7 and 8. Lump in neck and lymphadenopathy Flashcards
1
Q
History taking neck lump/lymphadenopathy
A
Duration of onset
Any recent change in size, number of neck lumps
Associated symptoms (especially red flag symptoms, discussed below)
Relevant past medical history – smoking status, alcohol intake, previous head and neck cancers, and known radiation exposure (e.g. previous radiotherapy)
How long has the lump been present?
Is it painful?
Has it changed? If so, over what time frame?
Are there symptoms of recent infection of nearby structures (cough, cold, sore throat, earache, toothache, skin problems, head lice, bites)?
Has there been a fever?
Does eating affect the lump?
Is there pain when swallowing?
Is there any effect on voice?
Does the person smoke?
Is there a history of travel?
Is there a past history of cancer?
Are there red flag symptoms of systemic illness? For example:
Night sweats.
Weight loss.
Unexplained bruising or bleeding.
Persistent fatigue.
Breathlessness.
2
Q
Examination neck lump and lymphadenopathy
A
Look, feel, move
LOOK:
Location (anterior triangle, posterior triangle or midline)
Size
Shape (oval, round or irregular)
Skin changes (erythema, tethering or ulceration)
Pulsatile (e.g., carotid body tumours)
FEEL
Consistency (hard, soft or rubbery)
Surface eg rough, smooth, irregular
Shape
Warmth (e.g., infection)
Tenderness (e.g., infection)
Size: use a tape measure
Compressible?
Fluctuant?
Pulsatile (high blood flow) or expansile (aneurysmal)? Is there a palpable thrill?
MOVE
● Skin tethering - attempt to pick up a fold of skin over the swelling and compare the
degree of tethering with the other side
● Tethering to deeper structures - attempt to move the swelling in different planes
relative to the surrounding tissues.
● Tethering to muscles and tendons - palpate the swelling whilst asking the patient to
use the relevant muscle.
Movement with swallowing (e.g., thyroid lumps) or sticking their tongue out (e.g., thyroglossal cysts)
Special tests:
Transilluminates with light (e.g., cystic hygroma – usually in young children)
● Auscultation for bruits or bowel sounds
ENT
- ear infections –> reactive lymphadenopathy
- nose –> h&n ca,
- throat - h&n ca,
Thyroid
Cranial nerves
Respiratory
- clubbing - lung ca
Abdo
- hepatosplenomegaly eg EBV, leukemia, lymphoma
- gastric ca
3
Q
differentials neck lump and lymphadenopathy
A
Infectious
Reactive lymphadenopathy eg post-URTI
Skin infection such as abscess
Measles, mumps, rubella
Generalised lymphadenopathy (HIV, EBV, HSV, CMV)
Cat scratch disease
Extra-pulmonary tuberculosis
Specific risks (toxoplasmosis, lyme disease, cat scratch)
Immune
Amyloidosis
Sarcoidosis
Kawasaki
Malignant lymphadenopathy
Lymphoma
Leukaemia
Tumours
Head and neck cancer
Sarcoma
Salivary gland tumours/pathology
Metastasis - lung and gastric
Lipoma
Neural tumours
Vascular tumours such as hemangioma
Thyroid
Goitre
Congenital
Thyroglossal cyst
Cystic hygroma
Branchial cyst
Dermoid cyst
Degenerative
Pharyngeal pouch
Vascular
Carotid body tumour
Carotid aneurysm
Trauma
Haematoma
4
Q
red flags for lump in neck ?
A
buffer
5
Q
infectious ddx lump in neck
A
Reactive lymphadenopathy eg post-URTI
Skin infection such as abscess
Measles, mumps, rubella
Generalised lymphadenopathy (HIV, EBV, HSV, CMV)
Cat scratch disease
Extra-pulmonary tuberculosis
Specific risks (toxoplasmosis, lyme disease, cat scratch)
6
Q
what is the most common cause of neck swellings?
A
Reactive lymphadenopathy
7
Q
what local lesions of infection may you see on the neck
A
boils
carbuncle
abscess
pustule
8
Q
boil vs carbuncle
A
Boil/furuncle: staphylococcal infection around or within a hair follicle.
Carbuncle: staphylococcal infection of adjacent hair follicles (i.e. multiple boils/furuncles).
9
Q
pustule vs abscess
A
Abscess: a localised accumulation of pus.
Pustule: a pus-containing lesion less than 0.5cm in diameter.
10
Q
most common causative organism boils/carbuncle/abscess
A
staph aureus
may be MRSA or PVL-SA
11
Q
when should you take a swab of boils/carbuncles/abscess
A
Consider taking a swab of pus from the contents of the lesion if:
The boil or carbuncle is:
Not responding to treatment.
Persistent or recurrent, to exclude atypical mycobacteria or Panton-Valentine leukocidin Staphylococcus aureus (PVL-SA).
There are multiple lesions.
The person:
Is immunocompromised.
Is known to be colonized with MRSA.
Has diabetes.
Is a member of a household, or resides in an institutional setting, where recurrent outbreaks of skin and soft tissue infections have been reported (to exclude PVL-SA).
12
Q
management boil/caruncle/abscess?
A
- urgent same-day incision and drainage if large
- admit for IV abx based on clinical judgement eg systemically unwell or on face or immunocompromised
if not req ref or admis
1. prescribe 7-day abx if fever, cellulitis, sev pain, co-morbidities, on face
+ advise apply moist heat tds to hasten drainage of pus and alleviate pain
+ once drained, cover with steruke dressing
+ safety net
abx
Flucloxacillin is recommended first line (erythromycin [preferred in pregnancy and breastfeeding] or clarithromycin are alternatives if the person has a true allergy to penicillin)
13
Q
what is the most common site of s.aureus colonisation
A
nose
14
Q
when might you consider staph aureus carriage and decolonisation?
what do you do to investigate?
A
recurrent boils/abscesses or infections caused by s.aureus
Take swabs from the contents of the boil or carbuncle.
If recurrent boils or carbuncles are localized to the facial area, swab the nasal cavity.
If the boils or carbuncles are more extensive, consider swabbing the perineum, groin, axillae, and umbilicus in addition to the nose.
15
Q
process of s.aureus decolonization
A
Do not start decolonization until acute infection has resolved.
Eliminate nasal carriage by prescribing Naseptin® cream (chlorhexidine plus neomycin), four times a day for 10 days. Be aware that Naseptin® contains arachis oil (peanut oil) and should not be used by a person known to be allergic to peanuts or soya.
