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General Surgery > Endocrine Surgery > Flashcards

Endocrine Surgery Flashcards

1
Q

What are the differentials for an anterior triangle mass?

A

Lymph node – along anterior border of sternocleidomastoid (levels II, III, IV)
2. Thyroid Nodule
3. Submandibular gland mass (see later section on Salivary gland swellings)
4. Branchial cyst + fistula
5. Chemodectoma (carotid body tumour)
6. Carotid aneurysm
7. Pharyngeal pouch
8. Laryngocoele (rare; an air-filled, compressible structure seen in glass-blowers)

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2
Q

What are the differentials for a posterior triangle mass?

A

Lymph node – level V
2. Cystic hygroma
3. Cervical Rib
4. Brachial plexus neuroma/schwannoma

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3
Q

What are the differentials for a midline mass?

A
  1. Submental lymph node
  2. Thyroglossal cyst
  3. Pyramidal lobe of thyroid / Thyroid nodule in the isthmus
  4. Sublingual dermoid cyst
  5. Plunging ranula (retention cyst of the sublingual)
  6. Rarely, hyoid pathology e.g. bursa
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4
Q

What are the investigations for a neck mass?

A
  • Clinical examination
  • Biochemical: - FBC, U/E/Cr, Thyroid Function (i.e. TSH / T4), +/- Calcium Panel, +/- calcitonin (medullary thyroid cancer)
  • Imaging → Usually CT neck with contrast
  • Histology → Usually FNAC (as opposed to core biopsy in breast)
  • Endoscopy
    — Flexible Nasopharyngoscopy (evaluate nasal cavity, nasopharynx, oropharynx, hypopharynx and glottis) evaluate UADT
    – Bronchoscopy
    – Esophagogastroscopy
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5
Q

If FNAC yields suspected adenocarcinoma, what should the next investigations be?

A
  • CT neck/thorax/abd/pelvis
  • OGD / Colonoscopy
  • Bilateral mammogram (female patients)
  • If primary lesion found, this represents stage 4 disease
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6
Q

If FNAC yields suspected SCC, what should the next investigations be?

A

CT head / neck +/- thorax (?lung cancer)
- Panendoscopy of the upper aerodigestive tract (i.e. direct laryngoscopy, esophagoscopy, nasopharyngoscopy and
bronchoscopy)
- Biopsies of the nasopharynx, base of tongue, pyriform sinus, tonsil

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7
Q

If FNAC yields suspected lymphoma, what should the next investigations be?

A

Excisional lymph node biopsy
- CT neck/thorax/abd/pelvis
- Bone marrow biopsy (stage 4 disease)
- Stage disease – number of nodal groups / which side of diaphragm
- Chemotherapy (CHOP)

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8
Q

If FNAC yields suspected infective cause, what should the next investigations be?

A
  • Treat underlying condition
  • +/- Toxoplasma, HIV, EBV
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9
Q

What is a thyroglossal duct cyst

A

Congenital Cyst of Epithelial Remains of thyroglossal tract

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10
Q

What is the pathophysiology of a thyroglossal duct cyst?

A

A cystic expansion of the remnant thyroglossal tract – failure of the thyroglossal duct to obliterate after embryologic
descent of the thyroid from the foramen cecum at the base of the tongue to low anterior neck

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11
Q

What are possible locations of thyroglossal duct cysts?

A

Located anywhere from base of tongue to behind sternum – A & B – lingual (rare), C & D – adjacent to hyoid bone (common),
E & F – suprasternal fossa (rare)

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12
Q

What should be done if a thyroglossal duct cyst is infected?

A

directed antibiotics coverage, avoid incision and drainage (risk seeding cells outside the cyst which
increases risk of recurrence), wait for 3 months for inflammation to resolve prior to definitive operation

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13
Q

What are the pre-operative investigations and treatment for thyroglossal duct cysts?

