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SRB’s Surgery for

Dental Students
SRB’s Surgery for
Dental Students

Sriram Bhat M MS (General Surgery)


Associate Professor
Department of Surgery
Kasturba Medical College, Mangalore
Karnataka, India
e-mail: meera_sriram2003@yahoo.com

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SRB’s Surgery for Dental Students

© 2008, Jaypee Brothers Medical Publishers


All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by
any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and
the publisher.
This book has been published in good faith that the material provided by author is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of
any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2008


ISBN 978-81-8448-401-4
Typeset at JPBMP typesetting unit
Printed at Ajanta Press
Dedicated to
My Beloved Father—Mr Sri Krishna Bhat
and also to
My Father-in-Law—Late Dr Krishna Karath
Foreword

I am delightful to write a foreword for this book entitled SRB’s Surgery for Dental Students by Dr Sriram
Bhat.
It is a manual of surgery covering all general surgical topics for dental students with clinical
methods in brief. All topics are discussed in detail as needed for dental students with adequate
diagrams, photos and illustrations. This book will be very useful to all the students of BDS as well
as MDS. The book deals comprehensively with basic general surgery and topics like wounds, shock,
trauma, vascular diseases, burns, thyroid, basic orthopedics, basic ENT topics and instruments.
A comprehensive manual of this standard can be best compiled only by a person with in depth
knowledge of the subject and teaching experience to understand the requirements of the dental
students. It is very apt that Dr Sriram Bhat a person whom the above description applies to has
come out with this book.
I wish Dr Bhat the very best in this and all his other professional endeavors.

Dr. V Surendra Shetty


Dean
Manipal College of Dental Sciences
Mangalore 575 001
Preface

My first book SRB’s Manual of Surgery is well accepted by medical students in our country. But
I felt, it will be much comprehensive for dental undergraduate (BDS) students and it should be
condensed and be selective. Keeping the surgery subject syllabus of BDS students in mind I wrote
SRB’s Surgery for Dental Students mainly concentrating on general surgery, head and neck, oral cavity
and maxillofacial injuries. I also included Basic Orthopedics, Neurosurgery, Adjuvant Therapy,
Sterilization and Instruments in the book. Miscellaneous chapter contains clinical examination of
swelling/hernia/hydrocele/arterial diseases/varicose veins/thyroid/oral cavity/salivary gland to
complete the fulfillment of the clinical surgical university examinations so that it will be easier for
students to get required subject in a single text. I essentially eliminated gastrointestinal and urology
topics. Adequate diagrams, photos, tables and illustrations are added wherever needed. I also
discussed about the topics with staff members of few dental colleges. I hope the book will be
appreciated by the dental faculty and students. Any suggestions and criticisms are well accepted.