Use an antiseptic preparation (such as chlorhexidine 4% body wash/shampoo or Triclosan 2%) daily as liquid soap in the bath, shower, or sink for 5 days.
consider other options for sensitive skin/dermatological conditions
16
Q
what infections should you specifically assess for in children with neck lump
A
measles
mumps
rubella
infectious mononucelosis
17
Q
features measles
A
prodromal phase
irritable
conjunctivitis
fever
Koplik spots
typically develop before the rash
white spots (‘grain of salt’) on the buccal mucosa
rash
starts behind ears then to the whole body
discrete maculopapular rash becoming blotchy & confluent
desquamation that typically spares the palms and soles may occur after a week
diarrhoea occurs in around 10% of patients
18
Q
what is measles?
A
RNA paramyxovirus
one of the most infectious known viruses
spread by aerosol transmission
infective from prodrome until 4 days after rash starts
incubation period = 10-14 days
19
Q
invetsigations measles
A
IgM antibodies can be detected within a few days of rash onset
20
Q
management of measles
A
mainly supportive
admission may be considered in immunosuppressed or pregnant patients
notifiable disease → inform public health
21
Q
most common complication of measles
A
otitis media
22
Q
most common cause of death following measles
A
pneumonia
23
Q
complications measles
A
otitis media: the most common complication
pneumonia: the most common cause of death
encephalitis: typically occurs 1-2 weeks following the onset of the illness)
subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness
febrile convulsions
keratoconjunctivitis, corneal ulceration
diarrhoea
increased incidence of appendicitis
myocarditis
24
Q
how should you manage a contact of measles who is unvaccinated against measles
A
give MMR within 72 hours
25
what is mumps?
Mumps is a caused by RNA paramyxovirus and tends to occur in winter and spring
Spread
by droplets
respiratory tract epithelial cells → parotid glands → other tissues
infective 7 days before and 9 days after parotid swelling starts
incubation period = 14-21 days
26
clinical features mumps?
fever
malaise, muscular pain
parotitis ('earache', 'pain on eating'): unilateral initially then becomes bilateral in 70%
27
how effective is MMR at preventing mumps?
MMR vaccine: the efficacy is around 80%
28
management mumps
rest
paracetamol for high fever/discomfort
notifiable disease
29
complications mumps
orchitis - uncommon in pre-pubertal males but occurs in around 25-35% of post-pubertal males. Typically occurs four or five days after the start of parotitis
hearing loss - usually unilateral and transient
meningoencephalitis
pancreatitis
30
what is rubella?
Rubella is caused by the togavirus.
If contracted during pregnancy there is a risk of congenital rubella syndrome
outbreaks more common around winter and spring
the incubation period is 14-21 days
individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash
31
features rubella
prodrome, e.g. low-grade fever
rash: maculopapular, initially on the face before spreading to the whole body, usually fades by the 3-5 day
lymphadenopathy: suboccipital and postauricular
32
complications rubella
arthritis
thrombocytopaenia
encephalitis
myocarditis
33
what is the classic triad of infectious mononucleosis
sore throat, pyrexia and lymphadenopathy
34
features of infectious mononucleosis
sore throat, pyrexia and lymphadenopathy
Other features include:
malaise, anorexia, headache
palatal petechiae
splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture
hepatitis, transient rise in ALT
lymphocytosis: presence of 50% lymphocytes with at least 10% atypical lymphocytes
haemolytic anaemia secondary to cold agglutins (IgM)
a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis
35
diagnosis infectious mononucleosis
heterophil antibody test (Monospot test)
NICE guidelines suggest FBC and Monospot in the 2nd week of the illness to confirm a diagnosis of glandular fever.
36
when do symptoms resolve infectious mononucleosis
Symptoms typically resolve after 2-4 weeks.
37
management infectious mononucelosis
rest during the early stages, drink plenty of fluid, avoid alcohol
simple analgesia for any aches or pains
consensus guidance in the UK is to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture
Safety netting
If you get any severe symptoms such as difficulty breathing, severe abdominal pain then go to a&e
38
how does HIV seroconersion present?
glandular fever type illness
sore throat
lymphadenopathy
malaise, myalgia, arthralgia
diarrhoea
maculopapular rash
mouth ulcers
rarely meningoencephalitis
39
how does lymph node TB present?
A “cold abscess” is a firm painless abscess caused by TB, usually in the neck. They do not have the inflammation, redness and pain you would expect from an acutely infected abscess.
40
what is toxoplasmosis
Toxoplasma gondii is an obligate intracellular protozoan that infects the body via the gastrointestinal tract, lung or broken skin. It's oocysts release trophozoites which migrate widely around the body including to the eye, brain and muscle. The usual animal reservoir is the cat, although other animals such as rats carry the disease.
41
How does toxoplasmosis affect immunocompetent patients?
Most infections are asymptomatic. Symptomatic patients usually have a self-limiting infection, often having clinical features resembling infectious mononucleosis (fever, malaise, lymphadenopathy). Other less common manifestations include meningoencephalitis and myocarditis.
42
what causes cat scratch disease
Gram negative rod Bartonella Henselae
Cats become infected with Bartonella henselae from the bites of infected fleas or contact with infected blood
43
features of cat scratch disease
fever
History of cat scratch
Regional Lymphadenopathy
Headache, malaise
- one or more erythematous lesions at the site of inoculation, 3-12 days after scratch from a cat - most likely a kitten with fleas
- O/e: crusted papeles or, rarely, a pustule
- 1-3 weeks after primary lesion, regional lymphadenopathy appears, usually next to innoculation site - painful and may suppurate
- Systemic symptoms: fever malaise, headache, anorexia
44
complications cat scratch
aseptic meningitis
Encephalopathy
Prolonged fever
Myelitis, paraplegia, cerebral arthritis
Joint pain
Back pain
If innoculation directly into eye —> unilateral granulomatous conjunctivitis
Neuroretinitis
Abdominal pain (hepatitis/splenitis)
45
management cat scratch disease
supportive - antipyretics and analgesia
may need fluctulant tender nodes aspirated
Antibiotics are indicated in immunocompromised patients and atypical cases involving severe or systemic disease
Patients should follow up in 2-6 months for confirmation of symptom resolution.
