eMentorSurgery

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An abscess

An abscess is surrounded by an acute inflammatoryresponse, and a pyogenic membrane composed of fibrinous exudate and oedema, andthe cells of acute inflammation.

•        The middle of an abscess is full of pus and debris.

•        Painful and warm to touch,abscesses can show up any place on the body.

•        The most common sites are in the armpits (axillae), areas around the anus and vagina (Bartholingland abscess), the base of the spine (pilonidalabscess), around a tooth (dentalabscess), and in the groin. Inflammation around a hair follicle can also lead to the formation of an abscess, which is called a boil(furuncle).

 Causes & Pathalogy

•        By obstruction of oil(sebaceous) glands or sweat glands,

•        Inflammation of hair follicles,

•        From minor breaks and puncturesof the skin.

•        Germs get under the skin orinto these glands, which causes an inflammatory response as the body's defenses try to kill these germs.

•        The middle of the abscess liquefies and contains dead cells, bacteria, and other debris. This area begins to grow, creating tension under the skin and further inflammation of thesurrounding tissues. Pressure and inflammation cause the pain.

•        People with weakened immune systems get certain abscesses more often. Those with any of the following areall at risk for having more severe abscesses.

Symptoms

•        Most often, an abscess becomesa painful, compressible mass that is red, warm to touch, and tender.

•        As some abscesses progress,they may "point" and come to a head so you can see the materialinside and then spontaneously open (rupture).

•        The infection can spread to the tissues under the skin and even into the bloodstream.    If the infection spreads into deeper tissue.

 When to Seek Medical Care

•        A sore larger than 1 cm or a half-inch across.

•        The sore continues to enlargeor becomes more painful.

•        An underlying illness such as AIDS, cancer, diabetes, leukemia, sickle cell disease, or have poorcirculation.

•        An IV drug abuser.

•        On steroid therapy or chemotherapy.

•        The sore is on or near the rectal or groin area.

•        Fever of 101.5°F or higher.

•        Red streak going away from the abscess.

Treatment. Self-Care at Home

•        If the abscess is small (lessthan 1 cm or less than a half-inch across), applying warm compresses to the area for about 30 minutes 4 times daily can help.

•        Do not attempt to drain theabscess by pressing on it. This can push the infected material into the deeper tissues.

•        Do not stick a needle or othersharp instrument into the abscess center because you may injure an underlyingblood vessel or cause the infection to spread.

 Surgical Treatment

•        Incise  and drain the abscess.-By Hilton’s principle.

•        Under general or local anesthesia can make the procedure almost painless.

•        Sedative if the abscess is large.

•        The area will be covered withan antiseptic solution and sterile towels placed around it.

•         Cut open the abscess and totally drain it of pus and debris.

•        Once the sore has drained  -

•         Insert some packing into the remaining cavityto minimize any bleeding and keep it open for a day or two.

•        A bandage

•        Most people feel better immediately after the abscess is drained.

•        Still experiencing pain,Analgesics over the next 1-2 days.

 Hilton’s principle

•        Make a small incision by knife parallel to deeper vital structures.

•        Then, use a blunt( Not a sharp knife like) instrument.

•        Avoid injury to deeper vital structures.

Tumours

•        A tumour is a new growth of tissue (a mass) which can refer to an inflammatory swelling such as Pott’spuffy tumour  or to a neoplasticgrowth.

•        A neoplastic tumour is an uncontrolled proliferation of a clone of cells without useful function.

 Definitions

Hypertrophy is an increase in the size of an organ without an increase in cell numbers.

 •   Hyperplasia is an increase in the size ofan organ due to an increase in cell numbers.

 Dermoid cysts.

•        ‘Dermoid’ is a loose term given to cysts lined by squamous epithelium occurring in various parts of the body.Sebaceous cysts are lined by superficial squamous cells and should more accurately be called ‘epiderrnoid’.

•           Teratomatous dermoids are found in the ovary, testis retroperitoneum, superior mediastinurn and the presacral area. Malignant change (carcinomatous or sarcomatous) can occur.

•            Sequestration dermoids  are not new growths, but are formed by the inclusion of epithelial ‘nests’ beneath the surface at placeswhere lines of devel­oping skin meet and join: midline, external angularprocess, root of nose, branchial cysts.

