Head & Neck Flashcards
What are the boundaries of the anterior cranial fossa? Whats in it? What are its important features? What foramen are within it? Please explain its clinical significance.
A = orbital part of frontal bone
P= prechiasmatic sulcus of sphenoid bone & lesser sphenoid wing
F = frontal, ethmoid & body of sphenoid bone
Contains frontal lobe
Features:
1. Frontal crest attaching to falx cerebri (
2. Crista galli of ethmoid bone attaches to falx cerebri also - cribriform plate is either side (CNI)
3. Anterior clinoid processes attach to tentorium cerebelli
Foramen:
1. Cribriform plate (CNI)
2. Ant/post. ethmoidal (a/n/v)
Clinically: cribriform # = anosmia (CNI) & CSF rhinorrhoea due to tearing of meningeal brain coverings
What are the boundaries of the middle cranial fossa? Whats in it? What are its important features? What foramen are within it? Please explain its clinical significance.
A: lesser sphenoid wing & chiasmatic sulcus
P: petrous temporal bone & dorsum sella of sphenoid
F: body/greater sphenoid wing & squamous/petrous temporal bone
Contains pituitary gland & temporal lobes
Features:
1. Sella turcica = tuberculum sellae, hypophyseal fossa (pituitary gland) & dorsum sellae
2. Posterior clinoid process attaches to tentorium cerebelli
3. Hiatus of greater petrosal n (CNVII)
4. Hiatus of lesser petrosal n (CNIX)
Foramen:
1. Optic canal (CNII & opthalmic a)
2. SOF (CNIII, CNIV, CNVa, CNVI, opthalmic veins & symphathetics)
3. Foramen rotundum opens into pteryopalative fossa (CNVb)
4. Foramen ovale opens into infratemporal fossa (CNVc & accessory meningeal a)
5. Foramen spinosum opens into infratemporal fossa (middle meningeal a/v & CNVc meningeal branch)
6. Carotid canal (ICA & deep petrosal n)
Clinical significance: transphenoidal pituitary surgery via nostrils, nasal cavity, sphenoid sinus & sella turcica (complications: CSF rhinorrhea, meningitis, DI, haemorrhage & visual disturbances)
What are the boundaries of the posterior cranial fossa? Whats in it? What are its important features? What foramen are within it? Please explain its clinical significance.
A: dorsum sellae of sphenoid & petrous temporal bone
P: squamous occipital bone
F: mastoid temporal bone & squamous/condylar/basilar occipital bone
Contains brainstem (medulla, pons & midbrain) and cerebellum
Foramen:
1. IAM in temporal bone (CNVII, CNVIII & labryinthine a)
2. Foramen magnum in occipital bone (medulla, meninges, vertberal a, CNXI, dural veins & ant/post spinal a’s)
3. Jugular foramen (CNIX, CNX, CNXI, IJV, inf. petrosal sinus, sigmoid sinus & meningeal branches of ascending pharyngeal & occipital a’s)
4. Hypoglossal canal (CNXII)
Features:
1. Clivus connects foramen magnum with dorsum sellae
2. Cerebellar fossae divided by internal occipital crest
Clinical significance: cerebellar tonsillar herniation through foramen magnum due to raised ICP compressing pons/medulla and depressing cardioresp centres causing death
What are the layers of the scalp and what is their relevance? What is its supply?
Skin: hair follicles & sebaceous glands (cysts may form)
Connective tissue: blood vessels highly adherent to tissue so they cant constrict if lacerated causing profuse bleeding
Aponeurosis of occipitofrontalis: pulling prevents closure of bleeding vessels & skin
Loose areolar tissue: emissary valveless veins connect scalp to diploic veins & venous sinuses allowing infection spread
Periosteum: continuous with endosteum at suture lines
Arterial supply:
- Superficial temporal, post. auricular & occipital (ECA)
- Supraorbital & supratrochlear a (opthalmic a of ICA)
Venous drainage:
- Superficial follows above
- Deep region drained by pterygoid venous plexus that goes into maxillary vein
Innervation:
- Supratrochlear & supraorbital (CNVa)
- Zygomatricotemporal (CNVb)
- Auriculotemporal (CNVc)
- Lesser occipital (C2), greater occipital (C2), great auricular (C2/3) & 3rd occipital (c3) (cervical plexus)
High yield: Auriculotemporal supplies ant/sup auricle whilst greater auricular supplies posterior ear and angle of mandible
Name the 5 skull bones and their important features.
