2nd Year All Clinicals AIMC Academia

REVISED IMPORTANT CLINICALS
ABDOMEN & PELVIS
ANTERIOR ABDOMINAL WALL & INGUINAL REGION
LIPOSUCTION
● Liposuction is a surgical method for removing unwanted subcutaneous fat using a
percutaneously placed suction tube and high vacuum pressure.
SPACE OF BOGROS
● An anterolateral part of potential space between the transversalis fascia and the
parietal peritoneum (space of Bogros) is used for placing prostheses when repairing
inguinal hernias.
EXTERNAL SUPRAVESICAL HERNIA
● An external supravesical hernia leaves the peritoneal cavity through the supravesical
fossa.
● It is medial to direct inguinal hernia.
● Iliohypogastric nerve is preserved during surgery.
UMBILICAL HERNIA
● Umbilical hernia may occur due to failure of the midgut to return to the abdomen early
in fetal life.
● It occurs as a protrusion of the bowel through the natural weak spot or defect at the
umbilicus.
● It is more common in girls and in premature babies.
● Acquired umbilical hernias occur most commonly in women and obese people.
● Extraperitoneal fat and/or peritoneum protrude into the hernial sac.
EPIGASTRIC HERNIA
● An epigastric hernia is a protrusion of extraperitoneal fat or a small piece of greater
omentum through a defect in the linea alba b/w the umbilicus & xiphoid process.
SPIGELIAN HERNIAS
● Spigelian hernias are those occurring along the semilunar lines.
INGUINAL HERNIA
● “Inguinal hernia is a condition in which a portion of the intestine protrudes through a
weak spot in the inguinal canal or in the inguinal triangle.”
● On the basis of severity, an inguinal hernia can take one of the following forms
1. REDUCIBLE HERNIA
● A reducible hernia is a hernia in which the contents of the hernial sac can be returned
to their normal position.
2. INCARCERATED HERNIA
● An incarcerated hernia is an irreducible hernia in which the contents of the hernial sac
are entrapped or stuck in the groin.
3. STRANGULATED HERNIA
● A strangulated hernia is an irreducible hernia in which the intestine becomes tightly
trapped or twisted.
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DIFFERENCE BETWEEN FEMORAL AND INGUINAL RING
FEMORAL HERNIA INGUINAL HERNIA
It is more common in females It is more common in males
It lies inferior and lateral to the pubic tubercle It lies superior and medial to the pubic
tubercle
DETECTION OF INGUINAL HERNIA
● The superficial inguinal ring is palpable superolateral to the pubic tubercle by
invaginating the skin of the upper scrotum with the index finger. Should a hernia be
present, a sudden impulse is felt against the tip of the finger when the patient is asked
to cough.
● However, because both inguinal hernia types exit the superficial ring, palpation of an
impulse at this site does not discriminate type.
● With the palmar surface of the finger against the anterior abdominal wall, the deep
inguinal ring may be felt like a skin depression superior to the inguinal ligament, 2–4
cm superolateral to the pubic tubercle.
● Detection of an impulse at the superficial ring and a mass at the site of the deep ring
suggests an indirect hernia (Ring finger test).
● Direct hernia can be identified by placing the thumb in the inguinal triangle.
DIFFERENCE BETWEEN DIRECT AND INDIRECT HERNIA
DIRECT (Acquired) HERNIA INDIRECT (congenital) HERNIA
Less common More common
Common in older people Mostly in younger individuals
It is due to the weakness of the anterior Due to the persistent processus vaginalis
abdominal wall
Peritoneum plus transversalis fascia exits Peritoneum plus all three layers of chord
through the abdominal wall
It passes through the posterior wall of the It passes through the deep inguinal ring
inguinal canal
It lies external and parallel to the vestiges of It lies within processus vaginalis
processus vaginalis
It exits the abdominal wall via a superficial It exits from the abdominal wall via a
ring superficial ring
Rarely enters the scrotum Commonly passes into the scrotum
SUPERFICIAL ABDOMINAL REFLEX

● Superficial abdominal reflex is elicited by quickly stroking horizontally, lateral to
medial, toward the umbilicus.
● Usually, contraction of the abdominal muscles is felt.
CREMASTERIC REFLEX
● Cremasteric reflex is a drawing up of the testis by contraction of the cremaster muscle
when the skin on the upper medial side of the thigh is stroked.
● The efferent limb of the reflex arc is the genital branch of the genitofemoral nerve.
ABDOMINAL INCISIONS
● The incisions follow the cleavage lines (Langer lines).
● Instead of transecting muscles, causing irreversible necrosis (death) of muscle fibres,
the surgeon splits them in the direction of their fibers.
● The rectus abdominis is an exception; it can be transected because its muscle fibers run
short distances between tendinous intersections, can regenerate easily and the
segmental nerves supplying where they can be located and preserved.
● Muscles and viscera are retracted toward, not away from, their neurovascular supply.
● Injury to nerves of the anterolateral abdominal wall (during incision) may result in the
weakening of the muscles.
INCISIONAL HERNIA
● An incisional hernia is a protrusion of the omentum (a fold of the peritoneum) or an
organ through a surgical incision (when muscles don't heal properly).
TYPES OF INCISIONS
LONGITUDINAL INCISIONS (median & paramedian incisions)
● Median or midline incisions can be made along the length of the linea alba from the
xiphoid process to pubic symphysis.
● Because the linea alba transmits only small vessels and nerves to the skin, a midline
incision is relatively bloodless and avoids major nerves.
● Because of its relatively poor blood supply, the linea alba may undergo necrosis and
degeneration after incision.
PARAMEDIAN INCISIONS (lateral to the median plane)
● They are made in a sagittal plane and may extend from the costal margin to the pubic
hairline.
● After the incision passes through the anterior layer of the rectus sheath, the muscle is
freed and retracted laterally to prevent tension and injury to the vessels and nerves.
GRIDIRON INCISIONS (Muscle Splitting)
● Gridiron (muscle-splitting) incisions are often used for appendectomy.
● The oblique McBurney incision is made at the McBurney point, 2.5 cm superomedial
to the ASIS on the spino-umbilical line.
● The external oblique aponeurosis is incised inferomedially in the direction of its fibers
and retracted.
● Internal oblique and transversus abdominis are then split in the line of their fibers and
retracted. The iliohypogastric nerve, running deep to the internal oblique, is identified
and preserved.
● It cuts no musculoaponeurotic fibers.
● The abdominal wall is as strong after the operation as it was before.
SUPRAPUBIC INCISIONS
● Suprapubic (Pfannenstiel) incisions (“bikini” incisions) are made at the pubic hairline.
● These are—horizontal with a slight convexity—are used for most gynaecological and
obstetrical operations (e.g., for cesarean section).
● The linea alba and anterior layers of the rectus sheaths are transected and resected
superiorly, and the rectus muscles are retracted laterally.
● Ilioinguinal & iliohypogastric are preserved.
TRANSVERSE INCISIONS
● Transverse incisions through the anterior layer of the rectus sheath and rectus
abdominis provide good access and cause the least possible damage to the nerve supply
(as they are parallel to nerves).
● Transverse incisions are not made through the tendinous intersections because
cutaneous nerves and superior epigastric vessels pierce them.
SUBCOSTAL INCISIONS
● Subcostal incisions provide access to the gallbladder and biliary ducts on the right side
and the spleen on the left.
● The incision is made parallel but at least 2.5 cm inferior to the costal margin to avoid
the 7th and 8th thoracic spinal nerves.
HIGH-RISK INCISIONS
● High-risk incisions include pararectus and inguinal incisions.
● Pararectus incisions along the lateral border of the rectus sheath are undesirable
because they may cut the nerve supply to the rectus abdominis.
● Inguinal incisions for repairing hernias may injure the ilioinguinal nerve.
ABDOMINAL GUARD
● Warm hands are important when palpating the abdominal wall because cold hands
make the anterolateral abdominal muscles tense, producing involuntary spasms of the
muscles, known as guarding.
ROUND LIGAMENT
● Uterine cancer can spread to the labia majora via round ligament.
TESTIS & SCROTUM
HYDROCOELE
● Hydrocele is an accumulation of fluid in the cavity of the tunica vaginalis of the testis
or along the spermatic cord due to an infection or injury to the testis.
HEMATOCOELE
● Hematocele is a haemorrhage into the cavity of the tunica vaginalis due to injury to the
spermatic vessels.
DETECTION
● Detection of a hydrocele requires transillumination, a procedure during which a bright
light is applied to the side of the scrotal enlargement in a darkened room.
● The transmission of light as a red glow indicates excess serous fluid in the scrotum.
● Blood does not transilluminate.
VARICOCELE
● Varicocele is an enlargement of the pampiniform venous plexus of the spermatic cord
that appears like a “bag of worms” in the scrotum.
● A varicocele may cause dragging-like pain, atrophy of the testis and/or infertility. It is
more common on the left side and can be treated surgically by removing the varicose
veins.
TESTICULAR TORSION
● Testicular torsion is twisting of the testis as the spermatic cord becomes twisted (due to
spasm of the cremaster muscle,)obstructing blood supply to the testis, and causing
sudden pain and swelling of the scrotum or nausea and vomiting.
ORCHITIS
● Orchitis is inflammation of the testis and is marked by pain, swelling, and a feeling of
heaviness in the testis.
● It may be caused by mumps, gonorrhoea, syphilis, or tuberculosis.
TESTICULAR CANCER
● Testicular cancer develops commonly from the
1. Spermatogenic cells (seminoma or germ cell tumour)
2. Leydig cells (Leydig cell tumor)
3. Sertoli cells (Sertoli cell tumor)
RISK FACTORS
● The major risk factors are
1. Cryptorchidism
2. Klinefelter’s syndrome
3. Seminiferous tubule dysgenesis
4. Gynecomastia
SIGNS & SYMPTOMS
● Signs and symptoms include a
1. Painless mass or lump
2. Testicular swelling
3. Hardness, and a feeling of heaviness or aching in the scrotum or lower abdomen.
METASTASIS
● Cancer of the scrotum metastasizes to the superficial inguinal lymph nodes.
● Metastasis of testicular cancer may also occur by the hematogenous spread of cancer
cells (via the blood) to the lungs, liver, brain, and bone.
● Cancer of the testis metastasizes to lumbar lymph nodes, mediastinal and
supraclavicular nodes.
CRYPTORCHIDISM
● Cryptorchidism is a congenital condition in which the testis fails to descend into the
scrotum during fetal development.
COMPLICATIONS
● Undescended testes are associated with
1. Reduced fertility
2. Increased risk of testicular cancer.
SPERMATOCELE
● A spermatocele is a retention cyst (collection of fluid) in the epididymis usually near
its head.
● Spermatoceles contain a milky fluid and are generally asymptomatic.
● An epididymal cyst is a collection of fluid anywhere in the epididymis.
PERITONEUM
PERITONITIS
● “Peritonitis is inflammation and infection of the peritoneum”
● It results from a
1. Burst appendix that leaks faeces into the peritoneal cavity
2. From a penetrating wound to the abdomen
3. From a perforating ulcer that leaks stomach contents into the peritoneal cavity
(lesser sac)
4. From poor sterile technique during abdominal surgery.
ASCITES
● Ascites is excess fluid in the peritoneal cavity due to spilling acid content because of
ulcer.
● It may occur due to mechanical injury, portal hypertension, cancer & starvation.
● If the abdomen is drawn in as the chest expands (paradoxical abdominothoracic
rhythm) and muscle rigidity is present, either peritonitis or pneumonitis may be present.
● People with peritonitis commonly lie with their knees flexed to relax their anterolateral
abdominal muscles. They also breathe shallowly (and hence more rapidly), reducing
the intra-abdominal pressure and pain.
ADHESIONS
● After abdominal incisions; fibrous tissue or scar may form an attachment between the
visceral peritoneum of adjacent organs or between the parietal & visceral peritoneum,
it is called Adhesions.
● Adhesiotomy refers to its surgical separation.
SPREAD OF INFECTIONS
● Infection can easily spread to the female peritoneal cavity via uterine tubes.
● It is prevented by a mucous plug that blocks external os to pathogens; but not to sperms.
LAPAROTOMY
● The peritoneum is well innervated, so laparotomy causes pain.
● During operation, efforts are made to remain outside the peritoneal cavity to avoid
peritonitis, adhesions.
● Intraperitoneal organs are easy to achieve due to serosa (covering of peritoneum) that
makes a watertight end to end anastomosis.
● However; it is more difficult to achieve water-tight anastomoses of extraperitoneal
structures that have an outer adventitial layer.
IMPORTANCE OF PERITONEUM
● The peritoneum is a semipermeable membrane with an extensive surface area, it
overlies blood and lymphatic capillary beds.
● Therefore, fluid injected into the peritoneal cavity is absorbed rapidly. So, anaesthetic
agents, (solutions of barbiturate compounds,) may be injected into the peritoneal cavity
by intraperitoneal (I.P.) injection.
● In renal failure, Peritoneal dialysis may be performed.
GREATER OMENTUM
● Greater omentum is known as policeman of the abdomen, as
1. It prevents the spread of infection by forming adhesion with an inflamed organ
such as the appendix.
2. It cushions the organs & forms insulations.
3. It prevents the visceral peritoneum to adhere to the parietal peritoneum.
4. It is mobile.
PERITONEAL RECESSES
● Peritoneal recesses determine the direction of the spread of pus.
● Paracolic gutters provide pathways for the flow of ascitic fluid, cancer & spread of
infection.
● Infection can spread to the pelvis & subphrenic recess.
PARACENTESIS
● Paracentesis (abdominal tap) is a procedure in which a needle is inserted 1 to 2 inches
through the abdominal wall into the peritoneal cavity to obtain a sample or drain fluid
while the patient’s body is elevated at a 45-degree angle.
● The puncture site is midline (linea alba) at approximately 2 cm below the umbilicus or
lateral to McBurney’s point, avoiding the inferior epigastric vessels.
PANCREATIC PSEUDOCYST
● An inflamed or injured pancreas can also result in the passage of pancreatic fluid into
omental
● bursa, forming a pancreatic pseudocyst.
STRANGULATION OF SMALL INTESTINE
● A loop of the small intestine may pass through the omental foramen into the omental
bursa and be strangulated.
IMPORTANCE OF OMENTAL FORAMEN
● If the cystic artery is severed during cholecystectomy, the hepatic artery is compressed
in the hepatoduodenal ligament by putting the index finger in the omental foramen &
thumb on its anterior wall.
STOMACH
PEPTIC ULCER
● A peptic ulcer is an erosion in the lining of the stomach or duodenum which is caused
by an infection with Helicobacter pylori but is also caused by stress, acid, and pepsin.
● It occurs more commonly in men than in women and has similar symptoms and
treatment regardless of location.
● The peptic ulcer has symptoms of
1. Epigastric pain (burning, cramping, or aching)
2. Abdominal indigestion
3. Nausea & vomiting
4. Loss of appetite, weight loss, and fatigue.
TREATMENT
● It may be treated with antibiotics or surgical intervention, including a partial
gastrectomy and vagotomy.
● Acid secretion is controlled by the vagus nerve; hence vagotomy is done to treat ulcers.
TRUNCAL VAGOTOMY
● (surgical section of the vagal trunks) is rarely performed because of denervation of other
abdominal structures.
● In selective gastric vagotomy, the stomach is denervated but the vagal branches to the
pylorus, liver and biliary ducts, intestines, and celiac plexus are preserved.
● In selective proximal vagotomy, attempts are made to denervate even more specifically
the area in which the parietal cells are present.
TYPES OF PEPTIC ULCERS
● Peptic ulcer occurs in the pyloric region of the stomach (gastric ulcer) or the first part
of the duodenum (duodenal ulcer) and less frequently in the distal oesophagus.
● Gastric ulcers may perforate into the lesser sac and erode the pancreas and the splenic
artery, causing fatal haemorrhage.
● Gastric ulcers occur typically along lesser curvature as
1. The mucosa is not freely movable
2. Epithelium is thin
3. Abundant nerve supply
4. Less blood supply
5. The gastric canal is present
6. Contraction stays longer
● Duodenal ulcers may erode the gastroduodenal artery, causing burning and cramping
epigastric pain, and are three times more common than gastric ulcers.
PARA-DUODENAL HERNIA
● If a loop of the intestine enters the paraduodenal fold and fossa ( lie to the left of the
ascending part of the duodenum fossa) it may strangulate.
● During repair of a paraduodenal hernia, the inferior mesenteric artery & vein and left
colic artery are preserved.
HIATAL HERNIA
● A Hiatal (hiatus) hernia is a protrusion of part of the stomach into the mediastinum
through the oesophagal hiatus of the diaphragm.
● In paraesophageal hiatal hernia, the cardia remains in its normal position but the
fundus of the stomach extends through the oesophagal hiatus.
● In the common sliding hiatal hernia, the abdominal part of the oesophagus, the cardia,
and parts of the fundus of the stomach slide superiorly through the oesophagal hiatus.
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS
● It is marked thickening of the smooth muscle (hypertrophy) in the pylorus.
● It resists gastric emptying. The stomach may become dilated.
GASTRIC CANCER
● When the body or pyloric part of the stomach contains a malignant tumour, the mass
may be palpable.
● The nodes along the splenic vessels can be excised by removing the spleen,
gastrosplenic, splenorenal ligaments, and the body and tail of the pancreas & greater
omentum. i.e; Cancer of the pyloric region involves removal of pyloric & right gastro-
omental lymph nodes.
● Celiac lymph nodes (to which gastric nodes drain) can also be removed.
GASTRECTOMY
TOTAL GASTRECTOMY
● Total gastrectomy (removal of the entire stomach) is uncommon.
PARTIAL GASTRECTOMY
● Partial gastrectomy (removal of part of the stomach) may be performed to remove a
region of the stomach involved by a carcinoma.
PYLOROSPASM
● Spasmodic contraction of the pylorus sometimes occurs in infants, usually between 2
and 12 weeks of age.
● Pylorospasm is characterized by failure of the smooth muscle fibres encircling the
pyloric canal to relax normally.
GASTROESOPHAGEAL REFLUX DISEASE
● Gastroesophageal reflux disease is a digestive disorder caused by a lower oesophagal
sphincter dysfunction (relaxation or weakness) and hiatal hernia, causing reflux of
stomach contents into the oesophagus.
● This disease has symptoms of
1. Heartburn or acid indigestion
2. Painful swallowing
3. Burping
4. Feeling of fullness in the chest.
SMALL INTESTINE
INFLAMMATORY BOWEL DISEASE
● Inflammatory bowel disease involves the small or large intestine or both and also
includes Crohn’s disease and ulcerative colitis.
CROHN’S DISEASE
● Crohn’s disease is an inflammatory bowel disease that occurs in the ileum (may be
called ileitis or enteritis), but it can affect any part of the digestive tract.
● Symptoms include
1. Diarrhoea
2. Rectal bleeding
3. Anaemia
4. Weight loss
5. Fever.
ULCERATIVE COLITIS
● Ulcerative colitis involves the colon and virtually always involves the rectum.
● It is characterized by a shallow inflammation of the large intestinal mucosa, mainly in
the rectum, and patients with prolonged ulcerative colitis are at increased risk for
developing colon cancer.
MECKEL’S DIVERTICULUM
● Meckel’s diverticulum is an outpouching (finger-like pouch) of the ileum which is a
persistent portion of the embryonic yolk stalk (vitelline or omphalomesenteric duct).
1. It is located 2 ft proximal to the ileocecal junction on the antimesenteric side
2. It is approximately 2 in. long, occurs in approximately 2% of the population
3. It may contain 2 types of ectopic tissues (gastric and pancreatic)
4. It presents in the first 2 decades of life and more often in the first 2 years, and
is found 2 times as frequently in boys as in girls.
5. It may be free or connected to the umbilicus via a fibrous cord or a fistula.
COMPLICATIONS
● The diverticulum is clinically important because diverticulitis, ulceration, bleeding,
perforation, and obstruction are complications requiring surgical intervention and
frequently mimicking the symptoms of acute appendicitis.
OCCLUSION OF VASA RECTA
● Occlusion of the vasa recta by emboli results in ischemia of the intestine.
● If the ischemia is severe, necrosis (tissue death) of the involved segment results and
ileus (obstruction of the intestine) of the paralytic type occurs.
● Ileus is accompanied by severe colicky pain, along with abdominal distension,
vomiting, and often fever and dehydration.
LARGE INTESTINE
DIVERTICULITIS
● “Diverticulitis is inflammation of the diverticula (out pocketing) of the intestinal wall.”
● It is commonly found in the colon, especially the sigmoid colon.
● The diverticula develop as a result of high pressure within the colon.
● Symptoms are abdominal pain in the left lower abdomen (but can be anywhere).
● Diets high in fibers reduce the chances of the diverticulum.
SIGMOID VOLVULUS
● Sigmoid volvulus is a twisting of the sigmoid colon around its mesentery (when the
sigmoid colon and its mesentery are abnormally long) creating a colonic obstruction.
● It may cause intestinal ischemia that may progress to
1. Constipation
2. Ischemia
3. Necrosis
4. Faecal impaction
5. Peritonitis
6. Abdominal distension.
MEGACOLON
● Megacolon (Hirschsprung’s disease) is caused by the absence of enteric plexus in the
lower part of the colon, which leads to the dilation of the colon proximal to the inactive
segment.
ACUTE APPENDICITIS
● Acute appendicitis is an acute inflammation of the appendix, usually resulting from
bacteria or viruses resulting from entrapment of faeces.
● It is common because
1. Lymphatic follicles are present in it
2. Appendicular artery is an end artery
3. Its lumen is small.
SYMPTOMS
1. Rebound tenderness
2. Periumbilical pain which may move to the right iliac fossa on McBurney’s point
3. Accompanied by loss of appetite, nausea, vomiting, fever, diarrhoea, and
constipation.
COMPLICATIONS
● Its rupture may cause peritonitis, leading to septicemia and eventually death, if
untreated.
TREATMENT
● Appendicitis can be treated by an appendectomy.
APPENDECTOMY
GRIDIRON INCISION
● An appendectomy may be performed through a transverse or gridiron incision
centred at the McBurney.
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● A gridiron incision is made perpendicular to the spino-umbilical line, but a transverse
incision is also used.
● The site of maximal pain and tenderness indicates the actual location.
LAPAROSCOPIC APPENDECTOMY
● Laparoscopic appendectomy has become a standard procedure for removing the
appendix.
● The peritoneal cavity is first inflated with carbon dioxide gas, distending the abdominal
wall, to provide viewing and working space.
● The laparoscope is passed through a small incision in the anterolateral abdominal wall.
● One or two other small incisions (“portals”) are required for surgical (instrument)
access to the appendix and related vessels.
COLONOSCOPY
● Colonoscopy is an internal examination of the colon, using a colonoscopy with a small
camera looking for bleeding, ulcers, diverticulitis, polyps, colon cancer, and
inflammatory bowel diseases.
● A tissue biopsy may be taken.
● The colon must be completely empty, the patient lies on his or her left side, and the
colonoscope is inserted through the anus and gently advanced to the terminal small
intestine.
ULCERATIVE COLITIS
● Ulcerative colitis (Crohn disease) is chronic ulceration & severe inflammation of the
colon and rectum with cramping abdominal pain, rectal bleeding, diarrhoea, and loose
discharge of pus and mucus with the scanty faecal part.
● Colectomy is performed, which is the removal of the terminal ileum, colon, rectum and
anal canal.
● An ileostomy is then constructed to establish a stoma, an artificial opening through
which the ileum is connected to the periphery of an opening in the anterolateral
abdominal wall.
● Following a partial colectomy, colostomy or sigmoidoscopy is performed to connect
the colon to a surgically created hole.
RECTAL EXAMINATION
● “Rectal or digital (finger) examination is performed by inserting a gloved, lubricated
finger into the rectum; using the other hand to press on the lower abdomen or pelvic
area”
● Examiner palpates the rectal lining for
1. Lumps, tumours, and enlargements
2. Tissue hardening
3. Haemorrhoids
4. Rectal carcinoma and prostate cancer
5. Seminal vesicle
6. Ampulla of the ductus deferens
7. Bladder, uterus, cervix, ovaries, anorectal abscesses, polyps
8. Chronic constipation.
RECTAL CANCER
● Rectal cancer develops in the epithelial cells lining the lumen of the rectum. Cancer can
be detected by colonoscopy.
● Rectal cancer may spread along lymphatic vessels and through the venous system.
● The superior rectal vein is a tributary of the portal vein, and thus, rectal cancer may
metastasize to the liver.
● Rectal cancer may penetrate posteriorly the rectal wall and invade the sacral plexus,
producing sciatica, and invade laterally the ureter and anteriorly the vagina, uterus,
bladder, prostate, or seminal vesicles.
ISCHIO-ANAL ABSCESSES
● “Ischio-anal abscesses ( pus) are painful.”
● Infections may reach the ischio-anal fossae in several ways:
1. After cryptitis (inflammation of anal sinuses).
2. Extension from a perirectal abscess.
3. After a tear in the anal mucous membrane.
4. From a penetrating wound in the anal region.
HAEMORRHOIDS
● Haemorrhoids are dilated internal and external venous plexuses around the rectum
and anal canal.
INTERNAL HAEMORRHOIDS EXTERNAL HAEMORRHOIDS
Dilated internal rectal venous plexus Dilated external rectal venous plexus
Situated above the pectinate line Situated below the pectinate line
Covered by mucous membrane Covered by skin
Less painful More painful
Pain sensations are carried by GVA fibers or Pain sensations are carried by GSA fibers of
the sympathetic system the somatic system
SUPERIOR MESENTERIC ARTERY OBSTRUCTION

