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Part 1 book “Clinical surgery pearls” has contents: Toxic goiter, solitary thyroid nodule, solitary thyroid nodule, multinodular goiter, early breast cancer, advanced breast cancer, epigastric lump, right hypochondrial lump without jaundice, right hypochondrial lump without jaundice, appendicular mass,… and pther contents.
CLINICAL SURGERY PEARLS CLINICAL SURGERY PEARLS SECOND EDITION R Dayananda Babu MS MNAMS Professor and Head Department of Surgery Sree Gokulam Medical College and Research Foundation Venjaramoodu, Thiruvananthapuram, Kerala, India Foreword Mathew Varghese ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi London Philadelphia Panama đ Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83, Victoria Street, London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: info@jpmedpub.com Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bld 237, Clayton Panama City, Panama Phone: +507-301-0496 Fax: +507-301-0499 Email: cservice@jphmedical.com Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: +08801912003485 Email: jaypeedhaka@gmail.com Jaypee Brothers Medical Publishers (P) Ltd Shorakhute, Kathmandu Nepal Phone: +00977-9841528578 Email: jaypee.nepal@gmail.com Jaypee Brothers Medical Publishers, Ltd The Bourse 111 South Independence Mall East Suite 835, Philadelphia, PA 19106, USA Phone: + 267-519-9789 Email: joe.rusko@jaypeebrothers.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2013, Jaypee Brothers Medical Publishers All rights reserved No part of this book may be reproduced in any form or by any means without the prior permission of the publisher Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work If not specifically stated, all figures and tables are courtesy of the author Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device Clinical Surgery Pearls First Edition: 2010 Second Edition: 2013 ISBN 978-93-5090-396-4 Printed at Dedicated to My late parents for their love and affection – Mr Raghavan and Mrs Mallakshy My only sister – late Ms Damayanthy My wife – Professor (Dr) Geetha Bhai and to my beloved son Deepak D Babu for their moral support My teachers for their wisdom My patients for their trust and support My students for their assistance Foreword Professor R Dayananda Babu is known to me for the past forty years I have great admiration for his wealth of knowledge in the subject of surgery He has written the book Clinical Surgery Pearls with careful and persistent effort The overriding goal has been the mobilization of information relative to the science and skills of surgery In addition to defining the frontiers of surgical knowledge, it affords the student to assimilate the fundamentals in an easy way This book will be an enormous help to those who are studying surgery at both undergraduate and postgraduate levels I wish the book a great success Professor (Dr) Mathew Varghese MS FRCS Ed Emeritus Professor of Surgery Government Medical College Kottayam, Kerala, India Preface to the Second Edition The first edition of this book was published in 2010 It is gratifying to note the wide acceptance of this book as an exam cracker by undergraduates and postgraduates alike; and, therefore, I was forced to bring out the second edition within years of the initial publication I am happy to note that now this book is recommended by many universities There is no need to stress the importance of refreshing a book like this I was forced to spend many hours in rectifying the errors which have crept up in the first edition The old chapters have been thoroughly revised and updated The new American Joint Committee on Cancer (AJCC), 7th edition, has been used for staging and management, instead of the 6th edition of AJCC as used in the first edition At the end of some of the important cases, colored boxes have been used under the title “What is new—For postgraduates, the unique unorthodox style, the student-oriented approach and the question-answer format are still retained.” I am grateful to Professor John S Kurian, who is Professor of Surgery at Government Medical College, Kottayam, Kerala, India, for the effort he has taken to find out the errors and for coming up with suggestions for improvement I also thank Dr Deepak George, for his valuable suggestions for improvement of many of the chapters I also thank the publisher M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for bringing out a high-quality second edition book quickly R Dayananda Babu Mesenteric Cyst • If a very large segment of small intestine is implicated, an anastomosis should be made between the