Photo illustrations of Bullous Myringitis

What is Bullous Myringitis ?

Bullous myringitis is painful inflammation blisters of the tympanic membrane and surrounding deep canal skin with the formation of serum or blood filled bullae. Petechial subcutaneous hemorrhages around the base of the bulla are characteristic.

Bullous Myringitis was thought that Mycoplasma pnumoniae was the most common pathogen but, recent studies have demonstrated that the pathogens are similar to otitis media. Bacteria are responsible for most cases of bullous myringitis. Streptococcus pneumoniae is the most common, followed by Haemophilus influenzae and Moraxella catarrhalis.

Examination shows a vesicular or bullous eruption over the tympanic membrane and adjacent bony canal wall. In the early stages, the vesicles are erythematous and surrounded by injected epithelium. In the later stages, they are larger and filled with fluid which may be clear and serous or blood filled. In this photograph, the bulla has now been incised with a myringotomy knife and the fluid drained. Notice the petechial hemorrhage around the base of the bulla and extending into the attic area.

Treatment of bullous myringitis requires strong analgesics because of the associated pain. Rupturing the bullae for relief of pain is controversial. Topical antibiotic eardrops are probably useful in preventing the development of a secondary bacterial otitis externa. The use of erythromycin has been advocated by those who believe that Mycoplasma is the prime etiologic agent. The tympanic membrane in this case is diffusely inflamed, with the presence of petechial hemorrhage over the attic and an associated hemotympanum

A large bulla filled with serous fluid has developed on the superficial surface of the tympanic membrane in the region of the umbo

Endoscopic Nasal Septoplasty

CopperT Insertion Animation

Antiemetics

This video shows Classification, Pharmacological actions, Mechanism of Action, Pharmacokinetics, Uses and Side effects of all Antiemetics.

How to differentiate between transmitted and expansile pulsations

If you are palpating a swelling like an abdominal swelling infront of the aorta, You have to decide whether the mass you feel is pulsatile/expansile in itself (in which case your fingers will move outwards A ) or whether the pulsation is transmitted through other tissue (in which case your fingers will move upwards B ).See diagram below

Also in transmitted pulsation you can make this pulsation disappear if you can move the swelling away from the aorta ( if you put the patient in the knee-elbow position, an enlarged intra-abdominal swelling which was transmitting aortic pulsation will get away from the aorta and the pulsations will disappear)

Wound Closure by Surigical Staples

Staples are formed from high-quality stainless steel and are available in regular and wide sizes.

Staples are composed of:

(1) a cross-member that lays on the surface of the skin perpendicular to the wound,
(2) legs that are vertically placed in the skin
(3) tips that secure the staple parallel to the cross-member.

Staples are relatively easy to place and may shorten the closure time by 70-80%.

The primary utility of staples is in the closure of wounds under high tension on the trunk, extremities, and scalp.ON the other hand they are not used in delicate tissues or wounds in finely contoured areas, over bony prominences, or in highly mobile areas.

Advantages of staples include:

* rapid speed of closure
* a decreased risk of infection
* improved wound eversion
* minimal tissue reactivity.

Disadvantages include

* the need for a second operator to evert and reapproximate skin edges during staple placement
* greater risk of crosshatch marking
* less precise wound approximation.
* The cost is usually more than that of suture material.

Surgical staples used on a skin incision in groin after inguinal hernia operation.

Common sites for Morton's neuromas

Morton's Neuroma is a painful condition of the forefoot that is caused by the entrapment of the common intermetatarsal nerve as it passes through the forefoot to the toes. Morton's Neuroma was first described by Dr. Morton, a Viennese physician, in 1876.
Where are most Morton's neuromas found?

A) In the tarsal tunnel
B) At the first metatarsal phalangeal joint
C) The second and third interdigital space
D) At the attachment of the plantar fascia
E) At the head of the fifth metatarsal

Answer and Discussion

The answer is C.

The interdigital spaces of the foot are common sites for painful neuromas, a condition termed Morton's neuroma. The second and third common digital branches of the medial plantar nerve are the most frequent sites for development of interdigital neuromas. Morton's neuromas develop as a result of chronic trauma and repetitive stress, as occurs in persons wearing tight-fitting or high-heeled shoes. Pain and paresthesias are usually mild at onset and are located in the interdigital space of the affected nerve. In some cases, the interdigital space between the affected toes may be widened as a result of an associated ganglion or synovial cyst. Pain is noted in the affected interdigital space when the metatarsal heads of the foot are squeezed together. Injection with 1% lidocaine (Xylocaine) can assist in confirming the diagnosis.

The symptoms of Morton's neuroma include the following;

• A dull achy sensation in the forefoot, usually between the 3rd and 4th toes.
• Pain that increased with the time a person spends on their feet, particularly in high heels and narrow fitting shoes.
• Pain that is not relieved by rest. Neuroma pain takes several minutes to hours to subside.
• Numbness of the 3rd and 4th toes.
• A sensation of walking on something, such as a bunched up sock
• .Occasionally, a snapping sensation or electrical shock sensation (Muldier's Sign).

The digital nerve(1) running in the narrow space between the metatarsal bones where it splits into two(2) and where a Mortons Neuroma is usually found.