● Superior mesenteric artery obstruction is caused by
1. Thrombus, embolus, or atherosclerosis
2. Aortic aneurysm
3. Tumour in the uncinate process of the pancreas
4. Compression by the third part of the duodenum
5. Surgical scar tissue.
● The obstruction leads to small and large intestinal ischemia, resulting in necrosis.
LIVER
LIVER CIRRHOSIS
● Liver cirrhosis is a condition in which liver cells are progressively destroyed and
replaced by fatty and fibrous tissue that surrounds the intrahepatic blood vessels and
biliary radicles, impeding the circulation of blood through the liver.
CAUSES
● It is caused by chronic alcohol abuse; hepatitis B, C, and D; and ingestion of poisons.
Alcoholic cirrhosis is characterized by a "hobnail" appearance of the liver.
SIGNS AND SYMPTOMS
1. Liver cirrhosis causes portal hypertension (due to shunting of blood from a hepatic
portal vein) resulting
2. Oesophagal varices (dilated veins in the lower part of the oesophagus)
3. Haemorrhoids (dilated veins around the anal canal)
4. Caput medusa (dilated veins around the umbilicus)
5. Spider nevi or spider angioma (small, red, spider-like arterioles in the cheeks, neck,
and shoulder)
6. Ascites (accumulation of fluid in the peritoneal cavity)
7. Edema in the leg
8. Jaundice.
9. Hepatic encephalopathy (shunted blood bypassing the liver contains toxins that reach
the brain).
10. Splenomegaly (that lead to thrombocytopenia, a low platelet count, and easy bruising)
11. Hepatomegaly (In hepatomegaly, the inferior edge of the liver is palpable.)
12. Palmar erythema (persistent redness of the palms)
13. Testicular atrophy and gynecomastia
14. Pectoral alopecia (loss of hair).
15. It also has symptoms of fatigue (tiredness), weakness, nausea, indigestion, loss of
appetite, weight loss, and fever.
TREATMENT OF PORTAL HYPERTENSION
● Portal hypertension can be treated by diverting blood from the portal to the caval system
by the
1. Portacaval shunt by creating a communication between the portal vein and the
IVC as they lie close together below the liver
2. Splenorenal (Warren) shunt accomplished by anastomosing the splenic vein
to the left renal vein
3. Transjugular intrahepatic portosystemic shunt (TIPS), in which a catheter
is placed into the right internal jugular vein through which an intrahepatic shunt
is created between a hepatic vein and a branch of the portal vein within the liver.
BUDD-CHIARI SYNDROME
● Budd–Chiari or Chiari syndrome is an occlusion of the hepatic veins and results in
high pressure in the veins, causing hepatomegaly, upper right abdominal pain, ascites,
mild jaundice, and eventually portal hypertension and liver failure.
CARCINOMA
● The liver is a common site of carcinoma from organs drained by portal veins or due to
the connection of lymph node.
● Cancer can spread to the liver from the thorax (right breast) because of the connection
of lymphatic vessels.
SUBPHRENIC ABSCESSES
● Subphrenic abscesses result from peritonitis.
● They are more common on the right side because of the frequency of ruptured
appendices and perforated duodenal ulcers.
HEPATECTOMY
● Because of their independent blood supply, hepatic lobectomies can be done without
bleeding.
● In hepatic segmentectomy; the segment infected with tumour or injury is resected.
LIVER LACERATIONS
● A fractured rib that perforates the diaphragm tears the liver.
● Because of the liver’s great vascularity, liver lacerations often cause considerable
haemorrhage and right upper quadrant pain.
RUNNER’S STITCH
● Engorgement of the liver with blood due to increased or sustained diaphragmatic
activity is called “runner’s stitch,”
LIVER BIOPSY
● Liver biopsy is performed by needle puncture, which goes through the right 8th or 9th
(perhaps 7th to 10th) intercostal space in the right midaxillary line under ultra-sound
or (CT) scan guidance.
● While taking the biopsy, the patient is asked to hold his or her breath in full expiration
to reduce the costodiaphragmatic recess and to lessen the possibility of damaging the
lung and causing pneumothorax.
● Transjugular liver biopsy is also accomplished by inserting a catheter into the right
internal jugular vein and guiding it through the superior vena cava, IVC, and right
hepatic vein.
PRINGLE’S MANOEUVRE
● Pringle’s manoeuvre is a temporary cross-clamping of the hepatoduodenal ligament
containing portal triads at the foramen of Winslow for control of hepatic bleeding
during liver surgery for living liver transplantation.
GALLBLADDER
GALL STONES
● Gallstones (choleliths or cholelithiasis) are formed by the solidification of bile
constituents and composed of cholesterol crystals, with bile pigments and calcium.
● Gallstones present commonly in fat, fertile (multiparous) females who are older than
forty (40) years (4-F individuals).
● Stones may become lodged in the
1. Fundus of the gallbladder, where they may ulcerate into the transverse colon.
2. Duodenum because of their proximity (in the former case, they are passed
naturally to the rectum, but in the latter case, they may be held up at the ileocecal
junction, producing an intestinal obstruction)
3. Bile duct, where they obstruct bile flow to the duodenum, leading to jaundice
4. Cystic duct, here they cause cholecystitis.
5. Hartman pouch; from where they can lodge to the duodenum.
6. Hepato-pancreatic ampulla (constricted part) where they block both the biliary
and the pancreatic duct systems. In this case, bile may enter the pancreatic duct
system, causing pancreatitis.
CHOLECYSTITIS
● Cholecystitis is an inflammation of the gallbladder, caused by obstruction of the cystic
duct by gallstones.
● The patient complains of pain over the right hypochondrium radiating to the inferior
angle of the right scapula or right shoulder.
MURPHY’S SIGN
● When the finger is placed below the costal margin (at the tip of the 9th cartilage), the
patient feels a sharp pain on inspiration. He winces with a catch in his breath.
CHOLECYSTECTOMY
● Cholecystectomy (surgical removal of the gallbladder) resulting from inflammation or
presence of gallstones in the gallbladder.
● The gallbladder is separated from the liver, and the cystic duct and cystic artery (in
calot triangle) are dissected and ligated.
● The right hepatic artery is in danger.
COURVOISIER’S LAW
● Dilation of the gallbladder occurs in extrinsic obstruction of the bile duct (i.e;
carcinoma of the head of the pancreas).
● Intrinsic obstruction by stones doesn’t cause any dilation because of associated
fibrosis.
PANCREAS
PANCREATITIS
● Pancreatitis is an inflammation of the pancreas and is caused by gallstones (gallstones
in hepatoduodenal ampulla divert bile duct towards pancreas) and alcohol consumption.
● Symptoms include upper abdominal pain (which may be severe and constant and reach
to the back).
PANCREATIC CANCER
● Pancreatic cancer frequently causes severe back pain, has the potential to invade into
the adjacent organs, & may be treated by a surgical resection called a
pancreaticoduodenectomy or Whipple’s procedure.
● Cancer of the pancreatic head often compresses and obstructs the bile duct, causing
obstructive jaundice.
● Cancer of the pancreatic neck and body may cause portal or IVC obstruction because
the pancreas overlies these large veins.
PANCREATECTOMY
● During pancreatectomy, the head of the pancreas is preserved to retain the blood supply
of the duodenum.
ANNULAR PANCREAS
● The annular pancreas occurs when the ventral and dorsal pancreatic buds form a ring
around the duodenum, thereby obstructing it.
SPLEEN
SPLENOMEGALY
● Splenomegaly is caused by venous congestion resulting from
1. Thrombosis of the splenic vein
2. Portal hypertension
3. Splenomegaly may result from granulocytic leukaemia, & hemolytic or
granulocytic anaemia.
● It causes thrombocytopenia (a low platelet count) and easy bruising.
● It has symptoms of, bone pain, weight loss, and night sweats.
SPLENIC RUPTURE
● Rupture of the spleen (most vulnerable organ) occurs frequently by fractured ribs (10-
12) or severe blows to the left hypochondrium and causes profuse bleeding.
● The ruptured spleen is difficult to repair; consequently, splenectomy is performed to
prevent the person from bleeding to death (profuse bleeding).
● The spleen may be removed surgically with minimal effect on body function because
its functions are assumed by other reticuloendothelial organs.
SPLEEN NEEDLE BIOPSY
● During a spleen needle biopsy, costodiaphragmatic recess is kept in mind (which
extends to the 10th rib).
KEHR’S SIGN
● Smaller branches of the splenic artery are end arteries.
● Their obstruction causes splenic infarction which causes referred pain in the left
shoulder.
KIDNEY
CONGENITAL ABNORMALITIES
ECTOPIC KIDNEY
● The pelvic kidney is an ectopic kidney that occurs when kidneys fail to ascend and thus
remain in the pelvis.
ROSETTE KIDNEY
● Two pelvic kidneys may fuse to form a solid lobed organ because of fusion of the renal
Anlagen, called a cake (rosette) kidney.
HORSESHOE KIDNEY
Horseshoe kidney develops as a result of the fusion of the lower poles of two kidneys and
may
● obstruct the urinary tract by its impingement on the ureters.
NUTCRACKER SYNDROME
● The left renal vein traverses between the SMA anteriorly and the abdominal aorta
posteriorly.
● Downward traction on the SMA may compress the left renal vein (may compress 3rd
part of duodenum) resulting in a renal vein entrapment syndrome also known as
“nutcracker syndrome” based on the appearance of the vein in the acute arterial angle
in a sagittal view.
● The syndrome may include
1. Hematuria or proteinuria
2. Abdominal (left flank) pain
3. Vomiting (due to compression of the duodenum)
4. Left testicular pain in men.
PERINEPHRIC ABSCESS
● Fascia at the renal hilum attaches to the renal vessels and ureter, preventing the spread
of pus to the contralateral side.
● However, pus from an abscess (or blood from an injured kidney) may force its way into
the pelvis between the loosely attached anterior and posterior layers of the renal
fascia.
KIDNEY TRANSPLANT
● The kidney is removed from the donor without damaging the adrenal gland.
● The site for transplanting a kidney is in the iliac fossa of the greater pelvis (as major
blood vessels & bladder are close and there is no inferior support in the lumbar region).
● This site supports the transplanted kidney so that traction is not placed on the surgically
anastomosed vessels.
● The renal artery and vein are joined to the external iliac artery and vein.
● The close relationship of the kidneys to the psoas major muscles explains why the
extension of the hip joints may increase pain resulting from inflammation in the
pararenal areas.
NEPHROPTOSIS
● Nephroptosis is downward displacement of the kidney, dropped kidney, or floating
kidney caused by loss of supporting fat.
● The kidney moves freely in the abdomen and even into the pelvis.
● It may cause a kink in the ureter or compression of the ureter by an aberrant inferior
polar artery, resulting in hydronephrosis.
POLYCYSTIC KIDNEY DISEASE
● Polycystic kidney disease is a genetic disorder characterized by numerous cysts filled
with fluid in the kidney.
● The cysts can slowly replace much of normal kidney tissues, reducing kidney function
and leading to kidney failure.
KIDNEY STONES
● Kidney stone (renal calculus or nephrolith) is formed by the combination of a high
level of calcium with oxalate, phosphate, urea, uric acid, and cystine.
● Crystals are collected in the calyces of the kidney or in the ureter.
OBSTRUCTION
● Obstruction of the ureter caused by renal calculi occurs at its three constrictions.
REFERRED PAIN
● The pain passes inferio-anteriorly “from the loin to the groin” as the stone progresses
through the ureter. (The loin is the lumbar region, and the groin is the inguinal region.)
● The pain may extend into the proximal anterior aspect of the thigh by projection
through the genitofemoral nerve (L1, L2), the scrotum in males and the labia majora in
females.
TREATMENT
● Ureteric calculi can be observed and removed with a nephroscope, an instrument that
is inserted through a small incision.
● Lithotripsy focuses a shockwave through the body that breaks the calculus into small
fragments that pass with the urine.
HYDRONEPHROSIS
● Hydronephrosis is a fluid-filled enlargement of the renal pelvis and calyces as a result
of obstruction of the ureter.
● It is due to an obstruction of urine flow by kidney stones in the ureter, by compression
on the ureter by abnormal blood vessels, or by the developing fetus at the pelvic brim.
● It has symptoms of nausea and vomiting, urinary tract infection, fever, dysuria (painful
or dif cult urination), urinary frequency, and urinary urgency.
RENAL ANGLE
● The renal angle is the angle between the lower border of the 12th rib & the outer angle
of the erector spinae (which overlies the lower part of the kidney).
● Tenderness in the kidney is elicited by applying pressure by the thumb over it.
POSTERIOR MEDIASTINAL WALL
PSOAS ABSCESS
● An abscess resulting from tuberculosis in the lumbar region tends to spread from the
vertebrae into the psoas fascia (even from mediastinum), where it produces a psoas
abscess.
● As a consequence, the psoas fascia thickens to form a strong stocking-like tube.
● Pus from the psoas abscess passes inferiorly along with the psoas muscle within this
fascial tube over the pelvic brim and deep to the inguinal ligament.
● The pus usually surfaces in the superior part of the thigh.
POSITIVE PSOAS SIGN
● The person is asked to lie on the unaffected side and extend the thigh on the affected
side against the resistance of the examiner’s hand.
● The elicitation of pain with this manoeuvre is a positive psoas sign.
● It indicates disease of the kidney, ureter, cecum, appendix, sigmoid colon & pancreas
(these structures are related to iliopsoas).
● An acutely inflamed appendix will produce a positive right psoas sign.
COLLATERAL ROUTES IN IVC OBSTRUCTION
● Three collateral routes are available for venous blood return to the heart when the IVC
is obstructed or ligated.
a. First involves the superior and inferior epigastric veins
b. Another involves the thoracic-epigastric vein
c. The third collateral route involves the epidural venous plexus inside the
vertebral column.
PELVIC GIRDLE
TYPES OF PELVIS
GYNAECOID PELVIS (normal female type)
Its pelvic inlet has a rounded oval shape and a wide transverse diameter.
ANDROID PELVIS
An android (masculine or funnel-shaped) pelvis in a woman may present hazards to the
successful vaginal delivery of a fetus.
ANTHROPOID PELVIS
The pelvis in which anteroposterior diameter is greater than transverse diameter is called the
Anthropoid pelvis.
PLATTYPLOID PELVIS
Pelvis in which anteroposterior diameter is less than transverse diameter is called plattyploid.
SIZE OF LESSER PELVIS
● The size of the lesser pelvis is important in obstetrics because it is the bony canal
through which the fetus passes during normal childbirth.
● Anteroposterior (AP) diameter of the lesser pelvis, true (obstetrical) conjugate from
the middle of the sacral promontory to the posterosuperior margin (closest point) of the
pubic symphysis is the narrowest fixed distance (less than 11cm) through which the
baby’s head must pass in a vaginal delivery. It cannot be measured directly.
● Diagonal conjugate (11cm) is measured by palpating the sacral promontory with the
tip of the middle finger, using the other hand to mark the level of the inferior margin of
the pubic symphysis on the examining hand.
● Ischial spines extend toward each other, and the interspinous distance between them is
normally the narrowest part of the pelvic canal (the passageway through the pelvic
inlet, lesser pelvis, and pelvic outlet) through which a baby’s head must pass at birth.
WEAK AREAS OF PELVIS
● Weak areas of the pelvis, where fractures often occur, are the pubic rami, the
acetabula, the region of the sacroiliac joints, and the alae of the ilium.
● Fractures in the pubo-obturator area are relatively common and are often complicated
because of their relationship to the urinary bladder and urethra, which may be ruptured.
RELAXATION OF LIGAMENTS
● Increased levels of sex hormones and the presence of the hormone relaxin cause the
pelvic ligaments to relax during the latter half of pregnancy, allowing increased
movement at the pelvic joints.
● Relaxation of the sacroiliac joints and pubic symphysis permits as much as a 10–15%
increase in diameters (mostly transverse & interspinous diameter) true obstetrical
diameter remains unaffected.
PELVIC CAVITY
INJURY TO NERVES DURING DELIVERY
● During childbirth, the fetal head may compress the nerves of the mother’s sacral plexus,
producing pain in the lower limbs.
● The obturator nerve is vulnerable to injury.
BLADDER CANCER
● Bladder cancer usually originates in cells lining the inside of the bladder (epithelial
cells).
● The most common symptom is blood in the urine (hematuria) & pain upon urination
(dysuria).
TENESMUS
● Tenesmus is a constant feeling of the desire to empty the bladder or bowel,
accompanied by pain, cramping, and straining due to a spasm of the urogenital
diaphragm.
INTERSTITIAL CYSTITIS
● Interstitial cystitis is a chronic inflammatory condition of the bladder that causes
frequent, urgent, and painful urination.
URETER RETRACTION DURING SURGERY
● Blood supply to the abdominal segment of the ureter approaches from a medial
direction, that of the pelvic segment approaches from a lateral direction, the ureters
should be retracted accordingly.
CYSTOCELE
● Loss of bladder support in females by damage to the pelvic floor during childbirth can
result in the collapse of the bladder onto the anterior vaginal wall.
● When intraabdominal pressure increases, the anterior wall of the vagina may protrude
through the vaginal orifice into the vestibule.
URINARY CALCULI
● Urinary calculi, foreign bodies, and small tumours may also be removed from the
bladder through a suprapubic extraperitoneal incision (part of bladder superior to
pubis).
CLINICAL SIGNIFICANCE OF FEMALE URETHRA
● The female urethra is distensible because it contains elastic tissue, as well as smooth
muscle.
● It can be easily dilated without injury; consequently, the passage of catheters or
cystoscopes is easier in females than in males.
● Infections of the urethra, and especially the bladder, are more common in women
because the female urethra is short, more distensible, and is open to the exterior through
the vestibule of the vagina.
PERINEUM
COLLECTION OF EXTRAVASATED URINE IN PERINEUM
● Extravasated urine may result from rupture of the bulbous portion of the spongy urethra
below the urogenital diaphragm
● The urine may pass into the superficial perineal space and spread inferiorly into the
scrotum, anteriorly around the penis, and superiorly into the lower part of the
abdominal wall.
● The urine cannot spread laterally into the thigh because the perineal membrane and
the superficial fascia of the perineum are firmly attached to the ischiopubic rami and
are connected with the deep fascia of the thigh.
● It cannot spread posteriorly into the anal region (ischiorectal fossa) because the
perineal membrane and Colles’s fascia are continuous with each other around the
superficial transverse perineal muscles.
● If the membranous part of the urethra is ruptured, urine escapes into the deep perineal
space and can extravasate upward around the prostate and bladder or downward into
the superficial perineal space.
PERINEAL MUSCLES SUSCEPTIBLE TO INJURY
● The perineum, levator ani, and ligaments of the pelvic fascia may be injured during
childbirth.
● The pubococcygeus and puborectalis, are the muscles torn most often. These muscles
encircle and support the urethra, vagina, and anal canal.
● Weakening of the levator ani and pelvic fascia (e.g., tearing of the parapodium) from
stretching or tearing during childbirth, may decrease support for the vagina, bladder,
uterus, or rectum, or alter the position of the neck of the bladder and the urethra.
● These changes may cause urinary stress incontinence, characterized by dribbling of
urine when intra-abdominal pressure is raised.
PRENATAL TRAINING
● Prenatal training (Lamaze class) aims at training women to learn how to relax
voluntarily the muscles of the pelvic floor while simultaneously increasing intra-
abdominal pressure through contraction of the diaphragm and abdominal muscles.
● The aim of this method is to facilitate the passage of the fetus through the birth canal,
actively pushing (“bearing down”) to aid the uterine contractions.
HYSTERECTOMY
● During a hysterectomy, when the uterine artery is ligated; the ureter is in danger of
being transected as the ureter passes immediately inferior to the uterine artery.
CULDOCENTESIS
● Culdocentesis is the aspiration of fluid from the cul-de-sac of Douglas (rectouterine
pouch) by a needle puncture of the posterior vaginal fornix near the midline between
the uterosacral ligaments.
● It is because the rectouterine pouch is the lowest portion of the peritoneal cavity, it can
collect fluid.
MALE REPRODUCTIVE SYSTEM
CONGENITAL ANOMALIES
EPISPADIAS
Epispadias is a congenital malformation in which the spongy urethra opens as a groove on the
dorsum of the penis, frequently associated with bladder exstrophy.
HYPOSPADIAS
SEMINAL ABSCESS