apex of the coil of small intestine and the cyst wall (the cyst wall will hold sutures well) Q 15 What is the role of marsupialization? This is an old form of treatment not recommended nowadays because of the fear of fistula and recurrence Q 16 What is the surgical treatment if it is an omental cyst? Omentectomy Q 17 What are the neoplasms of the mesentery? They are classified as benign and malignant Benign Malignant • Lipoma • Lymphoma • Fibroma • Secondary carcinoma • Fibromyxoma Q 18 What is the management of benign neoplasms? Benign tumors are excised in the same way as mesenteric cyst, along with resection of the adjacent intestine Q 19 What is the management of malignant neoplasms? • Biopsy confirmation • Chemotherapy for lymphoma • Chemotherapy for secondary carcinoma Q 20 How does tuberculous lymphadenitis occur? The tubercle bacilli are usually ingested and they enter the mesenteric lymph node by way of Peyer’s patches The organism may be human or bovine It can occur after ingestion of raw milk It may affect a single lymph node or multiple lymph nodes presenting as massive abdominal swelling Q 21 What is pseudomesenteric cyst? When tuberculous mesenteric lymph nodes breakdown, the tuberculous pus may remain between the leaves of the mesentery and cystic swelling similar to mesenteric cyst is formed When such a situation is found the pus is evacuated without soiling the peritoneal cavity and anti tuberculous treatment is instituted Q 22 What is the cause for yellow-colored lymph nodes in the ileocecal region? Metastasis from carcinoid of the appendix will give rise to yellow color for the lymph nodes Q 23 What are the causes for calcified shadows in the plain radiograph of the abdomen? Causes for radiopaque shadow in plain X-ray abdomen Renal or ureteric stone (renal stones are uniform in density, take the shape of pelvicalyceal system and lies superimposed on the shadows of the vertebral column in the lateral view) Gallstones are (less dense in the center and in front of the vertebral bodies on the lateral view) Pancreatic calculi Calcified tuberculous lymph node—usually in the ileocecal region and line of attachment of the mesentery—outline is irregular and the nodes are mottled like black berry Phlebolith Calcified costal cartilage Fecolith Stone in the appendix Calcified renal artery 10 Calcified aneurysm of the abdominal aorta 11 Chip fracture of the transverse process of the vertebrae 281 Clinical Surgery Pearls Q 24 How long it will take for calcification to occur in tuberculous lymph nodes? Eighteen months Q 25 Will the nodes be noninfective in such a situation? No The node need not be defunct So infection is still possible Q 26 What is the cause for acute non specific ileocecal mesenteric adenitis? The etiology of this condition is unknown, it affects children and unusual after puberty Some cases are associated with Yersinia infection of the ileum In other situations unidentified virus is blamed Respiratory infection precedes an attack of mesenteric adenitis This is a self-limiting disease It is called nonspecific in order to distinguish it from tuberculous mesenteric adenitis Q 27 What are the clinical manifestations of nonspecific mesenteric adenitis? • Central abdominal pain lasting for 10–30 minutes • Associated circumoral pallor • Vomiting is common Contd 282 Contd • No alteration in bowel habits • Intervals of complete freedom from pain • The patient seldom looks ill • Temperature may be elevated but never exceeds 38.5 • Tenderness along the line of mesentery • Shifting tenderness (after the patient lies on the left side for a few minutes the tenderness shift to the left side) • Pelvic peritoneum is tender to palpation Q 28 What will be the total leukocyte count like? There is often leukocytosis in contrast to tuberculosis Q 29 What is the treatment of nonspecific mesenteric adenitis? • Bed rest for a few days (if the diagnosis can be made with certainty) • If appendicitis cannot be excluded laparoscopy followed by appendectomy if required Section Short Cases 22 Case Non-thyroid Neck Swelling Examination of non-thyroid neck swellings: Diagnostic algorithm for a neck swelling Identify the anatomical situation of the swelling (in relation to the triangle in the neck) ↓ Decide the plane of the swelling ↓ Recollect your anatomy (what are the normal anatomical structures situated in the region of the swelling in that plane) ↓ Check for mobility/fixity of the swelling ↓ Find out the external (size, shape, surface, edge, temperature, tenderness, etc.) and internal features of the lump (solid or cystic, compressible/ reducible, pulsation, transillumination) and auscultation of the swelling ↓ Find out its effect on the surrounding tissue (feel the superficial temporal artery, examine the relevant cranial nerves and look for Horner’s syndrome) ↓ Look for regional nodes (if the swelling is a node look for another group and contralateral side of the neck) ↓ In the case of paired organs like salivary gland, look for contralateral pathology also ↓ Look for a primary lesion (scalp, oral cavity, pharynx, hidden areas, etc.) ↓ 10 Come to an anatomical diagnosis ↓ 11 Come to a pathological diagnosis (Decide whether it is congenital /traumatic/inflammatory/neoplastic— primary or secondary) ↓ 12 If it is an organ concerned with function decide whether it is hyper functioning, normally functioning or hypofunctioning (functional diagnosis) The final diagnosis = Anatomical + Pathological + Functional diagnosis Clinical Surgery Pearls Q What are the causes for non-thyroid neck masses? All regions • Skin and subcutaneous tissue Sebaceous cyst Lipoma Neurofibroma • Lymphadenopathy Acute infection Chronic infection—tuberculosis Primary malignant—lymphoma Secondary malignant—metastasis Midline Sublingual dermoid Thyroglossal cyst/fistula Pharyngocele Laryngocele Note: and not lie in the midline but arise from the midline Lateral Parotid swellings Submandibular salivary gland Branchial cyst Carotid body tumor Carotid aneurysm Carotid tortuosity Cystic hygroma Subclavian aneurysm 286 Triangles of the Neck The neck is divided into Anterior and Posterior triangles (Fig 22.1) The boundaries of the anterior triangle are: • Midline Fig 22.1: Triangles of the neck • Anterior border of the sternomastoid (oncologically the boundary is the posterior border of the sternomastoid) • Inferior border of the ramus of the mandible The anterior triangle is further divided into: • Digastric • Carotid • Muscular The boundaries of the posterior triangle are: • Posterior border of the sternomastoid • Anterior border of trapezius • Upper border of the middle-third of the clavicle Table 22.1 showing the Triangles of the neck, its boundaries, contents and possible swellings in each area Non-thyroid Neck Swelling Triangle Digastric Carotid Muscular Posterior Table 22.1: Triangles of the neck Contents • Submandibular gland Boundaries • Inferior border of the ramus of the mandible • Anterior portion of the digastric muscle • Posterior portion of the digastric muscle • Midline • Anterior belly of omohyoid • Anterior border of sternomastoid • Posterior belly of digastric • Lymph node Possible swellings • S ubmandibular swellings—sialadenitis, tumor • Lymph nodes swelling • Facial artery • Ranula (plunging) • Common carotid artery dividing to internal and external at the level of hyoid bone • Vagus nerve • Lymph nodes • Internal jugular vein • Anterior belly of digastric • T hyroid—may extend beyond • Anterior belly of omohyoid this area including the posterior • Midline triangle • Laryngeal structures • Posterior border of sternomastoid • Lymph nodes • Anterior border of trapezius • Accessory nerve • Upper border of middle third of • Scalenus anterior muscle clavicle • Sublingual dermoid • Carotid body tumor • Branchial cyst • Carotid aneurysm • Pharyngocele • Thyroid swelling • Laryngocele • Innominate aneurysm • Thyroid swelling • Cystic hygroma • Lymph nodes • Subclavian aneurysm *Note: Skin and subcutaneous swellings like lipoma, sebaceous cyst and neurofibroma can occur in all the regions Remember the etiology of non-thyroid neck mass Midline swellings of the neck Sublingual dermoid Plunging ranula Thyroglossal cyst Pharyngocele Laryngocele Swellings from isthmus of thyroid Prelaryngeal lymph node Pretracheal lymph node Lymph nodes in the space of burns Remember the hidden areas of primary for a metastasis in the neck Remember the midline swellings of the neck They are from above downwards: Hidden areas for primary • Pyriform sinus • Base of tongue • Vallecula • Fossa of Rosenmüller • Tonsillar fossa 287 23 Case Tuberculous Cervical Lymph Node Case Capsule A 20-year-old male patient with multiple swellings on the side of the neck involving the jugulodigastric group of lymph nodes and nodes on the anterior and posterior triangles of neck The nodes are of varying consistency, some are soft and some are firm The jugulodigastric and upper deep cervical nodes are matted together The patient complains of evening rise of temperature Read the diagnostic algorithm for a neck swelling Read the checklist of case no 15 of long cases Checklist for history • • • • • Family history of tuberculosis H/o exposure to tuberculosis H/o BCG vaccination