Skip to content

Tumor Puffy Pott (Osteomyelitis Egungun iwaju ati Abscess Subperiosteal Lẹhin Sinusitis Iwaju): Wiwu Iwaju Iwaju Doughy ati Iyatọ Inu inu inu

Awọn nọmba pajawiri yato nipasẹ orilẹ-ede. Oju-iwe yii nlo 911, nọmba fun Amẹrika ati Kanada. Ọpọlọpọ awọn orilẹ-ede miiran lo 112, 999, tabi nọmba miiran. Wa nọmba fun orilẹ-ede rẹ.

Pelu orukọ itan itanjẹ ṣinilọna rẹ, ** tumor puffy Pott ** kii ṣe akàn tabi neoplasm : o jẹ nla kan, pajawiri ajakalẹ-arun eewu-aye ninu eyiti a ko tọju tabi ni apakan ti a tọju ** sinusitis iwaju ti kokoro-arun nla ** (tabi ibalokan iwaju iwaju bulu kekere) ti npa siwaju nipasẹ tabili ** iwaju ti egungun iwaju lati gbejade egungun iwaju. timole (periosteum / pericranium) lati ṣe gbona, tutu, iyẹfun, apo pus boggy (subperiosteal abscess) taara ni aarin tabi ẹgbẹ iwaju. Lakọkọ ṣapejuwe nipasẹ oniṣẹ abẹ Gẹẹsi Sir Percivall Pott ni ọdun 1760, ipo yii jẹ asia pupa neurosurgical to ṣe pataki nitori odi ẹhin posterior table) ti ẹṣẹ iwaju ko kere ju idaji bi nipọn bi ogiri iwaju ** o si pin nẹtiwọki kan ti ** awọn iṣọn diploic ti ko ni valveless (veins of Breschet ti o san taara sẹhin sinu ** dural veno sinuses a awọn lobes iwaju ti ọpọlọ ***. Nitoribẹẹ, laarin **60 and 85 percent ti awọn ọmọde ati awọn ọdọ (ati 30 to 40 percent ti awọn agbalagba) ti o ṣafihan pẹlu tumo puffy Pott ni ita iwaju wọn TẸTẸ ni ibudo igbakanna, nigbagbogbo ipalọlọ Intracraal Complication (epidural abscess, subdural empyema, frontal lobe brain abscess, or superior sagittal sinus thrombosis) ní inú agbárí wọn. Ti ọmọ, ọdọ, tabi agbalagba ti o ni ikolu sinus lọwọlọwọ tabi aipẹ tabi ijalu ori ti ndagba **agbegbe, rirọ, iyẹfun, tabi wiwu ni iwaju lori oju oju oju, ofifo iwaju ti o lagbara, iba, wiwu ipenpeju oke, eebi, tabi iyipada eniyan arekereke / itusilẹ, pe agbegbe rẹ pajawiri awọn nọmba (911 ni Ilu Amẹrika ati Kanada, 112 jakejado European Union, 999 ni United Kingdom, tabi 000 ni Australia) tabi lọ lẹsẹkẹsẹ si Ẹka Pajawiri ile-iwosan kan. Lakoko ti o n murasilẹ fun gbigbe, ṣayẹwo awọn itọsọna ẹlẹgbẹ wa lori orbital cellulitis ati cavernous sinus thrombosis, meningitis ati meningococcal septicemia triage, ati mastoiditis coalescent nla ati eewu abscess ọpọlọ.

Kini idi ti ** awọn ọdọ ati awọn ọdọ ti o wa ni ọdun 10 si 18 (paapaa awọn ọmọkunrin ọdọ) *** ẹgbẹ #1 ti o ni eewu giga fun tumor puffy Pott ati subdural empyema? Nitori ** awọn sinuses iwaju ** (eyiti ko si ni ibimọ ati bẹrẹ pneumatizing nikan ni ayika ọjọ-ori 6) ni idagbasoke iyara ni iyara ni akoko puberty, ti o tẹle pẹlu iṣọn-ẹjẹ ti o ga julọ ati ṣiṣi-ipo, valveless ** awọn iṣọn diploic ti Breschet ** tunneling nipasẹ ọra-ara spongy ti egungun iwaju idagbasoke. otutu ọlọjẹ ti o rọrun ti o yipada si sinusitis iwaju ti kokoro-arun nla ni ọmọ ọdun 14 le fun irugbin mejeeji iwaju iwaju ati aaye intracranial intracranial laarin awọn ọjọ, paapaa ti ọdọ ba ti gba oogun amoxicillin oral tabi azithromycin tẹlẹ ni ile-iwosan itọju iyara kan.