•           Implantation dermoids  may follow puncture wounds,commonly of the fingers, when living epithelial cells are implanted beneath thesurface.

 Benign tumour.

•        usually encapsulated, and does not disseminate or recur after complete removal.

•        Symptoms and effects, which can be harmful, are due to its size, position, and pressure.

•        Certain adenomas secretea  hormone which may affect bodily functions.

•        Benign tumours are often multiple.

 Malignant tumour.

•        invasion of surrounding tissues;

•          pleomorphism (variableshapes) of cells and nuclei;

•        rapid growth;

•         the tendency to spread to other parts of the body (metastasis) by the lymphatics, the bloodstream, along nerve sheaths and across body cavities;

•        general weight loss (cachexiain advanced disease).

 Lipoma

•        slowly growing tumour composedof fat cells adult type.

•        encapsulated or diffuse.

•        The head and neck area,abdominal wall and thighs are particularly favoured sites.

•        Encapsulated lipomas areamong the commonest. 

•         the presence of a defi­nite edge and lobulation.

•        A sense of fluctuation may be obtain­ed.

•        Most  painless, but some give rise to an aching sensation which may radiate.

•        Multiple lipomas are not uncommon.

•         sometimes painful, in which case the condition is probably one of neurolipo­matosis. Dercum ‘s disease (adiposis dolorosa),characterised

•        by tender deposits of fat,especially on the trunk, is an associated condition.

•        Should the lipoma contain an excessive amount of fibrous tissue, it is termed a fibrolipoma. In othercases, considerable vascularity is present, often with telangiectasis of the over­lying skin, in which case the tumour is a naevolipoma.

 classified according to Situation.

Subcutaneous. Commonly found on the shoulders or the back.

•  Sub fascial. Occurring under the palmar or plantar fascia,tenosynovitis, .

•  Subsynovial. From the fatty padding around joints, especially the knee.

•  Intra-articular.

•  Intenmuscular. Mainly in the thigh oraround the shoulder. 

•  Panosteal occasionally occur under the periosteum of a bone.

•  Subserous are sometimes found beneath the pleura,

•  Submucous occur under the mucous membrane of the respiratory or alimentary tracts. One situated in the intestine is likely to cause an intussusception,

•  Central nervous system. - the extradural spaces, the spinal cord and brain; 

•  Intraglandular. -in the pancreas, underthe renal capsule and in the breast

•  Retropenitoneal. Large lipomas are seen not infrequently in the retroperitoneal tissues. Some of  them turn Out to be liposarcomas.

 Benign to malignant transformation

 • increase in size: comparatively rapid enlargement is always suspicious, e.g. a neurofibroma which is becoming sarcomatous;

•  increased vascularity: dilated cutaneous veins,ulceration and bleeding in the case of a superficial growth (e.g. melanoma);

• fixity: due to invasion of surrounding structures;

• involvement of adjacent structures: e.g. facial palsy sug­gests malignant change in an otherwise longstanding parotid pleomorphicadenoma;

• dissemination: discovery of secondary deposits.

 Cysts

•        meaning ‘bladder’.

•        The pathological term ‘cyst’means a swelling consisting of a collection of  fluid in a sac which is lined by epithelium or endothelium.

 True cysts

•        True cysts are lined by epithelium or endothelium.

•        The fluid is usually serous or mucoid and varies from brown-staining by altered  blood to almost colourless.

•        In epidermoid, dermoid and branchial cysts the contents are like porridge or toothpaste, as a result of the shedding of desquamated cells.

•        Cholesterol crystals are often found in the fluid of branchial cysts.

 False cysts (pseudocysts)

•        not lined by epithelium.

•        A pseudocyst of the pancreas is an encysted collection of pancreatic enzyme rich fluid lined by granulation tissue or fibrous tissue.

•        bulging into the lesser sac;they may occur anywhere in the abdominal .

 Classification of cysts

  Congenital            Sequestration dermoids

                            Tubuloembryonic (tubulodermoid)

                            Cyst of embryonic remnants

Acquired              Retention

                            Distention

                            Exudation

                            Cystic tumours

                            Implantation dermoids

                            Trauma

                            Degeneration

Parasitic              Hydatid, trichniasis, cysticercosis

Complications

•        Infection

•        Haemorrhage

•        Torsion

•        Calcification

•        Rupture

•        Malignant transformation