Head and Neck Pathology Flashcards
What are common head and neck symptoms?
Sore throat, dysphagia, dysphonia, odynophagia, ulcers, neck lumps, sore throat, earache (referred otalgia?), discharge, cough, snoring, stretor, hoarseness, drooling.
What investigations can you use to investigate head and neck symptoms?
Endoscopy, indirect laryngoscopy, fibre optic nasolaryngoscopy, auscultation for carotid/thyroid bruites, FNAC (for non-pulsatile lumps), cytology, CT, MRI, PET, USS, XRay, contrast swallow.
What are the 7 S’s you use to describe neck lumps?
Site (level I-V), size, shape, sore, skin, stuck, soft?
What are the causes of neck lumps?
Reactive lymph nodes, thyroglossal cysts, cystic hygroma, solitary thyroid nodules, parathyroid disease, thyroid cancer, diffuse thyroid enlargement, multinodular goitre, branchial cyst.
What are reactive lymph nodes? What do they appear like?
Normal, swollen nodes in response to acute infection.
They are oval, round, soft, smooth, mobile and non-tender.
What is a thyroglossal cyst?
What imaging is useful for this?
How would you treat this?
Dilatation of thyroglossal duct remnant, may become infected and start discharging if ruptures through skin. If it ruptures it may become a sinus. It appears as a lump over thyroid that moves on tongue protrusion and grows with age.
USS prior to removal to ensure functional thyroid tissue elsewhere.
Antibiotics, cyst drainage, must remove hyoid bone to reduce chances of recurrence.
What is a cystic hygroma?
What imaging is useful for this?
How would you treat this?
It is a collection of fluid filled sacs (cysts) that result from lymphatic malformation. Appears as soft, painless lump, may be translucent.
USS, MRI.
Surgical excision.
What can be the cause of a solitary thyroid nodule?
Cyst (due to haemorrhage), adenoma (benign follicular tissue), carcinoma, lymphoma, prominent nodule in multinodular goitre.
How should you investigate a solitary thyroid nodule?
USS. If fine reassure and discharge, if not FNAC and cytology (can’t distinguish between follicular adenoma and follicular carcinoma (must do tissue biopsy and histology - graded 1-5; 1 - didn’t get enough tissue, 2 - normal, 3 - dysplastic 4 - mostly likely cancer, 5 - carcinoma).
What are the red flag symptoms associated with a solitary thyroid nodule?
Pain going to ear, weight loss, hoarseness, haematemesis.
How are solitary thyroid nodules generally treated?
Thyroid lobectomy.
What are the four types of thyroid cancer and how do they differ?
Papillary - lymphatic metastasis common.
Follicular - haematogenous metastasis common.
Medullary - familial aggression, arises from parafollicular C cells.
Anaplastic - aggressive, local spread, very poor have poor prognosis.
How is thyroid cancer treated?
Removal of neoplasm with thyroid gland and lymph nodes.
What are the causes of diffuse thyroid enlargement?
Colloid goitre, Grave’s disease, thyroiditis.
What is goitre?
Swelling in the neck caused by an enlarged thyroid gland.
NB - can cause compressive neck symptoms (dysphagia, stridor, compression of trachea).
What are the causes of colloid goitre?
Gland hyperplasia, iodine deficiency, puberty, pregnancy, lactation.
What sign indicates retrosternal goitre?
Pemberton’s sign: if choking when raising arms.
What is the aetiology of Grave’s disease?
Auto-antibodies directed against thyroid stimulating hormone. Results in hyperparathyroidism.
In which gender and age group is Grave’s disease most common?
Females, middle age.
What symptoms are associated with Grave’s disease?
thyroid eye disease (exophthalmos), fatigue, acropachy, clubbing, pre-tibial myxoedema, weight loss.
How is Grave’s disease treated?
anti-thyroids, beta-blockade (as patients are tachycardic), radio-iodine, surgery.
What is thyroiditis? What can cause it?
General term for swelling of the thyroid gland.
Causes: post-partum thyroiditis, infection, autoantibodies against thyroid gland, drugs/chemical damage.
What are the indications for thyroidectomy?
Airway obstruction, (suspected) malignancy, thyrotoxicosis, cosmesis, retrosternal extension.
What are the complications of a thyroidectomy?