Ṣe eyi ni bayi

  1. ** Ṣayẹwo iwaju iwaju ni profaili ati ki o rọra palpate pẹlu ika ika kan fun “Ewiwu Iwaju Iyẹfun, Boggy, tabi Fluctuant Forehead Ewiwu.”** Duro si ẹgbẹ alaisan ni itanna to dara ki o wo oju-ọna iwaju wọn lati oju oju titi de ori irun:
  2. Ko dabi hematoma ti o ni lile “goose-egg” ni kete lẹhin ijalu lori ori, ** tumor puffy ti Pott ** ndagba ni ọpọlọpọ awọn ọjọ si awọn ọsẹ ti “tutu sinus” tabi orififo (tabi ọsẹ 1 si 3 lẹhin ipa iwaju iwaju kekere kan), ti n ṣafihan bi ** ti o ni iyasọtọ daradara, gbona, tutu pupọ, iyẹfun / loon-bi omi-omi.fluctuant) wiwu *** lori aarin tabi agbegbe oju oju iwaju.
  3. Loorekoore, edema gravitational wa si isalẹ lati iwaju si ọkan tabi mejeeji ** ipenpeju oke (periorbital edema)**, nfa ki awọn onisegun ṣe ayẹwo ni akọkọ bi awọn nkan ti ara korira ti o rọrun tabi cellulitis eyelid eyelid pre-septal ayafi ti wọn ba fi ọwọ kan egungun iwaju loke brow.
  4. Ipe 911 / 112 / 999 lesekese ti wiwu iwaju tabi irora ẹṣẹ iwaju iwaju ti o lagbara ba wa pẹlu KANKAN INtracranial tabi Orbital Red Flag:
  5. ** Iwa arekereke, iṣesi, tabi awọn iyipada eniyan ("Silent Frontal Lobe Sign"):** Ni itara tuntun, irritability ti ko ni ihuwasi, rudurudu, ilọra lati dahun awọn ibeere (abulia), tabi oorun.
  6. ** Awọn ami ti Ipa Intracranial Dide (ICP) tabi Meningismus:** Ẹfọfifo ti o buru si ti o ji alaisan lati orun, ríru / eebi, ifamọ si ina didan (photophobia), tabi ọrun lile.
  7. ** Awọn aipe Neurological Focal tabi Awọn ikọlu:** Eyikeyi ifọkansi tuntun tabi ijagba gbogbogbo (occurs in up to 30% of subdural empyemas), ailera ni ẹgbẹ kan ti oju / apa / ẹsẹ (hemiparesis), tabi ọrọ sisọ.
  8. ** Itẹsiwaju Orbital:** Oju gbigbo (proptosis), nipo sisale ati ita ita ti bọọlu oju (globe dystopia), iran meji, tabi irora / ihamọ awọn gbigbe oju (subperiosteal orbital roof abscess).
  9. ** Lọ taara si Ẹka Pajawiri Ile-iwosan pataki kan pẹlu Neurosurgery-wakati 24 ati Otolaryngology (ENT) agbegbe, MAA ṢE si ile-iwosan amojuto ni kiakia tabi ile-iwosan ile elegbogi rin.
  10. **MASE gbiyanju lati lan, fun pọ, abẹrẹ-aspirate, tabi agbejade wiwu iwaju ni ile tabi ni ile ìgboògùn.bony defect) ninu awọn tabili iwaju ati lẹhin ti egungun timole iwaju ọtun si isalẹ si **dura mater ti o bo ọpọlọ ati ẹṣẹ iṣọn sagittal ti o ga julọ ***. Lila ile ìgboògùn ti a ko ni iṣakoso laisi aworan CT/MRI ṣaaju le ṣafihan kokoro arun ara taara sinu aaye epidural tabi nfa ẹjẹ ẹjẹ iṣọn iṣọn nla.
  11. ** Jeki alaisan ni muna NPO (ko si ohun ti ẹnu: ounje odo, odo omi, odo roba olomi) nigba gbigbe.** Lori 90 percent ti Pott's puffy tumor igba nilo isunmọ yara iṣẹ ni kiakia (** ilana endoscopic frontal sinusotomy / Draf IIb-III ilana, trephination ita, ati/tabi neurosurgical craniotomy/burr iho evacuation **) labẹ akuniloorun gbogbogbo laarin awọn wakati ti dide.
  12. ** Jeki ori alaisan ati torso oke ga ni 30 degrees** lakoko gbigbe lati mu idominugere iṣọn-ẹjẹ ọpọlọ pọ si nipasẹ ẹṣẹ sagittal ti o ga julọ ati dinku titẹ intracranial.

Pakute 'Iwaju Iwaju ipalọlọ': Kilode 60% si 85% Ni Ọpọlọ/Aisan Arun Arun Pẹlu Idanwo Ipilẹ 'Deede'

Kini idi ti awọn oniwosan pajawiri fi paṣẹ fun pajawiri ** Iyatọ Brain MRI / Contrast CT *** lori * gbogbo * alaisan pẹlu tumor puffy Pott, paapaa ti alaisan ba nrin, sọrọ, ati pe o ni 100% agbara apa ati ẹsẹ deede? Nitori ** awọn lobes iwaju iwaju ti ọpọlọ (prefrontal cortex*** maṣe ṣakoso gbigbe ọkọ tabi ọrọ sisọ, wọn ṣakoso ** ihuwasi adaṣe, iṣesi, ati idajọ ***. Aisan nla **epidural, empyema subdural, tabi iwaju lobe ọpọlọ abscess *** joko ni ọtun lẹhin ogiri ẹhin ti o bajẹ ti ẹṣẹ iwaju nigbagbogbo n pese **ailagbara odo ati numbness odo ** ni kutukutu, ti o farahan bi orififo, iba, ati “irẹwẹsi ọdọmọkunrin” tabi aifọkanbalẹ titi titẹ intracranial yoo fa spikes tabi ipo ọpọlọ lojiji.

Igi ipinnu: Yiyan wiwu iwaju, orififo iwaju nla, ati sinusitis

flowchart TD
    Presentation["Ọmọde, Ọdọmọkunrin, tabi Agbalagba Pẹlu Sinusitis, Iwaju Iwaju, tabi Iwaju Iwaju Iwaju Ti ndagba Wiwu iwaju (+/- Puffiness Eyelid Oke)"] --> PalpateForehead{"Igbesẹ 1: Ayewo & Rọra Palp Tẹ Iwaju Loke Awọn Iwoju: Njẹ Agbegbe Wa, Irẹlẹ, Gbona, Doughy, Pitting, tabi Fluctuant ('Boggy') Wiwu Lori Egungun Iwaju?"}

    PalpateForehead -->|"BẸẸNI: Ewiwu Iwaju Iyẹfun/Boggy = TUMOR PUFFY POTT (Egungun iwaju Osteomyelitis + Subperiosteal Abscess)"| CheckNeuro{"Igbesẹ 2: Iboju fun Intracranial & Awọn ilolu Orbital (Ti o wa ni 60% si 85% ti Awọn ọran): orififo nla, eebi, aibalẹ, Iyipada ti ara ẹni, ijagba, Ọrun lile, Apa / Ẹsẹ ti ko lagbara, TABI bulging / Oju tutu?"}

    CheckNeuro -->|"BẸẸNI si eyikeyi Neurological tabi Orbital Sign"| Emergent911["TUMUR PUFFY POTT PẸLU INTRACRANIAL / ORBITAL EXTENSION (Ascess epidural, Subdural Empyema, Brain Abscess, or Sagittal Sinus Thrombosis): Pe 911/112/999 Lẹsẹkẹsẹ -> Gbe ori 30 Degrees NPO -> S."]