H/o evening rise of temperature H/o loss of appetite and loss of weight Checklist for lymph node examination: Remember the pneumonic – PALS (P – Look for Primary lesion in the drainage area, A – Look for Another lymph node, L – Look for Liver, S – Look for Spleen) (Read case no.15 of long cases) Tuberculous Cervical Lymph Node Remember the lymphatic water sheds in the body for the skin lymphatic drainage (Read case no.15 of long cases) Remember the order of palpation of cervical lymph nodes (Fig 23.1) Remember the causes for matting of lymph nodes Always examine the oral cavity including the tonsil Examine the chest for evidence of pulmonary tuberculosis Q What is the anatomical diagnosis in this case? Lymph nodes Q What are the diagnostic points in favor of lymph nodes? Shape of the swelling Plane of the swelling—deep to deep fascia Fig 23.1: Cervical lymph node examination Q What is the plane of the cervical lymph nodes? For all practical purposes majority of the cervical lymph nodes are deep to deep fascia Flow chart 23.1: Classification of cervical lymph nodes 289 Clinical Surgery Pearls Q What are the groups of lymph nodes which are superficial to the deep fascia in the neck? The external jugular group of lymph nodes The submental nodes The occipital nodes The facial nodes Postauricular nodes Q How many lymph nodes are there in the neck? • Roughly 300 nodes (out of total 800 nodes in the human body) • About 150 are in the mesentery Q What are the functions of lymph nodes? Filtration of effete cells, bacteria and antigens Presentation of antigens to the lymphocytes Regulation of protein content of efferent lymph Q How will you classify cervical lymph nodes? They may be classified as shown in flow chart 23.1 Note: SM muscle—sternomastoid muscle 290 Q What is the sequence of palpation of cervical lymph nodes? The following sequence is recommended Start palpitating from above from the submental node and proceed backwards (Fig 23.1) Submental Submandibular Preauricular Postauricular Occipital Then proceed downwards laterally from the jugulodigastric Jugulodigastric Deep cervical Jugulo-omohyoid Scalene 10 Supraclavicular Now proceed upwards to the external jugular nodes (superficial) Q What are the causes for lymphadenopathy? The causes may be classified as shown in Flow chart 23.2 Q 10 What is the plan of action for finding out the source of the enlarged lymph nodes? Search for primary lesion in cervical lymph adenopathy Start from above and work downwards 10 Examine the skin of the scalp, face, ears and neck Examine the nose Transilluminate the air sinuses Examine the oral cavity Examine the nasopharynx and larynx (ENT examination) Palpate the salivary glands (parotid and submandibular) Examine the thyroid gland Examine the breast Examine the chest Examine the abdomen and genitalia Q 11 What is the pathological diagnosis in this case? Most probably this is a case of tuberculous cervical lymphadenitis Q12 What are the points in favor of tuberculosis of the lymph node? Matting of lymph nodes Varying consistency of the nodes Jugulodigastric node is affected (which is the most common group affected in tuberculosis) Evening rise of temperature Tuberculous Cervical Lymph Node Flow Chart 23.2: Classification of causes for lymphadenopathy Q 13 What are the causes for matting? Causes for matting of lymph nodes: Tuberculous lymphadenitis Acute lymphadenitis Late stages of lymphoma Late stages of metastasis neck Q 14 What is the cause for matting? The organism will reach the lymph node from the primary focus via the lymphatics The lymphatics are distributed along the periphery of the lymph nodes and from there it will reach the subcapsular sinus The subcapsular sinuses of adjacent lymph nodes are involved subsequently and this will produce matting Q 15 Can you get tuberculosis of the nodes without matting? Yes In miliary tuberculosis there won’t be any matting The organisms coming via the blood vessels enter the medullary region directly and therefore there is no periadenitis and matting in miliary tuberculosis Q 16 What is the anatomy of the cut section of lymph node? The lymph node is kidney-shaped and it has got a hilum The afferent and efferent vessels enter and leave the hilum It has got a capsule and beneath the capsule there is the subcapsular space All around the lymph nodes you get the lymphatics reaching 291 Clinical Surgery Pearls the capsule and sub-capsular space Organisms coming to the lymph node thus reaches the subcapsular space initially The lymph node has got a cortex and a medulla.The cortex has lymph follicles which is situated