Head and Neck incl. Thyroid and oropharyngeal cancers

Question 1

If you needed to perform an emergency airway where would you perform it? What muscle is directly beneath it? What is that muscle directly innervated by?
If it was an elective airway procedure, where would you perform it?

Answer 1

Cricothyrodotomy if emergency, Platysma muscle, cervical branch of the facial nerve
Tracheostomy if elective

Question 2

List causes of neck masses found on exam
OR List Ddx for neck masses

Answer 2

Infectious: Reactive Lymphadenopathy, Tb, Taxoplasmosis (TORCH)
Inflammatory: Sialadenitis, thyroiditis
Congenital: Branchial cleft cyst, Thyroglossal duct cyst, Cervical rib, Cystic Hygroma/Lymphangioma/hemangioma
Neoplastic: Benign (lipoma, fibroma, hemangioma, thyroid nodule) or Malignant (SCC, Thyroid cancers, lymphoma (rubbery + splenomegaly), HPV oropharyngeal/tonsilar, EBV nasal or non-hodgkins lymphoma
Autoimmune: Grave’s, Hashimoto’ Thyroiditis
Atherosclerotic: Carotid Aneurysm

Question 3

What is a Branchial Cleft Cyst?
Where is it typically found?

Answer 3

It is a remnant of embryonic branchial cleft typically found as a mass on the lateral neck

Question 4

What is the medical term for stone in the salivary glands?
What is the most common site of manifestation? Why?

Answer 4

Sialolithiasis
Most commonly occurring at the submandibular gland due to it having a more tortuous duct and thicker production

Question 5

What salivary gland is most prone to lymphadenopathy?

Answer 5

Superficial lobe of the parotid gland is most prone to lymphadenopathy

Question 6

While examining a patient, there appears to be a mass found in the midline. Quick! List your ddx

Answer 6

Inflammatory: Lingual gland sialadenitis/ranula, thyroiditis
Infectious: Lymphadenopathy
Autoimmune: Grave’s, Hashimoto’s thyroiditis
Congenital: Thyroglossal duct cyst, Dermoid cyst
Neoplastic: Thyroid carcinoma, thyroid nodule

Question 7

What are the 6 levels of the cervical lymph nodes that you will explore during palpation?

Answer 7

Level 1a: Submental triangle
Level 1b: Submandibular triangle
Parotid: Superficial lobe has 20+ nodes and bisected from deep lobe by facial nerve
Levels 2,3,4 alone the SCM starting from the mastoid
Level 2: mandible to hyoid
Level 3: Hyoid to cricoid
Level 4: Cricoid to clavicle
Level 6: Anterior midline and tracheoesophageal gutter
Level 5: Posterior triangle (Palpate along SCM and midline)

Question 8

Define Dysplasia and metaplasia
How does the presence of each determine patient outcomes

Answer 8

Dysplasia: Tranformation into an abnormal version of self
Metaplasia: Transformation to another type of cell

Dysplasia is irreversible whereas metaplasia is reversible => Metaplasia indicates a more favorable prognosis

Question 9

In determining the prognosis of a patient with a head and neck cancer, The degree of differentiation often plays a role along with the presence of dysplasia and metaplasia. How does the degree of differentiation indicate patient outcomes?

Answer 9

The more well-differentiated the cell is, the most likely the parent cell it is => better prognosis. A poorly differentiated cell indicates that it is further along the process and hence poor prognosis.

Question 10

What are the 2 main functions of the thyroid gland?

Answer 10

1) Thyroid hormone production -> metabolism, mentation, movement (hypomenstruation too lol)
2) Calcitonin production (decreases calcium)

Question 11

Thyroid cancer is often over-diagnosed and over-treated. 50% of adults over 50 and 80% over 80 will have a thyroid nodule.
List the 3 most common well-differentiated thyroid carcinoma, highlighting the most common thyroid cancer.

What investigation is used to detect these types?

List 2 poorly differentiated types of thyroid carcinoma

Answer 11

Papillary thyroid carcinoma (>90%)
Follicular thyroid carcinoma
Hurthle cell carcinoma
All these 3 are detected via raised levels of Thyroglobulin

Poorly differentiated: Medullary Thyroid cancer and Anaplastic Thyroid Cancer

Question 12

Medullary Thyroid Cancer is a cancer of which cell?
What investigation would you order to screen if the patient may have this?