Sriram Bhat M
e-mail: meera_sriram2003@yahoo.com
Acknowledgments

I acknowledge Dr V Surendra Shetty, Dean, Manipal College of Dental Sciences, Mangalore for
writing foreword to this book. I acknowledge helps given by Dr Rajendra Prasad, Dean, AB Shetty
Institute of dental sciences, Mangalore; Dr Sripathi Rao, Dean, Yenepoya Dental College, Mangalore;
Dr Sureschandra, Dean, AJ Shetty Institute of Dental Sciences, Mangalore; Dr Moksha Nayak, Dean,
KVG Dental College, Sullia. I also thank all staff members of different dental colleges who have
given me proper guidance to bring out this book.
I extremely thank Dr Raghuveer, Dean, Kasturba Medical College, Mangalore for his
encouragement for all academic activities.
I appreciate our beloved, Head of Surgery Department, KMC, Mangalore, Dr Thangam Verghese
Joshua for her guidance and help.
Heads of all departments in KMC, Mangalore and colleagues from my department always stood
with me for all my works. I remember all of them always for their kind heart.
I thank district surgeon for providing enough clinical materials from Government Wenlock
Hospital, Mangalore where I am working.
I thank to Professor Kishorechandra Prasad and to Sampath, Assistant Professor in ENT
Department for this all kind half.
I thank Dr Ganapathy, Director, Mangala Hospital, Mangalore for his encouragement.
I thank my dear friend Dr Ashok Pandith, Mch (Urology) for his constant guidance to me in
all my endeavors.
I thank Dr Jagadishchandra, MDS, Associate Professor and Dr Veena Jagadischandra, MDS, for
their affectionate help. Dr Jagadish has provided photos, X-rays and syllabus for dental students.
Dr Ragavendra Bhat and Dr Ravichandra, radiologists, Balmatta Diagnostic Center, Mangalore
have helped me a lot by giving necessary X-rays/CT scans/MRI pictures. I remember them a lot.
I acknowledge Dr Achaleshwar Dayal, MS from KMC, Mangalore, Assistant Professor, Surgery
Department for his all help for this work.
I appreciate Dr Ishwarkeerthi, MBBS, who has helped me by sketching diagrams needed for this
book. My beloved daughter, Ananya did many diagrams beautifully and helped me to reduce my
work. My wife, Dr Meera Sriram, MD (ObG), has done the corrections in the script and I owe her
a lot. I thank all my patients and all who have directly or indirectly helped me in bringing out this
book. I thank a lot Shri JP Vij, Chairman and Managing Director of M/s Jaypee Brothers Medical
Publishers (P) Ltd, New Delhi for his constant help and guidance. In spite of his busy schedule
he is always in touch with authors for any needed help. I appreciate him for his scintillating active
approaches.
I thank every production staff of M/s Jaypee Brothers for bringing out this book more effectively.
Contents

1. Wounds, Sinus Fistula and Ulcer ................................................................................................ 1


