Modified Essay Questions, MEQs in General Surgery - Tubercular Lymphadenitis

 TUBERCULAR LYMPHADENITIS 

A teenage boy comes to you with multiple swelling on the neck which is around the SCM.
a. Mention the important points which you would like to ask during history taking from this patient.
- Presence of chest symptoms: cough, sputum production, hemoptysis
- Presence of constitutional symptoms- fever, night sweats, weight loss
- Presence of similar history in other family members or any members having or  previously had Tuberculosis
- Any treatment history

b. Write the examination points.
 i. General: pulse, temperature, Respiratory rate, BP

ii. Look for similar swellings in other areas

iii. Local examination:
- Inspection: Site, number, size, shape, overlying skin, movement with deglutition, movement with protrusion of tongue, pulsations
- Palpation: a local rise of temperature, tenderness. Size, shape, surface, consistency,  margins, mobility, compressibility, fluctuation, fixity to skin or underlying structures, cough impulse, pulsations,
- Auscultation for bruit

iv. Examination of respiratory system

On examination you find that the swelling is non-tender, mobile, firm in consistency, matted and located beneath the SCM. 

c. List two other D/D other than TB.
- Chronic Lymphadenitis, Anaplastic lymphoma

d. Enumerate the cost effective investigations you would order to reach a logical working diagnosis. i. CBC: may reveal low Hb
ii. ESR: elevated in most cases
iii. FNAC: gives diagnosis in about 75% cases
iv. Chest XRay and sputum for AFB — if chest symptoms

The report suggests TB.
e. Describe the stages through which a tuberculous cervical lymph node passes along with the sketching.
i. Stage of lymphadenitis — non-tender discrete mobile firm lymph nodes

ii. Stage of Periadenitis/ Stage of Matting: Due to the inflammation of the capsule. Nodes move together, firm non-tender matted.

iii. Stage of Cold abscess — due to caseation of the lymph nodes — fluctuant swelling in the neck.

iv. Stage of Collar stud abscess- results when cold abscess which is deep to the deep fascia and forms another swelling in the subcutaneous plane which is fluctuant.

v. Stage of Sinus: occurs when the collar stud abscess ruptures through the skin.

f. How should you manage a TB Abscess?
- Non dependent aspiration using a wide bore needle. Dependent drainage causes persistent
Tuberculous sinus. Antituberculous treatment is given.

g. What is the pathogenesis of TB cervical nodes?
1. In 80% cases — mycobacteria pass through tonsillar crypts and affect tonsillar node or jugulodigastric group of nodes in the anterior triangle of the neck.
2. In 20% of cases- nodes in the posterior triangle are infected due to infection of adenoids.

3. Rarely- infection can spread from the tuberculosis of the apex of the lungs.

h. How will you treat this case?
a. Give ATT for 6 months (CAT l)
b. If persistent matting — Excision of nodes

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