Abscess in seminal glands may rupture allowing the pus to enter the peritoneal cavity.
Hypospadias is a congenital malformation in which the urethra opens on the underside of the
penis because of a failure of the two urethral folds to fuse completely.
It is frequently associated with chordee, which is a ventral curvature of the penis.
CIRCUMCISION
1. Circumcision is the removal of the foreskin (prepuce) that covers the glans of the penis.
2. It is performed as a therapeutic medical procedure for pathologic phimosis, chronic
inflammations of the penis, and penile cancer.
3. It is also performed for cultural, religious, and medical reasons.
PHIMOSIS
● Phimosis is a condition in which the foreskin (prepuce) cannot be fully retracted to
reveal the glans due to a narrow opening of the prepuce.
● A very tight foreskin may interfere with urination or sexual function.
PARAPHIMOSIS
● Paraphimosis is a painful constriction of the glans penis caused by a tight band of
constricted and retracted phimotic foreskin behind the corona.
VASECTOMY
● Vasectomy is surgical excision of a portion of the ductus deferens through the
scrotum.
● It stops the passage of spermatozoa(hence no fertilization) but neither reduces the
amount of ejaculate greatly nor diminishes sexual desire.
CONSTITUENTS OF SEMINAL FLUID
● Seminal vesicles produce the alkaline constituent of the seminal fluid, which contains
fructose and choline.
● Fructose provides a forensic determination for the occurrence of rape.
● While choline crystals provide the basis for the determination of the presence of semen
(Florence’s test).
BENIGN PROSTATIC HYPERTROPHY
● Hypertrophy of the prostate is a benign enlargement of the prostate that affects older
men and occurs most often in the middle lobe, obstructing the internal urethral orifice.”
● This leads to
1. Nocturia (excessive urination at night),
2. Dysuria and urgency (sudden desire to urinate)
TURP
● Transurethral resection of the prostate (TURP) is the surgical removal of the prostate
by means of a cystoscope passed through the urethra.
PROSTATITIS
● Prostatitis is inflammation of the prostate.
PROSTATE CANCER
● Prostate cancer is slow-growing cancer that occurs particularly in the posterior lobe.
METASTASIS
● Prostate cancer spreads to the bony pelvis, pelvic lymph nodes, vertebral column, and
skull via the vertebral venous plexus, producing pain in the pelvis, the lower back, and
the bones.
● This cancer also metastasizes to the heart and lungs through the prostatic venous
plexus, internal iliac veins, and into the inferior vena cava.
DIAGNOSIS
● It can be detected by digital rectal examination
● Ultrasound imaging with a device inserted into the rectum
● PSA test.
PROSTATECTOMY
● Prostatectomy is the surgical removal of a part or all of the prostate gland.
● Perineal prostatectomy is the removal of the prostate through an incision in the
perineum.
● Radical prostatectomy is the removal of the prostate with seminal vesicles, ductus
deferens, some pelvic fasciae, and pelvic lymph nodes through the retropubic or the
perineal route.
● Transurethral prostatectomy is a resection of the prostate by means of a cystoscope
passed through the urethra.
ERECTILE DYSFUNCTION
● Erectile dysfunction (ED) may occur in the absence of a nerve insult due to Central
nervous system (hypothalamic) and endocrine (pituitary or testicular) disorders.
● To achieve an erection, a surgically implanted, semirigid penile prosthesis may assume
the role of the erectile bodies.
FEMALE REPRODUCTIVE SYSTEM
PUDENDAL NERVE BLOCK
● The pudendal nerve block is performed by injecting a local anaesthetic near the
pudendal nerve.
● It is accomplished by inserting a needle through the posterolateral vaginal wall,
beneath the pelvic diaphragm and toward the ischial spine.
EPISIOTOMY
● Mediolateral episiotomy is a surgical incision through the posterolateral vaginal wall,
just lateral to the perineal body, to enlarge the birth canal.
● The mediolateral episiotomy allows greater expansion of the birth canal into the
ischiorectal fossa.
● However, the incision is more difficult to close layer by layer, and there is an increased
risk of infection because of contamination of the ischiorectal fossa.
● In a median episiotomy, the incision is carried posteriorly in the midline through the
posterior vaginal wall and the central tendon (perineal body).
● The median episiotomy is relatively bloodless and painless, but this incision provides
a limited expansion of the birth canal with a slight possibility of tearing the anal
sphincters.
REGIONAL ANAESTHESIA FOR CHILDBIRTH
● Women choose regional anaesthesia (to reduce pain during childbirth) such as a spinal
( L3-L4), pudendal nerve( S2-S4), or caudal epidural block in the sacral canal (S2-S4).
OVARIAN CANCER
● Ovarian cancer develops from germ cells, stromal cells, and epithelial cells that cover
the outer surface of the ovary.
● Its symptoms include a feeling of pressure in the pelvis or changes in bowel or bladder
habits.
● Some germ cell cancers release certain protein markers, such as human chorionic
gonadotropin and alpha-fetoprotein, into the blood.
UTERINE PROLAPSE
● Uterine prolapse is the protrusion of the cervix of the uterus into the lower part of the
vagina and causes a bearing-down sensation in the womb and an increased frequency
of burning sensation on urination.
● The prolapse occurs as a result of advancing age and menopause and results from
weakness of the muscles, ligaments, and fasciae of the pelvic floor.
● Treatment includes kegel exercise.
BENIGN NEOPLASM OF FEMALE GENITAL TRACT
● Fibromyoma or leiomyoma is the most common benign neoplasm of the female genital
tract derived from smooth muscle.
● It may cause urinary frequency, dysmenorrhoea, abortion, or obstructed labour.
● A fibroid is a benign uterine tumour made of smooth muscle cells and fibrous
connective tissue in the wall of the uterus.
ENDOMETRIOSIS
● Endometriosis is a benign disorder in which a mass of endometrial tissue (stroma and
glands) occurs aberrantly in various locations, including the uterine wall, ovaries, or
other extra endometrial sites.
ENDOMETRIAL CANCER
● Endometrial cancer is the most common type (approximately 90%) of uterine cancer
and develops from the endometrium of the uterus usually from the uterine glands.
● Its symptoms include,
a. Vaginal bleeding, which allows for early detection (diagnostic)
b. Clear vaginal discharge
c. Lower abdominal pain
d. Pelvic cramping.
RISK FACTORS
● Risk factors include obesity, nulliparity, infertility, early menarche & late menopause.
CERVICAL CANCER
● Cervical cancer is slow-growing cancer that develops from the epithelium covering the
cervix.
RISK FACTORS
● The major risk factor for the development of cervical cancer is human papillomavirus
infection.
DIRECTION OF METASTASIS
● Cancer cells grow upward to the endometrial cavity, downward to the vagina, and
laterally to the pelvic wall, invading the bladder and rectum directly.
● This cancer metastasizes to extrapelvic lymph nodes, liver, lung, and bone and can be
treated by surgical removal of the cervix or by hysterectomy.
EARLY DETECTION
● A Papanicolaou (Pap) smear or cervical smear test is effective in detecting cervical
cancer early.
HYSTERECTOMY
● Hysterectomy is the surgical removal of the uterus, performed either through the
abdominal wall or through the vagina.
● It may result in injury to the ureter, which lies in the transverse cardinal ligament
beneath the uterine artery.
VAGINAL EXAMINATION
● Vaginal examination is an examination of pelvic structures through the vagina:
SPECULAR EXAMINATION
● Inspection with a speculum allows observation of the
a. Vaginal walls
b. The posterior fornix as the site of culdocentesis
c. The uterine cervix
d. The cervical os
DIGITAL EXAMINATION
● The digital examination allows palpation of the
a. Urethra and bladder through the anterior fornix of the vagina
b. The perineal body, rectum, coccyx, and sacrum through the posterior fornix
c. The ovaries, uterine tubes, ureters, and ischial spines through the lateral fornices
BIMANUAL EXAMINATION
● The bimanual examination is performed by placing the fingers of one hand in the vagina
and exerting pressure on the lower abdomen with the other hand to determine the size,
shape, and position of the uterus, to palpate the ovaries and uterine tubes, and to detect
pelvic inflammation or neoplasms.
VAGINISMUS
● Vaginismus is a painful spasm of the vagina resulting from involuntary contraction of
the vaginal musculature, preventing sexual intercourse.
VAGINAL LAXITY
● The vagina can be markedly distended, particularly in the region of the posterior part
of the fornix.
● The distension accommodates the erect penis & fetus during parturition.
HEAD AND NECK
SKULL
HEADACHE
● Headache is associated with
1. Tension
2. Fatigue or fever
3. May indicate a brain tumour
4. Subarachnoid haemorrhage
5. Meningitis.
FRACTURE OF PTERION
● Fracture at the pterion rupture the middle meningeal artery, and cause clot formation
& epidural hematoma.
● Clot compresses the motor area of the brain leading to paralysis of the opposite side.
FRACTURE OF PETROUS TEMPORAL BONE
● A fracture of the petrous portion of the temporal bone may cause
a. Blood or cerebrospinal fluid (CSF) to escape from the ear
b. Hearing loss
c. Facial nerve damage.
MALAR FLUSH
● Malar (zygomatic) flush is redness of the skin over the zygomatic process &
associated with
a. Fever
b. Tuberculosis.
COMMON FRACTURED BONES
● Most commonly fractured bones are
a. Nasal
b. Mandible
c. Parietal eminence
LE FORT CLASSIFICATION OF MAXILLAE
● Le Fort classified 3 fractures of maxillae.
a. Horizontal fracture of maxillae (alveolar process) with nasal septum.
b. Oblique fracture as it passes from maxillary sinus thru infraorbital foramen,
lacrimal to the bridge of the nose.
c. A horizontal fracture that passes thru superior orbital fissure, ethmoid & nasal
bone and extends thru sphenoid & frontozygomatic suture
FRACTURE OF MANDIBLE
● The mandible is fractured at
a. Canine socket i.e; most commonly fractured
b. Neck; this fracture results in dislocation of the TM joint.
c. Angle; it may involve 3rd molar teeth
CRANIAL FOSSAE
FRACTURE OF ANTERIOR CRANIAL FOSSA
● Fracture of the anterior cranial fossa causes
1. Anosmia
2. Epistaxis
3. Black eye
4. Exophthalmos
5. CSF leakage from the nose (rhinorrhea).
FRACTURE OF MIDDLE CRANIAL FOSSA
● Fracture of middle cranial fossa produces
a. Blood & CSF discharge thru ear.
b. Bleeding thru the nose.
c. Damage to 7th & 8th cranial nerves.
FRACTURE OF POSTERIOR CRANIAL FOSSA
● Fracture of posterior cranial fossa causes bruising over the mastoid region extending
over sternocleidomastoid.
FRACTURE OF CALVARIA
● Depressed fracture in which bone is depressed inward.
● The linear fracture occurs at the point of effect & radiates away from it in two or
more direction.
● Comminuted fracture; bone is broken into several pieces.
● Counterblow fracture occurs at the opposite side of the cranium to the point of
impact
CAPUT SUCCEDANEUM
● Caput succedaneum is soft tissue swelling on the skull due to rupture of capillaries
during delivery.
CLINICAL SIGNIFICANCE OF FONTANELLES
● Palpation of the fontanelles enables the physician to determine
a. Growth in the surrounding bones
b. The degree of hydration of the baby (e.g., if the fontanelles are depressed
below the surface, the baby is dehydrated)
c. The state of the intracranial pressure (a bulging fontanelle indicates raised
intracranial pressure)
d. Determine the age in 1-2 years of a child.
HEAD TRAUMA
● A blow to the top of the head may fracture the skull base with related cranial nerve
(CN) injury, CSF leakage.
TRIPOD FRACTURE
● Tripod fracture is a facial fracture involving the three supports of the malar (cheek or
zygomatic) bone including the zygomatic processes of the temporal, frontal, and
maxillary bones.
POND FRACTURE
● In the young child, the skull may be likened to a table tennis ball in that a localized
blow produces a depression without splintering.
● This common type of circumscribed lesion is referred to as a “pond” fracture.
FACE & SCALP
TRIGEMINAL NEURALGIA
● Trigeminal neuralgia (tic douloureux) is marked by paroxysmal pain (sudden sharp
pain) along the course of the trigeminal nerve, especially radiating to the maxillary or
mandibular area.
● Paroxysm is set off by touching face, shaving, drinking or chewing.
CAUSES
● The common causes of this disorder are
a. Aberrant blood vessels
b. Aneurysms
c. Chronic meningeal inflammation
d. Brain tumours
e. Multiple sclerosis.
PAIN MANAGEMENT
● Pain is relieved
a. By injecting 90% alcohol, or
b. By sectioning the affected nerve (rhizotomy)
TRIGEMINAL NERVE LESION
● Trigeminal nerve lesion causes anaesthesia along
a. Corresponding anterior half of scalp
b. Face except cornea, conjunctiva & angle of the mandible.
c. The mucous membrane of the nose & mouth
HERPES ZOSTER INFECTION
● Herpes Zoster Infection is followed by the eruption of groups of vesicles following
the course of the affected nerve.
CAUSES OF HEADACHES
● The sensory distribution of the trigeminal nerve explains why headache is a uniformly
common symptom in involvements of the
a. Nose (common cold, boils)
b. The paranasal air sinuses (sinusitis)
c. Infections and inflammations of teeth and gums
d. Refractive errors of the eyes
e. Glaucoma and meningitis.
FACE BRUISING
● The face has no deep fascia but its subcutaneous tissue is loose hence fluid & blood
can accumulate in it following bruising.
● Facial inflammation causes swelling i.e; bee sting.
FACIAL NERVE INJURY
● Damage to facial nerve proximal to the origin of greater petrosal nerve result in loss
of motor, taste & autonomic function.
● Facial nerve paralysis can be a complication of parotidectomy, & may be associated
with dental manipulation, vaccination, pregnancy, HIV, Lyme disease & middle ear
infection.
PULSE
● Superficial temporal and facial arteries may be used for taking the pulse.
SCALP LACERATION
● Scalp laceration bleeds profusely & require surgical care because arteries bleed from
both ends owing to the rich anastomosis.
SQUAMOUS CELL CARCINOMA OF LIPS
● Squamous cell carcinoma of the lip occurs due to exposure to sunshine and smoking.
LESIONS OF FACIAL NERVE
INFRANUCLEAR LESIONS
● In infranuclear lesions of the facial nerve, known as Bell's palsy.
a. The whole of the face of the same side gets paralysed.
b. The face becomes asymmetrical and is drawn up to the normal side.
c. The affected side is motionless.
d. No wrinkles, smiling draws mouth to the normal side, eyes cannot be closed,
& food accumulates between teeth & cheek during mastication.
SUPRANUCLEAR LESIONS
● In supranuclear lesions of the facial nerve; usually, a part of hemiplegia.
a. Only the lower part of the opposite side of the face is paralysed.
b. The upper part with the frontalis and orbicularis oculi escapes due to its
bilateral representation in the cerebral cortex
FACIAL NERVE TESTING
● The facial nerve is testing by
1. Wrinkles (frontalis)
2. Showing the teeth
3. Closing the eyes
4. Blowing (buccinator)
DANGER AREA OF THE FACE
● The danger area of the face is the triangular area from the upper lip to the bridge of
the nose drained by the facial veins.
● Pustules (pimples) or boils or other skin infections, particularly on the side of the nose
and upper lip, may spread to the cavernous venous sinus via a superior ophthalmic
vein and pterygoid venous plexus via a deep facial vein and inferior ophthalmic veins.
INFRAORBITAL NERVE BLOCK
● For treating wounds of the upper lip & cheek, the infraorbital nerve is blocked by
injection in the infraorbital foramen, by elevating the upper lip & passing needle
thru the junction of oral mucosa and gingiva.
● Injection of the anaesthetic agent into the mental foramen blocks the mental nerve that
supplies the area of the lower lip.
FLARING OF NOSTRILS
● Flaring of nostrils is of diagnostic value
a. True nasal breathers can flare nostrils distinctly.
b. Habitual mouth breathing diminishes this ability.
SEBACEOUS CYSTS
● Because of the abundance of sebaceous glands, the scalp is a common site for
sebaceous cysts.
SCALP WOUNDS
● Scalp haemorrhage results from laceration of arteries in the dense connective tissue
layer that is unable to contract or retract and thus remain open, leading to profuse
bleeding.
● Deep scalp wounds gape widely when the epicranial aponeurosis is lacerated in the
coronal plane because of the pull of the frontal and occipital bellies of the epicranius
muscle in opposite directions.
DANGEROUS AREA OF THE SCALP
● The fourth layer of SCALP (loose connective tissue) is known as the dangerous area
of the scalp because the emissary veins, which open here may transmit infection from
the scalp to the cranial venous sinuses.
● Infection or fluid can enter eyelids(black eye) & the root of the nose because
occipitofrontalis inserts into the skin & subcutaneous tissue and has no bony
attachment.
CEPHALOHEMATOMA
● Cephalhematoma is blood accumulation between pericranium & calvaria after a
difficult birth.
TEMPORAL, INFRATEMPORAL FOSSA, TMJ & PAROTID GLAND
FREY’S SYNDROME
● Frey’s syndrome produces flushing and sweating instead of salivation in response to
the taste of food after injury of the auriculotemporal nerve, which carries
parasympathetic secretomotor fibres to the parotid gland and sympathetic fibres to the
sweat glands.
● When the nerve is severed, the fibres can regenerate along each other’s pathways and
innervate the wrong gland.
● It can occur after parotid surgery
● It can be treated by cutting the tympanic plexus in the middle ear.
PAROTID COMPLICATIONS
PAROTID SWELLINGS
● Parotid swellings are very painful due to the unyielding nature of the parotid fascia.
PAROTID ABSCESS
● A parotid abscess(pus) may be caused by
a. Spread of infection from the mouth cavity i.e; poor dental hygiene.
b. Suppuration of the parotid lymph nodes.
PAROTIDECTOMY
● “Parotidectomy (surgical removal of parotid).”
● The facial nerve is preserved by removing the gland in two parts, superficial and deep
separately.
● The plane of cleavage is defined by tracing the nerve from behind forwards.
REFERRED PAIN OF PAROTID DISEASE
● Parotid gland disease cause pain in the
a. Auricle
b. External acoustic meatus of the external ear
c. Temporal region & TMJ because of the same sensory nerve supply by
auriculotemporal & great auricular nerves.
SIALOLITH
● The parotid duct may be blocked by calcified deposit (calculus, sialolith) & pain is
made worse by eating or sucking.
SIALOGRAPHY
● Sialography (salt writing) is done by injecting radiopaque fluid into the duct system
of the parotid gland thru a cannula inserted thru the orifice of the parotid gland in the
mucous membrane of the cheek & followed by radiography.
● It demonstrates parts of the duct system that are displaced or dilated by disease.
MUMPS
● Mumps (epidemic parotitis) is an acute infectious and contagious disease caused by a
viral infection.
● It irritates the auriculotemporal nerve, causing severe pain because of in animation
and swelling of the parotid gland and stretching of its capsule, and may result in
sterility.
MANDIBULAR NERVE BLOCK
● The mandibular nerve is blocked by injecting an anaesthetic agent where the nerve
enters the infratemporal fossa.
● This anaesthetizes auriculotemporal, inferior alveolar, lingual & buccal branches.
DISLOCATION OF TMJ JOINT
ANTERIOR DISLOCATION
● Dislocation of the temporomandibular joint occurs anteriorly as the mandible head
glides across the articular tubercle during yawning, laughing or taking a large bite.
● Mandible remains depressed & the person is unable to close his mouth.
● Reduction is done by depressing the jaw with the thumb placed on the last molar teeth
& at the same time elevating the chin.
POSTERIOR DISLOCATION
● Posterior dislocation is uncommon being resisted by postglenoid tubercle & strong
lateral ligament.
TMJ SURGERY
● During TMJ surgery, facial & auriculotemporal nerves should be preserved.
● Injury to the auriculotemporal nerve leads to laxity & instability of the joint.
TMJ CLICKING
● TMJ may become inflamed from arthritis & this results in dental occlusion and joint
clicking (crepitus).
● Clicking results from delayed anterior disc movement during mandibular depression
& elevation.
MENINGES
HEADACHES
PAIN SENSITIVE STRUCTURES
● Pain sensitive intracranial structures are
a. The large venous sinuses
b. Dural arteries (dura is pain sensitive layer)
c. The dural floor of the anterior and posterior cranial fossae
d. Arteries at the base of the brain
CAUSES OF HEADACHES
1. Dilatation of intracranial & extracranial arteries
2. Traction or distension of intracranial pain-sensitive structures
3. Infection and inflammation of intracranial and extracranial structures supplied by
sensory cranial nerves and by cervical nerves.
CEREBRAL HEMORRHAGE
● Cerebral haemorrhage is caused by rupture of the thin-walled lenticulostriate artery, a
branch of the middle cerebral artery, producing hemiplegia (paralysis of one side of
the body).
SUBARACHNOID HEMORRHAGE
● Subarachnoid haemorrhage is due to the rupture of cerebral arteries and veins that
cross the subarachnoid space.
● It may be caused by the rupture of an aneurysm on the circle of Willis.
EXTRADURAL HEMORRHAGE SUBDURAL HEMORRHAGE