46
prevention of cat scratch disease
Vigilant elimination of fleas from cats.[12]
Avoiding traumatic injury from cats, especially kittens. Cat-scratches and bites should be washed immediately and cats should not be allowed to lick open wounds
47
what are the stages of lyme disease
Stage 1: inoculation and localised infection
PC; erythema migrans
Stage 2: dissemination
joints, heart, nervous system
PC: flu-like illness, headache, feve, tiredness, n&v
PC: facial nerve palsy, meningitis, encephalitis, peripheral mononeuritis
PC: migratory joint pain
PC: carditis with heartblock
Stage 3: late manifestations/ dysregualted host immune response
PC: chronic arthritis, encephalopathy or peripheral neuropathy, ‘post-Lyme syndrome’
48
what is lyme disease? causative organism?
transmitted by bite of infected Ixodes ticks
The risk of transmission increases with the duration of tick attachment, with the highest risk occurring after 36-48 hours.
Lyme disease is caused by the spirochete bacterium Borrelia burgdorferi,
49
investigations lyme disease
If considering testing for Lyme disease, speak to ID
Erythema migrans and a history of tick bite or likely exposure
Treat with oral abx for 2-3 weeks. DO NOT TEST
Discuss any other cases with ID
If high clinical suspicion - investigate but start treatment before results
1. ELIZA
2. Immunoblot
50
management lyme disease
Doxycycline or amoxicillin
51
what is kawasaki disease
Kawasaki disease is also known as mucocutaneous lymph node syndrome. It is a systemic, medium-sized vessel vasculitis. It affects young children, typically under 5 years. There is no clear cause or trigger. It is more common in Asian children, particularly Japanese and Korean children. It is also more common in boys.
52
key complication kawasaki disease
A key complication is coronary artery aneurysm.
53
symptoms and criteria for diagnosis kawasaki
Fever of ≥5 days' duration associated with at least four of these five changes
4 of 5 of Crash & burn
Conjunctivitis (bilateral non-purulent)
Rash (polymorphous, priamarily truncal)
Adenopathy (cervical)
Strawberry tounge (criteria is MM - throat redness, dry lips, red lips)
Hands (swelling and erythema) or arms or legs (redness, swelling, peeling)
and Burn (5 or more days of fever)
54
Invetsigations kawasaki
Full blood count can show anaemia, leukocytosis and thrombocytosis
Liver function tests can show hypoalbuminemia and elevated liver enzymes
Inflammatory markers (particularly ESR) are raised
Urinalysis can show raised white blood cells without infection
Echocardiogram can demonstrate coronary artery pathology
55
disease course kawasaki
Acute phase: The child is most unwell with the fever, rash and lymphadenopathy. This lasts 1 – 2 weeks.
Subacute phase: The acute symptoms settle, the desquamation and arthralgia occur and there is a risk of coronary artery aneurysms forming. This lasts 2 – 4 weeks.
Convalescent stage: The remaining symptoms settle, the blood tests slowly return to normal and the coronary aneurysms may regress. This last 2 – 4 weeks.
56
management kawasaki disease
High dose aspirin to reduce the risk of thrombosis
IV immunoglobulins to reduce the risk of coronary artery aneurysms
Patients will need close follow up with echocardiograms to monitor for evidence of coronary artery aneurysms.
57
when should you use aspirin in children
Kawasaki disease is one of the few scenarios where aspirin is used in children.
Aspirin is usually avoided due to the risk of Reye’s syndrome.
58
what is required urgently when leukemia is a ddx for a presentation
An urgent full blood count
59
what are lymphomas ? types?
Lymphomas are a group of cancers that affect the lymphocytes inside the lymphatic system. These cancerous cells proliferate within the lymph nodes and cause the lymph nodes to become abnormally large (lymphadenopathy).
Hodgkin's lymphoma: caused by proliferation of lymphocytes.
Non-hodgkin's lymphoma: encompasses all other types of lymphoma including burkitts
60
Presentation symptoms lymphoma
PC:
Painless lymphadenopathy
Bone marrow involvement
Anaemia
Thrombocytopenia → purpura
Infections
B symptoms:
Unintentional weight loss
Night sweats
Pyrexia
Mass effect
If mediastinal lymph nodes are involved, this can compress the airway and lead to dyspnoea, chest pain, and dry cough. It may also cause superior vena cava obstruction.
Compression of the superior vena cava: shortness of breath and facial oedema
Compression of the external biliary tree: jaundice
Compression of the ureters: hydronephrosis
Bowel obstruction: vomiting and constipation
Impaired lymph drainage: chylous pleural or peritoneal fluid, or lymphoedema of the lower limbs
Specific symptoms
Alcohol induced pain = hodgkins
Pruritus = more common in hodgkins
Burkitt's lymphoma: large abdominal mass and symptoms of bowel obstruction
61
when should you 2ww for susepcted lymphoma? when should it be done sooner?
- unexplained lymphadenopathy or splenomegaly for adults aged 25 years or more
- within 48 hours for children and young people up to and including 24 years of age
62
Initial investigations lymphoma
FBC (anaemia, thrombocytopenia, neutropenia, lymphocytosis)
U&E (acute kidney injury from obstructive nephropathy)
LFTs
LDH (often elevated in high grade lymphomas, but non-specific)
Viral screening tests (hepatitis B/C, HIV, HTLV-1)
Hodgkins blood tests:
Erythrocyte sedimentation rate (ESR): Non-specific but tends to be elevated and indicates a poorer prognosis when the ESR level is >50 mm/hour in patients without B symptoms or >30 mm/hour in those with B symptoms.
63
what imaging might you organise ?lymphoma
Chest x-ray
mediastinal adenopathy, pleural or pericardial effusions and parenchymal involvement
CT-PETchest abdo pelvis for staging
64
Diagnostic tests lymphoma
BIOPSY
1. excisional biopsy
Hodgkins = Reed-Sternberg cells (owl's eye appearance), or other distinctive Hodgkin's cells such as lacunar cells or popcorn cells.
If the lesion is in the lung or abdomen, a core needle biopsy is preferred
IMMUNOPHENOTYPING FOR NHL
FISH (fluorescence in situ hybridisation) is used to identify a MYC rearrangement (Burkitt's lymphoma) in all people newly presenting with histologically high-grade B-cell lymphoma
If a MYC rearrangement is found, FISH is then used to identify the immunoglobulin partner and the presence of BCL2 and BCL6 rearrangements
65
what is a CT vs PET scan
The CT scan takes a series of x-rays from all around your body and puts them together to create a 3 dimensional (3D) picture.
The PET scan uses a mildly radioactive drug to show up areas of your body where cells are more active than normal.
therefore called PET-CT
66
staging imaging lymphoma?