    CheckNeuro -->|"Ko si Awọn ami Neuro ti o han gbangba sibẹsibẹ (Alaisan Itaniji pẹlu Wiwu iwaju iwaju iyẹfun & iba / orififo)"| UrgentHospital["TUMO PUFFY POTT (Ewu giga ti ipalọlọ EPIDURAL ABSCESS): Lọ Lẹsẹkẹsẹ si Ẹka pajawiri Ile-iwosan Tertiary (Pẹlu Neurosurgery & Ibora ENT) -> NPO to muna fun Aworan & TABI"]

    PalpateForehead -->|"KO SI Ewiwu iwaju tabi Irora Egungun: Pupa Oju Oju Nikan"| CheckEye["Ṣe iṣiro fun Pre-Septal vs Post-Septal (Orbital) Cellulitis: Ṣayẹwo Awọn iṣipopada Oju, Iran, & Proptosis -> Wa Iṣoogun Ọjọ Kanna / Iṣiro ED"]

    Emergent911 --> HospitalBundle["Ilana Ile-iwosan Itọkasi: 1. Awọn aṣa Ẹjẹ STAT + Meningeal-Dose IV Vancomycin + IV Ceftriaxone (2g q12h) + IV Metronidazole, 2. Iyatọ ti o ga julọ CT ti Sinuses / Orbits / Brain (Bone + Soft Tissue Windows, ENT ENT Brain) + Contrast. Endoscopic Frontal Sinus Drainage + Ilọkuro Neurosurgical ti Eyikeyi Arun Arun/Subdural/Ọpọlọ Inu + Awọn oogun aporo inu ọsẹ 6"]
    UrgentHospital --> HospitalBundle

Apakan 1: Ẹkọ aisan ara anatomical: Awọn odi mẹta ti Iwaju Sinus ati Awọn iṣọn Valveless ti Breschet

Lati loye idi ti ikolu ẹṣẹ lasan ti o wa loke awọn oju oju oju le yo iho kan nigbakanna nipasẹ awọ iwaju ATI fi pus sẹhin sori dada ti ọpọlọ, wo apakan agbelebu sagittal ti iwaju eniyan (** egungun iwaju**):

========================================================================
       SAGITTAL CROSS-SECTION OF THE FRONTAL SINUS & POTT'S TUMOR
========================================================================

  [ FOREHEAD SKIN ]
         |
  [ PERIOSTEUM ] ===> (Lifted off skull by PUS -> "POTT'S PUFFY TUMOR"
         |             Subperiosteal Forehead Abscess)
         |
  +------+-----------------------------------+
  | ANTERIOR TABLE OF FRONTAL BONE           | <-- Thick Bone (2 to 4 mm)
  | (Contains Valveless Diploic Veins        |     Erodes OUTWARD.
  |  of Breschet in Spongy Marrow)          |
  +------------------------------------------+
  |                                          |
  |        [ FRONTAL SINUS CAVITY ]          | <-- Blocked Nasofrontal
  |        (Filled with Pressurized Pus:     |     Outflow Tract
  |         Streptococcus milleri +          |     (Pressure Cooker)
  |         Anaerobes + Staph aureus)        |
  |                                          |
  +------------------------------------------+
  | POSTERIOR TABLE OF FRONTAL BONE          | <-- PAPER-THIN (0.5 to 1 mm)
  +------------------------------------------+     Erodes INWARD.
         |                                                |
         v (60% to 85% Intracranial Spread)              v
  [ EPIDURAL ABSCESS / SUBDURAL EMPYEMA / ]    [ SUPERIOR SAGITTAL SINUS ]
  [ FRONTAL LOBE BRAIN ABSCESS            ]    (Septic Venous Thrombosis)
  ======================================================================
  (Note: Floor of Frontal Sinus = Roof of Eye Socket -> Orbital Abscess)
========================================================================

1. Awọn Odi Egungun Mẹta ti Iwaju Iwaju Sinu Ipilẹ ounjẹ

Nigbati wiwu mucosal, polyps, tabi pus ti o nipọn ṣe awọn bulọọki ṣiṣan ṣiṣan wakati gilasi dín ni isalẹ ti ẹṣẹ iwaju (** ifasilẹ iwaju / isan iṣan nasofrontal ), ẹṣẹ iwaju yoo yipada si iyẹwu titẹ egungun ti o ni edidi ti o yika nipasẹ awọn odi mẹta: 1. ** Tabili Iwaju (Front Wall: 2 to 4 millimeters nipọn): Fọọmu elegbegbe lile ti iwaju rẹ nisalẹ awọn oju oju ati awọ iwaju. Nigbati osteomyelitis ba tuka nipasẹ ogiri yii (tabi irin-ajo nipasẹ awọn iṣọn airi), pus n gba labẹ awọ ara periosteal ti ita ti o nira (* subperiosteal abscess ), ti o nmu iṣu iwaju iwaju iyẹfun ti ita ( Pott's puffy tumor**). 2. ** Tabili Atẹyin (Back Wall: Iwe-Tinrin ni 0.5 to 1.0 millimeter):** Ya sọtọ ẹṣẹ iwaju ti o ni arun taara lati **dura mater **, ẹṣẹ iṣọn iṣọn sagittal ti o ga julọ **, ati ** awọn lobes iwaju ti ọpọlọ ***. Nitoripe ogiri ẹhin yii jẹ ** igba meji si mẹrin tinrin ju odi iwaju lọ *, nipasẹ akoko ikolu ti o le to lati wọ inu nipọn. 4 mm odi iwaju si iwaju, o ti fẹrẹẹ nigbagbogbo ** ti wọ inu tinrin naa 1 mm pada odi sinu cranial iho . 3. ** Odi Isalẹ (Floor of the Frontal Sinus = Roof of the Eye Socket): Ya ara ese iwaju kuro ni oju. Ogbara sisale nipasẹ ilẹ n tú pus sinu oke iho oju ( abscess orbital subperiosteal abscess *), titari bọọlu oju ** sisale ati ita (inferolateral proptosis) ati nfa wiwu ipenpeju oke ti o fara wé cellulitis orbital.