(Epidural) (Dural)
It is arterial, occurs due to injury to the middle It is venous in nature

meningeal artery
No blood in the CSF Blood in the CSF is a common feature
Its symptoms occur late Its symptoms occur early
It compresses the brain to a little extent It compresses the brain to a greater extent
Paralysis is not haphazard Paralysis is haphazard
Lucid interval is present i.e temporary phase Lucid interval is absent

of consciousness between the earlier
unconsciousness and the later drowsiness &
coma.
TENTORIAL HERNIATION
● Lesions (Tumors) in the supratentorial compartment may cause part of the temporal
lobe to herniate through the tentorial notch.
● The temporal lobe may be lacerated by tough tentorium cerebelli and the oculomotor
nerve may be damaged (causing paralysis of extrinsic eye muscles).
THROMBOSIS
● Occlusion of cerebral veins & dural venous sinuses mar result from thrombi,
thrombophlebitis (venous inflammation) or tumours.
● Most frequently thrombosed venous sinuses are
a. Transverse sinus
b. Cavernous sinus
c. Superior sagittal sinus
CAVERNOUS SINUS THROMBOSIS
● Cavernous sinus thrombosis result from
a. Infections in orbit, nasal sinus & dangerous area of the face.
b. Infection can spread from one side to the side through the inter-cavernous
sinus.
● It may affect the abducent nerve. It causes a
a. Headache
b. Vision loss
c. Diplopia
d. Exophthalmos
e. Papilledema
f. Ptosis
g. Meningitis.
BASILAR AND OCCIPITL SINUSES
● Basilar and occipital sinuses communicate through the foramen magnum with the
internal vertebral venous plexus.
● Compression of thorax, abdomen & pelvis during coughing or straining may force
venous blood from these regions into the vertebral venous system & dural venous
sinuses.
● Hence, pus and tumour in these regions may spread to vertebrae & brain.
PULSATING EXOPHTHALMOS
● Communication between the cavernous sinus and the internal carotid artery may be
produced by cranial base fracture.
● When this happens the eyeball protrudes(exophthalmos) and pulsates with each
heartbeat. It is called the pulsating exophthalmos.
● The conjunctiva becomes engorged (chemosis).
● The 3rd 4th 5th & 6th cranial nerve may also be affected.
LEPTOMENINGITIS
● Leptomeningitis is inflammation of leptomeninges (arachnoid & pia) resulting from
pathogens.
● Infection is confined to subarachnoid space & arachnoid-pia.
● Bacteria can enter subarachnoid space through septicemia (blood poisoning), infection
from the heart, lungs, cranial fracture, nasal fracture.
EYE
BLOWOUT FRACTURE
● Blowout fracture (Fracture of the orbital floor involving the maxillary sinus) occurs
as a result of blunt force to the face & causes displacement of the eyeball
● It causes symptoms of Double vision (diplopia)
● Injury to the infraorbital nerve and the inferior rectus muscle.
● Fracture of the medial wall (the thin one) can also occur.
CLINICAL SIGNIFICANCE OF CONJUNCTIVA
● The palpebral conjunctiva is examined for anaemia and for conjunctivitis
● The bulbar conjunctiva for jaundice.
INFLAMMATORY LESIONS
HORDEOLUM
● Stye or hordeolum is a suppurative (pus producing) inflammation of ciliary glands or
Zeis glands.
● The gland is swollen, hard and painful, and the whole of the lid is oedematous.
CHALAZION
● A chalazion is inflammation of a tarsal or sebaceous gland causing a localized
swelling pointing inwards.
BLEPHARITIS
● Blepharitis is inflammation of the eyelids, especially of the lid margin.
PINK EYE
● Inflammed conjunctiva (conjunctivitis) i.e; pinkeye is a common contagious infection
of the eye.
UVEITIS
● Uveitis is inflammation of the vascular eye layer (uvea) & may progress to blindness.
PAPILLEDEMA
● Papilledema (choked disk) is oedema & swelling of the optic disk or optic nerve,
often resulting from increased intracranial pressure
a. Increased CSF pressure or thrombosis of the central vein of the retina, slowing
venous return from the retina
b. Head injury
c. Brainstem disease.
DIPLOPIA
● Diplopia (double vision) is caused by paralysis of one or more extraocular muscles,
resulting from injury of the nerves supplying them.
HYPEREMIA
● Hyperemia of the conjunctiva is caused by local irritation (dust, smoke or chlorine).
RETINAL DETACHMENT
● Retinal detachment is a separation of the sensory layer from the pigment layer of the
retina.
● It may occur in trauma such as a blow to the head.
COLOBOMA
● Coloboma of the iris is the absence of a segment of the iris.
● It may result from
a. Birth defect
b. Eyeball injury
c. Iridectomy.
HYPHEMA
● Hyphema is a haemorrhage within the anterior chamber of the eye resulting from
blunt trauma (squash, racquet & hockey stick) to the eyeball.
FASCIAL SHEATH OF EYEBALL
● When the eyeball is removed, the fascial sheath of the eyeball forms a socket for the
artificial eye because the fascial sheath of muscles remains attached to the fascial
sheath of the eyeball.
STRABISMUS
● Strabismus (squint-eyed or crossed-eye) is a visual disorder in which the eyes are
misaligned and point (look) in different directions as a result of weakness or paralysis
of extrinsic eye muscle due to damage to the oculomotor nerve.
BOGARD’S SYNDROME
● Crocodile tears syndrome (Bogorad’s syndrome) is spontaneous lacrimation during
eating caused by a lesion of the facial nerve proximal to the geniculate ganglion.
● It follows facial paralysis and is due to misdirection of regenerating parasympathetic
fibres, which formerly innervated the salivary (submandibular and sublingual) glands,
to the lacrimal glands.
EYE REFLEXES
CORNEAL REFLEX
● The corneal reflex is blinking in response to touching the cornea & it checks the
ophthalmic & facial nerve.
PUPILLARY LIGHT REFLEX
● Pupillary light reflex is constriction of the pupil in response to light stimulation
(direct reflex), and the contralateral pupil also constricts (consensual reflex).
● It is mediated by parasympathetic nerve fibres in the oculomotor nerve (efferent limb)
and its afferent limb is the optic nerve.
CORNEAL INJURIES
● Corneal Abrasion results from sand or metal particles & cause stabbing pain and
tears.
● Corneal Laceration is caused by sharp objects such as tree branch, fingernail &
corner of the page.
● Damage to the ophthalmic nerve leaves the cornea vulnerable to injury.
● People with corneal lesion may receive corneal transplant/plastic material.
HORNER’S SYNDROME
● Horner’s syndrome is caused by injury to cervical sympathetic nerves and
characterized by
a. Miosis: constriction of the pupil
b. Ptosis; eyelid drooping
c. Enophthalmosis; retraction of the eyeball.
d. Anhydrosis (absence of sweating)
e. Vasodilation.
OCULOMOTOR NERVE PALSY
● Oculomotor nerve palsy paralyzes ocular muscles, levator palpebrae superioris &
sphincter pupillae.
● It results in
a. Drooping of the eyelid (due to the unopposed activity of orbicularis oculi)
b. Dilated pupil (unopposed dilator papillae)
c. The pupil is abducted and depressed (unopposed lateral rectus & superior
oblique)
ABDUCENT NERVE PALSY
● Abducent nerve palsy paralyzes the lateral rectus; hence no abduction of the pupil
occurs.
● Pupil remains adducted due to unopposed action of medial rectus.
BLOCKAGE OF CENTRAL RETINAL ARTERY
● The central artery of the retina is the end artery; hence its blockage by embolus
results in an instant & total blindness.
PUPIL
● Anisocoria is an unequal size of the pupil
● Miosis is a constricted pupil caused by paralysis of the dilator pupillae resulting from
a lesion of the sympathetic nerve
● Mydriasis is a dilated pupil caused by paralysis of the sphincter pupillae resulting
from a lesion of the parasympathetic nerve
GLAUCOMA
● Glaucoma is characterized by increased intraocular pressure resulting from impaired
drainage of aqueous humour.
● The increased pressure causes impaired retinal blood flow, producing retinal ischemia
or atrophy of the retina; degeneration of the nerve fibres in the retina, particularly at
the optic disk; defects in the visual field; and blindness.
● Glaucoma can be treated by surgical iridectomy or laser iridotomy.
CATARACTS
● A cataract is a clouding (opacity or milky white) of the crystalline eye lens or of its
capsule.
● It results in little light being transmitted to the retina, causing blurred images and poor
vision.
PRESBYOPIA
● Presbyopia is a condition involving a reduced ability to focus on near objects.
● It is caused by the loss of elasticity of the crystalline lens, which occurs in advanced
age.
EYE TUMOURS
● Tumour in eye compresses optic nerve & orbital contents; hence results in
exophthalmos. Tumour can enter from
a. Sphenoidal & posterior ethmoidal sinus
b. Middle cranial fossa thru superior orbital fissure
c. Infratemporal fossa thru inferior orbital fissure.
DIRECTION OF APPROACH
● The lateral side affords a good approach for operations as
a. It does not reach as far anteriorly as the medial wall.
b. 2.5cm of the eyeball is exposed when the pupil is turned medially.
CORNEAL TEARS
● Damage to the facial nerve involves paralysis of orbicularis oculi, preventing eyes
from closing fully.
● The blinking is lost; the cornea becomes dry & tear production is increased.
NOSE
FRACTURES
● Because of the prominence of the nose, nasal bone fractures are common in accidents
& sports.
● The bone may be deformed & bleeding occurs.
● The direct blow may fracture the cribriform plate.
NASAL POLYP
● A nasal polyp is an inflammatory polyp that develops from the mucosa of the
paranasal sinus, which projects into the nasal cavity and may fill the nasopharynx.
● The most common cause of nasal polyps is allergic rhinitis.
RHINITIS
● Rhinitis is an inflammation of the nasal mucous membrane, caused by allergies.
● Infection can spread to
i. Anterior cranial fossa thru the cribriform plate
ii. Nasopharynx & retropharyngeal soft tissue
iii. Middle ear thru the auditory tube
iv. Paranasal sinus
v. Lacrimal apparatus & conjunctiva.
RHINORRHEA
● Rhinorrhea (runny nose) is caused by tears draining into the inferior nasal meatus
through the nasolacrimal duct.
● It is also associated with the common cold, hay fever, flu, and allergy.
RHINOPLASTY
● Rhinoplasty is plastic surgery that changes the shape or size of the nose.
DEVIATED NASAL SEPTUM (DNS)
● Deviation of the nasal septum may result from a birth injury or trauma & obstruct
breathing and block the openings of the paranasal sinuses.
EPISTAXIS
● Epistaxis (nosebleed) is common because of the rich blood supply to the nasal
mucosa.
● Bleeding is from the anterior nasal septum (Kiesselbach’s area).
● It is associated with infection, hypertension & vasodilation (in summer).
● Blood spurting results from the rupture of an artery. Its cause is trauma.
● Mild epistaxis occurs from nose picking, which tears the veins in the vestibule of the
nose.
SNEEZE REFLEX
● Sneeze is an involuntary, sudden, violent, and audible expulsion of air through the
mouth and nose.
● The afferent limb of the reflex is carried by branches of the maxillary nerve, which
convey general sensation from the nasal cavity and palate
● The efferent limb is medicated by the vagus nerve.
PARANASAL SINUSES
● Infection can spread from the nasal cavity to the paranasal sinus.
ETHMOIDAL SINUSITIS
● Ethmoidal sinusitis (inflammation in the ethmoidal sinuses) may erode the medial
wall of the orbit.
● It may cause blindness because posterior ethmoidal cells lie close to the optic canal
(passage to optic nerve & ophthalmic artery).
● Infection may cause optic neuritis.
FRONTAL SINUSITIS
● Frontal sinusitis may erode the thin bone of the anterior cranial fossa, producing
meningitis or brain abscess.
MAXILLARY SINUSITIS
● Maxillary sinuses are most commonly infected because their Ostia(opening) are small
and are located high on the superomedial wall.
● When they are obstructed; they are difficult to drain i.e; can be drained only by lying
on one side.
● Infection may spread from the maxillary sinus to the maxillary molar teeth (because
the thin layer of the bone separates the roots of the maxillary teeth from the sinus
cavity) and irritate the nerves to these teeth, causing a toothache.
SPHENOIDAL SINUSITIS
● Sphenoidal sinusitis may spread, may come from the nasal cavity or from the
nasopharynx, and may erode the sinus walls to reach the cavernous sinuses, pituitary
gland, optic nerve, or brain stem.
ORAL REGION, SUBLINGUAL & SUBMANDIBULAR GLANDS
GAG REFLEX
● When the posterior part of the tongue is touched, the individual vomits.
● 9th & 10th cranial nerves are responsible for muscular contraction of the pharynx.
● The glossopharyngeal nerve provides an afferent limb of gag reflex.
PARALYSIS OF GENIOGLOSSUS
● When the Genioglossus (safety muscle of the tongue) is paralyzed, the tongue has the
tendency to fall posteriorly, obstructing the airway that may cause suffocation.
● Genioglossus is relaxed during anaesthesia, so an airway is inserted to prevent the
tongue from relapsing.
LESION OF HYPOGLOSSAL NERVE
● Lesion of the hypoglossal nerve (from fractured mandible) results in paralysis and
atrophy of one side of the tongue.
● Tongue deviates to the paralyzed side because of the unopposed action of the
unaffected genioglossus muscle of another side.
NITROGLYCERIN
● Nitroglycerin (vasodilator used in the treatment of angina pectoris), pill or spray is
put under the tongue for quick absorption that dissolves & enters deep lingual veins.
METASTASIS OF LINGUAL CARCINOMA
● Lingual carcinoma (in posterior part) metastasizes to superior deep cervical lymph
nodes, submandibular & sublingual regions and along IJV in the neck.
LESIONS OF VAGUS NERVE
● Lesion of the vagus nerve causes deviation of the uvula toward the opposite side of
the lesion on phonation because of paralysis of the musculus uvulae.
● This muscle is innervated by the vagus nerve and elevates the uvula.
TONGUE-TIE
● Tongue-tie (ankyloglossia) is an abnormal enlargement of the frenulum, resulting in
limitation of its movement and thus a severe speech impediment.
● It can be corrected surgically by cutting the frenulum.
● A wound of the tongue is often caused by the patient’s teeth following a blow on the
chin when the tongue is partly protruded from the mouth i.e; while eating.
ANGIOEDEMA OF THE UVULA
● Angioedema of the Uvula (Quincke’s Uvula).
The uvula has a core of the voluntary muscle, the musculus uvulae, that is attached to
the posterior border of the hard palate.
● Surrounding the muscle is the loose connective tissue of the submucosa that is
responsible for the great swelling of this structure secondary to angioedema.
CLEFT PALATE
● A Cleft palate occurs when the palatine shelves fail to fuse with each other or the
primary palate.
● Uvula gives a fishtail appearance.