CT chest abdomen pelvis or PET/CT
FDG-PET-CT imaging to confirm staging should be offered to people diagnosed with:
Stage I diffuse large B-cell lymphoma by clinical and CT criteria
Stage I or localised stage II follicular lymphoma if disease is thought to be encompassable within a radiotherapy field
Stage I or II Burkitt lymphoma with other low-risk features
67
what staging system is used to stage lymphoma? explain it.
Ann-Arbor
Stage 1: Confined to one region of lymph nodes.
Stage 2: In more than one region but on the same side of the diaphragm (either above or below).
Stage 3: Affects lymph nodes both above and below the diaphragm.
Stage 4: Widespread involvement including non-lymphatic organs such as the lungs or liver.
68
HL vs NHL- which is more common?
Non-hodgkins is more common
69
HL vs NHL - which has alcohol induced pain?
hodgkins
70
HL vs NHL which is associated with pruritis
HL
71
HL vs NHL - which is associated with extra-nodal disease? what does extra-nodal dsease mea?
Extra-Nodal disease more common in non-hodgkins
N!!!
gastric (dyspepsia, dysphagia, weight loss, abdominal pain)
bone marrow (pancytopenia, bone pain)
lungs
skin
central nervous system (nerve palsies)
72
HL vs NHL reed sternberg cells?
hodgkins
Mature B cells - Reed Sternberg cells
73
which lymphoma associated w increasing age?
non-hodgkins
hodgkins has bimodal age distribution
74
HL vs NHL which has continguous spread lymph nodes
hodgkins
75
lymphoma large abdominal mass and symptoms of bowel obstruction
burkitts
a type of NHL
76
what is mass effect lymphoma? what can it cause?
If mediastinal lymph nodes are involved, this can compress the airway and lead to dyspnoea, chest pain, and dry cough. It may also cause superior vena cava obstruction.
Compression of the superior vena cava: shortness of breath and facial oedema
Compression of the external biliary tree: jaundice
Compression of the ureters: hydronephrosis
Bowel obstruction: vomiting and constipation
Impaired lymph drainage: chylous pleural or peritoneal fluid, or lymphoedema of the lower limbs
77
management lymphoma
chemo and radiation
78
what type of cancer are head and neck cancers usually - histology
squamous cell carcinomas arising from the squamous cells of the mucosa.
79
what areas of the head and neck may head and neck cancers arise
The potential areas of head and neck cancers are:
Nasal cavity
Paranasal sinuses
Mouth
Salivary glands
Pharynx (throat)
Larynx (epiglottis, supraglottis, vocal cords, glottis and subglottis)
80
why is lymphadenopathy sometimes important in head and neck ca diagnosis
Head and neck cancers usually spread to the lymph nodes first. Squamous cell carcinoma cells may be found in an enlarged, abnormal lymph node (lymphadenopathy), and the original tumour cannot be found. This is called cancer of unknown primary.
81
risk fatcors ehad and neck ca
Smoking
Chewing tobacco
Chewing betel quid (a habit in south-east Asia)
Alcohol
Human papillomavirus (HPV), particularly strain 16
Epstein–Barr virus (EBV) infection
82
what vaccine can help prevent head and neck ca
The HPV vaccine (Gardasil) protects against strains 6, 11, 16 and 18.
83
what strain of HPV is ass with head and neck ca
Human papillomavirus (HPV), particularly strain 16
84
Presenting symptoms and signs that may indicate head and neck cancer?
persistent sore throat, difficulty swallowing, hoarseness, or a lump in the neck. Other common symptoms include ear pain, facial pain, and changes in vision or hearing.
Red flags:
Lump in the mouth or on the lip
Unexplained ulceration in the mouth lasting more than 3 weeks
Erythroplakia
Erythroleukoplakia
Persistent neck lump
Unexplained hoarseness of voice
Unexplained thyroid lump
85
what is erythroplaki and erythroleukoplakia?
Erythroplakia = red patch on oral mucous membranes, including your tongue, inner cheeks or floor of your mouth
Erythroleukoplakia = Erythroplakia affects the mucous membranes of your mouth. It causes red lesions (spots) that may appear in combination with white patches (leukoplakia). Erythroplakia may be cancerous or noncancerous. Smoking and chewing tobacco use are the leading causes of erythroplakia.
86
rf criteria laryngeal cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with:
persistent unexplained hoarseness or
an unexplained lump in the neck.
87
rf criteria oral cancer
- unexplained ulceration in the oral cavity lasting for more than 3 weeks
- a persistent and unexplained lump in the neck.
- a lump on the lip or in the oral cavity
- a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
88
what are sarcomas?
Sarcomas are a diverse group of malignant tumours originating from mesenchymal tissue.
Sarcomas can be classified based on their tissue of origin:
Bone Sarcomas
Osteosarcoma
Chondrosarcoma
Ewing's sarcoma
Soft Tissue Sarcomas
Liposarcoma
Rhabdomyosarcoma (striated muscle origin)
Synovial sarcoma
Fibrosarcoma
Angiosarcoma
Leiomyosarcoma (smooth muscle origin))
89
presentation sarcomas?
Pain: Often a presenting symptom in bone sarcomas and occasionally in soft tissue sarcomas.
Swelling or a palpable mass: More common in soft tissue sarcomas.
Impaired function: Depending on the location, sarcomas may cause limitations in motion, difficulty breathing, or other functional impairments.
Pathologic fractures: Bone sarcomas can weaken the bone, leading to fractures.
Systemic symptoms: Fatigue, weight loss, and fever may be present, particularly in advanced cases.
90
features of a mass/lump that should raise suspicion for sarcoma?
Large >5cm soft tissue mass
Deep tissue location or intramuscular location
Rapid growth
Painful lump
91
when should you refer ?bone sarcoma
2ww adult where x-ray suggests bone sarcoma
48hr children and young ppl unexplained bone swelling or pain OR where x-ray suggests bone sarcoma
92
when should you refer ?soft tissue sarcoma?
Consider an urgent direct access ultrasound scan (to be performed within 2 weeks) to assess for soft tissue sarcoma in adults with an unexplained lump that is increasing in size.
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for adults if they have ultrasound scan findings that are suggestive of soft tissue sarcoma or if ultrasound findings are uncertain and clinical concern persists.
Consider a very urgent direct access ultrasound scan (to be performed within 48 hours) to assess for soft tissue sarcoma in children and young people an unexplained lump that is increasing in size.
