By Z. Vibald. Rollins College.
Relative indications include severe ophthalmopathy purchase 160 mg super p-force overnight delivery, which Graves’ Disease is not improved with antithyroid medication 160mg super p-force sale, and poor com- Diffuse toxic goiter purchase super p-force 160mg line, or Graves’ disease, is a disorder charac- pliance with medications. The remaining patients should undergo thyroidism including heat intolerance, increased sweating, subtotal thyroidectomy. Additionally approximately 50 % of patients increases the chance of recurrence while lowering the chance with Graves’ disease develop ophthalmopathy characterized of postoperative hypothyroidism. Typically surgeons are rec- by prominent stare, periorbital edema, conjunctival swelling, ommended to leave a 4–7 g remnant in adults and 3 g in chil- proptosis, and limitation of upward and lateral gaze. Prior to surgery patients should be started on Lugol’s iodide three drops twice daily to reduce the vascularity of the P. When performing subtotal thyroidectomy, tissue can Department of Surgery, University of Iowa, 200 Hawkins Dr. More extensive resection is not recommended due to invasive ﬁbrosis, which Toxic Multinodular Goiter renders surgery difﬁcult. Symptoms are patients with continued symptoms after wedge resection often precipitated by iodide administration, as occurs with improve with corticosteroids. Most patients are thyroid hormone to suppress recurrent goiter formation, so asymptomatic, but as goiters become large, they cause com- leaving adequate thyroid tissue to prevent hypothyroidism is pressive symptoms including dysphagia, dysphonia, and not necessary. Care must be taken in identifying the recurrent even tracheal deviation and obstruction of venous ﬂow in the laryngeal nerve as it can be displaced laterally or anteriorly neck. Operative indications include obstructive symptoms, sub- sternal extension, proven or suspected malignancy, contin- Toxic Adenoma ued growth despite T4 suppression, and cosmesis. Most occur in young patients pected malignancy will be discussed in the next section. Small nodules typically can be managed medi- cally while large nodules can be treated with lobectomy or isthmusectomy. Total thyroidectomy is rarely required as Thyroid Carcinoma these nodules have a low rate or recurrence and very low malignant potential. The majority of thyroid nodules are benign; however, it is important to determine the risk for underlying malignancy. Riedel’s Thyroiditis Risk factors for malignancy include local symptoms (pain, Riedel’s thyroiditis is a rare disorder characterized by the dysphagia, hoarseness, choking), history of external beam replacement of the thyroid parenchyma with ﬁbrous tissue. The most common symptoms are of mass effect history of external beam radiation or a strong family history on the trachea and esophagus (dyspnea, dysphagia, hoarse- have an increased concern for malignancy and in some cases ness). Aspiration can be performed as many 119 Concepts in Thyroid, Parathyroid, and Adrenal Surgery 1045 as three times, after which the patient should undergo node dissection is advocated by some investigators; however, thyroidectomy for recurrent cysts. Patients with benign Follicular Thyroid Carcinoma cytology can be treated with suppressive T4 therapy, but Follicular carcinoma of the thyroid gland accounts for treatment has not been shown to inﬂuence the development around 10 % of thyroid cancer in non-iodine-deﬁcient areas or progression of thyroid carcinoma, the rate of thyroidec- and is more common in regions of iodine deﬁciency. In However, the false-negative rate of intraoperative pathol- some institutions, patients undergo thyroid lobectomy with ogy is around 20 % leading to a high rate of reoperation. Solitary follicular nodules in the setting of the risk of bilateral recurrent laryngeal nerve injury and a normal contralateral lobe can be treated with lobectomy, permanent hypocalcemia and preventing the need for thy- and no further treatment is necessary if pathology conﬁrms roid hormone replacement in 60–80 % of patients. Distinction of adenoma from carcinoma can with thyroiditis or multinodular disease have a higher inci- be difﬁcult, and up to 20 % of patients with benign frozen dence of requiring thyroid hormone replacement following section will reveal malignancy on formalin-ﬁxed parafﬁn- hemithyroidectomy. Patients with malignancy on ﬁnal pathology should return to the operating room for Papillary Thyroid Carcinoma completion thyroidectomy. Although completion thyroidec- Papillary carcinoma of the thyroid is the most common tomy in the setting of adequate resection margins has not malignant disorder of the thyroid and accounts for 80 % of been shown to increase survival, this approach enables the all thyroid malignancies. Patients with papillary thyroid car- use of thyroglobulin as a marker of recurrence and allows cinoma