A
  • Pre-op TFT
  • CT neck with contrast – confirms diagnosis (well circumscribed lesion with homogenous fluid attenuation surrounded by a
    thin enhancing rim) and identifies normal orthotopic thyroid tissue
  • U/S thyroid and thyroglossal cyst – well-defined, thin-walled, hypoechoic mass with posterior acoustic enhancement in
    midline
  • Sistrunk Operation – en bloc cystectomy, include its tract upward to the base of the tongue and resection of the central
    portion of the hyoid bone (to minimize recurrence, 2-5%)
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14
Q

What are risk factors for recurrence?

A

simple cyst excision (38-70%), intra-operative cyst rupture, presence of cutaneous
component secondary to infection & post-operative wound infection

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15
Q

What is the definition of a dermoid cyst

A

Small non-tender mobile subcutaneous lump, may be fluctuant, skin-coloured or bluish

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16
Q

What is the pathophysiology of dermoid cysts?

A

Can be congenital or acquired.
▪ Congenital – developmental inclusion of epidermis along lines of fusion of skin dermatomes (seen in younger patients,
present since birth). Locations include:
o medial & lateral ends of the eyebrows (internal & external angular dermoid cysts)
o midline of the nose (nasal dermoid cysts)
o midline of the neck and trunk

▪ Acquired – due to forced inclusion of skin into subcutaneous tissue following an injury, usually on fingers. Seen in older
patients, no previous history of mass, history of trauma to the area (may have associated scar).

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17
Q

What is the management of a dermoid cyst?

A
  • Imaging investigations (e.g. XR, U/S, CT) are important especially for cysts on the skull as they can communicate with
    cerebrospinal fluid.
  • Complete surgical excision of the cyst, preferably in one piece w/o spillage of cyst contents
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18
Q

What is a plunging ranula?

A

A pseudocyst associated with the sublingual glands and submandibular ducts.

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19
Q

What is the pathophysiology of plunging ranulas?

A

Ranulas can be congenital or acquired after oral trauma
▪ Congenital: secondary to an imperforate salivary duct or ostial adhesions
▪ Acquired: trauma to sublingual gland leading to mucus extravasation and formation of a pseudocyst (mucus escape
reaction)

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20
Q

Compare simple ranulas to plunging ranulas?

A

Simple Ranula: confined to floor of the mouth
- Plunging Ranula: a large ranula can present as a neck mass if it extends through the mylohyoid musculature of the floor of
the mouth

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21
Q

What is the treatment of plunging ranulas?

A

Complete resection if possible, often in continuity with the associated sublingual gland (but often difficult due to close
association with the lingual nerve and submandibular duct).
- If complete resection is not possible, marsupialisation and suturing of the pseudocyst wall to the oral mucosa may be
effective.

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22
Q

What is a branchial cyst?

A

Failure of fusion of the embryonic 2nd and/or 3rd branchial arches (failure of obliteration of the 2nd branchial cleft)
- All branchial cleft/groove (II, III, IV) are obliterated except for branchial cleft/groove I which give rise to the epithelial lining
of the external auditory meatus
- It is lined by squamous epithelium

  • usually presents in adults in their 20s
23
Q

What are the features of a branchial cyst? (4)

A

Located close to the parotid gland, sinus persist as the external auditory canal (1st branchial cleft anomaly)
- Occurs anterior to the upper or middle third of the sternocleidomastoid muscle (2nd branchial cleft anomaly)
- Smooth firm swelling, ovoid in shape, with its long axis running downwards and forwards
- May be fluctuant, usually not transilluminable (due to desquamated epithelial cell contents)

24
Q

What does FNA show in a branchial cyst?

A

opalescent fluid with cholesterol crystals under microscopy

25
Q

What are the possible complications of a branchial cyst?

A
  1. branchial fistula will run between tonsillar fossa and the anterior neck, passing between the
    external and internal carotid arteries
  2. Recurrent infections – purulent discharge, fixation to surrounding structures
26
Q

What is the management of a branchial cyst?

