DrE: Head and Neck

Question 1

General appearance

Hyperthyroid Vs Hypothyroid

Answer 1

• Hyperthyroid:
  
  • Restless
  • Hair - NAD
  • Face - wasting
  • Neck - thyroid swelling/scars
  • Trunk - Weight loss
• Hypothyroid
  
  • Docile
  • Hair - brittle, dry, thin
  • Face - myxoedema facies
  • Neck - thyroid swelling & scars
  • Trunk - weight gain

Question 2

Hands

Hyperthyroid Vs Hypothyroid

Answer 2

• Hyperthyroid:
  
  • Nails: acropachy
  • Palpation: warm and sweaty
  • Paraesthesia: NAD
  • Tremor: present
  • Pulse: Tachy/irregular
• Hypothyroid
  
  • Nails: NAD
  • Palpation: Cold, dry, rough, inelastic skin
  • Paraesthesia: CTS
  • Tremor: absent
  • Pulse: bradycardic

Question 3

Eyes

Hyperthyroid Vs Hypothyroid

Answer 3

• Hyperthyroid:
  
  • Graves
    
    • Lid retraction
    • exophthalmos
    • Lid lag
• Hypothyroid:
  
  • Sunken eyes
  • Periorbital puffiness
  • Loss of outer third of eyebrow

Question 4

Legs

Hyperthyroid V Hypothyroid

Answer 4

• Hyperthyroid
  
  • Graves
    
    • Pretibial myxoedema
  • Ankle reflexes: brisk
• Hypothyroid:
  
  • Ankle reflexes: slwa relaxing

Question 5

History

Hyperthyroid V Hypothyroid

Answer 5

• Hyperthyroid:
  
  • Mood - anxiety
  • Appetitie - increased
  • Temp - Hot
  • Weight - loss
  • Hand sensation - NAD
  • HB - palpitations, fast
  • Bowel - diarrhoes
  • Period - menorrhagia
  • Meds - carbimazole & propanolol
• Hypothyroid
  
  • mood - depression
  • appetite - decreased
  • temp - always cold
  • weight - increased
  • hand sensation - CTS
  • HR - brady
  • Bowel - constipated
  • Period - oligomenorrhoea
  • Meds - levothyroixine

General

• • Op/radiotherapy: total thyroidectomy -> hypothyroidism (commonest cause)
    
    • Voice change - goitre compressing recurrent laryngeal N
    • Breathing difficulty - goitre on larynx
    • Swallowing difficulty - goitre on oesophagus
    • Autoimmune assoc: anaemia/DM/Pigmentation

Question 6

Outline the parasympathetic connections in the head

Answer 6

Question 7

Opening of Standen’s duct

Answer 7

Parotid gland
Opening in buccal vestibule at level of maxillary 2nd molar

Question 8

Opening of Wharton’s duct

Answer 8

Submandibular gland

open on either side of lingular frenulum

Question 9

What do you know about the embryology of the thyroid gland?

Answer 9

• 1st endocrine organ to develop
• Development begins gestation day 24
• Development begins between 1st and 2nd pharyngeal pouches at foramen caecum
• Develops as proliferation of endodermal cells on pharyngeal floor, sided between tuberculum impar and copula
• Descent is via pathway outlines by thyroglossal duct
• Gestation wk 10 - thyroid gland lies with it’s isthmus over tracheal rings 2-4
• Inferior parathyroid glands and thymus derived from pharyngeal pouch 3
• Superior parathyroid glands are derived from pharyngeal pouch 4

Question 10

What are the clinical implications of disorders of thyroid gland embryology?

Answer 10

Abn of descent & embryology:

1) lingual thyroid - lump @ foramen caecum -> speach diff/dysphagia

Rx - surgical excision

2) suprahyoid thyroglossal cyst
3) Infrahyoid thyroglossal cyst
4) Retrosternal goitre
5) Thyroglossal fistula - occasionally congenital, more commonly due to infection/surgery.

Rx - surgical excsion

Question 11

How would you investigate a thyroid lump?

