning is done over the thyroid.
  • If radioactive iodine is used 123I is the isotope of choice for diagnostic purposes.
Q 28. What is the half-life of the various radioisotopes used in thyroid?
Isotope
Halflife
Route
Rays
Comment
123I
13 hours
Oral
Gamma rays
Will not detect nodules <1 cm size
131I
8 days
Oral
Gamma and beta rays
Too much irradiation if used for diagnostic scanning
132I
2.3 hours
Oral
Gamma and beta rays
Not used for clinical purposes
99Tc
6 hours
IV
Gamma rays
Commonly used for diagnostic scanning of thyroid
Q 29. What is the problem with technetium scanning?
Carcinoma concentrates technetium and therefore a hot nodule need not necessarily be benign.
Q 30. What is discordant scan?
A nodule which is warm on technetium scanning and cold on radioiodine scanning is called discordant scan. This is suggestive of malignancy.
Q 31. Why technetium is preferred over radioiodine for diagnostic scanning?
It gives small amount of radiation and you get the image within minutes.
Q 32. What will be the appearance in scintigraphy in primary, secondary and toxic nodule?
  • Primary: Uniform diffuse increased uptake (Fig. 1.1).
  • Secondary: Heterogeneous pattern with some focal areas of enhanced uptake (Fig. 1.2).
  • Toxic nodule: Increased uptake only in the nodule, with no uptake in the surrounding thyroid tissue (Figs 1.3 and 1.4).
zoom view
Fig. 1.1: Primary toxicosis
24
zoom view
Fig. 1.2: Secondary toxicosis
zoom view
Fig. 1.3: Toxic nodule
Q 33. What are the toxic situations where there is decreased uptake of isotope in thyroid gland?
Low uptake is seen in:
  • Thyroiditis
  • Postpartum thyrotoxicosis
  • Struma ovarii
  • Factitious thyrotoxicosis
  • Jod-Basedow thyrotoxicosis.
Q 34. What are the features of toxic adenoma?
Toxic adenoma
  • These are—benign, monoclonal thyroid tumors of more than 3 cm size
  • These are autonomous rather than responding to TSH stimulation
  • Eye signs and other stigmata of Graves’ are absent
zoom view
Fig. 1.4: Toxic nodule (autonomous nodule showing uptake in nodule alone. No uptake in the other lobe)
  • Somatic mutation of TSH receptor gene or G protein gene is present
  • T4 may be normal (hence check T3 levels).
Q 35. What are the conditions in which thyroid binding globulins (TBG) are increased?
The concentrations of TBG are increased in pregnancy, liver diseases and where there is hyperestrogenism. The levels of free T3 and T4 in these conditions are normal despite high TBG.
Q 36. What are the conditions in which the TBG levels are decreased?
High androgens, severe hypoproteinemia, chronic liver disease and acromegaly.
Q 37. What is the problem with the measurement of free T3 and T4?
The method usually used is radioimmunoassay and it is costly.
Q 38. What is the normal free T3 and T4 value?
Free T3—3.5–7.5 pmol/L
Free T4—10–30 nmol/L
It is to be noted that 0.3% of the total T3 and 0.03% of the total T4 are free and physiologically active.
Q 39. What is T3 thyrotoxicosis?
T3 alone is raised and TSH is decreased in this condition.25
Q 40. What is subclinical hyperthyroidism?
  • Seen in 1% of hyperthyroids
  • Serum TSH is low but the free T4 is normal
  • Symptoms are absent and hence called ‘subclinical’.
Q 41. What is apathetic hyperthyroidism (masked)? (PG)
Q 42. Is there any role for fine needle aspiration cytology (FNAC) in thyrotoxicosis?
Yes. Sometimes the thyrotoxicosis may be associated with a papillary carcinoma of the thyroid. It is better to do after controlling toxicosis because of the increased vascularity of the gland.
Q 43. How you will manage thyrotoxicosis?
In primary thyrotoxicosis we have three options:
  1. Antithyroid drugs
  2. Radioiodine therapy
  3. Surgery.
Q 44. What will be the choice of therapeutic agent in thyrotoxicosis?
We have some broad guidelines. This must be modified according to the facilities available and wishes of the patient.