externally Beneath the cortex you get the medulla where the medullary cords are seen Organisms coming via the vessels reach directly the medulla in contrast to the lymphatics (Fig 23.2) Q 19 What is the incidence of cervical node tuber culosis secondary to pulmonary tuberculosis? • In 80% of cases the tuberculosis process is limited to the affected lymph nodes • Primary focus in the lungs must always be suspected and investigated • Atypical mycobacterial adenitis is seldom associated with pulmonary tuberculosis Q 17 What is the primary focus for cervical lymph node tuberculosis? The tonsil is usually the primary focus for the cervical node tuberculosis This can lead to jugulodigastric node enlargement (the tonsillar group of lymph nodes) and from there it will reach other groups in the neck Q 20 What are the groups of lymph nodes affected by tuberculosis in the body? Upper deep cervical Supraclavicular Mediastinal nodes Axillary Inguinal nodes Q 18 If you get isolated posterior triangular group of nodes which are proved to be tuberculosis, what is the likely primary focus? Adenoids Note: a Supraclavicular nodes represent the upward extension of hilar and mediastinal lymph adenopathy b Axillary and inguinal nodes are involved by hematogenous or retrograde lymphatic spread Q 21 What are the pathological stages of tuberculous lymph nodes? There are five stages (Fig 23.3): Stage 1: The lymph nodes are enlarged and solid There is no matting of lymph nodes (no periadenitis) Stage 2: The lymph nodes are large, firm and matted together (fixed to each other) because of the periadenitis 292 Fig 23.2: Lymph node section Stage 3: Stage of caseation and cold abscess— The lymph nodes breakdown, and liquefy The pus will collect beneath the deep fascia A fluctuant mass will be palpated without any overlying skin inflammation (cold abscess) In addition, nodes Tuberculous Cervical Lymph Node Fig 23.3: Tuberculosis lymphadenitis stages in order without softening will also be present which will give rise to varying consistency Stage 4: Stage of collar-stud abscess—The deep cervical fascia is eroded eventually resulting in the escape of pus beneath the superficial fascia which is a laborious space Q 24 What are the characteristics of tuberculous ulcer? The tuberculous ulcer has got undermined edges, seropurulent discharge and pale granulation tissue Q 22 Will the cold abscess contain tubercle bacilli? Yes The abscess is lined by granulation tissue and caseous material Q 25 What is collar-stud abscess? The pus is formed as a result of breakdown of a lymph node which will subsequently erode the deep fascia and come to the space beneath the superficial fascia There is a superficial soft swelling, which is nothing but pus, and is communicating with the offending lymph node situated deep to the deep fascia The node, the connection and the superficial soft swelling together will take the shape of a collar-stud Q 23 How a tuberculous ulcer is formed? Once a sinus is formed the discharge will infect the surrounding skin and cause ulceration Q 26 What are the clinical types of tuberculous lymphadenitis? There are four types: Stage 5: Stage of sinuses and ulcers—The pus will eventually burst through the skin resulting in a discharging sinus or ulcer 293 Clinical Surgery Pearls Acute type – Seen in infants and children below five years – Inflammatory signs may be there and may resemble acute lymphadenitis Caseating type—commonest type seen in young adults with typical matted nodes with caseation, cold abscess and sinuses Hyperplastic type—this is seen in patients with good resistance The lymphoid hyperplasia is more predominant than caseation The nodes are usually firm and discrete Atrophic type—seen in elderly where the lymph nodes undergo natural involution The nodes are small and burst resulting in caseation Q 27 What is scrofuloderma? The skin involvement as a result of tuberculosis is called scrofuloderma The skin will be discolored bluish or hyperpigmented 294 Q 28 How will you investigate and confirm your diagnosis? ESR—will be raised X-ray chest—evidence of pulmonary tuberculosis need not be there because majority of the cervical lymph node tuberculosis are primary (and not secondary to pulmonary tuberculosis) Tuberculin test (Mantoux)—a positive test has no diagnostic value (because of BCG vaccination) a negative test is useful in excluding tuberculosis FNAC of the lymph node Biopsy of the lymph node for pathology and microbiology Aspiration of the cold abscess for AFB staining Q 29 How Mantoux test is done? One unit of PPD (Purified Protein Derivative) is injected intradermally