Answer 11

• Bloods: FBC, U&E, LFT, CRP, TFT, Ca, Clotting
• USS & FNA: Tx - solitary/multinodular/solitary nodule/cyst. FNA - Cytology
• Core biopsy - if FNA is inconclusivity
• CT/MRI - complex anatomy, retrosternal extension, airway deviation or compression and oesophageal compression
• Radioisotope scan - hot & functioning or cold & non functioning. hot=rarely malignant

Question 12

How would you categorise the causes of thyroid swellings?

Answer 12

Causes of thyroid swellings:

• Nodular:
  
  • True solitary nodule c.50%
    
    • 80% adenomas
    • 10% - cysts/fibrosis/thyroiditis
    • 10% cancer
• Diffuse
  
  • Multinodular goitre - i.e. false solitary nodule c.50%
  • Physiological - increased demand e.g. pregnancy
  • Dietary iodine deficiency - rare but endemic due to high altitude areas e.g. Alps/Himalayas
  • Dietary goitrous agents - uncooked cabbage & turnips, calcium/fluoride in drinking water, various drugs
  • Grave’s disease - hyperthyroid & graves complications
  • Hashimoto’s thyroiditis - hypothyroid & autoimmune goitre
  • De Quervain’s thyroiditis - self limitting, viral
  • Hereditary errors of thyroid metabolism - rare autosomal recessibe inborn errors of metab c.8 types. Failute to respond to TSH or T3/T4 synthesis/release
  • Other:
    
    • lymphoma
    • amyloid
    • Congenital absence/atrophy - if untreated -> cretinism, assoc with Pendred’s syndrome (congenital hypothyroid & high tone deafness)

Question 13

What are the treatment options for benign thyroid swellings?

Answer 13

• Conservative
  
  • removal of goitrogens e.g. cabbage
• Medical
  
  • Hyperthyroid:
    
    • carbimazole/propylthiouracil
    • Beta blocker - propranolol
  • Hypothyroid:
    
    • levothyroxine
• Surgical - diagnostic/compressive (dysphagia/spnoe/sphonia)/ thyrotoxicosis (refreactory) / cosmetic
  
  • lobectomy
  • total thyroidectomy

Question 14

What are the common thyroid cancers?

Answer 14

• Papillary adenocarcinoma - 70% - children, 90% have lymphatic mets at presentation
• Follicular carcinoma - 20% - c.50yrs - haematological spread
• Medullary carcinoma - 5% - parafolicular c cell origin - calcitonin - 90% sporadic, 10% MEN related
• Anaplastic carcinoma - <5% - common in older patients
• Lymphoma - <5% - core biopsy best - Rx DXT & chemotherapy

Question 15

Treatment options for malignant thyroid disease diagnosed following FNAC

Answer 15

• Papillary adenocarcinoma:
  
  • <1cm Stage T1 = Thyroid hormone suppression, hemithyroidectomy
  • >1xm T2-4 = Radio-iodine ablation, total thyroidectomy & level VI neck disection
• Follicular adenocarcinoma:
  
  • unable to distinguish adnoma from adenocarcionoma on FNA = hemithyroidectomy
  • once confirmed = total thyroidectomy, radio-iodine ablation
    
    • &level VI neck dissection if histology shows malignancy
• Medullary thyroid cancer
  
  • Total thyroidectomy
    
    • & level VI dissection with removal of LN
    • Calcitonin lifelong follow up testing
• Analplastic carcinoma:
  
  • Surgical debulking, DXT, doxorubicin
    
    • Survival = 1 yr

Question 16

What is MEN?

Answer 16

MEN = Multiple endocrine neoplasia

AD

• MEN I = 3xPs
  
  • Pancreatic islet cell tumour
  • Pituitary adenoma
  • Primary hyperparathyroidism
• MEN IIa = 3xCx
  
  • Catecholamines (phaeochromocytoma)
  • Calcitonin (Thyroid medullary carcinoma)
  • Calcium (Primary hyperparathyroidism)
• MEN IIb:
  
  • MENIIa +
    
    • Marfanoid habitus
    • Multiple neuromas

Question 17

Answer 17

1. Submandibular gland swelling, chemodactoma (expansile)
2. Submental gland swelling, dermoid cyst
3. Thyroglossal cyst
4. Branchial cyst
5. Thyroid nodule
6. Cystic hygroma, tip of cervical rib, subclavian artery aneurysm

Question 18

What investigations would you order for a neck lump and in what order?