Bleeding (primary/secondary), voice hoarseness, thyroid storm (life-threatening: produce too many hormones, leading to increased HR, BP and temperature), infection, hypoparathyroidism, hypothyroidism, keloid/hypertrophic scar.
What are the causes of thyrotoxicosis?
Hyperparathyroidism, inflammation of the thyroid gland, meds (e.g. amoidarone, lithium as these encourage excess hormone production).
What symptoms are associated with thyrotoxicosis?
Diarrhoea, weight loss, tremor, sweating, palpitations, agitation, increased HR, thinning of hair.
How is thyrotoxicosis treated?
Anti-thyroids, beta-blockers, radio-iodine, surgical excision.
What is thyrotoxicosis? How does it differ from hyperthyroidism?
Thyrotoxicosis is the presence of too much thyroid hormone in the body and hyperthyroidism is when thyrotoxicosis is due to overproduction of thyroid hormone by the thyroid gland.
What is the difference between hyperthyroidism and hypothyroidism?
Hyperthyroidism = producing too many hormones. Hypothyroidism = producing too little hormones.
What are the symptoms associated with hyperthyroidism?
Anxiety, irritability, difficulty sleeping, fatigue/tiredness, sensitivity to heat, enlarged thyroid, palpitations, tremor, weight loss.
What are the symptoms associated with hypothyroidism?
Fatigue, weight gain, depression, sensitivity to cold, dry skin/hair, muscle ache.
How do you treat hyperthyroidism?
Anti-thyroids, beta-blockade, radio-iodine, surgery.
How do you treat hypothyroidism?
Daily hormone replacement (levothyroxine).
What are the causes of hyperthyroidism?
Grave’s disease, hyper-functioning thyroid nodules, thyroiditis, meds (iodine), pregnancy, thyroid cancer.
What are the causes of hypothyroidism?
Some autoimmune dx, damage from thyroid cancer/hyperthyroidism Rx.
How would you investigate thyroid disease?
TFTs (TSH, T3, T4), low TSH and high T3/4 indicates hyperthyroidism.
What are two causes of multi-nodular goitre?
Toxic goitre, Grave’s.
Who is toxic goitre seen in? What investigations should you use? And what signs will you see?
Mostly seen in elderly. Do TFTs, FNAC, CXR. No eye signs, AF and hyperthyroidism.
What kind of parathyroid disease is most common? What investigations would be useful in investigating parathyroid disease?
Hyperparathyroidism most common.
U&Es, creatinine, Ca, phosphate, parathyroid hormone, bicarbonate, vit D, USS, CT, MRIs (identify ectopic glands), isotope scanning (detect diseased glands).
What symptoms are associated with parathyroid disease?
Painful stones - renal calculi, polyuria, renal failure.
Aching bones - pathological fractures, osteoporosis, bone pain.
Psychic moans - anxiety, depression, confusion, paranoia.
Abdominal groans - abdominal pain, constipation, peptic ulcers, pancreatitis, weight loss.
What surgery do you do for hypoparathyroidism?
You ONLY do surgery for hyperparathyroidism.
What are the causes of hyperparathyroidism? How is this investigated and treated?
Adenoma(s), hyperplasia, secondary hyperparathyroidism (due to dx lowering Ca, body compensates too much, so normal Ca, but high phosphate, e.g. in renal failure).
Overproduction of PTH leads to increased serum Ca. This is because PTH normally regulate Ca, phosphorus and vit D.
Supplements and dietary change.
What is stridor?
Clinical sign of airway obstruction.
What are the different types of stridor and what sort of obstruction are they caused by?
Inspiratory - laryngeal
Expiratory - tracheobronchial
Biphasic - glottis/subglottis
How would you treat stridor?
Nebulised oxygen and adrenaline, IV dexamethasone (heliox), (definitive) airway management.
What is a branchial cyst?
Congenital remnant of fusion failure of branchial arches which has become infected and enlarged and lymph node degeneration.
What are the signs of a branchial cyst?
Transilluminates, smooth, soft, non-tender lump anterior to the SCM at junction between upper and middle thirds.
How are branchial cysts managed?
Excision to prevent further infection.
Categorise the neck lumps into
- non-thyroid related
- parathyroid related
- solitary thyroid nodule
- Diffuse thyroid enlargement
- reactive lymph node, thyroglossal duct, cystic hygroma, branchial cyst.
- hyperparathyroidism, hypoparathyroidism.