Consider a very urgent referral (for an appointment within 48 hours) for children and young people if they have ultrasound scan findings that are suggestive of soft tissue sarcoma or if ultrasound findings are uncertain and clinical concern persists.
93
management sarcomas
Surgery: The primary treatment for most sarcomas, aiming for complete resection with negative margins to reduce the risk of local recurrence. In some cases, limb-sparing surgery can be performed to preserve function, while amputation may be necessary for more advanced or aggressive tumours.
+/- radiation, chemo, targeted therapies
94
what are the three salivary glands? what are the three pathologies that can affect the salivary glands?
The three salivary gland locations are the:
Parotid glands
Submandibular glands
Sublingual glands
Stones blocking the drainage of the glands through the ducts (sialolithiasis)
Infection
Tumours (benign or malignant) part of head and neck cancer
95
which salivary gland is most likely to be affected by stones?
submandibular glands
96
contributing factors salivary gland stones?
Calcium metabolism may play a role but this is not certain
History of renal stones is associated with increased risk
The only systemic disease associated with stone formation is gout, in which case stones will be formed of uric acid rather than calcium.
Multiple medications are associated with higher risk:
Diuretics
Anticholinergic medications
Other risk factors include smoking, trauma and hypovolaemia
97
presentation saliavry gland stones
Pain and swelling triggered when salivary flow is stimulated
Patients may present with a hard, palpable lump within the salivary duct or orifice.
Secondary infection is suggested by persistent pain and swelling, sometimes with fever and systemic upset. Sometimes these infections can lead to spreading cellulitis with deep neck infection and airway compromise.
98
investigations salivary gland stones
Salivary gland stones are usually diagnosed clinically based upon history and examination alone. Sometimes a stone may be seen at the opening of the salivary duct into the oral cavity.
Imaging can be used if there is diagnostic doubt or there is suspicion of secondary infection/abscess formation. Both CT and ultrasound are highly sensitive for detection of stones.
99
management salivary gland stone?
Conservative
- hydration
- encourage saliva flow - sucking sweets
- nsaids
Assess for complications
- infection
?tracking ?sepsis --> ENT urgent assessment
100
how does saliavry gland malognancy present?
persistent/painless unilateral salivary gland mass.
most common - parotid gland tumour - can cause facial nerve palsy
101
what cancers commonly metastasie to cervical lymph nodes
lung cancer, gastric cancer
102
histological types of lung cancers? how common?
The histological types of lung cancer can be broadly divided into:
Small cell lung cancer (SCLC) (around 20%)
Non-small cell lung cancer (around 80%)
Non-small cell lung cancer can be further divided into:
Adenocarcinoma (around 40% of total lung cancers)
Squamous cell carcinoma (around 20% of total lung cancers)
Large-cell carcinoma (around 10% of total lung cancers)
Other types (around 10% of total lung cancers)
103
whata re small cell lung cancers
Small cell lung cancer cells contain neurosecretory granules that can release neuroendocrine hormones. This makes SCLC responsible for multiple paraneoplastic syndromes.
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is mesothelioma a type of lung cancer?
Mesothelioma is not a form of lung cancer. Mesothelioma develops in the lining around the lungs (the pleura). Lung cancer develops inside the lungs.
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Presentatuon lung cancers?
Shortness of breath
Cough
Haemoptysis (coughing up blood)
Finger clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy – often supraclavicular nodes are the first to be found on examination
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association mesothelioma?
asbestos inhalation. There is a huge latent period between exposure to asbestos and the development of mesothelioma of up to 45 years. The prognosis is very poor. Chemotherapy can improve survival, but it is essentially palliative.
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what is a paraneoplastic syndrome?
A paraneoplastic syndrome is a set of signs and symptoms that can occur when you have cancer. The symptoms develop when a malignant tumor causes changes in your body that aren't directly caused by the cancer itself. The tumor may secrete a hormone or protein that affects a particular body system.
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pt lung cancer w hoarse voice? what is the paraneoplastic syndrome?
Recurrent laryngeal nerve palsy presents with a hoarse voice. It is caused by a tumour pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum.
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pt lung cancer w diaphragm wekaness and SOB? what is the paraneoplastic syndrome?
Phrenic nerve palsy, due to nerve compression, causes diaphragm weakness and presents with shortness of breath.
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pt lung cancer w facial swelling, difficulty breathing ? what is the paraneoplastic syndrome?
Superior vena cava obstruction is a complication of lung cancer. It is caused by direct compression of the tumour on the superior vena cava. It presents with facial swelling, difficulty breathing and distended veins in the neck and upper chest. “Pemberton’s sign” is where raising the hands over the head causes facial congestion and cyanosis. This is a medical emergency.
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pt lung cancer partial ptosis, anhidrosis and miosis
Horner’s syndrome is a triad of partial ptosis, anhidrosis and miosis. It can be caused by a Pancoast tumour (tumour in the pulmonary apex) pressing on the sympathetic ganglion. Pancoast tumours are cancers that start in the top part of the lung (the apex).usually adenocarcinoma
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pt with lung cancer and hyponautraemia? what paraneoplastic syndrome?
Syndrome of inappropriate ADH (SIADH) can be caused by ectopic ADH secreted by a small cell lung cancer. It presents with hyponatraemia.
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pt with lung cancer and cushings syndrome? what apraneoplastic
Cushing’s syndrome can be caused by ectopic ACTH secretion by a small cell lung cancer.
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pt with lung cancer and hypercalcaemia
Hypercalcaemia can be caused by ectopic parathyroid hormone secreted by a squamous cell carcinoma.
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pt with lung cancer and symptoms such as short term memory impairment, hallucinations, confusion and seizures.
Limbic encephalitis is a paraneoplastic syndrome where small cell lung cancer causes the immune system to make antibodies to tissues in the brain, specifically the limbic system, causing inflammation in these areas. This causes symptoms such as short term memory impairment, hallucinations, confusion and seizures. It is associated with anti-Hu antibodies.
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pt with lung cancer and weakness, particularly in the proximal muscles but can also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia (difficulty swallowing). Patients may also experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction.
Lambert-Eaton myasthenic syndrome can be caused by antibodies produced by the immune system against small cell lung cancer cells. These antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones. This leads to weakness, particularly in the proximal muscles but can also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia (difficulty swallowing). Patients may also experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction.
