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General Surgery > Endocrine, H&N > Flashcards

Endocrine, H&N Flashcards

1
Q

Ant triangle of neck boundaries

A

Superior: lower border of mandible
Anterior: midline
Posterior: anterior border of SCM

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2
Q

What does the ant triangle of the neck contain?

A

Carotid sheath

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3
Q

Post triangle of the neck boundaries + what does it contain

A

Anterior: posterior border of SCM
Posterior: anterior of trapezius
Inferior: clavicle

Contains spinal accessory nerve

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4
Q

Bony landmarks of C3-T3

A

C3: hyoid bone
C4: thyroid cartilage notch
C6: cricoid cartilage
C5-T1: thyroid gland
T2/3: suprasternal cartilage

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5
Q

Common carotid arteries split at the level of

A

C4

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6
Q

External carotid artery branches

A

Superior thyroid
Ascending pharyngeal
Lingual
Facial
Occipital
Posterior auricular
Maxillary
Superficial temporal

(Some Anatomists Like Freaking Out Poor Medical Students)

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7
Q

Internal carotid artery branch

A

enters carotid canal, gives off ophthalmic artery

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8
Q

Right IJV unites with the ___ vein behind ___ to give rise to ___. This vein joins the left ___ to form the ___.

A

subclavian
sternoclavicular joint
right brachiocephalic
brachiocephalic vein
superior vena cava

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9
Q

Most common cause of neck mass is

A

enlarged lymph node

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10
Q

Rule of 80s in neck masses (5 rules)

A

80% non-thyroid are neoplastic
80% neoplastic masses are malignant
80% malignant are SCC
80% of malignant are metastatic
80% of metastases are from primary sites above level of clavicle

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11
Q

DD of midline neck mass

A

submental lymph node
thyroglossal cyst
thyroid nodule in isthmus
sublingual dermoid cyst
plunging ranula

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12
Q

DD of ant triangle neck mass

A

lymph node along ant border of SCM
thyroid nodule
submandibular gland mass
branchial cyst
carotid body tumour
carotid aneurysm

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13
Q

DD of posterior triangle neck masses

A

lymph node
cystic hygroma
cervical rib
brachial plexus neuroma

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14
Q

Investigation of neck masses

A

triple assessment
- clinical exam
- histology: FNAC
- imaging: CT neck w contrast

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15
Q

biochemical tests for neck masses

A

fbc
thyroid function
+/- calcium panel
+/- calcitonin (medullary thyroid cancer)

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16
Q

Types of endoscopy for neck masses

A

Panendoscopy - triple endoscopy
- flexible nasopharyngoscopy
- bronchoscopy
- esophagogastroscopy

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17
Q

Nodules that move with swallowing

A

thyroglossal cyst, thyroid nodule

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18
Q

nodules that move w swallowing and tongue protrusion

A

thyroglossal cyst

*thyroid nodule moves with swallowing but NOT with protrusion

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19
Q

what is a thyroglossal cyst?

A

cystic expansion of remnant thyroglossal tract - failure of thyroglossal duct to obliterate after descent of thyroid gland from foramen cecum at base of tongue to anterior neck

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20
Q

where can thyroglossal cyst occur?

A

anywhere from base of tongue to behind sternum, most commonly adjacent to hyoid bone

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21
Q

Treatment for thyroglossal cyst

A

Sistrunk operation - removal of cyst + thyroglossal tract + central portion of hyoid bone

removing cyst alone can risk recurrence

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22
Q

What is a dermoid cyst & causes

A

small non-tender mobile subcutaneous lump - can be fluctuant, skin-coloured, bluish

congenital - inclusion of epidermis along lines of fusion of skin dermatomes (ends of eyebrows, midline of nose, midline of neck/trunk)

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23
Q

what is a plunging ranula & causes

A

pseudocyst of sublingual/submandibular ducts

congenital: due to imperforate salivary duct
acquire: trauma to sublingual glands causing mucus extravasation, formation of pseudocyst

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24
Q

Branchial cysts form ___ masses. Occurs due to ___

A

anterior triangle neck

failure of fusion of 2nd and /or 3rd branchial arches, causing failure of obliteration of 2nd branchial cleft (most common)

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25
Q

Branchial cysts form ____ (location)

A

1st cleft: near parotid gland

2nd cleft: anterior to upper/middle third of SCM

3rd/4th cleft: left side of neck - can present as suppurative thyroiditis

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26
Q

Branchial cysts may form fistulas that run ___

A

between tonsillar fossa and anterior neck, passes between internal and external carotid arteries