- carcinoma (follicular, papillary, medullary, anaplastic), cyst, adenoma, lymphoma.
- colloid goitre, Grave’s disease, thyroiditis.
What is a pharyngeal pouch?
Herniation of pharyngeal mucosa between the thyropharyngeus and cricopharyngeus of inferior constrictor of pharynx.
How can you investigate a pharyngeal pouch?
With barium swallow (will see apple core).
What symptoms are associated with a pharyngeal pouch?
Hoarseness, dysphagia, aspiration pneumonia, regurgitation, weight loss.
How is pharyngeal pouch treated?
Excision (endoscopic/open), dilate.
What is a cleft lip or palate?
Gap in the upper lip/palate present from birth.
What causes of cleft lip or palate?
Happens due to baby’s face not joining together correctly. Related to folic acid intake during pregnancy.
What complications are associated with a cleft lip/palate?
Difficulties and malnutrition is not treated properly. Ear infections, speech problems, breathing problems can also result.
How is cleft lip/palate managed?
Surgery.
Give examples of salivary gland disease.
Tumour of the salivary glands, e.g. pleomorphic adenoma, inflammation of the salivary glands, e.g. parotiditis, duct calculi (blocks flow of saliva, v. painful but simple to remove, see swelling all over affected gland).
What do you want to ask in your history about a patient presenting with hoarseness?
Duration, persistent/intermittent? Pain? Choking? Coughing? Swallowing? Voice user (singer/teacher)? Asthma? Rhinosinusitis? Reflux? Smoker? Meds? H&N symptoms?
What can cause hoarseness?
Nodules (screamer’s/singer’s nodes), (haemorrhagic) cyst, vocal abuse, laryngitis, infection, smoking, reflux, laryngeal cancer (laryngeal stoma), chronic laryngitis (these patients are chronically hoarse).
What can cause vocal cord paralysis?
Remember - can paralysis one or both cords depending on cause.
Nothing visibly wrong with cords due to interruption of nerve supply (recurrent laryngeal nerves). On left side recurrent laryngeal nerve lies close to hilum (if lung cancer spreads to hilar lymph nodes can cause nerve compression).
What are the three different categories of things that can cause dysphagia?
- something in the lumen (e.g. foreign body)
- problem with the wall (stricture, tumour, pouch etc.)
- something compressing the lumen (e.g. thyroid, heart, mediastinal mass).
What are the key things to ask in a history of a patient with dysphagia?
What is difficult (eating or drinking or both)? - drinking suggests NM cause, eating suggests narrowing of tube. Persistent or intermittent? Pain? Where? Well localised in the neck? Poorly localised further down?
What is FOSIT/globus pharyngeus?
Persistent feeling of a lump in the throat where there is actually nothing there. Can swallow normally so not true case of dysphagia. NOT a red flag symptom.
What can cause FOSIT?
Silent acid reflux (larynpharyngeal reflux), stress/anxiety, circopharyngeal spasm.
How do you treat head and neck cancer?
Curative or palliative?
Surgery, chemotherapy, radiotherapy.
Surgery involves neck dissection, removal of tumour (and surrounding lymph nodes) and flap reconstruction.
How do malignant nodes differ from normal nodes?
They are round, firm, irregular, fixed and non-tender.
What are causes of airway obstruction?
Foreign body, infection (e.g. epiglottitis, tonsillitis, croup, bronchitis), neck swelling, tumour, vocal cord paralysis, laryngomalacia (commonest paed cause).
What are the signs of airway obstruction?
Stridor (high pitched, wheezing noise made by disrupted airflow.
Inspiratory airflow indicates an issue with tissue above vocal cords. Expiratory stridor indicates a blockage in the trachea. Biphasic stridor indicates vocal cord obstruction or just below.
How would you manage airway obstruction?
ABC, secure airway (intubate, cricothyroidectomy (through cricothyroid membrane), tracheostomy, humidified oxygen, steroids, adrenaline nebulised.
What is tonsillitis?
Inflammation of the tonsils.
What are the causes of tonsillitis?
Viruses (most common - these include EBV), bacteria (these include B-haem, strep B).
What are the differences between viral and bacterial tonsillitis?
Bacterial tonsillitis - patients have white pus spots on tonsils, swollen neck nodes, fever, no cough.
Viral tonsillitis - patients have red, swollen tonsils and a red throat.