2. Bawo ni akoran ṣe rekọja Paapaa Egungun Aarin kan (The Valveless Diploic Veins of Breschet)

Ni pataki, ** Alaisan ko nilo lati ni iho ti o han ti o bajẹ nipasẹ egungun timole lati ṣe idagbasoke tumọ puffy Pott tabi empyema subdural apaniyan ***. - Sandwiched laarin tabili ita lile ati tabili inu ti egungun agbọn iwaju jẹ Layer spongy marrow ti iṣan (**diploë ***) ti a ti ṣan nipasẹ labyrinth ti tinrin-olodi, ** 100% valveless awọn ikanni iṣọn-ẹjẹ ti a npe ni Diploic Veins of Breschet. - Awọn iṣọn diploic ti ko ni falifu wọnyi so **mucosa ti ẹṣẹ iwaju iwaju *** taara siwaju si **periosteum ti iwaju ** ATI taara sẹhin si ** dural venus plexus ati ẹṣẹ sagittal to gaju ti ọpọlọ ***. - Thrombophlebitis Septic Retrograde: Awọn didi ẹjẹ ti o ni akoran (septic thrombi) rin ni taara nipasẹ awọn iṣọn Breschet ti ko ni valve siwaju labẹ iwaju periosteum ati sẹhin kọja dura sinu aaye subdural ati parenchyma ọpọlọ, paapaa nigba ti tabili ẹhin egungun tun dabi pe o wa lori ọlọjẹ CT kan. - ** Kini idi ti Awọn ọdọ (10 to 18 Years Old) Ti wa ni Lile julọ: ** Lakoko idagbasoke idagbasoke ọdọ ti ẹṣẹ iwaju, sisan ẹjẹ iṣọn diploic ati caliber ti iṣan de opin igbesi aye wọn ti o pọju, ṣiṣẹda ọna opopona iṣọn-ẹjẹ ti o gbooro lati iwaju sinus sinu ọra inu egungun ati ọpọlọ.

3. Awọn 4 Etiologies (Okunfa) ti Pott ká Puffy tumo

  1. ** A ko ṣe itọju tabi Apa kan ti a ṣe itọju Bacterial Frontal Sinusitis (75% to 80% ti Awọn ọran): *** Nigbagbogbo tẹle otutu gbogun ti arinrin tabi ifihan odo; O to idaji awọn alaisan ni a ti fun ni ọna kukuru ti awọn oogun aporo ẹnu ti o kuna lati wọ inu ẹṣẹ iwaju ti idilọwọ.
  2. ** Ibanujẹ Iwaju iwaju (Blunt iwaju)15% to 20% ti Awọn ọran):** Ijamba ere (akọsori bọọlu afẹsẹgba, baseball, igbonwo bọọlu inu agbọn), isubu skateboard, tabi jamba ọkọ ayọkẹlẹ kekere kan fa fifọ irun ti ogiri iwaju iwaju tabi hematoma subperiosteal lori iwaju ti lẹhinna di alabojuto nipasẹ kokoro arun sinus 1 si 4 ọsẹ lẹhinna.
  3. ** Kokeni inu inu / Imukuro Methamphetamine:** Afẹfẹ onibaje onibaje ati negirosisi ischemic ba septum imu ati apa iṣan jade ti iwaju iwaju, ti o yori si osteomyelitis.
  4. **Ṣaaju Iṣẹ abẹ Neurofacial, Iwaju Sinu Osteoma, tabi Itankale Ehín/Awọ.

Maṣe Ṣe Puncture Lumbar kan (Pinal Tẹ ni kia kia) Ṣaaju CT/MRI ni Tumor Puffy Pott ti a fura si

Nitoripe awọn alaisan ti o ni èèmọ puffy Pott nigbagbogbo ma wa pẹlu iba giga, orififo nla, ati lile ọrun ti n ṣe apẹẹrẹ meningitis, awọn oniwosan le ni idanwo lati ṣe puncture lumbar lẹsẹkẹsẹ (spinal tap). ** Maṣe ṣe puncture lumbar ṣaaju gbigba CT itansan tabi Brain MRI ni eyikeyi alaisan ti o ni wiwu iwaju tabi sinusitis aifọwọyi: *** nitori 60% to 85% abo aaye kan ti o n gbe ** intracranial epidural abscess, subdural empyema, tabi abscess lobe iwaju *, fifa omi ọpa ẹhin lati isalẹ le fa apaniyan ** isale cerebral herniation (coning).

Bii o ṣe le Aami “Ipopada Globe Inferolateral” Nigbati Tumor Puffy Pott Yabo Socket Oju

Nitoripe ilẹ ti ẹṣẹ iwaju tun jẹ oke ti iho oju, pus lati èèmọ puffy Pott nigbagbogbo maa n lọ si isalẹ sinu orbit ti o ga julọ. Wo taara ni awọn oju alaisan mejeeji: ti a ba ta bọọlu oju kan ni akiyesi ** sisalẹ ati ita si ẹrẹkẹ (inferolateral proptosis)** ti o tẹle pẹlu ailagbara lati wo oke, **superiosteal subperiosteal orbital abscess *** wa ati nilo isunmi endoscopic ni iyara lati ṣafipamọ iran.

Apá 2: Awọn ilolu Intracranial 5 ti a rii ni 60% to 85% ti Awọn ọran

Nitoripe o to mẹrin ninu marun awọn alaisan pẹlu Pott's puffy tumor abo abo ikolu intracranial, awọn oṣiṣẹ ile-iwosan ti n ṣakiyesi fun awọn ile-iṣẹ neurosurgical marun pato:

Iṣoro inu ara Igbohunsafẹfẹ ni Pott ká Puffy tumo Anatomical Location & Mechanism Classic Clinical Igbejade & ewu
1. Ikun Arun inu inu 40% to 55% (Most Common) Apo ti pus idẹkùn laarin inu inu ti ** tabili ẹhin ti egungun iwaju ** ati Layer ita ti **dura mater ***. Nigbagbogbo Aibikita ("Idakẹjẹ"): Nitoripe dura wa ni wiwọ si timole, ifun naa n gbooro sii laiyara, ti o nfa orififo iwaju iwaju, iba, ati wiwu iwaju fun awọn ọjọ ṣaaju igbega titẹ inu inu.
2. Empyema Subdural (SDE) 25% to 35% (Most Rapidly Fatal) Pus ya nipasẹ (tabi kọja nipasẹ awọn iṣọn sinu) fife, ṣiṣi ** aaye subdural ** laarin dura mater ati awo arachnoid ti o bo kotesi ọpọlọ. ** KODE NEUROSURGICAL RED:** Ko dabi aaye apọju ti o nipọn, aaye abẹlẹ ni ** awọn idena odo , gbigba pus lati tan kaakiri bi ina olomi lori gbogbo ẹdẹbu ọpọlọ (tabi isalẹ aarin aarin ** fissure interhemispheric). O nfa thrombosis iṣọn cortical, infarction cerebral, ** coma dekun, hemiparesis, ati awọn ijagba ifasilẹ laarin wakati 24 si 48 ***.
3. Iwa ọpọlọ iwaju Lobe (Cerebritis -> Encapsulated Abscess) 10% to 20% Awọn irugbin thrombophlebitis septic jẹ ọrọ funfun / grẹy ti ** lobe iwaju iwaju **. Ni kutukutu ** awọn iyipada ti ara ẹni, ni itara, irritability, tabi ifọkansi ti ko dara ("Aisan iwaju Lobe"), lilọsiwaju si awọn ijagba idojukọ, papilledema, ati eewu rupture intraventricular apaniyan.
**4. Superior Sagittal Sinus Septic Thrombosis *** 5% to 15% Arun thrombus didi kuro ni **superior sagittal dural venous sinus ** nṣiṣẹ isalẹ aarin oke ti timole ọtun lẹhin ẹṣẹ iwaju. orififo ti o lewu, spiking giga “picket-fence” awọn ibà, iṣupọ iṣọn iṣọn-ẹjẹ meji, awọn infarcts iṣọn iṣọn-ẹjẹ, ati ikọlu.
5. Meningitis kokoro arun nla 10% to 15% Ikolu kokoro arun ti ito cerebrospinal subarachnoid (CSF). Iba giga, ** nuchal rigidity (ọrun lile)**, photophobia, awọn ami Kernig/Brudzinski rere, ati ipo ọpọlọ ti o yipada.