have a 10 years survival that is greater than 95 %. Prognosis Criteria that predict higher mortality are older patients, for patients with follicular carcinoma is good, with 10- and poorly differentiated tumors, extrathyroid invasion, metasta- 20-year mortality around 15 and 30 %, respectively. Presently the most common presen- thyroidectomy results in high rates of disease cure before tation is asymptomatic individuals noted to have elevated disease can be clinically detected. In some patients with low-risk mutations, it is mon symptoms include bone and abdominal pain, fatigue, safe to delay prophylactic thyroidectomy when calcitonin kidney stones, and bone demineralization. Localization studies are not used for diagnostic purposes but should be performed for operative planning. The World Health Organization the high false-positive and false-negative rates for all imag- classiﬁes Hurthle cell carcinoma as a type of follicular thy- ing individually, most centers use a combination of imaging roid carcinoma, and like follicular carcinoma, diagnosis of for preoperative localization. Hurthle also be difﬁcult, and although hypercellular glands are usu- cell carcinoma are more likely to be multifocal and bilateral, ally darker, ﬁrmer, and more vascular than normal glands, more likely to metastasize to lymph nodes and distant sites, the distinction sometimes requires the help of an experienced and have a higher mortality (20 % at 10 years) compared to pathologist. These ﬁndings have led some groups to to conﬁrm abnormal glands and identify additional hypercel- consider Hurthle neoplasms a separate entity. Operative management consists of hemithyroidectomy Approximately 85 % of patients with primary hyperpara- with isthmusectomy and intraoperative frozen section, fol- thyroidism have a single adenoma, while the remaining 15 % lowed by completion thyroidectomy for malignancy. Due to have multiple gland disease that may involve two, three, or the higher incidence of spread, patients with Hurthle cell car- all four parathyroid glands. Patients with four abnormal cinoma should undergo routine central neck dissection and glands (parathyroid hyperplasia) should be treated with 3. Embryologically the superior para- Secondary and Tertiary Hyperparathyroidism thyroid glands are derived from the fourth branchial pouch and the inferior glands from the third branchial pouch. In most patients the superior glands lie dor- renal failure, but other causes include inadequate calcium or sal to the recurrent laryngeal nerve at the level of the cri- vitamin D intake or absorption. Treatment is accomplished coid cartilage, with the inferior glands located ventral to medically through low-phosphate diet, phosphate binders, the nerve. Enlarged glands can migrate in position and can and calcium and vitamin D supplementation. The outer cortex is derived from the mesodermal the role of parathyroidectomy versus calcimimetic therapy tissue near the gonads and produces aldosterone, cortisol, for secondary hyperparathyroidism. Carcinoma of the parathyroid gland is rare and accounts for only 1 % of cases of primary hyperparathyroidism. Often it is identiﬁed intraoperatively by invasion performed for unrelated indications and occur on 1–5 % of into surrounding structures. The majority of incidentalomas are bloc resection including the ipsilateral thyroid lobe. Modiﬁed nonfunctioning tumors; however, up to 20 % of patients are radical neck dissection should be performed if metastases to found to have asymptomatic biochemical abnormalities. Hypertensive patients should be tested for serum electro- lytes and plasma aldosterone and renin to rule out Conn’s syndrome. Patients with functional tumors dis- are identiﬁable preoperatively and can undergo parathyroid- covered as incidentaloma should be treated as indicated by ectomy without four-gland exploration. Tumors that can have low rates of recurrent and persistent symptoms even are homogenous, well encapsulated, and hypoattenuat- in the setting of discordant or inconclusive imaging. Tumors with evidence of invasion, irregu- sensitive tool for adenoma localization but adds to the cost lar features, or high density or attenuation have higher of preoperative localization. The 24-h urinary cortisol measurement and, more recently, the Conn’s syndrome is characterized by excess secretion of salivary cortisol measurement are sensitive and speciﬁc for aldosterone by the adrenal gland and can be primary or hypercortisolism. Patients with steronism is successfully treated with treatment of the adrenal adenomas are treated with laparoscopic adrenalec- underlying cause. Patients require pre- and postoperative steroids due to of aldosterone from one or both adrenal glands. The classic long-standing suppression of the contralateral gland, which picture involves a hypertensive patient with hypokalemia; can be required for as long as 2 years after resection.