Wound 1; Compartment syndrome 4; Crush syndrome 4; Keloid (like a claw) 4; Hypertrophic
scar 5; Sinus 6; Fistula 6; Median mental sinus 8; Ulcer 9; Trophic ulcer 12; Pressure sore
(bedsore/decubitus ulcer) 13; Diabetic ulcer (diabetic foot) 14; Meleney’s ulcer 14; Lupus
vulgaris 15; Ulcer due to chilblains 15; Ulcer due to frostbite 15; Clinical examination of an
ulcer/sinus 15
2. Infectious Diseases ....................................................................................................................... 17
Cellulitis 17; Erysipelas 18; Pyogenic abscess 19; Boil (furuncle) 22; Carbuncle 22; Pott’s puffy
tumor 23; Pyogenic granuloma (Granuloma pyogenicum) 24; Pyemia 24; Tetanus 25; Gas
gangrene 27; Tuberculosis 28; Leprosy (Hansen’s disease) 29; Syphilis (great pox, French
disease) 30; Actinomycosis 31; Madura foot (Mycetoma pedis) 31; Rabies (hydrophobia) 32;
Anthrax 35; Nosocomial infection (hospital acquired infection) 35; Opportunistic infections
36; Necrotizing fasciitis 36; Acute pyomyositis 37; HIV infection and AIDS (acquired
immunodeficiency syndrome) 38; Gonorrhea 41
3. Swellings ......................................................................................................................................... 43
Lipoma 43; Papilloma 44; Cysts 46; Dermoids 46; Sebaceous cyst (Wen, epidermal cyst) 48;
Glomus tumor 49; Lymph cyst (lymphatic cyst) 50; Neuroma 50; Neurofibroma 51;
Neurilemmoma (schwannoma) 52; Fibroma 52; Ganglion 53; Bursae 53; Adventitious bursa
54; Morran baker cyst 55; Calcinosis cutis 55; Epignathus 56
4. Arterial Diseases ............................................................................................................................ 57
Surgical anatomy of 57; Thoracic outlet 57; Arteries of upper limb 58; Upper limb ischemia
58; Raynaud’s phenomenon 61; Acrocyanosis 62; Subclavian steal syndrome 62; Arteries of
lower limb 63; Arterial diseases 63; Thromboangiitis obliterans (TAO) syn. Buerger’s disease
68; Acute arterial occlusion 72; Compartment syndrome 73; Embolism 73; Caisson’s disease
or decompression disease 75; Aneurysms 75; Gangrene 79; Diabetic foot and diabetic gangrene
81; Ainhum 82; Hamartomata 82; Hemangioma 82; Cirsoid aneurysm 84; Arteriovenous
fistula (AVF) 85
5. Venous Diseases ............................................................................................................................ 88
Anatomy of veins of lower limb 88; Physiology of venous blood flow in lower limb 89; Deep
vein thrombosis (DVT) 89; Varicose veins 91; Venous ulcer 97; Thrombophlebitis 98;
Anticoagulants 98
6. Lymphatics .................................................................................................................................... 101
Lymphangiography 101; Isotope lymphoscintigraphy 102; Lymphedema 102; Lymphomas
106; Hodgkin’s lymphoma (HL) 106; Non-Hodgkin’s lymphoma (NHL) 109; Burkitt’s
lymphoma (Malignant lymphoma of Africa) 110; Tuberculous lymphadenitis 110
xii SRB’s Surgery for Dental Students
7. Shock and Hemorrhage ............................................................................................................. 113
Shock 113; Central venous pressure (CVP) 117; Pulmonary capillary wedge pressure (PCWP)
118; Systemic inflammatory response syndrome (SIRS) 118; Oxygen therapy 119; Hyperbaric
oxygen 119; Cardiac arrest 120; Mechanism of blood coagulation 122; Hemorrhage 123; Blood
transfusion 126; Blood fractions 126; Massive blood transfusion 127; Blood substitutes 128;
Tourniquets 128
8. Burns .............................................................................................................................................. 130
Burns 130; Management of burns 133; Eschar 134; Burns contracture 135; Electrical burns
135; Inhalation burns 136; Chemical burns 136
9. Reconstruction and Transplantation ........................................................................................ 138
Skin grafting 138; Flaps 140; Transplantation 141; Renal transplantation 142; Liver
transplantation 143; Bone marrow transplantation 143; Graft rejection 143; Cimino fistula
144
10. Fluids, Electrolyte and Nutrition .............................................................................................. 145
Water loss 145; Water intoxication 146; Hyponatremia 146; Hypernatremia 147; Hypokalemia
147; Hyperkalemia 147; Acid-base balance 148; Anion gap 149; Nutrition 149; Gastrostomy
150; Jejunostomy 151; Total parenteral nutrition (TPN) 151; Obesity 152
11. Nerves and Tendon .................................................................................................................... 153
Peripheral nerve injuries 153; Brachial plexus injuries 155; Causalgia 155; Median nerve
injuries 156; Carpal tunnel syndrome 156; Ulnar nerve injuries 157; Claw hand 158; Radial
nerve lesions 158; Common peroneal nerve 159; Axillary nerve injury 160; Long thoracic nerve
(nerve of bell) 160; Trigeminal neuralgia 160; Tendon 160; Tendon repair 161; Tendon transfer
161; Tendon graft 161
12. Hand and Foot ............................................................................................................................. 162