Apakan 3: Iyatọ Pott's Puffy Tumor lati Awọn Lumps iwaju iwaju ti ko dara ati Orbital Cellulitis

Lo tabili lafiwe ibusun yii lati ṣe iyatọ ** tumor puffy ti Pott ** lati ** hematoma ti o rọrun lẹhin-ti ewu nla “goose-egg” kan ** epidermoid cyst / carbuncle awọ***, ati ** cellulitis orbital orbital ti o ya sọtọ ***:

Ẹya ara ẹrọ 1. Tumor Puffy Pott(Egungun iwaju Osteomyelitis + Abscess Subperiosteal) 2. Subgaleal Traumatic ti o rọrun / Subperiosteal Hematoma ("Ẹyin Goose") 3. Arun Iwaju Epidermoid Cyst tabi Furuncle Awọ/Ascess *4. Ti ya sọtọ Pre-Septal / Orbital Cellulitis *** (Lati Ethmoid Sinusitis)
Ila akoko & Itan iṣaaju Idagbasoke lẹhin ** awọn ọjọ si awọn ọsẹ ti orififo sinus iwaju / isunmọ imu ** (tabi bẹrẹ ni agbara **1 si ọsẹ mẹta LEHIN *** ijalu iwaju). Han ** lẹsẹkẹsẹ (laarin iṣẹju si awọn wakati)** lẹhin fifun taara si iwaju. Irora ti ko ni irora onibaje ti o ni iwọn awọ ara ti o yipada lojiji pupa ati irora ni ọjọ meji si mẹrin; ko si sinusitis. Ṣiwaju nipasẹ sinusitis ethmoid, bug bug, tabi ipenpeju.
** Ipo & Ijinle lori Palpation *** Daju lori ** egungun iwaju / glabella loke awọn oju oju**; rilara ** jin, boggy, esufulawa, tabi rirọ nisalẹ periosteum ***, nigbagbogbo pẹlu rim egungun indurated. Taara lori aaye ikolu; duro ni akọkọ, lẹhinna rọra fun awọn ọjọ **laisi iba tabi erythema ti ntan ***. ** Egbò inu dermis/awọ *: o le fun pọ ati ki o gbe odidi diẹ pẹlu awọ ara lori egungun timole ti o wa labẹ; igba ni o ni a ** aarin dudu punctum (pore). Fi si ** awọn ipenpeju ati yipo ni isalẹ oju oju **; awọn ** iwaju egungun loke awọn eyebrow jẹ 100% alapin ati ti kii tutu ***.
Iba Sisstemic & Iwaju Iwaju ** Bayi ni 80-90%:** Gbigbọn orififo iwaju (ti o buru julọ nigbati o ba tẹriba siwaju), iba, ati isun imu imu purulent. Ibà odo; rirọ ọgbẹ agbegbe nikan. Iba kekere tabi ti ko si; irora ara agbegbe nikan. Iba ati irora oju wa, ṣugbọn ko si wiwu iwaju ori.
** Ailewu si Inise & Sisan ni Ile-iwosan Itọju Amojuto kan?** ** RẸ.** Ṣe ibasọrọ pẹlu egungun timole, dura, ati ẹṣẹ sagittal; nbeere ** Iyatọ CT + MRI ati OR neurosurgical / ENT egbe **. ** Rara *** (yanju lairotẹlẹ; incising ṣafihan ikolu egungun). ** Bẹẹni *** (ni kete ti ifarapa egungun ti o jinlẹ ti yọkuro, awọn cysts / abscesses ti awọ ara ti o rọrun ti wa ni imugbẹ ni aipe). ** Rara *** (abscess orbital nilo ile-iwosan IV aporo + ENT CT-idari idominugere).

Apá 4: Microbiology ati Ìṣàkóso Ilé-ìwòsàn pàtó (CT + MRI, CNS-Dose IV Antibiotics, ati Combined ENT/Neurosurgery)

1. Kini idi ti Tumor Puffy Pott jẹ Polymicrobial Microaerophilic & Ikolu Anaerobic

Nitoripe ẹṣẹ iwaju ti idinamọ di aaye ** atẹgun kekere (hypoxic ati acidic) *, awọn kokoro arun ti o fa tumor puffy Pott ati awọn abscesses intracranial jẹ iyatọ pupọ si eti ti o rọrun tabi awọn akoran awọ: - ** Ẹgbẹ Aṣebi # 1 (50% to 70%): Awọn * Streptococcus anginosus * (Streptococcus milleri) Ẹgbẹ ** ( S. anginosus *, * S. constellatus *, ati * S. intermedius *) ati awọn miiran microaerophilic viridans streptococci. Ẹgbẹ *** Streptococcus intermedius / milleri * jẹ olokiki ni oogun aarun ajakalẹ fun iṣelọpọ henensiamu ibinu rẹ (hyaluronidase and deoxyribonuclease) ti o yo egungun ati awọn fọọmu ** ọpọlọ iparun ati epidural abscesses . - ** Oral ti o muna & Sinus Anaerobes (30% to 50%): ** * Fusobacterium * eya ( F. nucleatum , * F. necrophorum ), * Prevotella , * Porphyromonas , * Bacteroides , ati * Peptostreptococcus * (ti o wa ninu ọpọlọpọ awọn ọran pẹlu itẹsiwaju intracranial). - *** Staphylococcus aureus (15% to 25%, pẹlu MRSA):* Paapa wọpọ ni awọn iṣẹlẹ lẹhin-ti ewu nla, awọn ọdọ, ati sinusitis onibaje. - *** Streptococcus pneumoniae , * Haemophilus influenzae, ati * Streptococcus pyogenes (Group A Strep)