Answer 18

• Bloods:
  
  • FBC, U&E, LFT, CRP, Clotting, CMV, EBV, toxoplasma, bartonella
• USS&FNA:
  
  • diagnosis if SCC/Infective/Inflammatory
• CT/MRI:
  
  • locate primary Tx. neck/chest/abdo/pelvis images asist staging
• LN biopsy
  
  • required when FNA inconclusive e.g. lymphoma

Question 19

Causes of neck lumps

Answer 19

• Congenital:
  
  • Anterior triangle:
    
    • Congenital dermoid cyst: children/young adults, lat & medial aspect of eyebrow and anywhere midline at sites of embryological fusion
    • Thyroglossal duct cyst: cyst along the tract of the obliterated thyroglossal duct. 90% midline. Childhood. Excised by Sistrunk’s procedure (cyst + middle 3rd of hyoid + thyroglossal duct remenant)
  • Posterior triangle:
    
    • cystic hygroma: lymphangioma in lower 3rd of neck. Rx with surgical excision
• Acquired
  
  • Anterior triangle:
    
    • implantation dermal cyst: due to repeated trauma
    • Branchial cyst: elements of squamous epithelium in LN, young adult, 60% males, ant border of SCM at junction of upper & mid 3rd in ant triangle
    • Thyroid lump
    • Parotid tumour
    • Submandibular swelling
    • Chemodectoma: benign, e.g. carotid body tumour, arise from carotid bulb, ?pulsatile, more common in high altitude areas e.g. mexico city
    • Pharyngeal pouch: herniation of pharyngeal mucosa (pulsion diverticulum) through weak point in muscular coat (killian’s dehiscence), between thyopharyngeaus above and cricopharyngeus below (2 muscles of inf constrictor), elderly, regurgitation of undigested food, barium swallow, Rx with endoscopic pouch stapling
    • Carotid artery aneurysm: expansile mass, caused by atheroma/infection/trauma, resect if -> TIA
    • Laryngocoel: laryngeal air sac from increased pressures e.g. glass blower
  • Posterior triangle:
    
    • Cervical rib: palpable bony swelling in spuraclavicular fossa -> Thoracic outlet syndrome
    • Lipoma: posterior triangle & overlying trapezius
    • Subclavian artery aneurysm: palpable in supraclavicular fossa, often due to thoracic outlet syndrome
  • all regions:
    
    • Lymphadenopathy

Question 20

Lymph nodes in head and neck?

Answer 20

• submental
• submandibular
• pre-auricular
• post-auricular
• anterior (deep) cervical chain
• posterior (superficial) cervical chain
• occipital
• supraclavicular
• pre-tracheal

Question 21

Cervical lymphadenopathy ‘levels’

Answer 21

1. submental and submandibular nodes withing digastric triangle
2. Upper anterior (deep) cervical nodes around upper 3rd of IJV where it is crossed anteriorly by spinal accessory nerve. From skull base c.jugular foramen, to carotid bifurcation.
3. Mid anterior (deep) cervical nodes c. lower 3rd of IJV, from carotid bifurcation to cricothyroid notch
4. Lower anterior (deep) cervical nodes c. lower 3rd of IJV, from cricothyroid notch to clavicle
5. Posterior triangle nodes between posterior border of SCM & ant border of trapexius, incl supraclavicular nodes
6. Ant compartment adj to trachea/thyroid

Question 22

What are the types of neck disection described for head and neck tumours?

Answer 22

• Radical:
  
  • level 1-V LN
  • accessory nerve
  • SCM
  • IJV
• Modified radical: Level 1-V nodes +
  
  • Type 1: presevr accessory nerve
  • Type 2: preserve accessory nerve & SCM
  • Type 3: preserve accessory nerve, SCM, IJV
• Extended radical:
  
  • Radical dissection with removal of paratracheal & mediastinal LN & parotid gland
• Selective: depends on LN level taken

Question 23

Parotid gland: what tests would you order to investigate parotid lump, & in what order?