What symptoms are associated with tonsillitis?
Sore throat, dysphagia, hoarseness, fever, headache, cough, nausea.
What are the complications associated with tonsillitis?
Risk of glomerulonephritis, rheumatic fever, quinsy.
How is tonsillitis treated?
Penicillin V +/- anaerobic cover if acute, analgesia, anti-septic gargle (difflam), tonsillectomy, airway obstruction management. AVOID amoxicillin/ampicillin.
What is quinsy?
A.k.a. peritonsillar abscess. Rare, potentially serious complication of tonsillitis.
What causes quinsy?
Bacteria from tonsils spreading to surrounding areas and forming a collection of pus (abscess) between the wall of the mouth and tonsils.
What are the indications for tonsillectomy?
If any of: - >1 quinsy/6-7 attacks in 1y -5 per year over 2y 3 per year over 3y -daily activities disrupted -obstructive sleep apnoea -malignancy (lymphoma, rhabdomyosarcoma) tonsillectomy indicated.
What is laryngomalacia?
Congenital softening of tissues of larynx above the vocal cords. Common cause of noisy breathing in children.
Laryngeal structure is floppy and malformed.
(self-limiting)
What is the most common nasal deformity?
Nasal septal deviation (can be congenital or acquired (trauma)).
What is a saddle deformity?
A marked depression/collapse along the mid portion of the nasal bridge.
What can cause a saddle deformity?
Septal perforation, surgery, trauma.
What are the complications associated with a saddle deformity?
Blockage of the nose, predisposing to rhino sinusitis, issues with Eustachian tube, nasal haematoma.
How is saddle deformity treated?
Post-traumatic rhinoplasty.
What is a nasal septal perforation?
Hole in the cartilage of nasal septum.
What can cause a nasal septal perforation?
Trauma, previous septoplasty, cocaine use.
What signs are associated nasal septal perforation?
Whistling when breathing in and out (smaller holes make more whistling).
What complications can arise from nasal septal perforation?
Can lead to collapse of the nose.
What happens in the nasal septum haematoma?
Anterior part of nasal septum composed of cartilaginous plate with closely adherent perichondrium and mucosa. Submucosal BVs are torn as buckling forces pull the perichondrium from the cartilage. Blood collects between the perichondrium and septal cartilage.
What complications are associated with nasal septal haematoma?
Progressive obstruction, deformity.
How is nasal septal haematoma treated?
Drain quickly, if left for a long time can become septic.
What is rhinosinusitis?
Concurrent inflammatory and infective processes affecting the nasal passage and continuous paranasal sinuses.
Can be chronic (allergic/non-allergic), with or without polyps (benign), or acute (bacterial, tends to last less than 12wks).
How can you investigate rhinosinusitis?
Sinus radiographs (poor visulisation of the osteomeatal complex and the anterior ethmoid sinuses, high rate of false positives (incl. air-fluid levels, mucosal thickening and sinus opacification).
What bacteria can cause rhinosinusitis?
S. pneumonia, H. influenza, both, M. catarrhalis, S. aureus, S. progenies, gram negatives.
How is adult rhinosinusitis classified?
Acute - acute onset of symptoms, duration <12 wks, symptoms usually resolve.
Recurrent acute - >1 to <4 episodes of acute rhinosinusitis per year, complete recovery between episodes, symptom free for >8wks between acute attacks in absence of Rx.
Chronic - duration of symptoms >12wks, persistent inflammatory changes on imaging >4wks after starting appropriate Rx.
Acute Exacerbations of Chronic - worsening of existing symptoms or appearance of new symptoms. Complete resolution of acute (but not chronic) symptoms between episodes.
What symptoms will patients experience with rhinosinusitis?
Major factors: facial pain/pressure, hyposmia/anosmia, nasal congestion/obstruction, purulent postnasal drain, olfactory disturbance, cough not due to asthma (children only).
Minor factors: headache, fever, fatigue, halitosis, dental pain, cough (adults).
What complications are associated with rhinosinusitis?
Infection can spread from sinuses and cause meningitis, intracranial abscesses and orbital sepsis.
How is rhinosinusitis treated?
B-lactams (penicillin, cephalosporins), macrocodes (erythromycin, clarithromycin).
What risks are associated with sinus surgery?
CSF leak, orbital complications, worse case scenario: blindness.