2. Lẹsẹkẹsẹ Awọn ilana oogun aporo inu iṣan inu iṣan (Meningeal / Iṣajẹ Arun ọpọlọ)

Lẹsẹkẹsẹ lẹhin ti awọn aṣa ẹjẹ ti fa (ati ṣaaju ki o to duro de ipari MRI), awọn oṣiṣẹ ile-iwosan bẹrẹ eto eto-aarin-aifọkanbalẹ-oògùn mẹta-wọnu ilana oogun aporo inu iṣọn-ẹjẹ : 1. ** Vancomycin inu iṣan (15 to 20 mg/kg IV every 6 to 8 hours) (lati bo meticillin-sooro S. aureus [MRSA] ati penicillin-sooro * S. pneumoniae), PLUS 2. ** Ceftriaxone iṣan iṣan (2 grams IV every 12 hours ninu awọn agbalagba; 100 mg/kg/day divided q12h ninu awọn ọmọde: kikun meningeal ni ilopo-meji) *** TABI ** Cefotaxime / Cefepime inu iṣọn-ẹjẹ (lati ṣe aṣeyọri CSF giga ati awọn ipele egungun lodi si ẹgbẹ * Streptococcus anginosus / Milleri * ati awọn ọpa odi Giramu), ** PLUS *** 3. ** Metronidazole ninu iṣọn-ẹjẹ (500 mg IV every 6 to 8 hours ninu awọn agbalagba; 30 to 40 mg/kg/day ninu awọn ọmọde) (nitori metronidazole ṣe aṣeyọri ** isunmọ-100% ilaluja sinu abscesses ọpọlọ, subdural pus, ati necrotic frontal egungun ** lati pa awọn anaerobes ti o muna bi * Fusobacterium * ati * Prevotella *). - * (Aṣatunṣe Yiyan: ** Meropenem + inu iṣọn-ẹjẹ Vancomycin *** - ** Iye akoko itọju ti o jẹ dandan: *** Nitori pe tumo puffy Pott jẹ nipasẹ asọye ** osteomyelitis nla ti egungun agbọn iwaju ** (nigbagbogbo so pọ pẹlu apọju epidural / subdural abscess), awọn alaisan nilo ** 6 si awọn ọsẹ 8 ni kikun ti ifọkansi iṣọn-ẹjẹ (tabi bioavailability giga-bioavailability ti gigun IV-si-isalẹ) nipasẹ laini oogun antibiotic gigun IV-si-isalẹ. idominugere abẹ.

3. Kini idi ti Awọn alaisan nilo mejeeji CT Itọpa ti o ga-giga ATI Iyatọ Brain MRI/MRV

  • ** Iyatọ ti o ga-giga CT ti ọpọlọ, Orbits, ati Paranasal Sinuses (Thin 1 mm Slices with Bone and Soft-Tissue Windows):**
  • ** Ferese Egungun ** jẹ pataki fun ENT ati neurosurgeon: o ṣe maapu awọn abawọn millimeter gangan nibiti osteomyelitis ti jẹun nipasẹ ** tabili iwaju **, ** tabili ẹhin **, ati ** orbital floor *** ti egungun iwaju, ati ṣafihan anatomi iwaju ẹṣẹ iwaju ti alaisan fun lilọ kiri iṣẹ abẹ.
  • Ferese ** Iyatọ Asọ Tissue *** ṣe afihan ni didasilẹ rim-imularada ** iwaju ori subperiosteal abscess *** labẹ pericranium ati eyikeyi nla ** orbital tabi abscess epidural **.
  • ** Kilode ti CT Nikan Ko To -> Imudara Imudara Iyatọ ti Ọpọlọ MRI pẹlu DWI ati MR Venography (MRV):**
  • Tinrin ni kutukutu subdural empyemas (paapaa awọn ti o farapamọ ni inaro laarin awọn hemispheres meji lẹgbẹẹ **falx cerebri / interhemispheric fissure ***), ni kutukutu ** frontal lobe cerebritis ***, ati ** superior sagittal sinus thrombosis *** le padanu lori ọlọjẹ CT kan.
  • ** MRI ọpọlọ pẹlu Iyatọ Gadolinium ati Aworan Iwọn Iyasọtọ (DWI)** ni boṣewa goolu: pus inu kan subdural empyema tabi epidural abscess fihan iyalẹnu ** itanka ihamọ didan lori DWI **, lakoko ti MRV jẹri boya ẹṣẹ sagittal ti o ga julọ jẹ itọsi tabi didi.

4. Otolaryngology idapọ (ENT) ati Iṣakoso orisun Neurosurgical ni Yara Iṣiṣẹ

Awọn oogun apakokoro nikan ** ko le ṣe iwosan tumo tumọ Pott's puffy; pus labẹ iwaju periosteum iwaju, inu ẹṣẹ iwaju ti dina, ati inu epidural/subdural aaye gbọdọ jẹ kuro ni iṣẹ abẹ (source control), ni igbagbogbo nipasẹ apapọ ẹgbẹ ENT + Neurosurgery ** lakoko igba akuniloorun kanna: 1. ** Endoscopic Frontal SinusotomyDraf IIa / IIb or Draf III Modified Endoscopic Lothrop Procedure) ± Iwaju Iwaju Ita: Lilo awọn endoscopes imu ti o ga ati lilọ kiri iṣẹ abẹ ti aworan nipasẹ awọn iho imu, oniṣẹ abẹ ENT ṣii aaye iṣan ti iṣan iwaju iwaju ti a dina mọ lati isalẹ, ti o fọ pus ati sequestra, ti o si fa omi iwaju iwaju subperiosteal kuro nipasẹ abscess ti oju-oju ti o ni iranlọwọ nigbagbogbo abẹrẹ percutaneous/sisọ gbigbe nitoribẹẹ ko si aleebu iwaju ti o han). 2. ** Sisilo Neurosurgical (Burr Hole or Craniotomy) + Yiyọ ti Egungun Necrotic: ** Ti o ba jẹ pe ** abscess epidural, subdural empyema, tabi abscess ọpọlọ ** wa lori MRI, neurosurgeon ṣe pajawiri ** frontal burr iho tabi craniotomy ** lati wẹ inu pus intracranial ati yọkuro eyikeyi ti o ti ku, awọn ajẹkù iwaju iwaju osteomskullticsequestrectomy).