Surgical anatomy of the hand 162; Hand infections 163; Acute paronychia 164; Chronic
paronychia 164; Terminal pulp space infection (FELON) 165; Infection of webspaces 165;
Deep palmar space infection 166; Acute suppurative tenosynovitis 167; Hand injuries 168;
Compound palmar ganglion 168; Dupuytren’s contracture 169; Syndactyly 170; Mallet finger
(base ball finger) 170; Heberden’s nodes 170; Spina ventosa 170; Callosity 170; Corn 171;
Plantar fasciitis (Policeman’s heel) 171; Ingrowing toe nail (Onychocryptosis) 171
13. Trauma ........................................................................................................................................... 173
Triage 173; Spinal injury 176; Neck injuries 176; Bullet injuries 176; Blast injuries 177;
Penetrating injury 177; Abdominal trauma 177; Duodenal injury 178; Pancreatic injury 179;
Small bowel injury 179; Colonic injury 179; Liver injury 179; Splenic injury 180; Renal injury
180; Urinary bladder injury 180; Abdominal compartment syndrome 180
14. Neoplasm and Soft Tissue Tumors ........................................................................................ 181
Neoplasm 181; Spread of malignant tumors 183; Paraneoplastic syndromes 183;
Investigations for neoplasm 184; Soft tissue tumors (sarcomas) 186; Kaposi’s sarcoma 191
Contents xiii
15. Skin Tumors ................................................................................................................................. 193
Classification of skin tumors 193; Skin adnexal tumors 193; Dermatofibroma 194;
Dermatofibrosarcoma protuberance 194; Keratoacanthoma (Molluscum sebaceum) 194;
Rhinophyma (potato nose) 195; Premalignant conditions of the skin 195; Squamous cell
carcinoma (epithelioma) 195; Marjolin’s ulcer 197; Basal cell carcinoma (Rodent ulcer) 197;
Nevi 199; Melanoma 200
16. Neck ............................................................................................................................................... 204
Anatomy of lymphatics of head and neck 204; Branchial cyst 205; Branchial fistula 206;
Pharyngeal pouch 206; Laryngocele 207; Cystic hygroma (cavernous lymphangioma) 208;
Ludwig’s angina 209; Parapharyngeal abscess 210; Retropharyngeal abscess 210; Carotid
body tumor (potato tumor, chemodectoma, non-chromaffin paraganglioma) 211; Torticollis
(wry neck) 212; Sternomastoid tumor 212; Subhyoid bursitis 213; Secondaries in neck lymph
nodes 213
17. Thyroid ........................................................................................................................................... 219
Development 219; Anatomy 219; Congenital anomalies 221; Thyroid function tests 223;
Classification of goiter 223; Diffuse hyperplastic goiter 224; Nodular goiter 224; Solitary thyroid
nodule 225; Retrosternal goiter 226; Thyrotoxicosis (hyperthyroidism) 226; Thyroid neoplasm
234; Papillary carcinoma 234; Follicular carcinoma 235; Anaplastic carcinoma 236; Medullary
carcinoma of Thyroid (MCT) 236; Malignant lymphoma 237; Hashimoto’s thyroiditis 237;
deQuervain’s subacute granulomatous thyroiditis 238; Reidel’s thyroiditis (0.5% common)
238; Thyroidectomy 238; Emil theodor kocher 240; Hypothyroidism 241
18. Parathyroid .................................................................................................................................... 242
Anatomy of parathyroid 242; Hyperparathyroidism 243; Acute hyperparathyroidism (Crisis)
243; Tetany 245; MEN syndrome (MEA syndrome) 245
19. Salivary Glands ............................................................................................................................ 246
Anatomy 246; Sialography 248; Salivary calculus 248; Sialosis 250; Sialectasis 250; Parotid
abscess (acute suppurative sialadenitis of parotid) 250; Parotid fistula 251; Sjögren’s syndrome
251; Mikulicz disease 252; Salivary neoplasms 252; Management of malignant salivary tumors
256; Minor salivary gland tumors 257; Frey’s syndrome (auriculo-temporal syndrome,
gustatory sweating) 258; Parotidectomy 259;
20. Oral Cavity .................................................................................................................................... 260
Ranula 260; Sublingual dermoids 261; Leukoplakia 261; Erythroplakia 262; Oral submucosal
fibrosis 262; Cancrum oris (NOMA) 262; Carcinoma cheek 263; Neoplasm of lip 268;
Carcinoma of lip 269; Tongue 271; Carcinoma tongue 272; Nasopharyngeal carcinoma 276;
Maxillary tumors 277; Carcinoma hard palate 280
21. Laryngeal Tumors ....................................................................................................................... 282
Benign papilloma 281; Malignant tumors 281; Total laryngectomy 284; Care after total
laryngectomy 285
22. Tonsils ............................................................................................................................................ 286
Anatomy of the tonsils 286; Acute tonsillitis 287; Chronic tonsillitis 287; Peritonsillar abscess
(QUINSY) 288; Tonsillectomy 288; Acute pharyngitis 290
xiv SRB’s Surgery for Dental Students