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27
Q

What is a chemodectoma and where is it located

A

carotid body tumour

tumour of the paraganglion cells - benign but locally invasive

located at the bifurcation of common carotid artery

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28
Q

Features of chemodectoma

A

solid, non-painful mass at level of hyoid bone

pulsatile but not expansile - transmitting pulses from carotid artery

mostly do not secrete catecholamines, but 5% do - rule out associated syndromes like pheochromocytoma

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29
Q

how to differentiate chemodectoma and carotid body aneurysm

A

aneurysm can occur at any level, tumour occurs only at level of hyoid bone

angiography to detect tumour - hypervascular mass that displaces bifurcation

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30
Q

Genetic associations of paragangliomas

A

MEN2, VHL, NF1, Carney-Stratakis dyad

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31
Q

What is a cystic hygroma, where is it found

A

congenital cystic lymphatic malformation

found posterior triangle of neck, can be multiple interconnecting/separate cysts

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32
Q

features of cystic hygroma

A

soft, fluctuant, compressible

can be found in other locations - axilla, groin

“brilliantly transilluminable”

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33
Q

What is a cervical rib, where is it found

A

hard mass in posterior triangle, at the root of neck

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34
Q

cervical rib causes ___

A

thoracic outlet syndrome - compression of brachial plexus trunks, subclavian artery and/or subclavian vein

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35
Q

Neuroma is a __, found in __

A

slow growing tumour arising from peripheral neural structures of neck (eg. brachial plexus)

posterior triangle of neck

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36
Q

Cervical lymph nodes are divided into ___ levels

A

seven

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37
Q

Drainage of H&N structures into what level of lymph nodes

A

Oral cavity: Level I, II, III

Thyroid, larynx: Level II - VI (thyroid first spreads to level VI - central nodes)

Nasopharynx: II - V

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38
Q

Differentials of enlarged lymph node (*categorise)

A

infectious
inflammatory
neoplastic

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39
Q

Infected lymph nodes causes

A

viral - EBV, CMV, HIV
bacterial - TB, strep/staph
fungal/parasitic - toxoplasma

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40
Q

neoplastic lymph node causes

A

primary - lymphoma
metastases - H&N (90%), other sites (breast, lung, renal, GIT)

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41
Q

inflammatory lymph nodes causes

A

Kikuchi, Kimura, SLE, sarcoidosis

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42
Q

Nerves easily injured in submandibular gland excision

A

marginal mandibular nerve (CN VII)
lingual nerve (CN V3)
hypoglossal nerve

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43
Q

Structures running in the parotid gland (lateral to medial)

A

facial nerve & branches
retromandibular vein
external carotid artery

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44
Q

Parotid duct runs 5cm across ____, below the ____, pierces the ___ and empties into ___

A

masseter
zygomatic arch
buccinator
opposite upper 2nd molar tooth

45
Q

Histology of each salivary gland & their contribution to saliva

A

parotid - mostly serous (25% of saliva)

submandibular - mixed serous and mucinous (70% of saliva)

sublingual - mostly mucinous (5% of saliva)

46
Q

What is sialolithiasis and which gland does it most commonly occur in

A

Stones in the salivary gland/duct

Submandibular gland

47
Q

Presentation of sialolithiasis

A

Pain and swelling of gland a/w meal times

Can cause gland inflammation (sialadenitis) and infection/abscess, purulent discharge observed at duct opening

48
Q

Most salivary gland tumours occur in the ___ gland, and are mostly __

A

parotid, benign

80% of the benign tumours are pleomorphic adenomas

49
Q

Tumours that occur in smaller glands are more likely to be ___

A

malignant

50
Q

Most common benign tumour of parotid gland

A

pleomorphic adenoma

51
Q

clinical features of pleomorphic adenoma

A

slow-growing, painless
irregular surface
chance of malignant transformation if left unexcised

52
Q

2nd most common tumour of salivary gland, only occurs in __. Related to ___, occurs in ___.