Awọn nọmba pajawiri ti agbegbe ati awọn ile-iṣẹ itọju ailera ọmọ / agbalagba

Tumor puffy Pott ti a fura si nilo gbigbe ile-iwosan lẹsẹkẹsẹ lọ si ** Ile-iṣẹ Iṣoogun ti Ile-ẹkọ giga tabi Ile-iwosan Awọn ọmọde ti a ti yasọtọ pẹlu Neurosurgery 24-wakati, Otolaryngology (ENT) Rhinology, Ophthalmology, ati Paediatric/Agbalagba Arun Arun agbegbe ***:

  • United States ati Canada: Titẹ 911 fun eyikeyi ti iṣan, wiwo, tabi awọn ami ikilọ sepsis, tabi lọ taara si ile-ẹkọ giga tabi ** Ẹka Pajawiri Ile-iwosan Awọn ọmọde . Ṣakoso labẹ ** Ile-ẹkọ giga Amẹrika ti Otolaryngology-Ori ati Iṣẹ abẹ Ọrun (AAO-HNS, Awujọ Arun Arun ti Amẹrika (IDSA, ati ** Ile-ẹkọ giga ti Ilu Amẹrika ti Awọn itọju ọmọde (AAP** idiju awọn itọnisọna kokoro arun rhinosinusitis.
  • United Kingdom: Tẹ 999 tabi lọ lẹsẹkẹsẹ si ile-iwosan nla kan ** Ẹka Pajawiri (A&E)** pẹlu ipe-lọ ENT ati Neurosurgery. Ṣakoso labẹ Itọsọna NICE NG79 (Sinusitis, Acute: Gbigbawọle Ile-iwosan Lẹsẹkẹsẹ fun Awọn ifura Intracranial tabi Awọn ilolu Agbeegbe) ati ENT UK/British Rhinological Society awọn ajohunše.
  • European Union: Titẹ 112. Ṣakoso labẹ ** Iwe Ipo European lori Rhinosinusitis ati Nasal Polyps (EPOS 2020/2024: Isakoso ti Osseous ati Intracranial Complications of Acute Rhinosinusitis)**.
  • ** Australia ati Ilu Niu silandii: *** Tẹ ** 000 *** ni Australia tabi ** 111 *** ni Ilu Niu silandii. Ti iṣakoso labẹ ** ASOHNS *** ati ** Royal Children's Hospital (RCH) Melbourne Complicated Sinusitis & Intracranial Sepsis Awọn Itọsọna**.
  • ** Asia-Pacific:** Titẹ 119 (Japan, Koria Guusu), 995 (Singapore), tabi 112/108 (India). Beere ile-iwosan giga ti o ni ipese pẹlu MRI wakati 24, neurosurgery, ati iṣẹ abẹ endoscopic sinus.

Awọn ibeere ti a beere nigbagbogbo

Ṣe " tumor puffy Pott " looto tumo tabi akàn bi?

Rara. Pelu ọrọ idẹruba "tumor" ni orukọ rẹ, tumor puffy Pott ni asopọ odo si akàn. Nigba ti oniṣẹ abẹ Gẹẹsi Sir Percivall Pott sọ orukọ rẹ ni ọdun 1760, ọrọ iwosan Latin "tumor" tumọ si eyikeyi "wiwu." Pott's puffy tumo jẹ ikolu kokoro-arun ti egungun (osteomyelitis) ti egungun agbọn iwaju ti o ṣẹda apo ti pus labẹ awọ ita ti iwaju iwaju (abscess subperiosteal), ti o wọpọ julọ ti o nfa nipasẹ aisan ti ko ni itọju tabi apakan ti a ṣe itọju iwaju iwaju tabi ijalu iṣaaju si iwaju.

Kilode ti ọpọlọpọ awọn ọdọ ti o ni tumo puffy Pott tun ni ikun ti o farapamọ ninu agbọn wọn nitosi ọpọlọ?

Ẹsẹ iwaju jẹ apo afẹfẹ ti o ṣofo si inu egungun iwaju ni ọtun laarin awọn oju oju rẹ. Odi iwaju rẹ (ti nkọju si awọ iwaju rẹ) jẹ egungun ti o nipọn (2 si 4 millimeters), lakoko ti ogiri ẹhin rẹ (yiya sọtọ ẹṣẹ kuro ninu ọpọlọ ati dura mater) jẹ tinrin-iwe (0.5 si 1 millimeter). Ni afikun, awọn iṣọn spongy pẹlu awọn falifu ọna kan (awọn iṣọn diploic ti Breschet) nṣiṣẹ taara lati inu ẹṣẹ siwaju si iwaju ati sẹhin si ibora ti ọpọlọ, ti o de iwọn ti o ga julọ ati sisan ẹjẹ ni akoko idagbasoke idagbasoke ọdọ. Nitoribẹẹ, ni akoko ti ikolu ẹṣẹ kan ti lagbara to lati Titari pus siwaju nipasẹ egungun iwaju ti o nipọn si iwaju, 60 si 85 ida ọgọrun ti awọn ọmọ ilera ati awọn alaisan ọdọ ti tẹlẹ ti ni kokoro arun kọja sẹhin nipasẹ ogiri ẹhin tinrin tabi awọn iṣọn valve lati dagba abscess epidural tabi empyema subdural ninu agbọnri.

Kini idi ti alaisan kan le ni apọju tabi iwaju iwaju ọpọlọ abscess lati tumọ puffy Pott ati tun rin ati sọrọ ni deede ni akọkọ?

Apa iwaju ti ọpọlọ joko taara lẹhin iwaju iwaju (kotesi iwaju iwaju ti awọn lobes iwaju) ko ṣakoso apa ati gbigbe ẹsẹ, aibale, tabi ọrọ, awọn agbegbe naa joko siwaju sẹhin ni ọpọlọ. Awọn oniwosan ile-iwosan n pe lobe iwaju iwaju ni “agbegbe ipalọlọ” ti iṣan nipa iṣan nitori apo ti o dagba ti pus titẹ ni iwaju iwaju lobe nigbagbogbo nfa ailera odo, numbness odo, ati ọrọ sisọ ni kutukutu. Dipo, awọn itọka akọkọ ti o kọja orififo ati iba jẹ eniyan arekereke tabi awọn iyipada iṣesi: ọdọ tabi agbalagba kan di idakẹjẹ laiṣe, aibalẹ, ibinu, oorun, tabi lọra lati dahun awọn ibeere. Ti o ni idi ti gbogbo alaisan ti o ni wiwu iwaju esufulawa gba iyatọ pajawiri CT ati ọpọlọ MRI laibikita bawo ni idanwo ipilẹ wọn ṣe ṣe deede.