Answer 23

1. Bloods: FBC, U&E, LFT, Ca, Clotting, Rheumatoid factor, autoantibody screen (sjogren’s syndrome)
2. USS & FNA: ?stones, delineates Tx, cytological Dx
3. Sialogram: anatomy of ductal system and stones, therapeutic e.g. crush/grasp stone
4. MRI: complex anatomy & deep lobe involvement

Question 24

What are the causes of diffuse parotid swelling?

Answer 24

• Infective: acute/chronic
  
  • Viral: coxsackie, echovirus mumps, HIV
  • Bacterial: actinomycosis, staph, TB
• Inflammatory:
  
  • Sjogrens: autoimmune assoc with RA. Sx: parotidomegaly, xerostermia, keratojunctivitis sicca
  • Mikulicz’s syndrome: characterised by salivary and lacrimal gland enlargement - assoc underlying cause e.g. TB/Sarcoid
• Drugs: ETOH, OCP, Thiouracil, Phenulbutazone, Isoprenaline
• Metabolic: bulimia, cirrhosis, cushing’s disease, diabetes, gout, myxoedema
• Sialectasis: progressive destruction of parotid gland, accompanied by duct stenosis and cyst formation. Congenital or aquired by epithelial debris/calculi
• Pseudo-parotidomegaly:
  
  • cyst
  • lipoma
  • pre-auricular lymphadenopathy
  • facial nerve VII neuroma
  • hypertrophic masseter
  • winged mandible
  • mandible tumour
  • branchial cyst
  • dental cyst

Question 25

causes of parotid gland tumour

Answer 25

• benign:
  
  • pleomorphic adenoma: commonest, c.80%, peak incident in 5th decade
  • Warthin Tumour (papillary cystadenoma): c.7th decade & 7x more common in males
  • Monomorphic adenoma: rare, most commonly basal cell adenoma, 6th decade
  • Lymphangioma: rare congenital hamartoma, <2yrs, removal for cosmetic reasons
  • neurofibroma - rare, nerve sheath tumour of facial nerve
• Varible malignancy:
  
  • mucoepidermoid carcinoma: most prevelant salivary neoplasm in children
  • Acinic cell carcinoma
• Malignant:
  
  • adenoid cystic carcinoma: most prevalent malignant Tx, peaks in 6th decade
  • Adenocarcinoma: within secretory ducts. Local & distant mets in c.33% at presentation
  • Undifferentiated carcinoma: uncommon, high grade cancer, Tx size = important prognostic indicator
  • Lymphoma: elderly men, Bx indicated as Rx includes chrom/radiotherapy

Question 26

How would you classify facial nerve palsy?

Answer 26

• upper motor neurone:
  
  • PC:
    
    • hemifacial palsy
    • able to raise eyebrow due to bilateral innervation of frontalis and orbicularis oculi
  • Cause:
    
    • CVA
    • MS
    • Meningitis
    • acoustic neuroma
    • glioma
• Lower motor neuron
  
  • PC:
    
    • Hemifacial palsy
    • Unable to raise eyebrow
  • Cause:
    
    • c.55% Bell’s palsy - ?viral/ischaemic aetiology. Rx high dose steroids/acyclovir for 7 days if <72hrs. 85% fully recovered @3mo
    • 19% trauma: iatrogenic e.g. parotidectomy, blunt, penetrating
    • 7% ramsay hunt syndrome: Herpes zoster viral infection -> shingles of facial nerve (VII). Vescicles seen in ear canal
    • 6% tumor: of facial nerve VII e.g. schwannoma/invasion or due to invasion e.g. malignant parotid Tx or due to extrinsic pressure e.g. vestibular nerve schwannoma
    • Infection e.g. acute/chronic suppurative otitis media/malignant otitis externa
• Mixed:
  
  • upper and lower MN signs
    
    • Cause: sarcoid, myasthenia gravis, guillain-barre syndrome & drugs

Question 27

What is sjogren’s syndrome?