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referral criteria for cxr lung ca
patients over 40 with:
Clubbing
Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes)
Recurrent or persistent chest infections
Raised platelet count (thrombocytosis)
Chest signs of lung cancer
consider in patients over 40 years old who have:
Two or more unexplained symptoms in patients that have never smoked
One or more unexplained symptoms in patients that have ever smoked
The unexplained symptoms that the NICE guidelines list are:
Cough
Shortness of breath
Fatigue
Chest pain
Weight loss
Loss of appetite
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first invetsigation ?lung ca? findings?
Chest x-ray is the first-line investigation in suspected lung cancer.
Findings suggesting cancer include:
Hilar enlargement
Peripheral opacity – a visible lesion in the lung field
Pleural effusion – usually unilateral in cancer
Collapse
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staging scan lung ca
contrast enhanced CT scan of chest, abdomen and pelvis
PET-CT (positron emission tomography) scans involve injecting a radioactive tracer (usually attached to glucose molecules) and taking images using a combination of a CT scanner and a gamma-ray detector to visualise how metabolically active various tissues are. They are useful in identifying areas that cancer has spread to by showing areas of increased metabolic activity.
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maanagment of lung ca
surgery
chemo, radio
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options for removing lung ca
Segmentectomy or wedge resection involves taking a segment or wedge of lung (a portion of one lobe)
Lobectomy involves removing the entire lung lobe containing the tumour (the most common method)
Pneumonectomy involves removing an entire lung
The types of surgery that can be used are:
Thoracotomy – open surgery with an incision and separation of the rib to access the thoracic cavity
Video-assisted thoracoscopic surgery (VATS) – minimally invasive “keyhole” surgery
Robotic surgery
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whata re the type of thoracotomy incisions
Anterolateral thoracotomy with an incision around the front and side
Axillary thoracotomy with an incision in the axilla (armpit)
Posterolateral thoracotomy with an incision around the back and side (the most common approach to the thorax)
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what things o/e indicate prev lung ca surgery?
If you see a patient with a thoracotomy scar in your OSCEs, they are likely to have had a lobectomy, pneumonectomy or lung volume reduction surgery for COPD. If they have no breath sound on that side, this indicates a pneumonectomy rather than lobectomy. If they have absent breath sound in a specific area on the affected side (e.g., the upper zone), but breath sounds are present in other areas, this indicates a lobectomy. Lobectomies and pneumonectomies are usually used to treat lung cancer. In the past, they were often used to treat tuberculosis, so keep this in mind in older patients. If it is a cardiology examination and they have a right-sided mini-thoracotomy incision, this is more likely to indicate previous minimally invasive mitral valve surgery.
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Risk factors gastric cancer
PRIAMRY - h.pylori
Additional:
Dietary factors: High salt intake, consumption of smoked or preserved foods, and low intake of fruits and vegetables
Smoking
Alcohol consumption
Pernicious anaemia and atrophic gastritis
Family history of gastric cancer
Genetic syndromes (e.g., hereditary diffuse gastric cancer, Lynch syndrome)
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Presentation gastric cancer
PC:
Symptoms of gastric cancer are often nonspecific, especially in the early stages. Common clinical features include:
Dyspepsia or indigestion
Epigastric pain
Early satiety or postprandial fullness
Weight loss
Anaemia
Nausea and vomiting
Gastrointestinal bleeding (e.g., melena, haematemesis)
Advanced disease may present with additional signs, such as palpable abdominal mass, ascites, and supraclavicular lymphadenopathy (Virchow's node).
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Examination findings gastric cancer
Advanced disease may present with additional signs, such as palpable abdominal mass, ascites, and supraclavicular lymphadenopathy (Virchow's node).
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Platelet count cancer
High
Cancer is believed to induce platelet formation through the release of interleukin 6, a proinflammatory cytokine that stimulates the production of thrombopoietin hormone.
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Investigations gastric cancer
diagnosis: endoscopy with biopsy
staging: CT or endoscopic ultrasound - endoscopic ultrasound has recently been shown to be superior to CT
CT scanning of the chest abdomen and pelvis is the routine first line staging investigation in most centres.
Laparoscopy to identify occult peritoneal disease
PET CT (particularly for junctional tumours)
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Management gastric cancer
Chemo
Radiation
Surgery
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goitre vs thyroid lump? causes of each?
A goitre refers to generalised swelling of the thyroid gland. A goitre can be caused by:
Graves disease (hyperthyroidism)
Toxic multinodular goitre (hyperthyroidism)
Hashimoto’s thyroiditis (hypothyroidism)
Iodine deficiency
Lithium
Individual lumps can occur in the thyroid due to:
Benign hyperplastic nodules
Thyroid cysts
Thyroid adenomas (benign tumours the can release excessive thyroid hormone)
Thyroid cancer (papillary or follicular)
Parathyroid tumour
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primary vs secondary hyperthyroidism
primary = thyroid is the problem
high T3/T4, low TSH
secondary = pituitary is the problem
high T3/T4, high TSH
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priamary vs secondary hypothyroidism
primary = thyroid is the problem
low T3/T4, high TSH
secondary = pituitary is the problem
low T3/T4, low TSH
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what tests help you ddx between different thyroid pathology
TFTs:
- T3
- T4
Hormone tests:
- TSH
Antibodies:
- anti-TPO : Anti-thyroid peroxidase
- TSHr AB : TSH receptor antibodies
- anti-Tg : Anti-thyroglobulin
Imaging:
- USS
- Radioisotope scans are used to investigate hyperthyroidism and thyroid cancers.
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interpretation radioisotope scans
Diffuse high uptake is found in Grave’s Disease
Focal high uptake is found in toxic multinodular goitre and adenomas
“Cold” areas (abnormally low uptake) can indicate thyroid cancer
( Reduced uptake/none could indicate thyroiditis )
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pathophysiology graves
Graves’ disease is an autoimmune condition where TSH receptor antibodies cause primary hyperthyroidism. These TSH receptor antibodies, produced by the immune system, stimulate TSH receptors on the thyroid. This is the most common cause of hyperthyroidism.
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pathophysiology toxic multinodular goitre
Toxic multinodular goitre (also known as Plummer’s disease) is a condition where nodules develop on the thyroid gland, which are unregulated by the thyroid axis and continuously produce excessive thyroid hormones. It is most common in patients over 50 years.
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Features specific to graves disease
exopthalmos (bulging of the eyes - caused by Graves’ disease. Inflammation, swelling and hypertrophy of the tissue behind the eyeballs force them forward, causing them to bulge out of the sockets.