Bawo ni MO ṣe le sọ iyatọ laarin ọgbẹ “Gussi-egg” deede lẹhin ijalu ori ati tumọ puffy Pott?

“Ẹyin Gussi” ti o ni ipalara deede (hematoma) wú soke laarin iṣẹju diẹ ti fifun ori rẹ, rilara ṣinṣin tabi rubbery, ko ni iba tabi itusilẹ ẹṣẹ, o si dinku ni imurasilẹ ni ọsẹ ti n bọ. Ni idakeji, tumo Pott's puffy yala ni idagbasoke lakoko ikun ti o lagbara / otutu laisi eyikeyi ipalara ori rara, OR han awọn ọjọ si awọn ọsẹ lẹhin ijalu iwaju kan nigbati ọgbẹ iwosan lojiji bẹrẹ si dagba sii lẹẹkansi, di gbona, pupa, doughy / squishy, ​​ati ki o ni itọra pupọ si ifọwọkan, ati pe o wa pẹlu gbigbọn iwaju iwaju iwaju, ibà ti ntan.

Njẹ tumo lewu ti Pott ṣe itọju pẹlu awọn oogun aporo inu ẹnu ni ile, tabi lanced ni ile-iwosan itọju ni kiakia?

Kò. Awọn oogun aporo ẹnu ko le wọ inu okú, egungun iwaju ti o ni akoran tabi fa apo idalẹnu kan ti pus labẹ iwaju periosteum, ni otitọ, ni aijọju idaji awọn alaisan ti o ni ayẹwo pẹlu tumọ puffy Pott ti n mu awọn oogun aporo ẹnu ti a fun ni aṣẹ fun ikolu ẹṣẹ nigbati iwaju wọn wú soke. Bakanna ni pataki, oniwosan itọju amojuto ni ko gbọdọ ge sinu wiwu iwaju laisi CT ile-iwosan ati ọlọjẹ MRI, nitori abscess nigbagbogbo sopọ taara nipasẹ iho kan ninu agbọn si awọ ita ti ọpọlọ (dura) ati sinus iṣọn-ẹjẹ pataki. Itọju nigbagbogbo nilo gbigba ile-iwosan, ENT ni idapo ati idominugere yara iṣẹ ṣiṣe neurosurgical, ati ọsẹ mẹfa si mẹjọ ti awọn oogun aporo inu iṣan.

Njẹ iṣẹ abẹ fun tumo puffy Pott yoo fi aleebu nla silẹ kọja iwaju?

Tẹ́lẹ̀tẹ́lẹ̀, àwọn oníṣẹ́ abẹ ní láti ṣe ọ̀gangan iwájú orí tàbí awọ orí láti ṣí egungun ìhà iwájú. Loni, ni ọpọlọpọ awọn ọran laisi iparun timole nla, Awọn oniwosan Otolaryngologists (awọn oniṣẹ abẹ ENT) lo ipakokoro diẹ, awọn endoscopes imu ti kọnputa ti o kọja patapata nipasẹ awọn iho imu (awọn ilana endoscopic iwaju sinusotomy / Draf) lati ṣii sinus iwaju ti a dina mọ lati inu, nigbagbogbo so pọ pẹlu irun kekere kan ti o farapamọ, ti o farapamọ nilo irun timillimenti 5. eyebrow ki iwaju ori larada pẹlu fere ko si aleebu ti o han.

Awọn orisun ati osise itoni

  • ** Iwe Iduro European lori Rhinosinusitis ati Nasal Polyps (EPOS 2020/2024, European Rhinologic Society):** * Iyasọtọ ati Itọju Pajawiri ti Osseous ati Intracranial Complications ti Arun Bacterial Rhinosinusitis (Pott's Puffy Tumor, Epiddural Absmpye) Idominugere)*.
  • ** Ile-ẹkọ giga ti Ilu Amẹrika ti Otolaryngology-Ori ati Iṣẹ abẹ Ọrun (AAO-HNS) & Ile-ẹkọ giga ti Ile-ẹkọ Ọdọmọkunrin ti Amẹrika (AAP, United States): ** * Awọn Itọsọna Iṣeduro Iṣegun fun Awọn Ẹjẹ Kokoro Awujọ Sinusitis ni Awọn ọmọde ati Agbalagba * (iṣẹlẹ peak ọdọ, diploic vein thrombophlebitis, thrombophlebitis)
  • ** National Institute for Health and Care Excellence (NICE) & ENT UK (United Kingdom):** * Sinusitis (Acute): Itọnisọna Antimicrobial and Emergency Hospital Referral Criteria fun Ifura Iwaju Egungun Osteomyelitis tabi Intracranial Itankale (NICE Itọsọna NG79)*.
  • ** Awujọ Arun Arun ti Amẹrika (IDSA, Orilẹ Amẹrika):** * Awọn Itọsọna Iṣeduro Iṣegun fun Awọn ilolu Suppurative Intracranial ati Osteomyelitis* (empiric CNS-dose intravenous vancomycin, cephalosporin iran-kẹta, ati metronidazole ti o bo *Streptococcus anginosus) si awọn ọsẹ 6.
  • ** Ile-iwosan Awọn ọmọde Royal (RCH) Melbourne & ASOHNS (Australia):** Iwaju Sinusiitis Iwaju Paediatric ati Pott's Puffy Tumor Neurosurgical/ENT Protocol.

Gba iwe-ẹkọ iranlọwọ akọkọ ti ifọwọsi ati kan si awọn alamọja

Itọsọna yii n pese idanimọ pajawiri ati ẹkọ iranlọwọ akọkọ ati pe ko rọpo iṣoogun ọjọgbọn, neurosurgical, tabi itọju iṣẹ abẹ otolaryngologic. Lati kọ ẹkọ awọn ọgbọn ti o wulo ni riri awọn ipalara ori, awọn akoran ti o lagbara, ati awọn asia pupa ti iṣan, mu iṣẹ iranlọwọ akọkọ ti ifọwọsi nipasẹ Red Cross, St John Ambulance, tabi olupese agbegbe kan.

Jẹmọ awọn itọsọna