in the volar surface of the forearm After 48 hours, look for area of induration surrounding the injection site A positive test is one where the induration exceeds12 mm A positive test is suggestive of prior or present infection with M tuberculosis Negative results not always rule out tuberculosis (immunosuppression, malnutrition and diseases like lymphomas suppress the test) Q 30 Is FNAC of the node reliable? For lymph node pathology biopsy of the intact lymph node is always superior because a pathologist can study the architecture of the lymph node (this is not possible with FNAC) If the needle is striking the granuloma in the lymph node, the pathologist will give a positive report Therefore, biopsy is always a superior investigation for lymph node Q 31 What are the important points to be rememb ered while taking cervical lymph nodes for biopsy? Always try to take an intact node for biopsy If possible take nodes (1 node for the pathologist and node for the microbiologist) Send the lymph node for the pathologist in formalin Send the lymph node for the microbiologist in saline solution (this is for AFB culture) Q 32 What is the media used for culture and how long it will take to get a positive culture? • Lowenstein—Jensen media • Takes weeks for positive culture • Selinite medium—shortens the time of growth to days Q 33 What are the new methods for the diagnosis of tuberculosis? PCR – The result will be ready in one week BACTECT – (Using radioactive C14) Result will be ready in days Q 34 Suppose there is only one lymph node, would you attempt FNAC? No FNAC will induce changes in the lymph node, which are likely to alter the pathological picture if it Tuberculous Cervical Lymph Node is subsequently taken for biopsy study This is called WARF (Worrisome Anomaly Related to FNAC) Q 35 What are the pathological changes in the lymph node? Pathologically we get the tubercle, which consists of an area of caseation surrounded by giant cells, epithelioid cells, lymphocytes and plasma cells Q 36 What is the difference between caseous material and tuberculous pus? Caseous material—dry, granular and cheese like material is called caseous material (granular structure less material) Tuberculous pus—softening and liquefaction of the caseous material results in the formation of a thick creamy fluid called tuberculous pus It is highly infective because liquefaction is associated with multiplication of the organism In addition, it contains fatty debris in serous fluid with few necrotic cells Q 37 Can you start antituberculous treatment empirically without pathological or microbiological report? No Pathological or microbiological support is necessary for starting the antituberculous treatment Q 38 What are the organisms responsible for lymph node tuberculosis? • Human tuberculosis • Bovine tuberculosis Q 39 What are the organisms responsible for atypical Mycobacterium tuberculosis? • Mycobacterium avium intracellulare • Mycobacterium scrofulaceum Q 40 Is there any role for urine examination? Yes The renal and pulmonary tuberculosis occasionally coexist Therefore, the urine should be carefully examined Q 41 Is it possible to get calcified cervical lymph node without prior symptoms of cervical lymph node tuberculosis? Yes In patients with natural resistance to the infection, the nodes may accidentally detected at a later date as calcified nodes Q 42 What is the treatment of choice in a proved case of cervical lymph node tuberculosis? Antituberculous chemotherapy – Triple Drug Therapy– Rifampicin, INH and Ethambutol—(Read the chapter on long cases- right iliac fossa mass abdominal tuberculosis) Q 43 What are the indications for surgery in cervical lymph node tuberculosis? Indications for surgery in tuberculous lymph-adenitis Biopsy (the most important indications) Excision of a group of nodes if it is not responding to antituberculous treatment Excision of the offending lymph node in cases of collar-stud abscess Excision of abscess if it is not responding to aspiration Persistent sinus Q 44 What are the causes for persistent sinus? Causes for persistent sinus: Secondary infection Considerable fibrosis Necrotic and calcified material replacing the lymph node Q 45 If the cervical nodes are not responding to the antituberculous drugs what should be suspected? Atypical mycobacterial adenitis Q 46 What is the treatment of cold abscess? Aspiration Incision and drainage is not recommended because it will result in sinus formation Q 47 How will you aspirate cold abscess? Aspiration is done through the nondependent part 295 ... 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