A shift of the mediastinum and depression of the diaphragm are frequently the first detectable signs super p-force 160mg with amex. The left hemithorax is completely virtually opaque generic 160 mg super p-force visa, and there is shift of the mediastinum to radiolucent and lacks vascular markings generic 160 mg super p-force overnight delivery. The left hemidi- aphragm is markedly depressed, and there is spreading of the left ribs. Pleural masses Metastatic tumor or malignant mesothelioma (ipsilateral lung may be completely opaque due to a massive pleural effusion). Partial absence of Striking shift of the heart to the left but no shift of pericardium other mediastinal structures (trachea, aorta). Many patients have no evidence of underlying lung (Figs C 32-1 and C 32-2) disease. Trauma to chest wall Closed-chest trauma causes an abrupt increase in intrathoracic pressure. Rupture of alveoli into the perivascular sheaths in the interstitial tissue of the lung results in the passage of air to the hilum and the mediastinum. Rupture of the esophagus Most frequently occurs during episodes of severe vomiting (Boerhaave’s syndrome), where the (Fig C 32-3) tear involves the lower 8 cm of the esophagus (relatively unsupported by connective tissue). The tear is classically vertical and involves the left posterolateral wall of the esophagus. Bronchial or tracheal injury Caused by trauma (shearing force) or a sudden increase in pressure against a closed glottis. After intubation and ven- tilation of a child with hydrocarbon poisoning, there is the Fig C 32-1 development of a pneumomediastinum (large arrow) and Pneumomediastinum. Note that the stiffness of the the mediastinal pleura (closed arrows), there is a characteris- lungs has prevented substantial collapse. Linear lucent shadows (arrows) represent localized mediastinal emphysema and correspond to the fascial planes of the medi- astinal and diaphragmatic pleurae in the region of the lower esophagus. Extension of gas from Trauma, surgical procedures, or perforating cervical lesions. May be associated with birth trauma, anesthesia, resuscitation attempts, and the straining and coughing associated with pulmonary disease. Hyaline membrane disease Frequent complication, probably related to extension of pulmonary interstitial emphysema. Frontal chest film made after blunt trauma to the upper chest that caused transection of both main-stem bronchi demonstrates free air in the mediastinum (upper black arrows) and through the fascial planes of the neck. The lucent zone (lower black ar- rows) along the left cardiac border simulates the pattern produced by a pneumopericardium or pneumothorax. However, the aortic arch is sharply circumscribed by air that extends around its cephalad and right lateral margins, at a level well above the pericardial reflection (white arrows). This clearly indicates that this air also is in the medi- astinum and not confined to the pericardium or pleural space. Pneu- astinal air (white arrows and black arrowheads) produces the angel’s-wings sign. Most common primaries are carcinomas of the (Fig C 33-3) bronchus, breast, ovary, and gastrointestinal tract. Pleural fluid (loculated or Smooth, sharply demarcated, homogeneous Loculated fluid collections are caused by adhesions interlobar) opacity. An interlo- bar fluid collection generally results from cardiac decompensation and may simulate a neoplasm, although it tends to absorb spontaneously when the heart failure is relieved (vanishing or phantom tumor). Pulmonary infarct Homogeneous, wedge-shaped peripheral con- Classic but uncommon manifestation of an infarct. Rib or chest wall lesion Extrapleural mass, often with destruction, Primary or metastatic neoplasm, osteomyelitis, (see Fig C 34-4) fracture, or expansion of the underlying rib or fracture with hematoma or callus. Multiple masses mogeneous soft-tissue mass (arrows) arising from the thicken the right pleura (arrows) in an elderly man with mediastinal pleura and projecting into the right hemitho- chronic asbestos exposure. The patient had only mild underlying interstitial fibro- sis and no pleural plaquing. May disap- pear spontaneously and rapidly or remain un- changed and mimic a solitary pulmonary nodule when viewed en face. Pancoast tumor (superior Apical mass, often with destruction of adjacent Site of 6% of bronchogenic carcinomas. In the absence (Fig C 33-6) of bone destruction, the tumor may be identified only by asymmetry of presumed apical pleural thickening. Large soft-tissue mass fills much of hemidiaphragm because of phrenic nerve involve- the left hemithorax. Elliptical fluid collection cal pleural thickening, the marked asymmetry and irregularity (arrow) in the major fissure in a patient with car- of the right apical mass should suggest the diagnosis of bron- diac decompensation. Rare lesion that may change shape during res- piration (due to its relatively fluid contents). May Actinomycosis, nocardiosis, blastomycosis, and (Fig C 33-7) have associated rib destruction. Pulmonary