Pretibial myxoedema is a skin condition caused by deposits of glycosaminoglycans under the skin on the anterior aspect of the leg (the pre-tibial area). It gives the skin a discoloured, waxy, oedematous appearance over this area. It is specific to Grave’s disease and is a reaction to TSH receptor antibodies.
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causes of thyroiditis
acute phase of:
- subacute (de Quervain's) thyroiditis
- post-partum thyroiditis
- Hashimoto's thyroiditis (later results in hypothyroidism)
- amiodarone therapy
- contrast
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causes of hyperthyroid
The causes of hyperthyroidism can be remembered with the “GIST” mnemonic:
G – Graves’ disease
I – Inflammation (thyroiditis)
S – Solitary toxic thyroid nodule
T – Toxic multinodular goitre
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features universal to hyperthyroidism
Anxiety and irritability
Sweating and heat intolerance
Tachycardia
Weight loss
Fatigue
Insomnia
Frequent loose stools
Sexual dysfunction
Brisk reflexes on examination
Tremor
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what is De Quervain's thyroiditis ? how does it present?
De Quervain’s thyroiditis, also known as subacute thyroiditis, is a condition causing temporary inflammation of the thyroid gland. There are three phases:
Thyrotoxicosis
Hypothyroidism
Return to normal
The initial thyrotoxic phase involves:
Excessive thyroid hormones
Thyroid swelling and tenderness
Flu-like illness (fever, aches and fatigue)
Raised inflammatory markers (CRP and ESR)
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management De Quervain's thyroiditis
Arrange referral or discuss with an endocrinologist
It is a self-limiting condition, and supportive treatment is usually all that is necessary.
This may involve:
NSAIDs for symptoms of pain and inflammation
Beta blockers for the symptoms of hyperthyroidism
Levothyroxine for the symptoms of hypothyroidism
A small number (under 10%) remain hypothyroid long-term.
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How to manage a pt with ?hyperthyroidism in primary care?
If a person has a confirmed diagnosis of overt hyperthyroidism following TFTs
Admission/rf
1. arrange emergency admission if features of thyroid storm
1. Arrange urgent rf to endocrine if pituitary/hypothalamic disorder suspected
1. Arrange referral or discuss with an endocrinologist if they have a goitre, nodule, or structural change in the thyroid gland, or if malignancy is suspected
While awaiting endocrine:
1. Consider prescribing a beta-blocker and titrating the dose depending on clinical response, to provide relief of adrenergic symptoms (such as palpitations, tremor, tachycardia, or anxiety).
+ Consider seeking specialist advice about starting antithyroid drugs such as carbimazole in primary care for people
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what auto-antibodies are seen in graves?
TSH receptor antibodies
are present in around 90-100% of patients with Graves' disease
there is overlap in the antibodies seen eg anti-TPO and anti-Tg can be seen in graves as well as hashimotos
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what autoantibodies are seen in hashimotos
Anti-thyroid peroxidase (anti-TPO) antibodies
are seen in around 90% of patients with Hashimoto's thyroiditis.
there is overlap in the antibodies seen eg anti-TPO and anti-Tg can be seen in graves as well as hashimotos
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How to manage a pt with ?hypothyroidism in primary care
If a person has confirmed overt hypothyroidism
Admission/rf
1. Arrange emergency admission if a serious complication such as myxoedema coma is suspected.
1. Arrange urgent referral to an endocrinologist if secondary hypothyroidism is suspected.
1.Arrange referral or discuss with an endocrinologist if they have a goitre, nodule, or structural change in the thyroid gland, or if malignancy is suspected
1. Arrange referral or discuss with an endocrinologist if suspected/associated endocrine disease, such as Addison's disease
If specialist referral is not needed:
1. treat overt primary hypothyroidism with levothyroxine (LT4) monotherapy.
Advise the person to take LT4 medication on an empty stomach in the morning before other food or medication.
Review the person and recheck TSH levels every 3 months after initiation of LT4 therapy and adjust the dose according to symptoms and TFT results. Consider checking FT4 in addition if the person has ongoing symptoms on treatment.
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After starting levothyroxine, when should you review the pt
Review the person and recheck TSH levels every 3 months after initiation of LT4 therapy and adjust the dose according to symptoms and TFT results.
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what is hashimotos?
It is an autoimmune condition causing inflammation of the thyroid gland. It is associated with anti-thyroid peroxidase (anti-TPO) antibodies and anti-thyroglobulin (anti-Tg) antibodies.
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what is the most common cuase of hypothyroidism in developing world?
Iodine deficiency is the most common cause of hypothyroidism in the developing world. In the UK,
iodine is particularly found in dairy products and may be added to non-dairy milk alternatives (e.g., soya milk).
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what drugs can cause hypothyroidism
Lithium inhibits the production of thyroid hormones in the thyroid gland and can cause a goitre and hypothyroidism.
Amiodarone interferes with thyroid hormone production and metabolism, usually causing hypothyroidism but can also cause thyrotoxicosis.
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causes of secondary hypothyroism
Tumours (e.g., pituitary adenomas)
Surgery to the pituitary
Radiotherapy
Sheehan’s syndrome (where major post-partum haemorrhage causes avascular necrosis of the pituitary gland)
Trauma
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features of hypothyroidism
Weight gain
Fatigue
Dry skin
Coarse hair and hair loss
Fluid retention (including oedema, pleural effusions and ascites)
Heavy or irregular periods
Constipation
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key complication of carbimazole?
pancreatitis
154
How is carbimazole titrated?
Carbimazole is the first-line anti-thyroid drug, usually taken for 12 to 18 months.
Once the patient has normal thyroid hormone levels (usually within 4-8 weeks), they continue on maintenance carbimazole and either:
The carbimazole dose is titrated to maintain normal levels (known as titration-block)
A higher dose blocks all production, and levothyroxine is added and titrated to effect (known as block and replace)
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what is the second-line anti-thyroid drug? why is it second-line?
Propylthiouracil is the second-line anti-thyroid drug. It is used in a similar way to carbimazole.
There is a small risk of severe liver reactions, including death, which is why carbimazole is preferred.
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what is a complication of both carbimazole and proylthiouracil?
agranulocytosis
Both carbimazole and propylthiouracil can cause agranulocytosis, with a dangerously low white blood cell counts. Agranulocytosis makes patients vulnerable to severe infections. A sore throat is a key presenting feature of agranulocytosis. In your exams, if you see a patient with a sore throat on carbimazole or propylthiouracil, the cause is likely agranulocytosis. They need an urgent full blood count and aggressive treatment of any infections.