Age over 25 years
  • Radioiodine therapy (when development is complete)
Under 25 years
  • Surgery for large goiter
  • Antithyroid drugs for the small goiter
Toxic nodular goiter usually will not respond very well to radioiodine and antithyroid drugs. Therefore, surgery is the treatment of choice.
Q 45. What are the drugs available for the treatment?
Q 46. What is the dose of propylthiouracil?
About 100 to 300 mg 3 times daily orally initially for 4 to 6 weeks followed by 100 mg 3 times daily.
Q 47. What is the action of propylthiouracil?
  • PTU blocks conversion of T4 to T3 in periphery (liver).
  • Inhibits iodine organification and coupling of iodotyrosines.
  • Immunomodulatory effects that reduces thyroid stimulating antibodies.
Q 48. What are the advantages of PTU?
  • PTU may be given during pregnancy (reduced doses in first trimester).
  • If thyroidectomy is required in second trimester, the patient can be prepared with PTU.
  • Useful for the treatment of thyroid storm (multiple doses needed).
26
Q 49. What are the adverse effects of PTU? (PG)
Q 50. What is the action of carbimazole?
Carbimazole acts by the following methods:
  • Blockage of organic binding and oxidation of iodine.
  • Immunosuppression (decreases thyroid antigen, prostaglandin and cytokine release).
  • Reduction of thyroid autoantibody titers.
Q 51. What are the side effects of carbimazole?
Q 52. What is the clinical manifestation of agranulocytosis?
Agranulocytosis presents as sore throat, which warrants immediate cessation of the drug.
Q 53. Can the thyroid be enlarged during medical treatment?
Yes. During treatment in 1/3rd to half of the patients, the thyroid will shrink. Enlargement usually occurs because of commencement of hypothyroidism, which should be avoided.
Q 54. What is “block and replacement” regime?
The thyroid enlargement because of the development of hypothyroidism during medical treatment is prevented by supplementing low dose of levothyroxine (0.1 mg) along with the antithyroid drugs.
Q 55. In what percentage of patients is medical treatment effective?
Permanent remission is possible only in a small minority of adults and 20% of children.
Q 56. What is the dose of beta blocker?
Propranolol is the drug of choice for initial control of adrenergic symptoms.
  • The dose is 20–80 mg every 6–8 hours orally.
  • 1–2 mg IV propranolol for thyroid storm.
Q 57. What is the action of propranolol?
  1. Peripheral conversion of T4–T3 is blocked
  2. Adrenergic antagonistic action helps to alleviate cardiac symptoms, tremor, etc.
Q 58. Is propranolol indicated in all patients with toxicity?
No;
  • It is given for emergency surgical management of toxicity
  • It is also used for control of the adrenergic symptoms.
Q 59. If the patient was prepared using propranolol before thyroid surgery, how long should it be continued postoperatively?
Propranolol should be given over a period of 1 week and preferably tapered over a period of 2 weeks after surgery.27
Q 60. What are the drugs inhibiting peripheral conversion of T4-T3? (PG)
Q 61. What is the minimum duration of medical treatment required before surgery?
Thyroidectomy performed immediately after control of thyrotoxicosis is associated with risk of thyroid crisis and it is preferable to wait approximately two months until after a patient is euthyroid.
Q 62. Is there any role for dexamethasone in the management of thyrotoxicosis? (PG)
  • It is used for the management of thyrotoxic crisis
  • Dose is 2 mg every 6th hourly (injection)
  • The actions are:
    • Inhibits glandular secretion of hormone
    • Inhibits peripheral conversion of T4 to T3
    • Immunosuppression.
Q 63. What is Lugol's iodine and what is its dose?
Five percent iodine in 10% potassium iodide is called Lugol's iodine.
The dose is 10 drops in a glass of water 3 times daily for 10 days.
Q 64. What are the actions of Lugol's iodine?
  • Decreases the vascularity of the gland
  • Makes the thyroid firm and less friable (helps in surgical removal)
  • Prevents the release of hormone from the gland—thyroid constipation.
Q 65. What will happen if Lugol's iodine is given for more than 10 days?
After 2 weeks the effect of Lugol's iodine therapy is lost due to the so called thyroid escape from iodine control.
Q 66. What are the indications for radioiodine therapy?