Answer 12

Medullary thyroid carcinoma is a cancer of the Parafollicular C cells.
Raised calcitonin levels are consistent with this diagnosis

Question 13

You are asked to assess a patient with a history of a GIT carcinoma. While conducting cervical lymph node palpation, you notice an enlarged lymph node. Where is that lymph node? Which level is that node considered to be in? What is the relation?

Answer 13

The GIT lymph drains into virchow’s node via the thoracic duct. It is located in the left supraclavicular fossa at the junction of the thoracic duct and the left subclavian vein. It is considered to be a part of level 4 => from cricoid to clavicle

Question 14

Most cases of anaplastic TC present with adjacent invasion. What is the management approach to anaplastic TC?

Answer 14

Palliative care. No Na/I symporter for radiactive iodine therapy and already metastasized => no curative surgery via excision.

Question 15

Radioactive Iodine therapy has fallen off over recent years as it used to be used as a non-surgical alternative to the treatment of thyroid carcinoma. It has no proven role in mild-moderate cases. Why is it not used in those with later stage carcinomas?

Answer 15

The lack of the Na/I symporter is advanced disease especially anaplastic TC, renders it not as effective. If curative surgery via excision is available, that should be chosen. The risks outweigh the benefits in radioactive iodine therapy.

Question 16

A patient presents to you with a midline neck mass. You ask the patient to drink a glass of water, where you notice the mass rising. State your full workup assuming neoplastic causes

Answer 16

1)First Hx and Exam to achieve differentials of thyroid masses such as neoplastic, thyroiditis, grave’s, and hashimoto’s. Bloods are then sent out including !TSH, Thyroid hormone, FBC with differentials, TPO serology (hashimoto), CRP…

2) Once the differentials are ruled out, my most likely diagnosis would be cancer

3) Flexible endoscopy looking for lesion and symmetrical vocal cord movement

4) US w/ U-Score!! From radiology. U1-U3 discharge/rescan, U4/U5 -> FNA indication

5) FNA sent to cytology. Cytologist gives THY score. THY3F or worse is indication for MDT FIRST!!! Then thyroid lobectomy (lobe + isthmus)

Question 17

While conducting your workup for thyroid carcinoma, you conduct a flexible endoscopy. While doing that, you are assessing for vocal cord movement. Why?

Answer 17

This applies for every endoscopy done. (Doctor asks patient to say E and happy birthday)
You are assessing for the integrity of the vocal cords as an indicator for Recurrent Laryngeal Nerve Integrity

Question 18

While conducting a flexible endoscopy, you note Thyroid mass compressing the airway. What symptom should you be concerned about that might indicate an emergency?

As you have found the lesion, you then move on to conducting ultrasound with radiology. How would this affect your next step?

Answer 18

Stridor (inspiratory) due to airway obstruction

Now we move on to US with radiology to obtain a U score. If the U-score is U3 or less then cancer is unlikely => try re-scan later or wait. We also take into account the size of the nodule and whether the patient is high risk when it comes to U3 or conservative management of high risk U1 and U2 patients
If U4 or higher then likely to be cancerous => proceed to FNA for cytology

Question 19

You have obtained a score of U4 as a U-score for a suspected thyroid carcinoma. You proceed to FNA. Why is that the preferred biopsy method?

Answer 19

A core biopsy will involve opening the site, causing adhesions. This would make it very difficult for surgeons to later excise the cancer if it needs to be excised leading to increased risk of complications => FNA.

Question 20

You have sent out the FNA thyroid to pathology. The cytologist comes back with what scoring system?

How would you interpret the results?

Answer 20

THY scoring system (specific tx to each tier is not needed. Just know

THY 1 = non-diagnostic -> consider repeat
THY 2 = Benign growth/non-neoplastic -> Correlate findings with US
THY3 a 15% -> Further US and MDT discussion on FNA repeat
THY3 f 40% -> Diagnostic Hemilobectomy
THY 4 = suspicious -> Diagnostic Hemilobectomy
THY 5 = cancer -> Surgery appropriate to tumor type

!THY 3f or more indicated a Diagnostic Hemilobectomy/Thyroid lobectomy

Question 21

What is the absolute indication for thyroid excision of tumour?
What is removed during a thyroid lobectomy

Answer 21

THY 3F or worse

Lobe + isthmus!

