Case Discussion - Ulcers

Q. What is your diagnosis ?
A. A chronic post-traumatic (non-specific) leg
ulcer in the (mention the region) of the Rt./Lt. leg.
Q. Why did you diagnose it non specific ulcer ?
A. Because it has the following characters (in
addition to a history of severe trauma) :
• Site : It is commonest over shin of tibia
• Size : Any size
• Shape : Rounded, oval or irregular
• Edge : Sloping edge
• Floor : shows healthy or unhealthy
granulations which may be raised, flat or
below surface
• Base : Indurated, may be fixed to the
underlying bone
• Margin : May be pigmented
• Discharge : Serous or pus discharge
• Draining LNs. : Usually show secondary
lymphadenitis
Q. What is the aetiology of this type of
ulcers ?
A. It is caused by wounds, burns, corrosives,
radiation or traumatic gangrene including bedsore
(decubitus ulcer), plaster sores and direct crushes.
Q. Why this type of ulcer has the tendency to
become chronic ?
A. It becomes chronic being maintained by
repeated trauma, pyogenic infection and poor
blood supply from congestion caused by long
sitting or standing.
Q. What is indolent ulcer ?
A. In very chronic ulcers with excess fibrosis base
and edge become hard (callous) and such an ulcer
resists healing and is called indolent ulcer.
Q. What are the investigations required in
this case ?
A. Plain X ray tibia to show any bony involvement,
culture and sensitivity to give the specific
antibiotic, Biopsy from the edge to confirm the
diagnosis. This is in addition to the routine
investigations.
Q. What is the treatment of this case ?
A.
1. Conservative treatment : This is indicated in
small ulcers, provided that they are not indolent.
(i.e. not callous). Conservative treatment includes :
rest, elevation of foot, avoid long sitting or
standing, frequent dressings, pressure bandage,
and antibiotics if indicated (according to culture
and sensetivity).
2. Surgery : It is indicated in 1) large ulcers, 2)
indolent ulcers. Surgery includes excision of the
ulcer and covering the defect by a skin flap.
Q. Why do you prefer a skin flap as the
method of coverage ?
A. Because skin grafts in the leg have the
tendency to re-ulcerate (venous congestion, poor
blood supply, frequent traumata,...)
Q. What are the characters of venous ulcer ?
A. Over the medial malleolus; surrounded by
pigmentation, dermatitis, scaly skin and leg
oedema; sloping edge; floor shows healthy or
unhealthy granulations which may be raised, flat
or below surface; indurated base, and serous or
pus discharge.
Q. What is the aetiology of this type of
ulcers ?
A. It is caused by 1ry or 2ry varicose veins but
more commonly with 2ry V.V (in postphlebitic
limbs following D.V.T.).
Q. What are the trophic ulcers ?
A. These are ulcers due to impaired nutrition of
the skin. They include both ischaemic ulcers and
neurotrophic ulcers.
Q. What is chronic osteomyelitis ulcer ?
A. It Develops at outer opening of osteomyelitis
sinuses. There are multiple sinuses discharging
sequestra.
Q. What are the malignant ulcers that can
develop in the leg ?
A. Malignant leg ulcers include :
• a. Primary Skin Cancer : squamous cell
carcinoma, melanoma
• b. Marjolin's Ulcer : Squamous cell carcinoma
in chronic ulcer, osteomyelitis sinus or old
scar. It is a slowly growing malignancy
• c. Ulcerating Deep Cancer as osteosarcoma,
fibrosarcoma of bone or muscle
Q. Is it common to find distant metastases in
Marjolin ulcer ?
A. This is very rare because of the severe fibrosis
surrounding the ulcer
Oral Questions on a Case of Cleft Lip & Palate
Case 1. CLEFT LIP
Q. What is your diagnosis ?
A. Unilateral incomplete simple cleft lip not
associated with cleft palate.
Q. What do you mean by incomplete ?
A. The cleft is not reaching the nostril floor.
Q. What do you mean by simple ?
A. There is no associated cleft of the alveolar
margin.
Q. Did you hear about cleft lower lip ?
A. It is an extremely rare anomaly it is
characterized by being median in position.
Q. What are the types of cleft palate you
know ?
A. Cleft uvula, cleft soft palate, incomplete cleft
palate (Cleft soft and hard palate not reaching the
alveolar margin), Complete cleft palate.
Incomplete and complete cleft palate could be
unilateral or bilateral.
Q. What do you mean by uni or bilateral cleft
palate ?
A. It depends on whether the mouth cavity is
communicating with one or the two nasal cavities.
Q. When do you repair cleft lip ?
A. At about the age of 3 months.
Q. Why this age specifically ?
A. It is preferred not to do the operation before
this age because at that age the Hb% is almost 10
gm% and the weight of the child is almost 10
bounds and this is optimum and safe for
anasthesia (in other words, the operation before
this age is rather risky).
On the other hand, the operation is preferred not
to be delayed after that age for the following
reasons : 1) for the proper development of teeth,
2) for psychological relief of the parents' worry
about their child and 3) for proper suckling
(although the role played by the lip in suckling is
not that considerable if compared with that of the
palate).
Q. What is the principle of any operation
described for the repair of cleft lip ?
A. The principles for any repair of cleft lip are :
1. To bypass the defect : by suturing the muscles,
skin and mucous membrane (3 layer closure)
2. To lengthen the lip : by interpositioning of flaps
from both sides adjusting all esthetic points.
Q. What is the commonest operation for the
repair cleft lip ?
A. Millard repair.
Q. Why not to do freshening and direct
suture without the need to do rotation and
advancement flaps ?
A. This direct suture would produce what is called
"a lip notch" because of the shortening of the lip
at the edges of the cleft.
Q. What are the complications of cleft palate ?
A. 1) Malnutrition due to improper suckling.
2) Repeated chest infection due to aspiration from
regurgitated food and water
3) Speech abnormalities
4) Otitis media due to Eustachean tube
obstruction by oedema around its mouth.
Q. What is the cause of improper suckling in
cleft palate ?
A. Failure to create an intraoral negative pressure.
Q. What are the speech abnormalities
encountered in cleft palate ?
A. 1) Nasal tone of speech (Rhinolalia) and 2)
Inability to pronounce some syllables like K, L, Q.
Q. At what age do you prefer to repair cleft
palate ?
A. The repair of the most anterior palate can be
done during the same operation of repair of the
cleft lip, while the remaining posterior palate is
repaired at about the age of 11/2 to 2 years.
Q. Is it preferred to postpone the operation
after the age of 2 years ?
A. No, because the speech abnormalities of the
cleft palate become irreversible (Imprinted in the
brain).
Q. So, you mean if the patient presents to
you at a later age, you do not recommend to
do the operation ?
A. No, the operation is still recommended as it
would prevent nasal regurgitation and might
improve the nasal tone of speech.