  • Radioiodine (131I) is usually given to patients above 45 years for primary thyrotoxicosis.
  • Isotope facility must be available.
Q 67. What are the problems of radioiodine therapy? (PG)
Q 68. What are the contraindications of radioiodine therapy?
Q 69. What is the dose of radioiodine? (PG)
300 to 600 MBq, if there is no clinical improvement after 12 weeks further dose is given. Two or more doses are necessary in 20 to 30% of cases.
Q 70. What is the method of radioiodine treatment for toxicity? (PG)
  • Make the patient euthyroid with drugs
  • Discontinue drugs for 5 days
  • Administer 131I 300–600 MBq (5–10 mCi)
  • Start antithyroid drugs after 1 week and continue for 6–8 weeks28
  • After 12 weeks, if there is no improvement, give another dose of radioiodine
  • Two or more doses of radioiodine may be required.
Q 71. What are the indications for surgery in thyrotoxicosis? (PG)
Q 72. What are the drugs used for preparation of a patient for“urgent thyroidectomy”? (PG)
Combination of oral iopanoic acid 500 mg bid and dexamethasone 1 mg bid and PTU or MMI and beta blockers for 5–7 days.
Q 73. What are the advantages of surgery? (PG)
Q 74. What is the surgical treatment of primary thyrotoxicosis?
Near total thyroidectomy is now recommended as the treatment of choice.
Q 75. What is the recommended treatment for secondary thyrotoxicosis?
Surgery is preferred over radioiodine for secondary thyrotoxicosis because:
  • It will not respond to radioiodine as most of the nodules may not take up radioiodine.
  • Large and repeated doses of radioiodine may be required.
Q 76. What is the recommended treatment of toxic nodule?
Once the patient is made euthyroid, surgery in the form of hemithyroidectomy will give permanent relief.
Q 77. What is subtotal (bilateral) thyroidectomy?
Two grams of thyroid remnant is kept on both sides and the rest of thyroid gland is removed in subtotal thyroidectomy.
Q 78. What is Hartley-Dunhill procedure?
Total lobectomy and isthmectomy on the affected side and 4 g remnant left on the contralateral (normal) side. This form of surgery is recommended by some authorities for the surgical management of toxic goiter.29
Operation
Part of thyroid removed
Indications
Lobectomy
Removal of one lobe of thyroid
Solitary thyroid nodule
Hemithyroidectomy
Removal of one lobe and isthmus
  • STN
  • Toxic nodule
  • Follicular neoplasm
Lobectomy
Removal of one lobe of thyroid
Solitary thyroid nodule
Hemithyroidectomy
Removal of one lobe and isthmus
  • STN
  • Toxic nodule
  • Follicular neoplasm
Bilateral subtotal thyroidectomy (Fig. 1.5)
2 g of thyroid remnant is kept on both sides and the rest of the thyroid gland is removed
  • Toxic goiter
  • Toxic nodular goiter
  • Multinodular goiter
(Near total is the preferred treatment for these conditions now)
(Near total is the preferred treatment for these conditions now)
Hartley-Dunhill procedure (Fig. 1.6)
Total lobectomy and isthmectomy on the affected side and 4 g remnant left on the contralateral side
Toxic goiter
Near total thyroidectomy
1-2 g remnant is left on the contralateral side of the lesion and the rest of the thyroid is removed
  • Toxic goiter
  • MNG
  • Papillary carcinoma
  • Follicular carcinoma
  • Medullary carcinoma, etc.
Total thyroidectomy isthmusectomy/isthmectomy
Entire gland is removed Removal of isthmus alone
Thyroid malignancy
  • Emergency decompression of trachea for anaplastic carcinoma
  • Biopsy for anaplastic carcinoma
Abbreviations: STN, solitary thyroid nodule; MNG, multinodular goiter
zoom view
Fig. 1.5: Subtotal thyroidectomy
zoom view
Fig. 1.6: Hartley-Dunhill procedure
30
Q 79. What is the management of intrathoracic goiter with toxicity? (PG)
  • Antithyroid drugs will increase the size of the retrosternal and intrathoracic goiter and therefore dosage should be carefully adjusted.
  • Surgery is the treatment of choice for intrathoracic goiter with toxicity.
