Choledochal cyst

Choledochal cyst

Choledochal cyst

¤Congenital cyst occuring in CBD
¤ manifest by 1 - 2 yrs of age
¤ TODANI classification
 type 1 - fusiform dilatation of              CBD
  type 2- lateral saccular                   diverticuli of CBD
  type 3 - Dilatation of intraduodenal segment of CBD
 type4-   Dilatation of CBD + intrahepatic biliary dilatation.
 type5 multiple intrahepatic cyst
CLINICAL FEATURES -
1. Age - children within 1-2 yrs of age
2. Common in females
3. Abdominal distention due to large cyst & cyst palpated.
4. Slow progressive laundice, recurrent attacks with abdominal pain.

INVESTIGATION -
1.USG - confirm presence of abnormal cyst
2. MRI - reveal relation between bile duct & pancreatic duct.
3. ERCP

¤TREATMENT -
  -premalignant anomaly
excision of cyst & reconstruction is treatment of choice
Type1- excision of cyst followed by Roux-en-y-hepaticojejunostomy.
 Type 2- excision of diverticulum wit suturing of CBD.
 Type 3 - endoscopic sphincterntomy is adequate
  Type 4- difficult to treat. Treated by Lilly's technique. In this technique posterior wall of byst can be left, after removal of mucosa
COMPLICATIONS -
1. Recurrent cholangitis wit high grade fever
2. Rupture of cyst
3. CBD  stones
4. Carcinoma in cyst

Cf of ca tongue

Cf of ca tongue

Cf of ca tongue

Clinical presentation_

1 bleeding ulcer.
2 pain in the tongue is due to involvent of lingual nerve.In such case,pain frm the tongue can b referred to the ear n lower temporal region.
3 Anlyloglossia is restricted mobility of tongue.It is due to infiltration of the floor of the mouth or mandible.
4 dysarticulation_ difficulty in talking is due inability to move the tongue freely.
5 dysphasia is a common presentation frm ca of post 1/3 rd .
6 foetor oris is due to infected necrotic growth.
7 bilateral massive enlargement of lower deep cervical nodes in an elderly pt is suggestive of ca of post 1/3 rd of the tongue.

Premalignant condition of ca tongue_

1 leuknplakia_causes of leukoplakia r smoking,spices,spirits,sharp tooth,sepsis,sunlight,syphilis etc.
2 erythroplakia
3 submucous fibrosis
4 papilloma of the tongue or cheek
5 chronic hyperplastic candidiasis.
6 syphilic glossitis
7 discoid lupus erythematosis
8 dyskeratosis congenita

Choleteatoma

Choleteatoma

Choleteatoma

Cholestesteatoma="Skin hn d wrong place"

it has 2 parts

a=matrgx
-made of keratinised squamous epithlm resting on d thin stroma of fibrous tissue

b=central white mass
-consisting of keratin debris produced by matrix
also caled epidermosis/keratoma

* Origin of cholestma

1=presence of congenital cell rests

2=invagination of tympanic membrne 4m d attic in form of retraction pocket=Wittmaacks theory

3=basal cell hyperplasia. The basal cels of germinal layer of skin proliferate due 2 infection=Ruedis theory

4=epithelial invasion. The epithelium 4m d meatus grows in2 middle ear through a pre-existing perforation=Habermans theory

5=metaplasia. Middle ear mucosa undergoes metaplasia due 2 repeated perforation and convert in2 squamous type=Sades theory

* Classification

1. Congenital

- arises 4m d embryonic epidermal cell
- sites: middle ear,petrous apex,cerebellopontine angle
- presents as white mass behind d intact tympanic membrane and causes conductive hearing loss

2. Acquired primary

- there is primary bcos there no history of previous otitis media/perforation
- theories :

a. invagimation of pars flaccida
- persistent -ve pressure in d attic causes a retraction pocket which accumulate keratin debris
b. basal cell hyperplasia
c. squamous metaplasia

3. Acquired secondary

- there is already pre-exisisting perforation in d pars tensa
- always asociated with d posterosuperior marginal or sometimes central perforation

- theories :

a. migration of squamous epithelium
b. metaplsia

* Expansion of cholestoma

- 4m d middle ear invade d surrounding structure and follows d path of least resistance and then enzymatic bone distruction
- attic cholstoma may extends backwards 2 aditus,antrum,mastoid, downward in2 mesotympanum and medialy surrounds d incus

* Distruction of bone

- cholstoma has d property 2 distroy bone e.g. ear occicles, bony labyrinth, canal of facial nerve, sinus plate, tegman tympani

Cervical Rib

Cervical Rib

Cervical Rib

This is an extra rib present in d neck in about 1 to 2% subject
unilateral
mostly on Rt side
it is d ant tubercle of d transverse proces of d 7th cervical vertebra whch atains excesive devlopment and result in cervical rib

¤ Types

1. Free end of d rib is expanded in2 a hard, bony mass whch can b felt in d neck
2. Complete cervical rib extend 4m c7 vertebra posteriorly 2 d manubrium ant
3. Incomplte cervical rb ir partly bony partly fibrous
4. A complete fibrous band whch gives rise 2 symptms but cant be diagnosed by x ray

¤ Clinicl features

1. Common in young females, it is congenital but symptoms apears only aftr puberty
2. Dull aching pain in d neck is causd by expanded bony emd of cervicl rib
3. Features of uper limb ishaemia
_claudication pain
_low temperature, palor, sweating, splinter hemorrhage, ischemic ulcers in finger and gangrene of d skin
4. Featurs of ulnar nerve paralysis
_paralysis of intercostal muscles, wasting of hypothenar muscles, tinglin, numbness
_it is tested by card test and froments sign
5. A hard mass may be visible or palpable in d root

¤D/D

1. Cervical spondylosis
2. Cervical disc protrusion and spinal cord tumour
3. Carpal tunnel syndrome
4. Raynauds phenomen
5. Pancost tumour

¤ Investigations

1. X ray neck

¤ Treatment

1. conservative
shouldr girdle exercises and correction of favlty posture