Facial nerve pointers

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Q) What is the most consistent anatomical landmark of the facial nerve?

A) Anterior border of the posterior belly of the digastric muscle.
B) Posterior border of the posterior belly of the digastric muscle.
C) Superior border of the posterior belly of the digastric muscle.
D) Inferior border of the posterior belly of the digastric muscle.

Ans C) Superior border of the posterior belly of the digastric muscle.

Why This Landmark Matters: The superior aspect of the posterior belly of the digastric muscle serves as a reliable intraoperative landmark for locating the facial nerve. Understanding this landmark can enhance surgical precision and reduce complications.

Key Anatomical Landmarks for Facial Nerve Identification:

  1. Posterior Belly of the Digastric Muscle:
    • The facial nerve is located about 2 to 4 mm inferior to the tympanomastoid suture line, making the superior border of the posterior belly a consistent guide.
  2. Tragal “Pointer” (of Conley):
    • The tragal cartilage, found in front of the ear, provides a helpful reference. The facial nerve lies approximately 1 cm deep, slightly anterior and inferior to this point, making it an essential landmark during dissection.
  3. Tendon of the Posterior Belly of the Digastric Muscle:
    • The attachment of the digastric muscle to the mastoid bone conceals the facial nerve about 1 cm deep. Careful dissection in this area is crucial to uncover this hidden structure.
  4. Tympanomastoid Suture/Fissure:
    • This area within the temporal bone marks another critical point for identifying the facial nerve, which is situated about 6-8 mm deep.
  5. Styloid Process:
    • Located laterally to the styloid process, the facial nerve resides in proximity, making it a significant marker during surgical approaches.

Conclusion: Understanding the superior border of the posterior belly of the digastric muscle as the most consistent anatomical landmark of the facial nerve is essential for safe surgical practice. Mastering these landmarks not only enhances surgical outcomes but also promotes patient safety.

Ivor Lewis Esophagectomy leak

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Q)  After Ivor Lewis esophagectomy, on postoperative day 5 (POD 5), bile is seen in the chest tube.

The patient presents with a heart rate of 120 bpm, a temperature of 101°F, and blood pressure of 100/70 mmHg. What is the next appropriate step in management?

 a) Stenting
b) Colonic replacement of gastric conduit
c) IV antibiotics
d) Conduit excision and esophageal diversion

Correct Answer: d) Conduit excision and esophageal diversion

In patients who develop a completely necrotic conduit post-esophagectomy, the risk of sepsis is high. These patients often require urgent surgical intervention. Upon confirming conduit necrosis, the conduit must be resected, and the patient should undergo diversion, which includes:

  • End esophagostomy
  • Venting gastrostomy
  • Feeding jejunostomy

It is crucial to maintain as much length of the remaining esophagus as possible to facilitate future reconstructive procedures.

Key Points:

  • Postoperative Day 5: Critical time for monitoring complications after esophagectomy.
  • Symptoms of Concern: Tachycardia, fever, and hypotension may indicate sepsis or other complications.
  • Surgical Intervention: Timely recognition and management are vital for patient outcomes.

For further reading, refer to Schakelford’s Surgical Anatomy of the Gastrointestinal Tract.

Schakelford page 477

Bone tumors

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Q) A 16 year old boy presents with severe groin pain after kicking a football. Imaging confirms a pelvic fracture. A previous pelvic x-ray performed 2 weeks ago shows a lytic lesion with 'onion type' periosteal reaction. What is the lesion?

a) Giant cell tumor

b) Ewing's 

c) Osteosarcoma

d) Osteomalacia

Question  from theme of test 14 

 

Pancoast tumor

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Q) 50 year old male with NSCL carcinoma of upper Rt lung which infiltrates the brachial plexus. WHat will be the managament? 

Lung and Thorax MCQS

a) Surgical resection

b) CCRT and resection

c) CCRT and access for response

d) Neoadjuvant and resection

Cystic lesion of pancreas

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Q_ A53 -year-old woman is found to have an incidental pancreatic lesion on abdominal imaging. CT scan reveals a microcystic mass with a central stellate scar located in the body of the pancreas. Cyst fluid analysis demonstrates low viscosity, and low levels of CEA, CA 19-9, and amylase. Which of the following is the most likely diagnosis?

A. Serous cystic lesion
B. Mucinous cystic lesion
C. Intraductal pancreatic mucinous neoplasm
D. Pseudocyst

Lung cancer

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Q) A 73 year male, old heavy smoker presents with haemoptysis.

On examination he is cachectic and shows evidence of clubbing. Imaging shows a main bronchial tumour with massive mediastinal lymphadenopathy together with widespread visceral metastases.

Which of the following variant is likely in him?

( Theme from mock test 12- 24) 

a)  Adenocarcinoma
B.  Small cell lung cancer
C. Large cell lung cancer
D. Squamous cell carcinoma

  • Patient: 73-year-old male, heavy smoker
  • Symptoms: Hemoptysis, cachexia, clubbing
  • Imaging: Main bronchial tumor with massive mediastinal lymphadenopathy and widespread visceral metastases

Likely Variant:

B. Small cell lung cancer (SCLC) is the most likely diagnosis.

Rationale:

  • Small Cell Lung Cancer: This type of cancer is strongly associated with heavy smoking and is characterized by aggressive behavior and early metastasis. Most patients present with disseminated disease, as seen in this case.
  • Clinical Features: The combination of hemoptysis, cachexia, and clubbing aligns well with SCLC, which can also lead to various paraneoplastic syndromes.
  • Other Tumors:
    • Adenocarcinoma: More common in never smokers and typically peripheral, not fitting the profile here.
    • Squamous Cell Carcinoma: Generally grows slower and is also typically centrally located, but not usually associated with such widespread metastasis at presentation.
    • Large Cell Lung Cancer: While it can be aggressive, it’s less commonly associated with extensive lymphadenopathy and visceral metastases compared to SCLC.

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