Q 80. What is the management of intrathoracic toxic goiter in pregnancy? (PG)
  • Antithyroid drugs are given in small doses in first trimester to prevent fetal goiter and airway obstruction
  • Antithyroid drugs may be combined with propranolol and surgery is done in the second trimester.
Q 81. What is the treatment for recurrent toxicity? (PG)
Radioiodine/medical treatment.
Q 82. What are the preoperative preparations for thyroid surgery?
Q 83. What are the preliminary steps of thyroid surgery?
  • Surgery is done under general anesthesia using endotracheal intubation (preoperative X-ray neck to rule out displacement of the trachea and luminal narrowing).
  • Position of the patient: Supine with sand bag behind the shoulders and head ring for adequate neck extension.
  • Skin is painted with antiseptics and proper draping with sterile towels and head cover.
  • Kocher's collar incision is used for incising the skin (1 to 2 cm above the manubrium sternum). Incision is deepened up to the deep fascia by incising the platysma.
  • Anterior jugular veins seen on the surface of the investing layer, may be ligated (communicating vein seen connecting the two anterior jugulars requires ligation).
  • Investing layer is opened vertically in the midline.
  • The strap muscles are retracted laterally (in big thyroids, they may be divided either on one side or bilaterally in the upper part to save the Ansa hypoglossi nerves entering the strap muscles in the lower part)
  • The pretracheal fascia is incised vertically and the thyroid gland is mobilized by ligating the middle thyroid vein (this is the first vessel to be ligated).
Q 84. What are the essential steps of thyroidectomy?
  1. Identification of parathyroid glands:
    • Identify the parathyroids before ligating the vessels.
    • Parathyroids have the color of peanut butter, each of 6 × 3 × 3 mm size and less than 40 mg weight.
    • The recurrent laryngeal nerve (RLN)—Inferior thyroid artery junction is critical in identifying the parathyroids (this is a critical area of RLN injury as well).
    • The superior parathyroid glands are above and behind this junction.
    • The inferior parathyroid glands are below and anterior to this junction having variable positions. The inferior glands may be situated on the inferior pole of the thyroid, thyrothymic ligament, in the thymus or in the perithymic fat.31
  2. Identification of the recurrent laryngeal nerve:
    • It is preferable to identify the entire course of the nerve in thyroid surgery.
    • There is no role for the old axiom “nerve seen is nerve injured”, which is called the ‘ostrich philosophy’.
    • The first identification is at the so-called Riddle's triangle, which is bound by inferior thyroid artery above, the carotid artery laterally and the trachea medially.
    • From there, the nerve is traced upwards to the point of its entry into the larynx at the greater cornu of the thyroid cartilage.
    • Before entry, the nerve may divide into two or more extralaryngeal branches.
    • When there is difficulty in identifying the RLN, the entry point of the nerve can be located by identifying Zuckerkandl's tubercle.
    • The nerve may cross the inferior thyroid artery usually deep to the artery, sometimes superficial or may even pass through the fork of the branches of the artery.
  3. Ligation of vessels:
    • The branches of the superior thyroid vessels are individually skeletonized and ligated as close to the superior pole as possible after identifying the external branch of the superior laryngeal nerve.
    • A medial approach to the superior pole via the avascular space between the cricothyroid muscle and the upper pole of the gland is ideal.
    • “Mass Ligation” of the superior pole is to be avoided.
    • Capsular ligation of the inferior thyroid artery:
      • Inferior thyroid artery is an end artery to the parathyroids and hence ligation of the trunk of the inferior thyroid artery is not recommended.
      • The small branches entering the capsule of the gland alone are ligated, thereby preserving the blood supply to the parathyroids.
      • These small branches are therefore situated between the parathyroid and the thyroid gland
        • Finally, the lower pole veins are ligated. Blind “mass ligation” of the lower pole may injure the RLN in this situation.
  4. Removal of the gland:
    • The gland is now free for removal. Depending on the type of surgery, the extent of removal and the amount of remainder may be decided.
    • Beware of the suspensory ligament of Berry, which is the last attachment of the gland to the cricoid cartilage.
    • The RLN may pass through the substance, superficial or deep to the Berry's ligament.
    • Take care of the nerve before the final removal of the gland.