granuloma Smooth, sharply circumscribed mass that may Primarily histoplasmoma. Although primary pleural lymphoma as the only (Fig C 33-8) site of malignancy is rare, lymphomatous involve- ment of the pleura may occur in association with mediastinal lymphadenopathy or pulmonary par- enchymal lymphoma. The lymphomatous pleural deposits arise from lymphatic channels and lym- phoid aggregates in the subpleural connective tissue below the visceral pleura. Associated pleural effusion is attributed to obstruction of lymphatic channels by mediastinal lymphadenopathy. Large peripheral thick-walled cavity (large arrows) that abuts the pleura and contains an intracavitary fungus ball (small arrow). Callus formation about an old rib fracture may be mistaken for a pulmonary nodule. Large extrapleural density (ar- associated with fractures of the first and second ribs (black rows) over the left upper lobe. A coned view of the right lower lung on a routine chest radiograph shows callus formation about a rib (arrows) in an asymptomatic person. Ewing’s tumor and metasta- tic neuroblastoma are the most common causes in children. Mediastinal, spinal, sternal, Tumors, cysts, and inflammatory processes may or subphrenic lesion produce extrapleural masses. A similar pattern may also be due to nocardiosis, blastomycosis, asper- gillosis, or, rarely, tuberculosis. Extrapleural lipoma Common chest wall lesion that may grow between ribs to present as both an intrathoracic and a sub- cutaneous mass. Surgery or blunt trauma Ruptured aneurysm, partial pleurectomy, sym- pathectomy, plombage, and mineral oil injection for the treatment of tuberculosis.
The two stages are considered in this process — (a) stage of vascularization and (b) stage of devascularization buy super p-force 160mg on line. The ingrowth of capillary loops and fibroblasts which help to form living granulation tissue is known as organization super p-force 160 mg mastercard. Solid buds of endothelial cells grow out of the existing damaged blood vessels at the surface of the wound discount super p-force 160mg amex. These undergo canalization and by anastomosis with their neighbours form a series of vascular arcades. Under the electron microscope gaps are seen between the endothelial cells and the basement membrane is poorly formed. These newly formed capillary loops leak protein and thus the tissue fluid which is formed is a very suitable medium for fibroblastic growth. Gradually these capillary loops differentiate, a few acquire muscle coat and become arterioles, whereas others enlarge to form thin walled venules. The source of smooth muscle fibres to form arterioles is either cell migration or differentiation of existing primitive mesenchymal cells. The fibroblasts, which accompany the capillary loop, gradually become larger to become elongated fibrocytes. Collagen is an extracellular secretion from specialized fibroblasts and the basic molecules which fibroblasts synthesise are frequently called tropocollagen. This tropocollagen condenses in the mucopolysaccharide extracellular space to form fibrils. This collagen is not inert and it undergoes constant turnover under the influence of tissue collagenase. There are several types of collagen which differ in the aminoacid sequence of the constituent chains, though hydroxyproline, proline and glycin dominate. Other fibrous tissues such as elastin do not contain significant amount of hydroxyproline. Fibroblasts are also thought to be responsible for the production of mucopolysaccharide ground substance. So the granulation tissue looks pale at this stage, which is known as devascularization. The new lymphatics develop from existing lymphatics in the same way as do the capillary loops. Mast cells also make their appearance and their granules are derived from the ground substance. The gross appearance of remodelling scars suggests that collagen fibres are altered and rewoven into different architectural patterns with time. Approximately 12 hours after injury has occurred and when inflammation is established, epithelial migration, which is the first clear cut signs of rebuilding occurs. In a secondary healing wound migration of cells is rapid, as the line of cells from the wound margin become extended, but progress becomes slower, so that days or even weeks may elapse before epithelialization is complete. Later on granulation tissue appears as mentioned earlier but collagen synthesis which is the main feature of scar remodelling cannot be found before 4th to 6th day. On or about the 7th day wounds will show a delicate fine reticulum of young collagen fibres. As fibrogenesis proceeds, purposefully oriented fibres seem to become thicker presumably because there occurring more collagen particles. The overall effect appears to be one of lacing the wound edges together by a 3-dimensional weave. There is one of replacing granulation tissue, allowing the surface to become covered with epithelium and filling the remaining skin defect with scar tissue after contraction is complete. As far as