● It is more common in females.
CLEFT LIP
● Cleft lip occurs when the maxillary prominence and the medial nasal prominence fail
to fuse.
● It is more common in males.
THERMOREGULATION
● Abundant superficial arterial blood flow give lips their pink appearance which play
important role in temperature regulation.
CYANOSIS
● Cyanosis (blueness of lips) is a sign of pathology.
● It may occur in cold as well because of decreased blood flow.
SUBMANDIBULAR STONES
● The submandibular gland is a common site of calculus formation.
● It causes intense swelling behind the mandible.
● This stone or tumour in the gland can be removed by skin incision 2.5cm inferior to
the angle of the mandible to avoid injury to the marginal mandibular nerve & lingual
nerve.
EXAMINATION OF GLANDULAR DUCTS
● The submandibular gland & its duct is examined after injection of contrast medium in
their duct.
● Sublingual duct cannot be examined due to their small size. Sublingual Salivary
Gland can be blocked by Cyst Formation.
LUDWIG’S ANGINA
● Ludwig’s angina is an infection of the floor of the mouth (submandibular space)
with secondary involvement of the sublingual and submental spaces, usually resulting
from a dental infection.
a. Painful swelling of the floor of the mouth
b. Elevation of the tongue
c. Dysphagia & dysphonia.
EAR
BOXER EAR
● Bleeding within the auricle (auricular hematoma) from trauma forms between the
perichondrium & auricular cartilage.
● As it enlarges, it distorts the contour of the auricle & spreads in surrounding skin
forming a distorted auricle known as cauliflower or boxer ear (seen in boxer or
wrestlers).
OTOSCOPIC EXAMINATION
● Otoscopic examination of external acoustic meatus & tympanic membrane is done
by straightening the meatus.
● In adults, the helix is pulled posterosuperior (up, out & back).
● This movement reduces the curvature of the external acoustic meatus, facilitating
insertion of the otoscope.
● Meatus is straightened in infants by pulling auricle inferoposteriorly (down & back).
● It provides information about tenderness or inflammation of auricle or meatus.
OTITIS EXTERNA
● Otitis externa is inflammation of the external acoustic meatus (known as swimmer’s
ear, who don't dry their meatus after swimming) which is usually caused by a
bacterial infection of the skin such as pseudomonas.
● It produces itching & pain in the external ear.
OTITIS MEDIA
● Otitis media is a middle ear infection (pus or fluid in the middle ear) that may be
spread from the nasopharynx through the auditory tube, causing temporary or
permanent deafness.
● The tympanic membrane becomes red & bulges.
● The person may complain of ear-popping & amber coloured bloody fluid may be
observed.
PERFORATIONS OF TYMPANIC MEMBRANE
● Perforation of the tympanic membrane results from
a. Otitis media
b. Foreign bodies in the ear canal
c. Trauma
d. Excessive pressure.
MYRINGOTOMY
● Incisions to release pus from the middle ear (myringotomy) are made posteroinferior
as it is less vascular & avoids injury to chorda tympani nerve & auditory ossicles.
● It is followed by tympanostomy or pressure equalization (PE) tubes in the incision to
enable drainage of effusion & ventilation of pressure.
MASTOIDITIS
● Mastoiditis is inflammation of mastoid antrum & mastoid cells resulting from otitis
media.
● Infection may spread superiorly to middle cranial fossa through petrosquamous
fissure in children & cause osteomyelitis of tegmen tympani.
● The facial nerve should be preserved during surgery.
● One point to access the tympanic membrane is the antrum.
SPREAD OF INFECTION THROUGH EUSTACHIAN TUBE
● Pharyngotympanic tube forms a route for infection to pass from the nasopharynx to
the tympanic cavity.
● The tube is blocked by swelling of its mucous membrane, infection or cold as its
cartilages are in apposition.
● After blockage, air present is absorbed in the blood, resulting in low pressure in the
tympanic cavity, retraction of the tympanic membrane & interference with its
movement;
finally, hearing is affected.
HYPERACUSIS
● Hyperacusis (hyperacusia) is excessive acuteness of hearing, because of paralysis of
the stapedius muscle (causing uninhibited movements of the stapes), resulting from a
lesion of the facial nerve.
● Normally, tympanic muscles damp large vibration of the tympanic membrane.
MOTION SICKNESS
● Motion sickness results from discordance between vestibular & visual stimulation.
OTOSCLEROSIS
● Otosclerosis is a condition of abnormal bone formation around the stapes and the
oval window, limiting the movement of the stapes and thus resulting in progressive
conduction deafness.
DEAFNESS
CONDUCTIVE DEAFNESS
● Conductive deafness is hearing impairment caused by a defect of a sound-conducting
apparatus such as the auditory meatus, eardrum, or ossicles.
NEURAL DEAFNESS
● Neural or sensorineural deafness is hearing impairment because of a lesion of the
auditory nerve or the central afferent neural pathway (from the cochlea to the brain)
HIGH TONE DEAFNESS
● High tone-deafness occurs in workers who are exposed to loud sound & don't wear
earmuffs.
● It causes degenerative changes in the spiral organ.
MENIERE’S DISEASE
● Ménière’s disease (endolymphatic or labyrinthine hydrops) is characterized by a
a. Loss of balance (vertigo)
b. Tinnitus (ringing or buzzing in the ears)
c. Progressive hearing loss resulting from excess endolymph production or
blockage of the endolymphatic duct.
d. Ballooning of the cochlear duct, utricle & saccule caused by increased
endolymph is the characteristic sign. It is accompanied by a sense of pressure
in air, distortion of sound & sensitivity to noise.
OTIC BAROTRAUMA
● Otic Barotrauma is an injury to the ear caused by an imbalance in pressure between
the surrounding ear & air in the middle ear.
● It occurs in fliers & divers.
NECK
NECK INFECTIONS
IN FRONT OF PRETRACHEAL FASCIA
● Neck infections in front of the pretracheal fascia may bulge in the suprasternal area or
extend down into the anterior mediastinum.
BEHIND PREVERTEBRAL FASCIA
● Neck infections behind the prevertebral fascia arise from tuberculosis of the cervical
vertebrae.
● Pus produced as a result may pass
a. Forward, forming a chronic retropharyngeal abscess which may form a
bulging in the posterior wall of the pharynx, in the median plane
b. Laterally through the axillary sheath, posterior triangle, or in the axilla
c. Downwards into the superior mediastinum, where its descent is limited by
fusion of the prevertebral fascia to the fourth thoracic vertebra.
IN FRONT OF PREVERTEBRAL FASCIA
● Neck infections in front of the prevertebral fascia in the retropharyngeal space usually
arise from suppuration, i.e. formation of pus in the retropharyngeal lymph nodes.
● The pus forms an acute retropharyngeal abscess forwards in the paramedian position
due to the fusion of the buccopharyngeal fascia to the prevertebral fascia in the
median plane.
● The infection may extend down through the superior mediastinum into the posterior
mediastinum.
FRACTURE OF HYOID
● Fracture of hyoid (or styloid process) occurs in people who are manually strangled by
compression of the throat.
● It results in depression of hyoid on thyroid cartilage; hence it cannot be elevated or
moved anteriorly to maintain separation of alimentary & respiratory tract, so it may
result in aspiration pneumonia.
HANGING & EXECUTION
● Death in execution by hanging is due to dislocation of the dens following rupture of
the transverse ligament of the dens, which then crushes the spinal cord and medulla.
● It can also cause fracture through the axis, or separation of the axis from the third
cervical vertebra.
CISTERNAL PUNCTURE
● Cisternal puncture is done when lumbar puncture fails.
● The patient sits up or lies down in the left lateral position.
● A needle is introduced in the midline just above the spine of the axis vertebra and is
passed forwards and upwards, parallel to an imaginary line joining the external
auditory meatus with the nasion.
● The needle pierces the posterior atlanto-occipital membrane at a depth of about 4- 5
cm & enters the cisterna magna.
● In this procedure, there is a danger of injury to the medulla.
CERVICAL SPONDYLOSIS
● Cervical spondylosis (disc prolapse) is injury or degenerative changes of old age that
may rupture the thin postero-lateral parts of the annulus fibrosus (of the intervertebral
disc) resulting in prolapse of the nucleus pulposus.
● It is commonest in the lumbar region, may occur in the lower cervical region.
● It causes shooting pain along the distribution of the cervical nerve pressed.
LESIONS OF ACCESSORY NERVE
● Lesion of the accessory nerve:
a. The arm cannot be abducted beyond the horizontal position as a result of an
inability to rotate the scapula.
b. Torticollis because of paralysis of the sternocleidomastoid
c. Shoulder drop from paralysis of the trapezius.
SUPRACLAVICULAR LYMPH NODES
● The most common swelling in the posterior triangle is due to enlargement of the
supraclavicular lymph nodes.
● Supraclavicular lymph nodes are commonly enlarged in
a. Tuberculosis
b. Hodgkin's disease
c. Malignant growths of the breast, arm or chest.
CERVICAL PLEXUS BLOCK
● Cervical plexus block before neck surgery is done by injecting an anaesthetic agent at
the junction of superior & middle third of SCM.
● For anaesthesia of the upper limb, injection is given in the supraclavicular part of the
brachial plexus.
TORTICOLLIS
● Torticollis (wryneck) is a spasmodic contraction or shortening of the neck muscles,
producing twisting of the neck with the chin pointing upward and to the opposite side.
● It is due to injury to the sternocleidomastoid muscle or avulsion of the accessory
nerve.
● Its types are
RHEUMATIC
● Rheumatic torticollis due to exposure to cold or draught
REFLEX
● Reflex torticollis due to inflamed or suppurating cervical lymph nodes which irritate
the spinal accessory nerve
CONGENITAL
● Congenital (birth defect) torticollis due to
a. Fibrous tissue tumour in SCM
b. Muscular torticollis due to injured SCM
c. Hematoma that compresses the spinal accessory nerve
SPASMODIC
● Spasmodic torticollis (cervical dystonia) is due to abnormal tonicity of SCM &
trapezius.
● Turning, tilting, flexing. or extending the neck, shifting of head & elevated shoulder
are its characteristics.
EAGLE’S SYNDROME
● Eagle’s syndrome is an elongation or calcification of the styloid process or
stylohyoid ligament that causes neck, throat, or facial pain and dysphagia (difficulty
in swallowing).
● The pain may occur due to compression of the glossopharyngeal nerve, internal and
external carotid artery.
SUBCLAVIAN STEAL SYNDROME
● Subclavian steal syndrome is a cerebral and brain stem ischemia caused by the
reversal of blood flow from the basilar artery through the vertebral artery into the
subclavian artery in the presence of occlusive disease of the subclavian artery
proximal to the origin of the vertebral artery.
● It may steal blood from the carotid, circle of Willis, and basilar circulation.
CAROTID SINUS SENSITIVITY TO PRESSURE
● External pressure on the carotid artery cause decreased heart rate, blood pressure &
cardiac ischemia resulting in fainting.
● Supraventricular tachycardia may be controlled by carotid sinus massage due to the
inhibitory effect of the vagus nerve on the heart.
● A tight necktie can compress the internal carotid artery, supplying the brain.
● Carotid sinus syncope is a temporary loss of consciousness caused by diminished
cerebral blood flow.
COMMON CAROTID ARTERY
● The common carotid artery can be pulsated by compressing against the carotid
tubercle i.e; the anterior tubercle of the transverse process of C6 vertebrae at the level
of the cricoid cartilage.
CAROTID ENDARTERECTOMY
● Carotid endarterectomy is the excision of atherosclerotic thickening of the intima of
the internal carotid artery for the prevention of stroke.
● It is done by opening the artery at its origin & stripping off the plaque with intima.
● Drugs inhibiting clot formation are administered until endothelium has regrown.
● 9th,10th, 11th or 12th cranial nerves may injure during this procedure.
EXTERNAL JUGULAR VEIN
AIR EMBOLISM
● Division of the external jugular vein in the supraclavicular space may cause air
embolism and consequent death.
● Because its lumen is held open by investing layer of deep cervical fascia & negative
intrathoracic pressure will suck air into the vein.
● It produces churning noise & cyanosis.
INTERNAL BAROMETER
● The right external jugular vein is examined to assess the venous pressure; right atrial
pressure because there are no valves in the vein.
● EJV may serve as an internal barometer; when venous pressure rises, it becomes
prominent throughout its course alongside neck & may give diagnostic signs of
a. Heart failure
b. SVC obstruction
c. Enlarged supraclavicular lymph node
d. Increased intrathoracic pressure.
DOPPLER TECHNIQUE
● Doppler technique is used for observing blood flow obstruction by comparing moving
blood with surrounding static fluid.
CPR
● During Cardiopulmonary resuscitation, the carotid pulse is felt by palpating the
common carotid artery between the trachea and infrahyoid muscles.
TEMPORAL ARTERITIS
● Temporal (giant cell) arteritis is granulomatous inflammation with multinucleated
giant cells, affecting the medium-sized arteries, especially the temporal artery.
INTERNAL JUGULAR VEIN
INTERNAL JUGULAR VEIN PUNCTURE
● A Central venous line is an intravenous needle and catheter placed into a large vein
such as the internal jugular or subclavian vein to give fluids or medication.
● A central line is inserted in the apex of the triangular interval between the clavicle and
the clavicular and sternal heads of the sternocleidomastoid muscle into the internal
jugular vein i.e; lateral to the common carotid artery at a 30 angle (this process is also
known as internal jugular vein puncture) or retroclavicular position (posterior to
clavicle). The needle is then directed inferolateral.
COMPLICATIONS
● Possible complications of catheterization
1. Air embolism or laceration of the internal jugular vein
2. Lung injury
3. Hemothorax
4. Pneumothorax.
RIGHT ATRIAL PRESSURE
● IJV is palpated superior to the medial end of the clavicle beneath SCM & can provide
information about ECG & right atrial pressure.
ANTERIOR MIDLINE SWELLINGS OF NECK
● The common anterior midline swellings of the neck are
a. Enlarged submental lymph nodes and sublingual dermoid in the submental
region
b. Thyroglossal cyst (remnant of the thyroglossal duct that attaches thyroid gland
to foramen cecum) and subhyoid bursitis just below the hyoid bone