Q 85. What are the critical areas of recurrent laryngeal nerve injury? (PG)
There are three critical areas of RLN injury:
  1. At the site of where the inferior thyroid artery crosses the RLN.
  2. At the region of the suspensory ligament of Berry.
  3. At the lower pole of the gland during ‘mass ligation’ of the vessels of the inferior pole, especially on the right side (Fig. 1.7).
Q 86. What is Zuckerkandl's tubercle? PG)
  • It is the posterior extension of the lateral lobes of the thyroid gland near the ligament of Berry.
  • It is found in 14–55% of cases.
32
zoom view
Fig. 1.7: Recurrent laryngeal nerve injury—critical sites
  • The RLN runs cranially in a fissure between the Zuckerkandl's tubercle and the main body of the gland or the tracheal surface.
  • The RLN may have a sharp angle beneath the tubercle.
  • The nerve is so constantly related to this tubercle, that it is often called “an arrow pointing to the RLN.
Q 87. What is non-recurrent laryngeal nerve?
  • This is seen on the right side as a result of failure of development of the 4th aortic arch.
  • The RLN here may arise as a branch from the vagus at the level of the inferior horn of the thyroid cartilage (instead of going down, curving around the subclavian artery and coming up).
  • The incidence is 0.2–0.5%.
Q 88. What is suspensory ligament of Berry?
  • It is nothing but a condensation of the pretracheal fascia attaching the thyroid gland to the cricoid.
  • The two ligaments on either side form a sling anchoring the gland to the larynx.
  • It must be severed before the gland can be removed.
  • The RLN is in immediate contact with the back of the ligament.
Q 89. What are the complications of thyroidectomy?
Q 90. What are the two most important complications of thyroidectomy?
  • Hypoparathyroidism
  • Recurrent laryngeal nerve injury.
Note: The incidence of both should be less than 1% for an experienced thyroid surgeon.
Q 91. What are the clinical manifestations of hypoparathyroidism?
Q 92. What will be the biochemical finding in hypoparathyroidism?
  • Decrease in calcium and increase in phosphorus is the feature of hypoparathyroidism.
  • Decrease in calcium with a decrease in phosphorus is suggestive of “hungry bone” syndrome.
Q 93. What is Chvostek sign?
With a knee hammer, gently tap the facial nerve as it courses in front of the external auditory meatus. When tetany (as a result of hyperparathyroidism) exists, the tapping of the hyperexcitable nerve provokes a brisk muscular twitch on the same side of the face.
Q 94. What is Trousseau's sign?
A sphygmomanometer cuff is placed around the arm and the pressure is raised to 200 mm of Hg. If tetany is present, in 5 minutes, typical contractions of the hand are seen: the fingers are extended except at the metacarpophalangeal joints and the thumb is strongly adducted, the combined effect of which is to produce the so-called obstetrician's hand (accoucheur's hand).
Note: The migratory superficial thrombophlebitis is also called Trousseau's sign (seen in visceral malignancies and TAO).
Q 95. What is carpopedal spasm?
Strong adduction of the thumb is always present in tetany and this when coupled with extension of the feet is called “carpopedal spasm”.
Q 96. What is spurious hypocalcemia? (PG)
  • Decrease in total calcium, albumin and hematocrit are seen in first two postoperative days following any surgery including nonthyroid.
  • This is as a result of antidiuretic hormone release from general stress of the surgery and the consequent water retention by kidneys and hemodilution.34
  • The albumin-bound total calcium is decreased as a result of this.
  • The nonprotein bound free (ionized) calcium will be normal in this situation and therefore estimation of the free calcium is important to distinguish spurious hypocalcemia from true hypocalcemia.
Q 97. How can you prevent hypoparathyroidism?
It is prevented by taking the following precautions during surgery:
  • Identification of parathyroids preoperatively
  • Protection of blood supply to parathyroid glands
  • Capsular ligation of inferior thyroid vessels
  • Autotransplantation of parathyroids in an event of inadvertent removal.
Q 98. What is the treatment of hypoparathyroidism? (PG)
  • Emergency: 20 mL of 10% calcium gluconate IV in 100 mL of D5W over 10–15 minutes
  • Chronic patient:
    • Calcium alone is not enough for the management of hypoparathyroidism.
    • Calcium carbonate 500 mg oral tablets (1.5 to 2.5 g per day).