Question 22

What scoring system is used to assess the prognosis of a patient with suspected/confirmed thyroid nodule/carcinoma? Go into detail

Answer 22

GAMES score
Grade: Well vs poorly differentiated
Age: <55 vs >55
Metastasis: No vs Yes
Extrathyroidal extension (e.g. retroperitoneal expansion) No vs Yes
Size: <4 cm vs >4cm

The vast majority of patients with nodules are young patients with a small (<4cm) well-differentiated mass, without metstasis or extrathyroidal expansion.

Question 23

List complications of Thyroid Lobectomy

Answer 23

Local: Hematoma, Hemorrhage, Hoarsness
Systemic: Hypocalcemia, Pyrexia, GA, Tachycardia, DVT

Question 24

How would a hematoma present post-thyroid lobectomy
How would you manage?

Answer 24

Most serious complication. Patient presents with dysphagia (inability to swallow saliva), hoarsness, neck swelling, trouble breathing
Emergency ABCDE then Cricothyrodotomy; remove any covering and cut open the sutures. Put fingers into wound and expose strap muscles. Move them away until you get to the trachea.

Question 25

How would hypocalcemia manifest post-thyroid lobectomy
How is it managed?
What might occur in the event that it is not managed appropriately?

Answer 25

Hypocalcemia here would occur not from the thyroid gland being removed as it produces calcitonin which decreases serum calcium. It is because of the removal of the parathyroid gland as well
Trousseau’s Sign (Carpopedal spasm)
Chvostick’s Sign (facial muscles twitch)

Managed via IV calcium gluconate and Vit. D

If not managed appropriately may lead to cardiac arrest -> Toursades de points -> V.Fib

Question 26

What is the most common cause of recurrent laryngeal nerve injury post-op?

Answer 26

Typically due to stretching or burning when using thermal ablation as opposed to cutting. Also could be due to swelling or hematoma.

Question 27

Hyperthyroidism is associated with Thiamine deficiency why?
What are the signs of thiamine deficiency?

Answer 27

hyperthyroidism boosts metabolism. Metabolism especially involving glucose requires vitamin B1 or Thiamine as a cofactor => Thiamine deficiency. This would lead to:
Weight loss
Lethargy
Altered mental state
Impaired glucose metabolism
Beri Beri/Wernicke Korsakoff (if w/alcohol hx)

Question 28

Questions about hypo and hyperthyroidism are one of the most common questions students get asked on exams. Hypo is typically just the opposite of hyper symptoms. State the symptoms of hyperthyroidism.

Answer 28

Thyroid hormone is responsible for 3 domains of functions
1) Increased Metabolism: HTN, tachycardia, A.fib, palpitations, heat sensitivity (excessive sweating), increased appetite with weight loss, increased bowel movement/diarrhoea , Thiamine deficiency (weight loss, fatigue, confusion)

2) Increased movement: Increased tremulousness, or shaky hand tremors, excessive sweating

3) Increased mentation: Anxiety, Insomnia!! (DFA, DMS, EMA), Dementia (older)

4) Other: Exompthalmos, Hypomenorrhoea, Syncope (from A.fib in hyper, and Hypotension in hypo)

Question 29

Why is syncope both a symptom of hyper and hypothyroidism?

Answer 29

From A.fib (biggest RF for syncope) in hyperthyroidism and Hypotension in hypothyroidism

Question 30

What is a thyroid storm? What is it commonly caused by?
How does it manifest?

Answer 30

Thyroid storm is when the thyroid gland releases a large amount of thyroid hormone in a short amount of time. Typically, it is caused by
1) Damage to thyroid gland in surgery or trauma
2) Diabetic Ketoacidosis
3) Abrupt discontinuation of Eltroxin
4) Toxic multinodular goitre
5) Pulmonary embolism

Manifestation is basically superhyperthyroidism: Hyperthermia, LOC/Altered GCS, Pyrexia, Mood swings, Massive Diarrhoea, A.Fib leading to palpitations, syncope, PE, cardiogenic shock, Muscle wasting/weakness

Question 31

Guaranteed MCQ:
A skin lesion on the lip is seen with possible lung metastasis on CXR. What is the likely type of cancer?
Do basal cell carcinomas have the capacity to metastasize?
Where is the most likely secondary tumour for skin lesions?
How much excision is typically needed for SCC and BCC?