23. Cleft Lip, Cleft Palate and Jaw Tumors ................................................................................. 291
Cleft lip and cleft palate 291; Diseases of the palate 296; Orthopentomogram (OPG) 296;
Preauricular sinus 296; Jaw tumors 296; Epulis 297; Ameloblastoma 298; Dentigerous cyst
(follicular odontome) 299; Dental cyst (radicular cyst, periapical cyst) 300; Alveolar abscess
(dental abscess) 300; Cherubism 301
24. Tracheostomy ................................................................................................................................ 302
Tracheostomy 302; Tracheostomy tubes 302
25. Esophagus ...................................................................................................................................... 306
Anatomy 306; Lower esophageal sphincter (LES) 308; Dysphagia 308; Achalasia cardia;
Gastroesophageal reflux Disease (GERD) 311; Barrett’s esophagus 312; Hiatus hernia 312;
Reflux esophagitis 313; Corrosive stricture of esophagus 313; Plummer-Vinson syndrome
(Patterson-Kelly syndrome) 314; Mallory-Weiss syndrome 314; Boerhaave’s syndrome 315;
Tracheoesophageal fistula 315; Carcinoma esophagus 316
26. Basic Orthopedics ........................................................................................................................ 319
Anatomy of the bone 319; Fracture 320; Plaster of Paris (POP) 324; Arthrodesis 326;
Arthroplasty 326; Osteotomy 328; Infections of the bone 328; Paget’s disease of bone 330;
Rickets 330; Bone disease of hyperparathyroidism 331; Osteoporosis 331; Scurvy 331;
Osteogenesis imperfecta 331; Achondroplasia 331; Tendinitis 332; Diaphyseal achalasia
(multiple exostoses) 332; Enchondromatosis (Ollier’s disease) Arthritis 332; Rheumatoid
arthritis 333; Osteoarthrosis 333; Ankylosing spondylitis 334; Kyphosis 334; Scoliosis 334;
Spondylolisthesis 335; Intervertebral disc prolapse (IVDP) 335; Bone tumors 336
27. Maxillofacial Injuries .................................................................................................................. 340
Primary care (early care) in maxillofacial injuries 341; Fracture middle third area 342; Fracture
mandible 349; Complications of maxillofacial injuries 357
28. Neurosurgery ................................................................................................................................ 358
Head injuries 358; Extradural hematoma 363; Subdural hematoma 364; Depressed skull
fracture 365; Subarachnoid hemorrhage 366; Intracranial abscess 366; Intracranial aneurysm
367; Hydrocephalus 368; Intracranial tumors 369; Pituitary tumors 371; Spina bifida 372
29. Adjuvant Therapy ....................................................................................................................... 373
Radiotherapy 373; Chemotherapy 376; Immunosuppression 377; Hormone therapy 377;
Immunotherapy 378; Hybridoma 378; Gene therapy 378
30. Instruments and Suture Materials ........................................................................................... 380
Instruments 380; Suture materials 391
31. Sterilization and Disinfection ................................................................................................... 394
Sterilization 394; Disinfection 394; Antisepsis 394; Asepsis 394; Halogens 395
32. Cautery, Laser, Cryosurgery and Day Care Surgery ........................................................... 398
Diathermy (electrocautery) 398; Lasers in surgery 399; Cryosurgery 399; Day care surgery
400
33. Advanced Imaging Methods ..................................................................................................... 401
Ultrasound 401; Doppler 402; CT scan 403; Magnetic resonance imaging (MRI) 404
Contents xv
34. Anesthesia ..................................................................................................................................... 406
Preoperative assessment 406; General anesthesia 407; Muscle relaxants 407; Reversal agents
408; Instruments in anesthesia 408; Complications in general anesthesia 409; Postoperative
care 409; Regional anesthesia 410; Spinal anesthesia 411; Epidural anesthesia 412; Caudal
anesthesia 412
35. Miscellaneous ............................................................................................................................... 413
A. History of Surgery .................................................................................................................. 413
B. Laboratory Values .................................................................................................................. 415
C. Clinical Methods for Dental Students ................................................................................ 418
Examination of a swelling/lump 418; Examination in arterial disease (arterial system) 422;
Examination of varicose veins 428; Examination of thyroid gland 432; Examination of inguinal
hernia 438; Hernioplasty 444; Examination of hydrocele 444; Examination of oral cavity 446;
Examination of salivary gland 446
Index ................................................................................................................................................ 449