A

If fistula present, perform fistulogram to delineate course.
- Surgical excision of the cyst where possible.
- If the fistula/sinus present, inject Bonney’s blue dye into the tract prior to surgery to allow accurate surgical excision.
- Treatment of infection with antibiotics
- Complications: cyst recurrence; chronic discharging sinus

27
Q

What are the contents of each of the pharyngeal pouches?

A
28
Q

What is a carotid body tumour?

A

tumour of the paraganglion cells (paraganglioma) of the carotid body

29
Q

What are the features of a carotid body tumour?

A

Solid, non-painful mass at the level of the hyoid bone (where the bifurcation is – level II of the neck) – be gentle during
palpation as pressure on the carotid body can cause vasovagal syncope.
- Mass is pulsatile but not expansile, due to transmitted pulsation from carotids.
- Due to close a/w carotid arteries, lump can be moved side to side but not up and down.

30
Q

What should be done if suspecting a carotid aneurysm?

A

listen for bruit, look for signs of Horner’s syndrome, and examine the rest of the peripheral vascular
system

31
Q

What are some pointers regarding investigations when suspecting carotid body tumours?

A

Main differential is carotid artery aneurysm; an aneurysm can occur at any level but carotid body tumour occurs at the level
of the hyoid bone.
- DO NOT PERFORM FNAC
- CT and/or MRI can be used to delineate tumour anatomy in relation to surrounding structures; CT reveals homogenous
mass with intense enhancement following IV contrast administration.
- Angiography is the gold standard investigation – hypervascular mass displacing the bifurcation. May also show vessel
compromise by tumour invasion and undetected synchronous tumours.

32
Q

What is the surgical management for carotid body tumours?

A

Rule out associated syndromes (i.e. pheochromocytoma) in the pre-op preparation!
- Surgical excision with preoperative embolization (reduces bleeding and complications, and facilitates resection); any
enlarged ipsilateral lymph nodes are also removed due to the small possibility of malignancy
- Radiotherapy is an effective alternative for patients who are unfit for surgery or whose tumours are too large.

33
Q

What is the pathophysiology of a pharyngeal pouch? (Zenker’s Diverticulum)

A

A herniation of the pharyngeal mucosa (pulsion diverticulum) between 2 parts of the inferior pharyngeal constrictor –
thyropharyngeus & cricopharyngeus – weak area situated posteriorly (Killian’s Dehiscence)
- Caused by failure of the cricopharyngeus to relax

34
Q

What are the features of Zenker’s Diverticulum?

A

A cystic swelling low down in the anterior triangle, usually on the left
- Halitosis, regurgitation of undigested food with coughing, upper oesophageal dysphagia, hoarseness, weight loss,
squelching sound on deep palpation

35
Q

What are the complications of Zenker’s Diverticulum?

A

chest infection (due to chronic aspiration); diverticular neoplasm/squamous cell carcinoma

36
Q

How can Zenker’s diverticulum be diagnosed?

A

barium swallow (best seen in lateral view), oesophageal manometry
(Endoscopy and NGT are contraindicated as risk of developing perforation of the pharynx is high)

37
Q

What is the management of Zenker’s diverticulum?

A
  • Leave it alone if small and asymptomatic
  • Minimally invasive treatment: endoscopic cricothyroid myotomy
  • Surgical: cricopharyngeal myotomy + diverticulectomy or diverticulopexy
    ▪ Left cervical incision along anterior border of left SCM
    ▪ Myotomy, extend cephalad dividing 1-2cm of inferior constrictor muscle and caudad dividing 4-5cm of cricopharyngeal
    muscle and cervical oesophagus
    ▪ If a diverticulum is present and is large enough to persist after a myotomy
    ▪ Diverticulopexy → diverticulum sutured in inverted position to the prevertebral fascia
    ▪ Diverticulectomy (if diverticulum is excessively large so that it would be redundant if suspended, thickened wall) → base of pouch crossed with a linear stapler and amputated, test with water-soluble contrast esophagogram on POD 1
38
Q

What are the complications of surgical management of Zenker’s Diverticulum?