157
pt with hyperthyroid and a sore throat?
agranulocytosis
Both carbimazole and propylthiouracil can cause agranulocytosis, with a dangerously low white blood cell counts. Agranulocytosis makes patients vulnerable to severe infections. A sore throat is a key presenting feature of agranulocytosis. In your exams, if you see a patient with a sore throat on carbimazole or propylthiouracil, the cause is likely agranulocytosis. They need an urgent full blood count and aggressive treatment of any infections.
158
pt with hyperthyroid and abdominal pain?
acute pancreatitis
The MHRA issued a warning in 2019 about the risk of acute pancreatitis in patients taking carbimazole.
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What is myxedema coma? presetation?
Life threatening hypothyroidism
Myxoedema coma typically presents with confusion and hypothermia.
Myxedema coma
Hypoxia
Decreased CO
Bradycardia
Hypothermia
Hypotension
causes:
- undiagnosed hypothyroid
- ill-managed hypothyroid
- trigger event such as an infection
160
management myxedema coma?
IV thyroid replacement
IV fluid
IV corticosteroids (until the possibility of coexisting adrenal insufficiency has been excluded)
electrolyte imbalance correction
sometimes rewarming
161
What is a thyroid storm? other name? how does it present? how is it managed?
thyrotoxic crisis
fever, tachycardia and delirium. It can be life-threatening and requires admission for monitoring.
beta-blockers: typically IV propranolol
anti-thyroid drugs(thionamides): e.g. methimazole or propylthiouracil then.. Lugol's iodine
dexamethasone - e.g. 4mg IV qds - blocks the conversion of T4 to T3
It is treated the same way as any other presentation of thyrotoxicosis, although they may need additional supportive care with fluid resuscitation, anti-arrhythmic medication and beta blockers.
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first line invgn any thyroid nodule!!!
USS
163
most common and second most common malignant cause of thyroid cancer
Papillary carcinoma 70%
Often young females - excellent prognosis
Follicular carcinoma 20%
164
management of papillary adn follicualr thyroid cancer?
total thyroidectomy
followed by radioiodine (I-131) to kill residual cells
yearly thyroglobulin levels to detect early recurrent disease
165
what are the names of some congenital neck lumps
thyroglossal cyst
cystic hygroma
branchial cyst
dermoid cyst
166
features of thyroglossal cyst
glossal = tounge - moves up and down with protrusion of the tounge
Mobile
Non-tender
Soft
Fluctuant
167
complication of thyroglossal cyst
The main complication is infection of the cyst, causing a hot, tender and painful lump.
168
invgn and management thyroglossal cyst
Ultrasound or CT scan can confirm the diagnosis.
Management
Thyroglossal cysts are usually surgically removed to provide confirmation of the diagnosis on histology and prevent infections. The cyst can reoccur after surgery unless the full thyroglossal duct is removed
169
when do branchial cysts often present?
Branchial cysts tend to present after the age of 10 years, most commonly in young adulthood when the cyst becomes noticeable or infected.
170
features of branchial cysts?
Branchial cysts present as a round, soft, cystic swelling between the angle of the jaw and the sternocleidomastoid muscle in the anterior triangle of the neck.
171
where does a branchial cyst originate from?
second branchial cleft
172
complications of branchial cysts
Sinuses and Fistulas
A sinus is a blind ending pouches. A fistula is an abnormal connection between two epithelial surfaces.
Sinuses and fistula pose an increased risk of infections in the branchial cyst, as they are a way for pathogens to get in.
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management branchial cyst
Where the branchial cleft is not causing any functional or cosmetic issues, conservative management may be appropriate.
Where recurrent infections are occurring, there is diagnostic doubt about the cause of the neck lump or it is causing other functional or cosmetic issues, surgical excision may be appropriate.
174
when do cystic hygromas present?
Cystic hygromas typically present at birth or within a few years following, with 90% being diagnosed before the age of 2 years.
175
associations cystic hygromas?
Turner syndrome and environmental factors such as alcohol abuse and viral illness during pregnancy.
176
presentation cystic hygroma?
occur anywhere within lymphatic system, but most common in the posterior triangle of the neck
cystic hygromas are more common on the left-side
soft and compressible
typically not painful
no movement on swallowing
transillumination is detected
may interfere with respiration or compromise the airway
177
which neck lump transilluminates?
cystic hygroma
178
plan ?cystic hygroma
Diagnosis and investigations:
consider and exclude other malignancy
ultrasound, CT or MR imaging
Management:
Observation (some tumours are small, static or slowly regress)
Surgical excision
179
what are dermoid cysts? where may they be found on the neck?
A cutaneous dermoid cyst may develop at sites of embryonic developmental fusion. They are most common in the midline of the neck, external angle of the eye and posterior to the pinna of the ear. They typically have multiple inclusions such as hair follicles that bud out from its walls. They may develop at other sites such as the ovary and in these sites are synonymous with teratomas.
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how do carotid body tumours present?
In the upper anterior triangle of the neck (near the angle of the mandible)
Painless
Pulsatile
Associated with a bruit on auscultation
Mobile side-to-side but not up and down
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what are carotid body tumours?
Carotid body tumours are formed by excessive growth of the glomus cells. They are also called paragangliomas. Most are benign
The carotid body is a structure located just above the carotid bifurcation (where the common carotid splits into the internal and external carotids). It contains glomus cells, which are chemoreceptors that detect the blood’s oxygen, carbon dioxide, and pH. Groups of these glomus cells are called paraganglia.
182
complication of carotid body tumours?
Carotid body tumours may compress the glossopharyngeal (IX), vagus (X), accessory (XI) or hypoglossal (XII) nerves. Pressure on the sympathetic nerves may result in Horner syndrome, with a triad of:
Ptosis
Miosis
Anhidrosis (loss of sweating)
183
plan ?carotid body tumour
imaging
A characteristic finding on imaging investigations is splaying (separating) of the internal and external carotid arteries (lyre sign).
They are mostly treated with surgical removal.
184
how does a carotid aneyrysm present?
Pulsatile lateral neck mass which doesn't move on swallowingf
185
ddx bilateral hilar lymphadenopathy
tb or sarcoidosis
186
complications of thyroidectomy
- damage to recurrent laryngeal nerve
- damage to parathyroid glands resulting in hypocalcaemia
- bleeding --> respiratory compromise/laryngeal oedema
187
which duct drains the submandu=ibular gland
Whartons duct
