DrE: Head and Neck Flashcards by Rachel Hawthorne

General appearance

Hyperthyroid Vs Hypothyroid

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

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Hands

Hyperthyroid Vs Hypothyroid

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

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Eyes

Hyperthyroid Vs Hypothyroid

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

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Legs

Hyperthyroid V Hypothyroid

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

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History

Hyperthyroid V Hypothyroid

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

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Outline the parasympathetic connections in the head

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Opening of Standen’s duct

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

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Opening of Wharton’s duct

Submandibular gland

open on either side of lingular frenulum

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

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

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

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

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How would you investigate a thyroid lump?

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

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How would you categorise the causes of thyroid swellings?

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)

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What are the treatment options for benign thyroid swellings?

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

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What are the common thyroid cancers?

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

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Treatment options for malignant thyroid disease diagnosed following FNAC

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

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What is MEN?

MEN = Multiple endocrine neoplasia

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

Submandibular gland swelling, chemodactoma (expansile)
Submental gland swelling, dermoid cyst
Thyroglossal cyst
Branchial cyst
Thyroid nodule
Cystic hygroma, tip of cervical rib, subclavian artery aneurysm

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

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

Causes of neck lumps

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

Lymph nodes in head and neck?

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

Cervical lymphadenopathy ‘levels’

submental and submandibular nodes withing digastric triangle
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.
Mid anterior (deep) cervical nodes c. lower 3rd of IJV, from carotid bifurcation to cricothyroid notch
Lower anterior (deep) cervical nodes c. lower 3rd of IJV, from cricothyroid notch to clavicle
Posterior triangle nodes between posterior border of SCM & ant border of trapexius, incl supraclavicular nodes
Ant compartment adj to trachea/thyroid

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

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

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

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

What are the causes of diffuse parotid swelling?

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

causes of parotid gland tumour

* 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

How would you classify facial nerve palsy?

* 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

What is sjogren's syndrome?

* 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

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

* 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

What are the treatment options for sjogrens syndrome?

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

Causes of acute tonsilitis

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

What are the clinical features of tonsilitis?

* 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

Investigations for patient with suspected tonsilitis?

* 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

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

* 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 *

What is epistaxis?

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

What are the causes of epistaxis?

* 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

Treatment options for epistaxis?

* 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