A

fistula, stenosis, abscess, hematoma, recurrent nerve injury, difficulty in phonation, Horner’s syndrome
(diverticulopexy – lower risk of stenosis / fistula but risk of malignancy remains)

39
Q

What is the pathophysiology of a cystic hygroma?

A

A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck, probably
formed during coalescence of primitive lymph elements. It consists of thin-walled, single or multiple interconnecting or separate
cysts which insinuate themselves widely into the tissues at the root of the neck.

40
Q

What are the clinical features of a cystic hygroma?

A

Lobulated cystic swelling that is soft, fluctuant, and compressible, located in the posterior triangle of neck
- Other locations – axilla, groin, mediastinum
- Classically “brilliantly transilluminable”
- A large cyst may extend deeply into the retropharyngeal space

41
Q

What are the complications of a cystic hygroma?

A

Cystic hygroma seen on prenatal ultrasound in the 1st trimester suggests chromosomal abnormality (i.e. trisomy 21) or other
structural abnormalities (i.e. congenital heart anomalies)
- May obstruct delivery
- Compressive problems after delivery – respiratory, swallowing
- Can become infected with staph / strep

42
Q

What is the management of a cystic hygroma?

A

Radiological investigations e.g. CXR, CT to delineate extent of cyst
- Non-surgical treatment – aspiration and injection of sclerosant (usually unsuccessful)
- Surgical excision – partial (to alleviate symptoms) or complete

43
Q

What is a schwannoma?

A
  • Slow growing tumour arising from peripheral neural structures of the neck (i.e. brachial plexus*, cervical plexus, vagus nerve,
    phrenic nerve, etc. → the trunks of the brachial plexus traverse the posterior triangle of the neck
44
Q

What should you avodi doing in a patient with schwanomma?

A

FNA

45
Q

Features and diagnosis of a symptomatic cervical rib?

A

A hard mass in the posterior triangle at the root of the neck
- Symptoms/signs:
▪ Arterial: pallor, gangrene or necrosis of the tips of the fingers
▪ Venous: oedema, cyanosis
▪ Neurological: complaints of radicular symptoms (pain, paraesthesia), wasting of the small muscles of the hand
- Adson’s test can be done – ask patient to extend neck and rotate it towards side of symptoms, radial pulse will be diminished,
occasionally with reproduction of radicular symptoms in the limb
- Diagnosis by CXR

46
Q

What are the differentials for pathological lymph nodes?

A
47
Q

What are the surgical options for neck dissection? and what are the potential complications?

A
48
Q

What is the nerve supply of the submandibular gland?

A

Secretomotor supply from lingual nerve carrying postganglionic fibres (facial nerve (chorda tympani)) from the submandibiular ganglion (preganglionic fibres in superior salivary nucleus)

49
Q

Where does the duct of the submadibilar duct originate from?

A

from superior part of the gland, running forward deep to the mylohyoid and drains into the oral cavity at the sublingual papilla just adjacent to the frenulum

50
Q

In the excision of the submandibular gland, which nerves are at risk of damage?

A
  1. Marginal Mandibular Nerve (Facial nerve)
  2. Lingual Nerve
  3. Hypoglossal Nerve
51
Q

For submandibular abscess:
a) Etiology
b) Complications
c) Management

A
  • Etiology: periodontal abscess, trauma to oral cavity (i.e. mandibular fracture), URTI, mandibular malignancies, sialadenitis
  • Complications: progression to Ludwig angina
  • Management:
    ▪ Early source control with surgical incision and drainage
    ▪ Broad Spectrum IV Antibiotics (directed against mixed flora of oropharyngeal cavity) – i.e. prevotella, peptostreptococcus,
    streptococci, staphylococci, gm negative organisms
52
Q

What structures run through the parotid gland?

A

Facial Nerve
Retromandibular Vein
ECA
(Lateral to Medial)

53
Q
A

General Surgery (37 decks)

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