A

Warthin’s tumour, parotid

cigarette smoking, occurs in older patients

53
Q

Unlike pleomorphic adenoma, Warthin’s tumour is ___ to become malignant

A

unlikely

can be left alone

54
Q

embryonic origin of thyroid, parathyroid glands

A

thyroid: endoderm, from foramen caecum

inferior para: from 3rd pharyngeal pouch, migrate tgt with thymus

superior para: from 4th pharyngeal pouch

55
Q

arterial supply of thyroid & parathyroid

A

superior TA - from external carotid
inferior TA - from thyrocervical trunk, branch of subclavian
Thyroid Ima Artery - 5% of pts

*inferior TA supplies parathyroid

56
Q

Venous supply of thyroid

A

Superior TV: drains into IJV
middle TV: drains into IJV
inferior TV: drains into brachiocephalic

57
Q

impt nerves and artery relationships in thyroid

A

1) external branch of superior laryngeal nerve & superior thyroid artery

2) recurrent laryngeal nerve & inferior thyroid artery

58
Q

nerve damage in thyroid surgery and what is affected

A

1) external branch of superior laryngeal nerve supplies cricothyroid - tenses vocal cord. damage affects ability to produce high pitch

2) RLN - supplies all intrinsic muscles of larynx except cricothyroid. unilateral damage causes hoarseness. bilateral causes acute dyspnea

59
Q

thyroid stimulation pathway

A

TRH (from hypothalamus) -> TSH (from pituitary) -> T3 , T4 (from thyroid)

60
Q

Common causes of primary hyperthyroidism

A

Graves’ disease
toxic multinodular goitre
toxic adenoma

61
Q

common causes of secondary hyperthyroidism

A

pituitary adenoma

gestational thyrotoxicosis

neoplasms - ovarian teratoma, choriocarcinoma, metastatic thyroid carcinoma

62
Q

antithyroid drugs: ___ used for 1st trimester, switch to ___ for 2nd and 3rd trimester

A

Propylthiouracil (PTU) - less teratogenic

Carbimazole - less hepatotoxicity

63
Q

Impt side effect of antithyroid drugs

A

agranulocytosis

64
Q

Common causes of hypothyroidism

A

iodine deficiency (most common)

hashimoto’s
autoimmune
cretinism - maternal hypothyroidism leading to thyroid agenesis/dysgnesis
myxedema coma - severe hypothyroidism precipitated by infection/trauma/surgery

65
Q

Risk factors for thyroid malignancy

A

Age, gender

Exposure to ionising radiation

Family history

Associated with familial adenomatous polyposis, Gardner syndrome, Cowden disease, MEN2

66
Q

what is gestational hyperthyroidism?

A

Hyperemesis gravidarum: High HCG levels in 1st trimester -> stimulates TSH receptors

67
Q

Thyroid cytopathology is graded by the ____

A

Bethesda system

used to grade chance of malignancy, guides management

68
Q

follicular cell derived thyroid cancers

A

papillary, follicular, hurthle cell, anaplastic cancers

69
Q

non-follicular cell derived thyroid cancers

A

medullary cancer, thyroid lymphoma

70
Q

PTC spread by ___, FTC spread by ___

A

lymph, blood

71
Q

Thyroid swellings move on ___, thyroglossal cyst moves on ___

A

swallowing only

swallowing & tongue protrusion

72
Q

Suspicious features on ultrasound (6) a/w thyroid cancer

A

1) taller than wide
2) micro-calcifications
3) intranodular vascularity
4) margins - infiltrative, spiculated
5) hypoechoic
6) presence of lymphadenopathy

73
Q

Radioisotope used for thyroid scan

A

Sodium pertechnetate
Iodine 123

74
Q

Indications for thyroid surgery (6 Cs)

A

Cancer
Cosmesis
Cannot treat medically
Compressive symptoms
Compliance problems
Child-bearing

75
Q

___ syndrome is associated with medullary carcinoma. Screen for ___

A

MEN2A/2B
Pheochromocytoma

76
Q

Hashimoto’s thyroiditis increases risk of ___

A

lymphoma

77
Q

Ionising radiation increases risk of ____ and ___

A

papillary and follicular cell carcinoma

78
Q

Medullary cancer causes ____ due to production of ___

A

flushing, diarrhea

calcitonin

79
Q

Most common sites of mets for thyroid cancers

A

lung, bone, brain
+ liver for medullary

80
Q

T staging for thyroid based on

A

size of nodule
T3: invaded strap muscle
T4: invaded major neck structures

81
Q

Molecular tests for each tumour

A

PTC: BRAF mutation
FTC: RAS mutation
Medullary: RET oncogene

82
Q

Immediate post-surgical complications of thyroidectomy

A

Haematoma formation under/above strap muscles - tracheal compression

Injury to RLN and SLN

tracheomalacia - tracheal floppines due to chronic compression by large goiter

thyrotoxic storm - resection release t4 into blood

83
Q

Intermediate post-thyroidectomy complication

A

Hypoparathyroidism causing hypocalcemia, leading to (CATS go Numb)