the filling of the defect is concerned, contraction is the major influence. The central scar seems to remodel itself to fill the defect after contraction is over. Development of tensile strength (strength of per unit of scar tissue) and burst strength (strength of the entire wound) is the result initially of blood vessels growing across the wound, epithelialization and aggregation of globular protein. There is an almost imperceptable gain in tensile strength for 2 years subsequent to that. Collagen content of the wound tissue rises rapidly between the 6th and 17th days, but increases very little after 17 days. It must be remembered that secondary wounds contain slightly less collagen than primary wound of the same age. More effective cross-linking of better physical weave of collagen subunits is responsible for rapid gain in strength for secondary wounds. Experimentally it may be estimated by measuring the force necessary to disrupt the wound. In the first few days the strength of a wound is only that of the clot which cements the cut surfaces together. Later on various changes take place in the wound healing process as mentioned above and at the end the tensile strength of the wound corresponds to the increase in amount of collagen present. Tensile strength of the wound becomes more when this is parallel to the lines of Langer. That is why the transverse abdominal incisions produce stronger scar than the longitudinal ones. This effect is well accepted in the experimental animals, but corticosteroid in normal dosage may not influence wound healing in human beings. Healing of a clean incised wound, the edges of which are closed (closed wound) — takes place by a process known as healing by first intention. The following changes take place — (i) initial haemorrhage results in the formation of a fibrin-rich haematoma. In the first 24 hours basal cells mobilise from the undersurface of the epidermis. By 48 hours the advancing epithelial edge undergoes cellular hypertrophy and mitosis. Epithelial cells gradually line the wound deep to the fibrin clot and it also lines the suture tracks. The use of adhesive tapes instead of sutures for closing wounds avoids these marks and gives better cosmetic result. The main bulk of tissue which performs the healing process is the granulation tissue and that is why this type of healing is also called healing by granulation. But this does not mean that granulations are not formed in the simple incised wounds. The followings are the various important processes of this type of wound healing :— (i) Initial inflammatory phase affects the surrounding tissues and the wound is filled with coagulum.
The patient sometimes complains of a sudden pain in the upper arm discount 160 mg super p-force otc, but it is often neglected cheap 160 mg super p-force overnight delivery. More commonly the patient complains of an abnormal swelling when he flexes his elbow due to bunching of the biceps muscle buy super p-force 160mg on line. The presenting complaint and the signs are similar to the rupture of the biceps tendon described above. In this condition the patient complains of pain and difficulty in abducting and extending the thumb. On examination a bulge is detected on the said tendons over the radial styloid process. With continued effort he suddenly becomes successful in forcing the swollen tendon through the constricted sheath and as soon as it is done the finger becomes extended quickly and abruptly like a trigger of a pistol. The only difference is that the cause is not only thickening of the flexor retinaculum but also some other pathology such as rheumatoid arthritis involving the synovial sheaths of the flexor tendons or dislocation of lunate bone which compresses on the contents of this osseo-fibrous canal, mainly the median nerve, also exits. The main complaint of the patient is some sort of difficulty in flexing fingers with pain and neurological deficits of the median nerve, e. Flexion movement of the fingers will be painful and conduction studies on the median nerve will demonstrate a delay at the carpal tunnel. There may be nodules in the fascia or in the subcutaneous tissue indicating excessive fibrous tissue activity. This condition mostly affects the medial part of the palmar fascia in which the ring finger and less often the little finger become flexed. This is due to the fact that the extensions of the palmar fascia are attached to the proximal as well as middle phalanges. Repeated trauma which was previously incriminated as the cause of this condition has been discarded due to the fact that it often involves the persons who do not inflict trauma so repeatedly in the palm. A ganglion on the dorsal aspect of the wrist in relation with the extensor tendon of the finger. On examination, there is thickening of the medial aspect of the palmar fascia with firm nodules within the fascia or in the subcutaneous tissue. The overlying skin is more or less fixed to the fascia and there is flexion deformity of the ring and the little fingers. It