In the early years, when I was a surgical instructor, I often told this case to the trainees and physicians who were instructed.
I think many young physicians should have been inspired.
In my second year of work, Corey has few staff, and I am also scheduled to go out to the clinic one day a week.
Across from my consulting room is another surgical ward, an old surgical director sitting in the outpatient clinic.
Such an arrangement, the result can be imagined, the old director was crowded with people, but I was deserted in front of the door.
I was bored sitting around in the outpatient clinic. I was so bored that every time I went out of the outpatient clinic, I could pick up a thick book of “Huang Jia Si Surgery” to read. At the time, it was still the fifth edition.
There are still a few patients in the morning, but after ten o’clock, there are very few people coming. When I see a patient who has registered with me, it is like meeting a friend.
On that day, I was bored in the outpatient clinic, and a patient came in, carrying a large plastic film, CT, MRI, B-ultrasound, electrophysiological examination, everything.
I asked him to sit down first and asked him what was wrong.
He said that he has tinnitus. No matter day or night, the ringing in his ears always keeps ringing, and it has been ringing for more than 3 months. It affects work, sleep, and more. Chatting with others is a pain in the ass.
Three months after the onset of the disease, he has traveled to several major hospitals, and has been to brain surgery, neurology and otolaryngology. Some doctors even suspected that he had a mental problem and even went to a psychiatrist. Health Section.
In various hospitals, various examinations, CT and MRI of various parts have been done many times, but the doctor still cannot find the cause of the tinnitus.
He came here this time to see the brain surgeon of our hospital. When he registered for the outpatient service, he registered the wrong number, and it was called surgery, so he simply went to the surgery. Want me to show him.
After listening to his words, my head was sweating. I don’t see tinnitus, so I asked him to cancel the number.
He insisted that I show it to him. Anyway, he went to so many hospitals and spent a lot of money, but he couldn’t cure it. I couldn’t see the problem, and he wouldn’t blame me.
He finally said, I am also idle when I see it.
Just like that, he was sitting in my consulting room, and I asked him about his medical history one after another, except that he had tinnitus more than three months ago, and it was rumbling like a machine The booming sound, which I feel is very loud, has continued until now, and I can’t ask anything other than that.
While chatting with him, I noticed that in front of the ear on his right face, where the superficial temporal artery and superficial temporal vein are, there is a vein-like blood vessel bulging, like a leg Varicose veins on the great saphenous vein.
Schematic representation of blood vessels in his face
I have seen many people with such varicose veins on their legs or hands, but I have never seen anyone with such varicose veins on their face, No. 1 At first glance, this vein is an abnormal place.
After asking the medical history, nothing special was found. According to the procedure, it was time for a physical examination.
My first move was to reach out and touch the bulging blood vessel on his face.
As soon as I touch it, I can feel the tremor of this blood vessel, which is obviously much more than the tremor of hyperthyroidism.
Such tremors must be able to make sounds.
I put the stethoscope on the surface of this blood vessel, put it on it gently, and I heard a rumbling machine-like sound. If I press it hard, the sound is very small.
I pressed the blood vessel with two fingers, and after squeezing the blood vessel, his tinnitus disappeared.
This shows that his tinnitus is caused by this blood vessel.
I asked him again, when did this blood vessel bulge, and was it like this before?
He told me that he was a plasterer. Three and a half months ago, when he was decorating the house, he fell from a shelf more than 3 meters high and injured his right face. There was a large bruise at that time.
Later, the bruises on his face subsided, and the bulging blood vessel appeared. He felt that tinnitus started to appear during that time.
At this time, I thought of a disease I learned in school: arteriovenous fistula caused by trauma.
But how to treat arteriovenous fistula, I forgot, what should I do?
At that time, there was no mobile phone to search online.
This is not difficult for me, I turned my head and thought about it.
I ordered a blood vessel B-ultrasound and asked him to do a B-ultrasound to confirm whether his blood vessel was a superficial temporal arteriovenous fistula, and also to branch him out, which was very convenient. I check the information.
After he left the clinic, I immediately took out “Huang Jiasi Surgery” and started to read about the formation mechanism and treatment methods of arteriovenous fistula.
At this time, I deeply realized that I hate less books when they are used up.
After 23 years, I still have a fresh memory of what I learned at that time.
The patient came back with an ultrasound report. The ultrasound report was: superficial temporal arteriovenous fistula.
I also finished the related content and figured out the ins and outs of his tinnitus and how to treat it.
Let me restore the cause of his tinnitus.
Anatomy of the superficial temporal artery and vein
The picture above is a schematic diagram of the anatomy of the superficial temporal artery and vein. Under the facial skin in front of the ears, there are such two blood vessels, which are close to each other.
Three and a half months ago, he fell from a height, punctured the superficial temporal artery and superficial temporal vein, and formed a large hematoma under the skin, so he had a large bruise on his face. Bag.
During the healing process, the wall of the superficial temporal artery cannot be closed, and the blood flow from the rupture of the superficial temporal artery, through the rupture of the superficial temporal vein, and into the superficial temporal vein, which A superficial temporal arteriovenous fistula is formed.
The arterial blood pressure is high and the flow rate is fast. The venous blood pressure is low and the flow rate is slow. The superficial temporal vein swells up because of the increase in pressure. We can see this facial vein, which flows inside. is high-pressure arterial blood.
When the fast-flowing arterial blood enters the slow-flowing venous blood, it will produce eddies and turbulence, resulting in a rumbling blood vessel murmur.
This noise is transmitted to the human ear through bone conduction, and of course it is very clear and loud.
His cause has been found, and the treatment is very simple, that is, “four-head ligation surgery”.
Schematic diagram of quadruple ligation
The ligation of the four heads of the arteriovenous fistula is as shown in the figure above. All the four heads of the two blood vessels of the arteriovenous fistula are ligated and cut off.
Human facial blood vessels form a network, and both arteries and veins have abundant collateral circulation. The ligation of the two blood vessels will not affect the blood supply to the face.
Because of the superficial blood vessels in his face, the operation was simple, an outpatient procedure under local anesthesia.
I put lidocaine on the skin of his face, and I cut the skin to expose these blood vessels, and it was good to ligate them.
He also recovered quickly after the surgery.
This case, I often talk to doctors and interns, and tell them that asking the medical history and doing physical examinations are the basic skills of every clinician.
No matter how advanced the technology and the advanced auxiliary examination are, the basic skills of doctors cannot be lost.
A doctor’s physical examination is the process of observing the patient.
A doctor cannot be familiar with all the signs of abnormality, but as long as he pays attention to observing normal people, he can always know what normal looks like. If he encounters abnormal appearances, he can at least know that this It is abnormal, and the diagnosis has a direction.
Looking back, the opportunity to be able to diagnose this case was seeing the bulging vein on the face.
Look at the face, ordinary people look at the appearance, and doctors focus on whether it is normal. This is the difference between doctors and ordinary people.