    • Vitamin D (ergocalciferol) 50–100,000 units per day or dihydrotachysterol (DHT) 250–1000 μg daily.
    • Magnesium parenteral IV/IM 0.5 g (4 mEq) and 2 to 4 mEq per kg body weight over 3–5 days. Magnesium gluconate oral 500 mg tablets.
    • Calcitriol (1,25, dihydroxycholecalciferol) 60,000 units.
Note: If true hypocalcemia is identified, it is better to treat it pre-emptively rather than to wait for the symptoms.
Q 99. Can the patient get recurrent thyrotoxicosis after surgery? (PG)
Yes, in 5% of cases. Cure is possible if the thyroid tissue can be reduced below a critical mass. This will result in reduction of TSAb. When the mass of thyroid tissue is small, it can produce only limited hypertrophy and hyperplasia even if the circulating TSAb is high.
Q 100. What are the causes for stridor postoperatively?
Q 101. What are the clinical manifestations of RLN injury?
The most common manifestation is hoarseness. The other manifestations are:
  • Dysphonia
  • Paralytic aphonia
  • Periodic aspiration
  • Ineffective cough.
Note:
  • Unilateral RLN palsy is well-compensated normally
  • Normal voice does not mean that the nerve is intact
  • All hoarseness are not because of nerve injury either.
Q 102. What is the indirect laryngoscopy finding in unilateral RLN palsy? (PG)
  • Paramedian position of the paralyzed cord
  • Hyperadduction of the normal cord during phonation as compensation.
Q 103. Is there any role for routine post-operative indirect laryngoscopy? (PG)
  • Early routine indirect laryngoscopy is done on fourth or fifth day.
  • Cord paralysis is more common than supposed.
  • Asymptomatic bilateral vocal cord paralysis is possible.
35
Q 104. What is the treatment of unilateral RLN palsy? (PG)
  • Symptomatic improvement is seen within 6 weeks.
  • Perioperative steroids are given to reduce the incidence of temporary RLN palsy resulting from edema or contusion.
  • Steroids should be started within 7 days of surgery.
  • Prednisolone 15 mg tid for 10 days is given.
  • Gradually taper the dose to zero over the next 10 days.
  • If there is not any recovery within 6 months, degeneration is to be suspected (recovery may be delayed for 6–12 months; no regeneration after 18 months).
  • Speech therapy is instituted if there is no recovery.
  • Medialization of the cord by Teflon injection or some other technique.
Q 105. What are the clinical presentations and treatment of bilateral RLN palsy? (PG)
  • This will cause paralysis in adduction
  • Clinically, this may go undetected for long periods.
  • Patient may tolerate minimal airway for many years.
  • May present as inspiratory stridor, dyspnea, or minimal dysphonia.
  • Emergency endotracheal intubation may be required.
  • It is better to do tracheostomy and wait for 1 year (valved tracheostomy tubes are available).
  • Arytenoidopexy, cordectomy or endoscopic laser treatment is done after 18 months.
Q 106. What is the innervation of external laryngeal nerve (a branch of superior laryngeal nerve)?
The nerve supplies the cricothyroid muscle, which is a tensor of the vocal cord.
Q 107. What is the clinical presentation of unilateral external laryngeal nerve injury?
Clinical presentation:
  • Loss of high pitch for the voice
  • Voice fatigue
  • Breathy voice
  • Frequent throat clearing.
Indirect laryngoscopy will reveal:
  • Shorter and hyperemic vocal cord
  • The affected vocal cord will be at a lower level
  • The glottic chink is oblique (rotation of the posterior commissure to the paralyzed side).
Q 108. What is thyrotoxic crisis (thyroid storm)?
It is a sudden life-threatening exacerbation of thyrotoxicosis seen in 1–2% of patients. This is a syndrome manifested by high-grade fever, sweating, tachypnea, hyperventilation, tachycardia, palpitation, restlessness, tremor, psychosis, delirium, diarrhea, dehydration, nausea, vomiting, hypotension and end-stage coma. The causes for crisis are:
  • Inadequate preparation prior to surgery
  • Infection in thyrotoxicosis
  • Trauma in thyrotoxicosis
  • Pre-eclampsia
  • Diabetic ketoacidosis
  • Surgical emergency
  • Emotional stress
  • Vigorous palpation of the gland.