c. Goitre, carcinoma of the larynx and enlarged lymph nodes in the suprasternal
region.
THYROID & PARATHYROID GLAND
SUSPENSORY LIGAMENT OF BERRY
● The thyroid gland and all thyroid swellings move with deglutition because the thyroid
is attached to the larynx by the suspensory ligaments of Berry.
ACCESSORY THYROID GLAND
● The aberrant or accessory thyroid gland may appear along the path of the thyroglossal
duct
a. The root of the tongue posterior to the foramen cecum
b. Neck (maybe on thyrohyoid)
c. Inferior to hyoid or in the thorax.
REMNANT OF THYROGLOSSAL DUCT
● Remnant of the thyroglossal duct is differentiated from thyroid by radioisotope
scanning.
● The ectopic thyroid gland is always present in the median plane of the neck.
THYROID IMA ARTERY
● During procedures in the midline of the neck, the thyroid ima artery is a potential
source of bleeding.
● It is the branch of the brachiocephalic trunk; and may arise from the carotid,
subclavian or internal thoracic artery, ascends on trachea to the isthmus of thyroid,
supplying to both structures.
THYROIDECTOMY
● Surgical Removal of the thyroid (thyroidectomy) with true capsule (extracapsular)
may be necessary for hyperthyroidism (thyrotoxicosis).
● The posterior parts of both lobes are left behind (near-total thyroidectomy). This
avoids the risk of simultaneous removal of the parathyroids and postoperative
myxoedema.
COMPLICATIONS
● Potential complications may include
a. Haemorrhage from injury of the thyroid ima artery, inferior thyroid vein or
anterior jugular vein
b. Nerve paralysis of the recurrent laryngeal nerves
c. Pneumothorax resulting from damage of the cervical dome of the pleura
d. Oesophagal injury
SUPERIOR THYROID ARTERY
● During operation, the superior thyroid artery is ligated near the gland to save the
external laryngeal nerve, and the inferior thyroid artery is ligated away from the gland
to save the recurrent laryngeal nerve.
HYPOTHYROIDISM
● Hypothyroidism causes cretinism in infants and myxoedema in adults.
TUMORS
● Benign tumours of the gland may displace and compress neighbouring structures, like
the carotid sheath, the trachea, etc.
● Malignant growths tend to invade and erode neighbouring structures. Pressure
symptoms and nerve involvements are common in carcinoma of the glands.
GOITRE
● Goitre is a non-neoplastic, non-inflammatory enlargement of the thyroid gland,
which is commonly caused by iodine deficiency (because iodine is vital to the
formation of thyroid hormone), hyperthyroidism or hypothyroidism.
● The enlarged gland compresses the trachea, larynx, oesophagus, and recurrent
laryngeal nerve, causing symptoms of dyspnea, dysphagia, coughing, speech difficulty
& dizziness.
GRAVE’S DISEASE
● Graves’s disease is an autoimmune disease in which the immune system
overstimulates the thyroid gland, causing hyperthyroidism that causes goitre and
exophthalmos.
HASHIMOTO’S DISEASE
● Hashimoto’s disease (chronic thyroiditis) is an autoimmune disease in which the
immune system destroys the thyroid gland, resulting in hypothyroidism and goitre.
PARATHYROID ADENOMA
● Tumours of the parathyroid glands lead to excessive secretion of parathormone
(hyperparathyroidism).
● This leads to increased removal of calcium from bone making them weak and liable to
fracture.
● Calcium levels in blood increase (hypercalcaemia) and increased urinary excretion of
calcium can lead to the formation of stones in the urinary tract.
INADVERTENT PARATHYROIDECTOMY
● Inadvertent parathyroidectomy may occur during thyroidectomy which would result
in decreased production of parathyroid hormone (PTH) and lead to low calcium
levels.
● It would lead to muscle spasms (tetany) twitches & cramp as well as high levels of
phosphorus and low levels of vitamin D.
● If the whole thyroid gland is to be removed, parathyroid glands are isolated &
transplanted to the arm.
VIRCHOW’S LYMPH NODES
● Left supraclavicular lymph nodes are called Virchow's lymph nodes.
● Cancer from the stomach & testis may metastasize to these lymph nodes which
become palpable.
TRACHEOSTOMY
● It establishes an airway in patients with upper airway obstruction.
● The neck is extended to bring the trachea forward.
● A vertical midline skin incision is made from the region of the cricothyroid membrane
inferiorly toward the suprasternal notch.
● Pretracheal muscles are split in the midline; a vertical incision is made thru the 2nd
ring of the trachea by retracting the isthmus & a tracheostomy tube is inserted.
● To avoid complication, the inferior thyroid vein, thyroid ima artery, left
brachiocephalic vein, thymus & trachea are protected.
PENETRATED STRUCTURES
● The incision is carried through the
a. Superficial fascia & platysma muscle
b. The investing layer of the deep cervical fascia.
COMPLICATIONS
1. Pneumothorax
2. Haemorrhage
3. Anterior jugular vein
4. Oesophagal injury
5. Recurrent laryngeal nerve paralysis
ESOPHAGUS, PHARYNX & TONSILS
INFECTION OF PALATINE TONSILS
● Infection of palatine tonsil cause enlargement of jugulodigastric lymph nodes which
adhere to IJV.
● Submandibular lymph nodes become enlarged because of infections in the tongue,
mouth, cheek and tuberculosis.
ESOPHAGEAL INJURIES
● Oesophagal injuries are penetrating neck trauma & are often hidden.
● Oesophagal cancer causes dysphagia, hoarseness of voice (compression of the
recurrent laryngeal nerve) and enlargement of inferior deep cervical lymph nodes.
DYSPHAGIA
● Dysphagia caused by compression of the oesophagus by an abnormal subclavian
artery is called dysphagia lusoria.
ADENOID
● Adenoid is hypertrophy or enlargement of the pharyngeal tonsils that obstructs the
passage of air from the nasal cavities through the choanae into the nasopharynx and
thus causes difficulty in nasal breathing and phonation.
● It may block the pharyngeal orifices of the auditory tube, and an infection may spread
from the nasopharynx through the auditory tube to the middle ear cavity, causing
otitis media, which may result in deafness.
PALATINE TONSILLECTOMY
● Palatine tonsillectomy is the surgical removal of a palatine tonsil & surrounding
connective tissue.
● During a tonsillectomy, the glossopharyngeal nerve is vulnerable to injury.
● Bleeding may arise from an external palatine vein, tonsillar artery.
● The internal carotid artery is also vulnerable.
QUINSY
● Quinsy (peritonsillar abscess) is a painful pus-filled inflammation or abscess of the
tonsils and surrounding tissues.
● It develops as a complication of tonsillitis, primarily in adolescents and young adults.
● The soft palate and uvula are edematous and displaced toward the unaffected side.
a. Sore throat
b. Fever
c. Dysphonia.
LARYNX
LARYNGITIS
● Laryngitis is an inflammation of the mucous membrane of the larynx.
● It is characterized by dryness and soreness of the throat, hoarseness, cough, and
dysphagia.
EPIGLOTTITIS
● Epiglottitis is an inflammation of acute mucosal swelling of the epiglottis, which
may cause life-threatening airway obstruction, especially in children.
LARYNGOTOMY
● Laryngotomy is an operative opening into the larynx through the cricothyroid
membrane (cricothyrotomy), the thyroid cartilage (thyrotomy), or the thyrohyoid
membrane (superior laryngotomy).
● It is performed when severe oedema or an impacted foreign body calls for rapid
admission of air into the larynx and trachea.
LARYNGEAL OBSTRUCTION
● Laryngeal obstruction (choking) is caused by aspirated foods, which are usually
lodged at the rima glottidis.
● It can be released by compression of the abdomen to expel air from the lungs and thus
dislodge the foods (e.g., the Valsalva manoeuvre).
LARYNGEAL CANCER
● Smokers develop cancer of the larynx associated with
a. Hoarseness
b. Earache
c. Dysphagia
d. Enlarged paratracheal or paratracheal lymph nodes.
● Laryngectomy may be performed in such cases.
CHANGES IN LARYNX WITH AGE
● At puberty in males; testosterone strengthens laryngeal walls, enlarge its cartilages &
its cavity and the larynx becomes prominent. Anteroposterior diameter of rima
glottidis doubles and vocal folds lengthen and thicken. It accounts for voice change in
males; pitch becomes lower.
● In girls, a slight increase in the size of the larynx occurs.
PIRIFORM FOSSA
● Foreign bodies (chicken bone or fishbone) may enter the piriform fossa.
● Piriform fossa is also used to smuggle out precious stones, diamonds; it is called
smuggler's fossa.
● If the object is sharp, it may pierce the mucous membrane & injure the internal
laryngeal nerve.
LARYNGOSCOPY
● Laryngoscopy is a procedure used to examine the interior of the larynx.
● It can be indirect laryngoscopy (using laryngeal mirror by pulling anterior part of
the tongue) or direct laryngoscopy (using laryngoscope which is a fibre optic
endoscope equipped with electrical lighting).
● The valleculae, the piriform fossae, the epiglottis, vestibular & vocal folds and the
aryepiglottic folds are clearly seen.
● The vestibular folds (appear pink) and the vocal folds (appear white) can be seen.
VALSALVA MANOEUVRE
● Valsalva manoeuvre is forced expiratory effort against a closed airway i.e; cough,
sneeze or strain. Vestibular & vocal folds abduct during deep inspiration.
● In the Valsalva manoeuvre, both folds are adducted at end of deep inspiration.
Abdominal muscles contract to increase intraabdominal & intrathoracic pressure that
impedes venous return to the heart.
● This manoeuvre is used to study cardiovascular effects of raised venous pressure and
decreased cardiac filling & cardiac output.
VESTIBULAR FOLDS
● Foreign object inhaled into airways become trapped superior to vestibular folds.
Laryngeal muscles go into spasm, the rima glottidis close, no air entry, laryngeal
obstruction & choke the person.
● Vestibular mucosa is sensitive to foreign objects, & violent coughing occurs when an
object passes thru the laryngeal inlet.
HEIMLICH MANEUVER
● Heimlich Maneuver dislodges foreign material from the larynx.
● A closed fist, with a base of palm inward, is placed on the victim's abdomen between
the umbilicus & the xiphoid process.
● The fist is grasped by the other hand & forcefully thurst inward & superiorly, forcing
the diaphragm superiorly.
● This action forces air from the lung & creates an artificial cough that expels the
foreign object.
LESION OF RECURRENT LARYNGEAL NERVE
● Lesion of the recurrent laryngeal nerve can be produced during
a. Thyroidectomy
b. Cricothyrotomy
c. Aortic aneurysm
● Such injury may cause
a. Respiratory obstruction
b. Hoarseness
c. Inability to speak
d. Loss of sensation below the vocal cord.
LESION OF INTERNAL LARYNGEAL NERVE
● Lesion of the internal laryngeal nerve results in loss of sensation above the vocal cord
and loss of taste on the epiglottis.
LESION OF EXTERNAL LARYNGEAL NERVE
● Lesion of the external laryngeal nerve may occur during thyroidectomy because the
nerve accompanies the superior thyroid artery.
● It causes paralysis of the cricothyroid muscle, thus the inability to lengthen the vocal
cord and loss of the tension of the vocal cord.
● Such stresses to the vocal cord cause a fatigued & shrilling voice and weak
hoarseness.
COMPLETE SECTION OF RECURRENT LARYNGEAL NERVE
● A unilateral complete section of the recurrent laryngeal nerve results in the vocal fold
on the affected side assuming the position midway between abduction and adduction.
● It lies just lateral to the midline.
● Speech is not greatly affected because the other vocal fold compensates to some
extent and moves toward the affected vocal fold.
BILATERAL SECTION
● A bilateral complete section of the recurrent laryngeal nerve results in both vocal
folds assuming the position midway between abduction and adduction.
● Breathing is impaired because the rima glottidis is partially closed, and speech is lost.
UNILATERAL PARTIAL SECTION
● Unilateral partial section of the recurrent laryngeal nerve results in a greater degree of
paralysis of the abductor’s muscles than of the adductor muscles.
● The affected vocal fold assumes the adducted midline position.
● The abductor muscles receive a greater number of nerves than the adductor muscles,
and thus partial damage of the recurrent laryngeal nerve results in damage to
relatively more nerve fibres to the abductor’s muscles.
● Another possibility is that the nerve fibres to the abductor’s muscles are travelling in a
more exposed position in the recurrent laryngeal nerve and are therefore more prone
to be damaged.
BILATERAL PARTIAL SECTION
● Bilateral partial section of the recurrent laryngeal nerve results in bilateral paralysis of
the abductor muscles and the drawing together of the vocal folds.
● Acute breathlessness (dyspnea) and stridor follow, and cricothyroidotomy or
tracheostomy is necessary.
ZONES OF NECK TRAUMA
ZONE 1 Root of the neck
● Structures at risk are
a. Cervical pleura
b. Lung apex
c. Thyroid & parathyroid gland
d. Trachea
e. Oesophagus
f. Common carotid artery
g. Jugular vein
h. Vertebral column
ZONE 2 It extends from the cricoid cartilage to the angle of the mandible
1. Thyroid gland
2. Thyroid & cricoid cartilage
3. Larynx & laryngopharynx
4. Carotid arteries
5. Jugular vein
6. Oesophagus
7. Vertebral column
ZONE 3 Superior to the angle of the mandible
a. Salivary glands
b. Oral & nasal cavity
c. Oropharynx, and nasopharynx).
Zone 1 & 3 have a great risk for morbidity & mortality.
NEUROANATOMY
SPINAL CORD
TABES DORSALIS
● Tabes Dorsalis is caused by syphilis due to the destruction of the posterior root of the
spinal cord.
SYMPTOMS
● There is
1. Stabbing pains in the lower limbs
2. Paresthesia in the lower limbs
3. Hypersensitivity of skin to touch, heat, and cold
4. Loss of sensation in the skin of parts of the trunk and lower limbs and loss of
awareness that the urinary bladder is full
5. Loss of appreciation of posture
6. Loss of deep pain sensation
7. Loss of pain sensation in the skin
8. Ataxia of the lower limbs as the result of loss of proprioceptive
sensibility
9. Hypotonia is the result of loss of proprioceptive information that arises
from the muscles and joints
10. Loss of tendon reflexes due to degeneration of the afferent fibre component
TYPES OF PARALYSIS
HEMIPLEGIA
● Hemiplegia is a paralysis of one side of the body and includes the upper limb,
one side of the trunk, and the lower limb.
MONOPLEGIA
● Monoplegia is a paralysis of one limb only.
DIPLEGIA
● Diplegia is paralysis of two corresponding limbs (i.e., arms or legs).
PARAPLEGIA
● Paraplegia is a paralysis of the two lower limbs.
QUADRIPLEGIA
● Quadriplegia is a paralysis of all four limbs.
DIFFERENCE BETWEEN UMN & LMN LESIONS
Upper Motor Neuron Lower Motor Neuron
Lesion (UMN) Lesion ( LMN)
Paralysis Group of muscles of one or Individual muscles are