may be due to a leakage in the capsule or the tendon sheath following trauma and subsequent encapsu-lation with fibrous tissue or it may be due to mucoid degeneration of the fibrous sheath. On examination, a tense and cystic swelling will be revealed in relation to a capsule of the joint or a tendon sheath. When it originates from a tendon sheath it can be moved sideways slightly but not at all along the length of the tendon particularly when Fig. Monostotic fibrous dysplasia, though rare, is chiefly a disease of adolescents but may remain symptomless till the bone breaks. Osteogenesis imperfecta (Brittle bones) Epiphysis : congenita presents with multiple fractures, dwarfism Epiphysitis Osteoclastoma and deformities since birth; whereas osteogenesis imperfecta tarda presents later near 10 years of age. Nearly all benign bone tumours occur in Chondroma Osteogenic sarcoma adolescent and in young adults; Osteoclastoma occurs Bone cyst between 20 and 30 years of age. Primary malignant bone tumours mainly occur in young people; Osteosarcoma occurs between 15 and 30 years of age; Multiple myeloma occurs late — 30 to 50 years. Diaphysis : Syphilitic osteitis Secondary carcinoma of bone is seen in old age above Ewing’s tumour 40 years. Spontaneous development of swelling is most likely to be seen in cases of bone tumours. Acute onset with high rise of temperature and toxaemia is a feature of acute osteomyelitis. In chronic osteomyelitis the onset is usually insidious, but acute exacerbation of chronic osteomyelitis is not uncommon. Malignant tumours grow very rapidly and the history is relatively short since the patient had discovered the swelling. But in bone the peculiar feature is that the malignant growth osteosarcoma presents with pain first and swelling later on. Otherwise the tumours whether they are benign or malignant are painless to start with. In malignant bony tumours the duration is relatively short in comparison to the benign bony swellings. In diaphyseal aclasis there will be multiple swellings arising from the metaphyses of different bones affecting a young boy. In osteosarcoma the skin over the swelling remains tense, glossy with dilated veins. In tuberculous osteomyelitis cold abscess will lead to a swelling in the beginning and later on sinus formation. The tuberculous sinus will reveal its characteristic features like undermined edge and bluish margin, whereas in chronic pyogenic osteomyelitis there will be sprouting granulation tissue which indicates presence of sequestrum at the depth. There may be paresis neous veins in case of osteo- due to involvement of the nerves by the bony swellings. Sometimes acute osteomyelitis may destruct the epiphyseal cartilage thereby hampering the growth of that particular bone. Genu valgum or genu varum may be the result of asymmetrical destruction of the lower epiphyseal cartilage of the femur. Shortening or lengthening of the bone — may sometimes be seen following infection of the bone which either provokes the growth of the bone or destroys the epiphyseal cartilage and hence retards the growth of the bone. In osteosarcoma the consistency varies — somewhere bony hard, somewhere firm and may be even soft at places. Being a bony swelling its consistency should also be bony hard, but the condition is so painful and tender that the clinician hardly reaches the bone during palpation and can only palpate the soft tissues overlying the bone which pits on pressure. Telangiectatic osteosarcoma, aneurysmal bone cyst, occasionally highly vascular osteoclastoma, very rarely haemangioma of bone and highly vascular metastatic carcinomas from thyroid cancer and renal adenocarcinoma. Note the foot drop on the right side due to involvement of the lateral popliteal nerve by an osteoma at the head of the fibula. These are commonly seen in chronic pyogenic osteomyelitis and tuberculous osteomyelitis. In case of the former there will be sprouting granulation tissue at the orifice of the sinus indicating presence of sequestrum in the depth and in case of the latter the ulcer will be undermining with bluish newly growing epithelial edge. In fact sometimes this fracture becomes the first presenting symptom of the primary carcinoma which may be in the lung, kidney, breast, prostate, thyroid etc. Shortening will be found when the epiphyseal cartilage is destroyed and the bone may be lengthened when the metaphysis is included within the zone of hyperaemia. Osteosarcoma, which mainly starts from the metaphysis, does not invade the epiphyseal cartilage until late and hence the joint remains unaffected. Swellings of the distal limb and venous engorgement may be due to pressure on the neighbouring veins. In tuberculous osteomyelitis general examination must be made to exclude pulmonary tuberculosis and lymphadenitis. Enquiry must be made whether the patiert had cough, evening rise of temperature, pain in the chest, haemoptysis, etc.
...or by Phone or Mail
PO Box 800
Buffalo, NY 14231 USA
Toll free 1-800-825-2675
Hours 8:30 am 5:00 pm EST M-F