Q 109. What is Bayley's symptom complex?
36
Q 110. What is the treatment of thyroid storm?
Q 111. What are the methods available to remove T3 and T4 from serum? (PG)
  • Oral cholestyramine
  • Peritoneal dialysis
  • Hemoperfusion.
Q 112. What is the treatment of thyrotoxicosis in pregnancy? (PG)
  • Radioiodine is absolutely contraindicated because of the risk to the fetus.
  • The antithyroid drugs and TSH cross the placenta and therefore the baby is born goitrous and hypothyroid.
  • Low dose antithyroid drugs, preferably PTU is the ideal treatment (to keep the free T4 of pregnant women in the high normal.
  • Avoid methimazole: Associated with cutis aplasia, and esophageal and choanal atresia.
  • The danger of surgery is miscarriage.
  • Surgery can be carried out in the second trimester.
Q 113. What is the treatment of hyperthyroidism during lactation? (PG)
  • Thionamides are secreted in breast milk and this was once considered a contraindication.
  • PTU at a dose of 750 mg is safe.
Q 114. What is postpartum hyperthyroidism? (PG)
Pregnancy will lead onto exacerbation of autoimmune diseases. This may occur with previously diagnosed or undiagnosed hyperthyroidism. There is a strong association with HLA-DR3 and HLA-DR5 haplotypes.
Q 115. What is thyrotoxicosis factitia?
This is usually seen in health cranks as a result of oral intake of thyroxine usually taken to reduce weight).
Q 116. What is Jod-Basedow thyrotoxicosis?
Large doses of iodide given to hyperplastic endemic goiter which is iodine avid may produce temporary hyperthyroidism. This is Jod-Basedow thyrotoxicosis.
Q 117. What is neonatal thyrotoxicosis?
This is seen in babies born to hyperthyroid mothers. TSAb can cross the placental barrier. The hyperthyroidism gradually subsides after 3 to 4 weeks.
Q 118. What is thyrocardiac?
Severe cardiac damage wholly or partly due to hyperthyroidism. This is usually because of secondary thyrotoxicosis and is mild. This must be rapidly controlled with propranolol to prevent further cardiac damage.37
Q 119. What is struma ovarii?
Teratoma of the ovaries may differentiate into thyroid tissue. This thyroid tissue becomes hyperactive resulting in mild thyrotoxicosis. T3 and T4 are raised with suppressed TSH. Radioactive iodine uptake (RAIU) in neck is suppressed and higher intake is seen in the pelvis.
Q 120. What is Hashitoxicosis? (PG)
  • This is because of painless thyroiditis.
  • This is an early stage of autoimmune thyroiditis.
  • FNAC picture is that of Hashimoto's thyroiditis.
  • Thyrotoxicosis in this situation is mild.
  • Glandular enlargement is seen only in 60% of cases.
  • The inflamed gland releases the already formed thyroid hormones into the bloodstream resulting in toxicosis.
Q 121. What is trophoblastic thyrotoxicosis? (PG)
The hCG from hydatidiform mole, choriocarcinoma and metastatic embryonal carcinoma exhibit cross specificity to thyroid stimulating hormone receptor (TSHR). This results in thyroid overactivity.
Q 122. What is the histopathological appearance of hyperthyroidism?
  • There is hyperplasia of the acini lined by high columnar epithelium.
  • The acini are empty and some of them contain vacuolated colloid (Scalloping).
  • Pseudopapillary formation is seen.
Q 123. What will happen to exophthalmos after surgery or radioiodine therapy?
Both will worsen ophthalmopathy. Thionamides will alleviate the eye problem through immunosuppression.
Q 124. What is the management of exophthalmos (thyroid associated ophthalmopathy)?
Symptom control:
  • Sleeping with head end elevation.
  • 1% methylcellulose eye drops to prevent corneal ulceration.
  • High dose prednisolone orally or hydrocortisone IV.
  • Collimated super voltage radiation to retro orbital space (needs expertise).
Note: Radioiodine is avoided in ophthalmopathy.
Q 125. Is there any role for surgery in exophthalmos?
Surgical removal of lateral wall or roof of orbit is done for decompression when optic nerve is in danger.
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