more limbs are paralyzed involved
Muscle tone Spastic paralysis Flaccid paralysis
Deep tendon reflexes Exaggerated Absent
Superficial reflexes like Absent Absent

abdominal & cremasteric
reflexes
Plantar response Extensor (Babinski sign Absent

positive)
Muscle atrophy No Present due to denervation
Fasciculations & Absent Present

Fibrillations
Other Loss of performance of fine There is muscle contracture

skilled movement & Clasp (shortening of paralyzed
knife reaction (due to muscles)
spasticity) is present
COMPLETE CORD TRANSECTION SYNDROME

● It occurs due to fracture-dislocation of the vertebral column, by a bullet, stab
wound, tumour)
LEVEL OF SPINAL CLINICAL SIGNS CAUSES
CORD
At the level of spinal cord Bilateral lower motor neuron Damage to neurons in
lesion paralysis & muscular anterior grey column (lower
atrophy motor neuron lesion)
Below the lesion Bilateral upper motor neuron

lesion i.e; Bilateral spastic Damage to descending
paralysis. tracts other than
corticospinal
Babinski sign positive
Damage to corticospinal
Bilateral loss of superficial tracts
abdominal & cremaster
reflex
Below the lesion Bilateral loss of all Damage to ascending tracts
sensations (tactile, vibratory in a posterior white column
& proprioceptive)
Loss of pain, temperature & Damage to lateral &

light touch anterior spinothalamic tract
Bladder & bowel function Damage to descending

are no longer voluntary autonomic fibres
ANTERIOR CORD TRANSACTION SYNDROME

● It occurs due to injury of the anterior spinal artery or vertebral fracture.
● Tactile discrimination and vibratory and proprioceptive sensations are preserved
because the posterior white columns on both sides are undamaged.
CORD
At the level of lesion Bilateral lower motor Damage of anterior grey
neuron paralysis & muscular column (LMN lesion)
atrophy
Below the level of lesion Bilateral Upper motor

neuron lesion i.e;
Bilateral spastic paralysis Corticospinal & other
descending tracts
Bilateral loss of pain,
temperature, and light touch Damage to anterior & lateral
sensations. spinothalamic tracts
CENTRAL CORD SYNDROME

● Central cord syndrome is most often caused by hyperextension of the cervical region
of the spine.
● The cord is pressed on anteriorly by the vertebral bodies and posteriorly by the
bulging of the ligamentum flavum.
AT THE LEVEL OF LESION
● There is a lower motor neuron lesion.
BELOW THE LEVEL OF LESION
● There is an upper motor neuron lesion.
● The lower limb fibres are affected less than the upper limb fibres because in the
lateral corticospinal tracts, the upper limb fibers located medially and the lower limb
fibers located laterally.
● Bilateral loss of pain, temperature, light touch, and pressure sensations with
characteristic sacral sparing.
● Because the ascending fibres in the lateral and anterior spinothalamic tracts are also
laminated, with the upper limb fibres located medially and the lower limb fibres
located laterally, the upper limb fibres are more susceptible to damage than the lower
limb fibres.
BROWN SEQUARD SYNDROME
● It is caused by fracture-dislocation of the vertebral column, by a bullet, stab
wound, or tumour
CORD
At the level of lesion 1.Ipsilateral lower motor 1.Damage to anterior grey

neuron paralysis & muscular column
atrophy
2.Ipsilateral band of 2. Damage to posterior nerve
cutaneous anaesthesia roots
Below the lesion 1.Ipsilateral upper motor Damage to descending tracts

neuron lesion i.e; other than corticospinal
Ipsilateral spastic paralysis. Damage to corticospinal
The Babinski sign is positive. tracts
Ipsilateral loss of superficial 2.Damage to ascending tracts
abdominal & cremaster reflex in a posterior white column
2.Ipsilateral loss of tactile 3.Damage to crossed lateral
discrimination, vibratory and spinothalamic tracts on the
proprioceptive sensations same side of the lesion
3.Contralateral loss of pain 4.Damage to crossed
and temperature sensations anterior spinothalamic tracts
4.Contralateral but not on the side of the lesion
complete loss of tactile
sensation.
SYRINGOMYELIA
● Syringomyelia is a developmental abnormality in the formation of the central canal,
affecting the brainstem and cervical region of the spinal cord.
● At the site of the lesion, there is cavitation and gliosis in the central region of the
neuraxis.
1. Loss of pain and temperature sensations in dermatomes on both sides of the
body. This loss has a shawl-like distribution caused by the interruption of the
lateral spinothalamic tracts as they cross the midline in the anterior grey and
white commissures.
2. Tactile discrimination, vibratory sense, and proprioceptive sense are normal
because ascending tracts in the posterior white column are unaffected.
3. Lower motor neuron weakness is present in the small muscles of the hand.
4. Bilateral spastic paralysis of both legs may occur, with exaggerated deep
tendon reflexes and the presence of a positive Babinski response.
5. Horner syndrome (interruption of the descending autonomic fibres in the
reticulospinal tracts) may be present.
POLIOMYELITIS
● Poliomyelitis is an acute viral infection of the neurons of the anterior grey columns
of the spinal cord and the motor nuclei of the cranial nerves.
● Following death of the motor nerve cells, there is paralysis and wasting of the
muscles.
● The muscles of the lower limb are more often affected than the muscles of the
upper limb.
● Respiration may be threatened due to the paralysis of intercostal muscles and
diaphragm.
● The muscles of the face,pharynx,larynx, and tongue may also be paralyzed.
MULTIPLE SCLEROSIS
● Multiple sclerosis is a common disease confined to the CNS, causing
demyelination of the ascending and descending tracts.
● It is a disease of young adults.
AMYOTROPHIC LATERAL SCLEROSIS
● Amyotrophic lateral sclerosis (Lou Gehrig disease) is a disease confined to the
corticospinal tracts and the motor neurons of the anterior gray column.
● The lower motor neuron signs of progressive muscular atrophy, paresis, and
fasciculations are superimposed on the signs and symptoms of upper motor
neuron disease with paresis, spasticity, and Babinski response.
● The motor nuclei of some cranial nerves may also be involved.
BRAIN STEM
ARNOLD-CHIARI MALFORMATION
● Arnold-Chiari malformation is a congenital anomaly in which there is a herniation of
the tonsils of the cerebellum and the medulla oblongata through the foramen magnum
into the vertebral canal.
● It results in the blockage of the exits in the roof of 4th ventricle causing internal
hydrocephalus.
LATERAL MEDULLARY SYNDROME
● Lateral medullary syndrome of Wallenberg is caused by thrombosis of the posterior
inferior cerebellar artery (branch of vertebral artery).
● It includes
STRUCTURES INVOLVED CLINICAL SIGN
Inferior cerebellar peduncle Loss of equilibrium (ataxia) and giddiness
Lateral spinothalamic tract Loss of sensation of pain and temperature

over the contralateral half of the body
Spinal nucleus and tract of the Loss of sensation of pain and temperature
trigeminal nerve over the ipsilateral half of the head and face
Nucleus ambiguus Difficulty in swallowing (dysphagia) and in
speech (dysarthria)
Vestibular nuclei Vomiting, nystagmus and vertigo
Descending autonomic fibres Ipsilateral Horner’s syndrome characterized

by ptosis, miosis, enophthalmos, anhidrosis
and loss of ciliospinal reflex
MEDIAL MEDULLARY SYNDROME

Medial medullary syndrome is caused by thrombosis of the medullary branch of vertebral
artery.
STRUCTURES INVOLVED CLINICAL SIGNS
Corticospinal fibres (pyramids) Contralateral hemiplegia
Hypoglossal nucleus and nerve fibres Ipsilateral (lower motor neuron type)
paralysis of muscles of tongue (on
protrusion, tongue deviates to the side of
lesion)
Medial lemniscus Contralateral loss of sensation of fine

touch, sense of movement and sense of
position
MEDULLARY TEGMENTAL SYNDROME

● Medullary tegmental paralysis(Babinski-Nageotte syndrome) results from lesion at
pontomedullary junction involving all the above structures.
● It is combination of medial and lateral medullary syndromes
PONTINE HEMORRHAGES
● Pontine Hemorrhage results from hemorrhage from basilar artery ; anterior, inferior,
and superior cerebellar arteries.
1. There will be facial paralysis on the side of the lesion (involvement of the
facial nerve nucleus and lower motor neuron palsy)
2. Paralysis of the limbs on the opposite side(damage to corticospinal fibers).
3. There is often paralysis of conjugate ocular deviation (damage to abducens
nerve nucleus and the medial longitudinal fasciculus).
4. There may be pinpoint pupils (sympathetic fibres) with bilateral paralysis of
face and limb.
5. Patients may become poikilothermic.
WEBER SYNDROME
● Weber syndrome is produced by occlusion of a branch of the posterior cerebral
artery that supplies the midbrain
● It results in the necrosis of brain tissue involving the oculomotor nerve & crus cerebri.
1. There is ipsilateral ophthalmoplegia & contralateral paralysis of the lower
part of face, tongue, and arm and leg
2. Eyeball deviated laterally ( paralysis of medial rectus muscle)
3. Drooping (ptosis) of the upper lid
4. Pupil is dilated and fixed to light & accommodation.
BENEDIKT SYNDROME
● Benedikt syndrome involves brain necrosis affecting medial lemniscus and red
nucleus, producing contralateral hemianesthesia and involuntary movements of the
limbs of the opposite side.
CROSSED HEMIPLEGIAS
● Alternating Hemiplegias occur when the descending corticospinal fibres along
with the cranial nerve nuclei and nerve fibres (abducent & facial nerve) get
affected due to vascular occlusion.
● Such a lesion, seen usually in the brainstem vascular occlusions, result in
contralateral hemiplegia and ipsilateral lower motor neuron paralysis of the
cranial nerve. This is called alternating hemiplegia or crossed hemiplegia.
CEREBELLUM
CEREBELLAR DISEASE
● Lesion in one cerebellar hemisphere gives rise to signs and symptoms that are
limited to the same side of the body.
● It includes
HYPOTONIA
It includes diminished muscle tone.
POSTURAL AND GAIT CHANGES