Convulsion
Arrhythmias
Tetany
Spasm
Numbness of extremities

84
Q

MEN1 tumour suppressor gene mutation affects

A

3Ps

Parathyroid - hyperplasia
Pancreas - neuroendocrine tumours
Pituitary - anterior pit adenoma, growth hormone secreting tumours

85
Q

MEN2A:
Activating proto-oncogene (RET) mutation causes/affects

A

Medullary thyroid CA
Pheochromocytoma
Parathyroid
Hirschsprung disease

86
Q

MEN2B: Activating proto-oncogene (RET) mutation causes/affects

A

Medullary thyroid CA
Pheochromocytoma

*no parathyroid in men2b

87
Q

Most common cause of painful thyroid gland

A

DeQuervain’s thyroiditis

preceded by URTI
viral infection causing damage to thyroid follicular cells

88
Q

Drugs that cause thyroiditis

A

Amiodarone, lithium, IL-2, IFN-alpha

89
Q

___ parathyroid migrates with the thymus, can sometimes be found within

A

Inferior

90
Q

Superior parathyroid arises from ___ pharyngeal ___, inferior arises from ____

A

4th pharyngeal pouch
3rd pharyngeal pouch

91
Q

PTH ___ calcium in blood, calcitonin ___ calcium in blood

A

increases, decreases

92
Q

PTH effects on kidney

A

increases reabsorption of calcium & vitamin D

increases excretion of phosphate

93
Q

Calcitonin effects

A

Inhibit reabsorption of calcium in kidney and intestines

Inhibit reabsorption of phosphate

94
Q

Mnemonic for hyperparathyroidism

A

stones, bones, moans, groans

kidney stones

bone pain - osteoporosis

abdominal groans - PUD,
pancreatitis, cholelithiasis

psychiatric moans - depression, psychosis

95
Q

parathyroid 4 gland hyperplasia associated with

A

MEN 1 and 2a

96
Q

most common cause of primary hyperparathyroidism

A

parathyroid adenoma

97
Q

What is hungry bone syndrome?

A
  • occurs after parathyroid gland removal
  • high calcium levels suppressed PTH production in normal glands
  • sudden drop in PTH stops osteoclastic activity in bone
  • osteoblastic activity continues. bone takes a lot of calcium, phosphate, magnesium
98
Q

What causes secondary hyperparathyroidism?

A

Chronic hypocalcaemia

Happens most commonly in chronic renal failure. Lack of calcium/vit D reabsorption

99
Q

What causes tertiary hyperPTH?

A

Long term secondary hyperPTH, parathyroid glands develop autonomous secretion of PTH without need for stimulation by calcium

100
Q

Substances produced by adrenal glands

A

Cortex:
- zona glomerulosa: aldosterone
- zona fasciculata: cortisol
- zona reticularis: sex hormones

medulla:
- catecholamines (epinephrine, norepinephrine)

101
Q

Adrenal incidentalomas can be classified into

A

Benign (non-secreting): adenoma, nodular hyperplasia

Benign (secreting): conn’s, cushing’s, pheochromocytoma

Malignant: adrenal cortical CA

102
Q

Hyperaldosteronism commonly presents with

A

resistant HTN (>= 3 drugs)
hypokalaemia

HTN can be young onset

103
Q

Most common cause of hypercortisolism

A

Iatrogenic (exogenous glucocorticoid use)

104
Q

Cushing’s disease is ___
Cushing’s syndrome is ___

A

pituitary adenoma causing excessive ACTH secretion

adrenal hyperplasia/adenoma/carcinoma causing cortisol hypersecretion

105
Q

Ectopic ACTH can cause cushing’s syndrome. Ectopic ACTH seen in

A

Small cell lung cancer
Thymic tumours
medullary thyroid cancer
carcinoid (neuroendocrine) tumours of pancreas/gut

106
Q

Hypercalcaemia can result from ___ malignancies

A

squamous cell lung cancer
multiple myeloma

107
Q

Clinical features of phaeochromocytoma (5 Ps)

A

pain - headache, chest pain
palpitation - tachycardia, tremor
pressure - HTN
perspiration
pallor

108
Q

Rule of 20 for pheochromocytoma (6)

A

20% malignant
20% children
20% extra-adrenal
20% bilateral
20-25% familial (MEN2, VHL, NF1, tuberous sclerosis)

109
Q

In managing pheochromocytoma, ___ given before ___ because

A

alpha blockers, beta blockers

Beta blockers block vasodilation in the peripheries -> alpha receptors are unopposed -> keep stimulating vasoconstriction -> high bp

Must use alpha blockers to block vasoconstrictive effects of alpha receptor first

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