Answer 31

SCC is the most likely carcinoma as it is in an area of high exposure to sunlight and is known to metastasize. Basal cell carcinomas are also common on places of high exposure to sun but are less likely to metastasize. BCC metastasis is rare but can occur

Most likely for both SCC and BCC are lung and cervical (neck) metastasis
BCC needs >4mm margin, SCC needs >6mm margin

Question 32

What is the most dangerous HPV subtype. What is the second most dangerous? What is the most common and how does it manifest?

Answer 32

16 and 18 are the worst subtypes (16 is worse)
HPV 1 is the common wart

Question 33

What is the major benefit of the HPV vaccine or Gardasil for boys and girls?>

Answer 33

Boys: Head and Neck cancers (Oropharyngeal and tonsillar) (late onset)
Girls: Cervical carcinoma (early onset)

Question 34

Patients who are undergoing a thyroid lobectomy will be discharged on 2 key medications. What are they?

Answer 34

I know theres the typical analgesia and antibiotic prophylaxis. What I mean here is:
1) Eltroxin - Thyroid hormone supplementation
2) Calcium Supplementation

Question 35

While palpating the cervical lymph nodes, you notice lymphadenopathy. What would indicate that this would be lymphoma? (not only the lymph node itself)

Answer 35

Rubbery, !Painless as opposed to painful in infective lymphadenopathy
Splenomegaly
Weight loss/night sweats

Question 36

What is a Cystic Hygroma?
If the size of the Cystic hygroma were to increase suddenly, what would that indicate?

Answer 36

It is a diffuse lymphangioma/hemangioma mass that is typically found on the neck laterally or posteriorly. It is due to lymphatic/vascular malformations.

Sudden size increase would indicate a possible hemorrhage and hence may become an emergency especially with airway compromise

Question 37

What hereditary disease increases the risk of thyroid cancer?

Answer 37

Cowden’s Syndrome
Hereditary AD causing hamartoma formation around the body including lips, palms, feet, tongue and gums. They also have macrocephaly

Question 38

Give Rf for Thyroid Cancer

Answer 38

Age (>55)
Family Hx
Neck radiation
Cowden’s Syndrome
MEN

Question 39

Why is genetic testing typically done with suspected thyroid cacners?

Answer 39

To rule out MEN 2 in medullary thyroid cancer
(RET gene)

Question 40

HPV oncogenes E6 and E7 bind to what tumour suppressor genes?
What type HPV is the most relevant

Answer 40

E6 - p53 gene
E7 - Rb (retinoblastoma)
16 (&18 for cancers). 1 for warts

Question 41

Oropharyngeal/laryngeal tumours AKA all ENT tumours

40% are clinically malnourished on presentation due to the tumour + aspiration pneumonia is common. How will you deal with it?

If airway is compromised, we must consider an emergency endotracheal intubation or tracheostomy. How will you address the speech concerns from this?

Answer 41

NG tube feeding in the immediate setting (being careful about refeeding syndrome)

Escalated to PEG feeding (endoscopic or radiologically-inserted)

Speech: Electrolarynx, Blom-singer valve (w/ tracheoesophageal puncture)

Question 42

Laryngeal cancer:
What is the most common histological subtype?
Most common location?
Management?
Surgical options?

Answer 42

Histology: 90% SCC
Location: 98% Glottic > Supraglottic&raquo_space;»»» subglottic

Stage 1,2 -> Surgery or Radiotherapy
Stage 3,4 -> Combination of Surgery, radiotherapy, chemotherapy (2/3 or 3/3/)

Surgical options:
- Transoral laser microsurgery
- Hemilaryngectomy with voice preservation
- Supraglottic/supracricoid laryngectomy
- Total laryngectomy

Question 43

Oral cancer:
Most common histological subtype?
Management?

Answer 43

SCC (90%)
Tx: Surgery w/ or without radiotherapy
If positive LN metastasis: Modified radical neck dissection

Remember these as differentials for Esophageal cancer

Question 44

Oropharyngeal cancer:
Most common histological subtype?
RFs?
Management:

Answer 44

SCC (90%)
RF: HPV, alcohol, smoking
Management: Surgery +/- radiochemotherapy