Answer 27

• autoimmune disease
• c.90% in women c.50yrs
• Histology: periductal lymphocytes in multiple organs
• 50% -> salivary duct involvement
• Lymphoma 1 in 6
• Pimary:
  
  • keratoconjunctivitis sicca & xerostomia
  • no connective tissue disorder association
• Secondary:
  
  • CTD association e.g. :
    
    • RA/SLE/Scleroderma

Question 28

What specific investigations would assist your diagnosis of sjogren’s syndrome?

Answer 28

• Schirmer’s test:
  
  • hyposecretion: special strip of filter paper under lower eyelid, wetting of paper <5mm in 5 mins (normal = 15mm)
• Autoantibodies:
  
  • RF, anti-Ro, anti-La
• Sublabial biopsy:
  
  • salivary gland histology

Question 29

What are the treatment options for sjogrens syndrome?

Answer 29

• Conservative:
  
  • Meticulous oral hygiene
  • Antibacterial mouth wash
  • Monitoring for lymphoma
• Medical:
  
  • artificial tears
  • steroids
  • immunosuppressants
• surgical:
  
  • lacrimal punctum diathermy

Question 30

Causes of acute tonsilitis

Answer 30

• Viral:
  
  • influenza
  • Parainfluenza
  • adenovirus
  • enterovirus
  • rhinovirus
  • EBV
• Bacterial:
  
  • beta haemolytic streptococcus
  • streptococcus pneumoniae
  • haemophilus influenzae
  • anaerobic organisms

Question 31

What are the clinical features of tonsilitis?

Answer 31

• pyrexia, malaise, headache - prodromal c.24hrs
• Hyperaemic tonsils, pus, debris in cryps
• sore throat
• muffled voice - due to oedema (hot potatoe mouth, exclude quinzy)
• neck pain - cervical lymphadenopathy
• Odynophagia
• Trismus
• Tender jugulodigastric lymphadenopathy
• Quinzy - peritonsillar abscess
• Resp obstruction - SEVERE

Question 32

Investigations for patient with suspected tonsilitis?

Answer 32

• Bloods:
  
  • paul bunnell/monispot test - EBV aka infectious mononucleosis
  • FBC - raised WCC, neutrophilia (Bacterial), Lymphocytosis (viral)
  • CRP
• Micro:
  
  • Throat swab and MC&S - if emperical Rx ineffective
  • Blood cultures - if suspicious of bacteraemia

Question 33

What treatment would you implement for a patient with suspected tonsilitis?

Answer 33

• Medical:
  
  • analgesia/antipyretics: reduced pain & temp
  • Penicillin: aerobic cover, erythromycin in pen allergic
    
    • avoid amoxicillin as this causes rash in patients with glandular fever (EBV)
  • Metronidazole: anaerobic cover
  • Dexamethasone - reduces inflammation in severe cases
• Hospital admission: patient unable to tolerate oral fluids, not safe for discharge
  
  • IV ABx/Fluids/Analgesia
• Surgical: if recurrent, >5 episodes in 2 consecutive years
  
  • tonsillectomy
    *

Question 34

What is epistaxis?

Answer 34

Acute haemorrhage from nostril, nasal carvity of nasopharynx

anterior c.90% or posterior

Anterior = Little’s area = richly vascularised due to kiesselbach’s plexus

Posterior = Woodruff’s plexus

Question 35

What are the causes of epistaxis?

Answer 35

• Local:
  
  • nose picking
  • trauma (direct/barotrauma)
  • infection (URTI)
  • Allergy (rhinitis/sinusitis)
  • Substance abuse (coccaine)
  • Tumors
  • Iatrogenic (nasal cannulae/NG tube)
• Systemic:
  
  • HTN
  • Blood dyscrasias
  • Drugs; aspirin, warfarin, heparin
  • ETOH
  • Liver failure
  • Haematological anaemias

Question 36

Treatment options for epistaxis?

Answer 36

• ALS/ATLS
• Conservative:
  
  • direct pressure c.20mins
  • nasal/post nasal packing
  • epistaxis balloon
  • stop aspirin/warfarin/heparin
• Medical:
  
  • IV fluid resuscitation
  • adrenaline spray
  • cautery
  • antibiotics (post packing)
• Interventional/surgical: arteries = spheonpalatine, posterior ethmoidal, maxillary
  
  • embolisation
  • ligation