● Head is often rotated and flexed, and the shoulder on the side of the lesion is lower
than on the normal side.
● The patient assumes a widebase when he or she stands and is often stiff legged to
compensate for loss of muscle tone.
● When the individual walks, he or she lurches and staggers toward the affected
side.These are more pronounced with the eyes closed (Romberg’s sign).
ATAXIA (DISTURBANCES OF VOLUNTARY MOVEMENTS)
● The muscles contract irregularly and weakly.
● Intention tremors occur when fine movement (buttoning clothes,writing,and shaving).
ASYNERGIA
● Muscle groups fail to work harmoniously,and there is decomposition of movement.
● When a patient is asked to touch the tip of the nose with the index finger, movements
are not properly coordinated, and the finger either passes the nose (past-pointing) or
orbits the nose.
DYSDIADOCHOKINESIA
● It is the inability to perform alternating movements regularly and rapidly.
● Ask the patient to pronate and supinate the forearm rapidly. He will not be able to do
so.
REFLEXES
● Movement produced by tendon reflexes tends to continue for a longer period of time
than normal i.e; The pendular knee jerk
NYSTAGMUS
● Nystagmus is ataxia of the ocular muscles and is an arrhythmic oscillation of the eyes.
● It is more easily demonstrated when the eyes are deviated in a horizontal direction.
● This rhythmic oscillation of the eyes may be of the same rate in both directions
(pendular nystagmus) or quicker in one direction than in the other (jerk nystagmus).
DYSARTHRIA
● Dysarthria is ataxia of the muscles of the larynx.Articulation is jerky, and the
syllables are separated from one another.
● Speech tends to be explosive and syllables are slurred.
CEREBELLAR SYNDROME ( Vermis Syndrome)
● Its most common cause is medulloblastoma of vermis in children.
● Since vermis is unpaired and influences midline structures, muscle incoordination
involves head & trunk and not the limbs.
1. There is a tendency to fall forward or backward.
2. There is difficulty in holding the head steady and in an upright position.
3. There also may be difficulty in holding the trunk erect.
CEREBELLAR HEMISPHERE SYNDROME
● Cerebellar Hemisphere Syndrome is caused by tumors of one cerebellar hemisphere.
● The symptoms and signs are unilateral and involve muscles on the diseased side.
1. Movements of the limbs, especially the arms, are disturbed.
2. Swaying and falling to the side of the lesion often occur.
3. Dysarthria and nystagmus are common findings.
CEREBRUM
PARTS OF CEREBRUM SIGNS & SYMPTOMS
Primary motor area (4) Contralateral monoplegia ( hemiplegia)

Jacksonian Epileptic seizures
Premotor area (6) Apraxia (Skilled movements are affected)
Frontal eye field (8) Deviation of eyes to side of lesion
Prefrontal area (9,10,11,12) Personality changes
Motor speech area / Broca(44,45) Expressive/motor aphasia–Difficulty in

spoken speech or writing (agraphia). Non-
fluent speech and telegraphic language. Key
words spoken are normal.
First somatosensory area (1,2,3) Contralateral sensory loss
Second somatosensory area inability to appreciate pain and temperature
areas behind the main sensory area Inability to identify objects by feeling them
(areas 5 and 7)
Sensory speech area/Wernicke area (40) Receptive/sensory aphasia–Loss of ability

to understand spoken and written speech.
Spoken speech is fluent but contains
paraphasias (substitution of a word with a
non-word, out of context word, and
neologism)
Left perisylvian area (Broca + wernicke Global aphasia (sensory & motor aphasia)
area)
Primary auditory area (41, 42) Slight bilateral loss of hearing if one side is
affected. Bilateral involvement of the
auditory area will result in deafness.
Auditory association area (22) Word deafness (auditory verbal agnosia)–

Inability to interpret meaning of the sounds
heard
Primary visual area (17) Contralateral homonymous hemianopia

with macular sparing in vascular lesions
(No macular sparing in trauma or tumours)
Visual association area (18, 19) Visual agnosia–Loss of ability to recognize

objects, Word blindness–alexia
ARTERIAL SUPPLY OF INTERNAL CAPSULE

● The arterial supply of internal capsule is of great clinical significance.
● Thrombosis in an artery supplying the internal capsule (cerebral thrombosis)
leads to a stroke that results in contralateral hemiplegia.
● As the tracts passing through the internal capsule are closely packed, even a
small lesion can cause extensive paralysis.
● Sensations can also be lost.
● Reflexes are exaggerated as in a typical upper motor neuron paralysis.
ALZHEIMER’S SYNDROME
● Alzheimer disease is a degenerative disease of the brain occurring in middle to late
life.
● Common signs and symptoms include
1. Early memory loss
2. A disintegration of personality
3. Complete disorientation
4. Deterioration in speech
5. Restlessness
THALAMUS
THALAMIC HAND
● The contralateral hand is held in abnormal posture with thalamic lesions.
● The wrist is pronounced and flexed,metacarpophalangeal joints are flexed and the
interphalangeal joints are extended.
● The fingers can be moved actively, but the movements are slow.
● The condition is due to altered muscle tone in the different muscle groups.
● Cauterization of intralaminar nuclei of thalamus has been shown to relieve severe
and intractable pain associated with terminal cancer.
THALAMIC SYNDROME
● It occurs due to vascular lesion of thalamic branch of posterior cerebral artery.
1. Threshold for appreciation of touch,pain,temperature is lowered.
2. Sensation that is normal may appear to be exaggerated or unpleasant.
3. There may be spontaneous pain.
4. Emotions may be abnormal.
RETICULAR FORMATION & LIMBIC SYSTEM
RETICULAR FORMATION
● Damage to the reticular formation causes persistent unconsciousness & coma.
FUNCTIONS OF LIMBIC SYSTEM
● Limbic structures are involved in the development of emotions.
● Hippocampus is concerned with recent memory.
SCHIZOPHRENIA
● It results from excess of dopamine in limbic receptors.
● Its symptoms include
1. Chronically disordered thinking
2. Blunted affect
3. Emotional withdrawal
4. Paranoid delusions and auditory hallucinations.
KLUVER-BUCY SYNDROME
● Lesions of the amygdaloid complex (temporal lobe) lead to the Kluver-Bucy
syndrome.
● They become docile & show no evidence of fear or anger and are unable to appreciate
objects visually.
● They have an increased appetite and increased sexual activity (even with male and
female).
BASAL GANGLIA
DISORDERS OF BASAL GANGLIA
● Disorders of the basal nuclei are of two general types.
HYPERKINETIC DISORDERS
● Disorders of excessive & abnormal movements i.e; chorea, athetosis, and ballism.
HYPOKINETIC DISORDERS
● Disorder that completely lack or shows slowness of movement
CHOREA
● Chorea involves involuntary, quick, jerky, irregular movements that are nonrepetitive
i.e; Swift grimaces and sudden movements of the head or limbs
HUNTINGTON DISEASE
● Huntington disease is autosomal dominant disease.
● There is a single gene defect on chromosome 4.This gene encodes a protein,
huntingtin.The codon (CAG) that encodes glutamine is repeated many more times
than normal.
● There is degeneration of the GABA-secreting & acetylcholine-secreting neurons of
striatonigral-inhibiting pathway.
● This results in the dopa-secreting neurons of the substantia nigra becoming
overactive; thus, the nigrostriatal pathway inhibits the caudate nucleus and the
putamen.
● Disease involves
1. Choreiform movements ( involuntary movements of extremities) and
twitching of the face (facial grimacing). Later more muscle groups are
involved, so the patient becomes immobile and unable to speak or swallow.
2. Progressive dementia occurs with loss of memory and intellectual capacity.
SYDENHAM CHOREA
● Sydenham chorea (St. Vitus' dance) is a disease of childhood in which there are
rapid, irregular, involuntary movements of the limbs, face,and trunk.
● The condition is associated with rheumatic fever. Antigens of the streptococcal
bacteria are similar in structure to proteins present in the membranes of striatal
neurons.
● The host's antibodies not only combine with bacterial antigens but also attack
membranes of neurons of basal ganglia.
HEMIBALLISMUS
● Hemiballismus is a form of involuntary movement confined to one side of the body.
● It involves the proximal extremity musculature,and the limb suddenly flies about out
of control in all directions.
● The lesion (small stroke)occurs in the opposite subthalamic nucleus.
PARKINSON’S DISEASE
● Parkinson disease includes both types of motor(hyperkinetic & hypokinetic)
disturbances.
● There is degeneration of the neurons of substantia nigra (that send their axons to
corpus striatum) & it results in reduction in the release of neurotransmitter dopamine
within corpus striatum.
● This leads to hypersensitivity of the dopamine receptors in the postsynaptic neurons in
the striatum.
● Following are signs & symptoms of parkinsonism (PARR)
1. POSTURAL DISTURBANCES
● Patient stands with a stoop with arms flexed.
● The patient walks by taking short steps and often is unable to stop.
2. AKINESIA
● There is a difficulty in initiating and performing new movements.
● The movements are slow, the face is expressionless, and the voice is slurred and
unmodulated.
● Swinging of the arms in walking is lost.
3. RIGIDITY
● This differs from the rigidity caused by lesions of the upper motor neurons in that it is
present to an equal extent in opposing muscle groups.
● If tremor is absent, the rigidity is felt as resistance to passive movement (plastic
rigidity).
● If the tremor is present,muscle resistance is overcome as a series of jerks, called
(cogwheel rigidity).
4. RESTING TREMORS
● Resting tremors occur due to alternating contraction of agonists & antagonists.
5. EFFECT OF PARKINSONISM ON MUSCLE POWER
● There is no loss of muscle power and no loss of sensibility. Since corticospinal tracts
are normal, the superficial abdominal reflexes are normal.
● There is no Babinski response.
● The deep tendon reflexes are normal.
POSTENCEPHALITIC PARKINSONISM
● Postencephalitic parkinsonism developed following the viral encephalitis outbreak of
1916-17 .
IATROGENIC PARKINSONISM
● Iatrogenic parkinsonism can be a side effect of antipsychotic drugs (drugs which
block D2 receptors)e.g., phenothiazines,Meperidine analogues.
ATHEROSCLEROTIC PARKINSONISM
Atherosclerotic parkinsonism can occur in elderly hypertensive patients.
TREATMENT
1. By elevating brain dopamine level. Unfortunately, dopamine cannot cross the blood-
brain barrier, but its immediate precursor L-dopa can and is used.
2. Selegiline inhibits monoamine oxidase, which is responsible for destroying dopamine
3. Transplantation of human embryonic dopamine-producing neurons into the
caudate nucleus and putamen & Pallidotomy (surgical lesions in the globus pallidus).
ATHETOSIS
● Athetosis consists of slow, sinuous, writhing movements that most commonly
involve the distal segments of the limbs.
● Degeneration of globus pallidus occurs with a breakdown of the circuitry involving
the basal nuclei and the cerebral cortex.
CSF & VENTRICLES
LUMBAR PUNCTURE
● Lumbar puncture is performed to obtain samples of cerebrospinal fluid for
various diagnostic and therapeutic purposes.
● In this procedure, a needle is introduced into the subarachnoid space through
the interval between the third and fourth lumbar vertebrae.
● With the patient lying on his or her side or in the upright sitting position,
with the vertebral column well flexed, the space between adjoining laminae in
the lumbar region is increased to a maximum.
STRUCTURES THAT ARE PENETRATED
● Structures through which the needle passes during a lumbar puncture are
1. Skin
2. Superficial fascia
3. Supraspinous ligament
4. Interspinous ligament
5. Ligamentum flavum
6. Areolar tissue.
PURPOSE OF LUMBAR PUNCTURE
● Purpose of lumbar puncture is to
1. Estimate CSF pressure
2. Collect CSF
3. Introduce air & radiopaque dyes to subarachnoid space
4. Spinal Anaesthesia
QUENKENSTEDT’S SIGN
● When there is a CSF block, there is no rise in manometer reading and
queckenstedt sign is said to be positive, in conditions like
1. Blockage of the subarachnoid space.
2. Compressed internal jugular vein in the neck
3. Cerebral venous pressure is increased & absorption of CSF is inhibited.
HYDROCEPHALUS
● An abnormal increase in the quantity of CSF can lead to enlargement of the
head in children.
● Abnormal pressure of CSF leads to degeneration of brain tissue.
● Hydrocephalus may be caused by excess production of CSF, by obstruction to its
flow,or by impaired absorption through the arachnoid villi.
● It is classified as obstructive/non-communicating, when there is obstruction to
flow of CSF from the ventricular system to the subarachnoid space or as
communicating, when such obstruction is not present.
INTRACRANIAL PNEUMOGRAPHY
● Intracranial pneumography is replacement of cerebrospinal fluid within the
ventricles and subarachnoid space with air or oxygen. Because the air or gas is less
dense than the fluid or neural tissue, ventricles and cerebral gyri can be visualized.
● In an encephalogram, the air or oxygen is introduced through a spinal
tap.Radiographs of the skull are then made.
● In a ventriculogram, air or oxygen is introduced into the lateral ventricle through a
needle inserted through a hole in the skull (in a young child, the needle may be
inserted through a suture). Radiographs of the skull are then made.
● In ventriculography, only the ventricles are visualized.

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REVISED IMPORTANT CLINICALS

ABDOMEN & PELVIS

ANTERIOR ABDOMINAL WALL & INGUINAL REGION

It is more common in females It is more common in males

Less common More common

Common in older people Mostly in younger individuals

Rarely enters the scrotum Commonly passes into the scrotum

SUPERFICIAL ABDOMINAL REFLEX

INTERNAL HAEMORRHOIDS EXTERNAL HAEMORRHOIDS

Covered by mucous membrane Covered by skin

Less painful More painful

SUPERIOR MESENTERIC ARTERY OBSTRUCTION

EXTRADURAL HEMORRHAGE SUBDURAL HEMORRHAGE

It is arterial, occurs due to injury to the middle It is venous in nature

No blood in the CSF Blood in the CSF is a common feature

Its symptoms occur late Its symptoms occur early

Paralysis is not haphazard Paralysis is haphazard

Lucid interval is present i.e temporary phase Lucid interval is absent

Paralysis Group of muscles of one or Individual muscles are

Muscle tone Spastic paralysis Flaccid paralysis

Deep tendon reflexes Exaggerated Absent

Superficial reflexes like Absent Absent

Plantar response Extensor (Babinski sign Absent

Muscle atrophy No Present due to denervation

Fasciculations & Absent Present

Other Loss of performance of fine There is muscle contracture

COMPLETE CORD TRANSECTION SYNDROME

Below the lesion Bilateral upper motor neuron

Loss of pain, temperature & Damage to lateral &

Bladder & bowel function Damage to descending

ANTERIOR CORD TRANSACTION SYNDROME

Below the level of lesion Bilateral Upper motor

CENTRAL CORD SYNDROME

At the level of lesion 1.Ipsilateral lower motor 1.Damage to anterior grey

Below the lesion 1.Ipsilateral upper motor Damage to descending tracts

Inferior cerebellar peduncle Loss of equilibrium (ataxia) and giddiness

Lateral spinothalamic tract Loss of sensation of pain and temperature

Vestibular nuclei Vomiting, nystagmus and vertigo

Descending autonomic fibres Ipsilateral Horner’s syndrome characterized

MEDIAL MEDULLARY SYNDROME

Corticospinal fibres (pyramids) Contralateral hemiplegia

Medial lemniscus Contralateral loss of sensation of fine

MEDULLARY TEGMENTAL SYNDROME

POSTURAL AND GAIT CHANGES

Primary motor area (4) Contralateral monoplegia ( hemiplegia)

Premotor area (6) Apraxia (Skilled movements are affected)

Frontal eye field (8) Deviation of eyes to side of lesion

Prefrontal area (9,10,11,12) Personality changes

Motor speech area / Broca(44,45) Expressive/motor aphasia–Difficulty in

Second somatosensory area inability to appreciate pain and temperature

Sensory speech area/Wernicke area (40) Receptive/sensory aphasia–Loss of ability

Auditory association area (22) Word deafness (auditory verbal agnosia)–

Primary visual area (17) Contralateral homonymous hemianopia

Visual association area (18, 19) Visual agnosia–Loss of ability to recognize

ARTERIAL SUPPLY OF INTERNAL CAPSULE

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