- Frontal: squamous, orbital (x2) & nasal parts
- Sphenoid: butterfly-shaped & contains body, lesser/greater wings & 2x pterygoid processes (medial/lateral plate)
- Ethmoid: cribriform plate, perpendicular plate & ethmoidal labyrinth
- Temporal: squamous, tympanic, petromastoid parts & zygomatic/styloid processes
- Occipital: squamous, condylar & basilar parts
Name the 14 bones of the facial skeleton.
Zygomatic x2
Lacrimal x2
Nasal x2
Inferior nasal conchae x2
Palatine x2
Maxilla x2
Vomer
Mandible
What are the sutures of the skull? What types of joint are they? When does mastoid develop?
Fibrous joints so immovable ossifying at 18-24 months (if fused at birth = craniosyntosis)
- Coronal: fuses frontal & parietal bones
- Sagittal: fuses parietal bones to one another
- Lambdoid suture: fuses occipital to parietal bones
Anterior fontanelle = coronal & sagittal suture junction - closes @ 18 months
Posterior fontanelle = sagittal & lambdoid suture junction - closes @ 2 months
Mastoid fully developed by 2 years old
Please describe anatomy of mandible.
Largest/strongest bone of face forming lower jaw & as a receptacle for lower teeth
Contains horizontal body & 2x verticle rami posteriorly
Rami contain head, neck & coronoid process
Foramen:
1. Mandibular (inferior alveolar n/a)
2. Mental foramen (mental n from inferior alveolar)
What are the foramen of the skull and what runs through them?
Ethmoid foramen
1. Cribriform plate: CNI
2. Optic canal: CNII, opthalmic a & sympathetics
Sphenoid foramen:
3. SOF: CNIII, CNIV, CNVa (lacrimal, frontal & nasociliary branches), opthalmic veins & CNVI
4. Foramen rotundum: CNVb
5. Foramen ovale: otic ganglion (not through), CNVc, accessory meningeal a, lesser petrosal n & emissary veins
6. Foramen spinosum: middle meningeal a/v & meningeal branch of CNVc
Temporal foramen:
7. Carotid canal: ICA, sympathetic plexus, deep petrosal n & emissary veins
8. IAM: CNVII, CNVIII & labryinthine artery
9. Jugular foramen: CNIX, CNX, CNXI, inferior petrosal sinus, sigmoid sinus & meningeal branches of occipital & ascending pharyngeal a’s
10. Stylomastoid foramen: CNVII + stylomastoid a
Occipital foramen:
11. CNXII
12. Foramen magnum: CNXI, medulla, meninges, vertebral a’s, ant/post spinal a’s, dural veins, tectorial membranes & apical ligament of dens
- Foramen lacerum is at junction of all bones and is filled by cartilage
Please describe the muscles of mastication, their function and their supply.
- Masseter: elevation of mandible (close mouth)
- Temporalis: elevation + retraction of mandible (close mouth)
- Medial pterygoid: elevation of mandible (close mouth)
- Lateral pterygoid: protraction/depression of mandible (open mouth) & side-to side movement
Develop from 1st pharyngeal arch supplied by CNVc - also supplies tensor tympani (dampens sound) & tensor veli palatini (elevate soft palate)
Please describe the anatomy of the tongue; its muscles, function and supply.
Function: taste & swallowing
Intrinsic muscles: longitudinal, transverse & vertical muscles (CNXII)
Extrinsic muscles: genioglossus, hyoglossus, styloglossus (CNXII) & palatoglossus (CNX)
Innervation:
Anterior 2/3rd = general sensation (CNVc lingual nerve) & taste (chorda tympani of CNVII)
Posterior 1/3rd = CNIX
Root = CNX
Blood supply:
Lingual a (ECA) and lingual v (IJV)
Lymph drainage:
Anterior 2/3rd = submental/submandibular nodes -> deep cervical
Posterior 1/3rd = deep cervical
What is the sympathetic and PS supply to the head?
Sympathetics (T1-6) ascend via sympathetic chain to form superior, middle & inferior cervical ganglion
Superior (ant. to C1-4) - eyes, pterygopalatine a, SM of arteries, pharyngeal plexus, cardiac, grey rami (C1-4) & CNII-IV, VI & IX
Middle (ant. to C6) - thyroid branches, cardiac & grey rami (C5-6)
Inferior (ant. to C7) - subclavian/vertberal a’s, cardiac & grey rami (C7-T1)
Damage = Horners (partial ptosis via sup. tarsal, miosis due to dilator pupillae paralysis & anhidrosis)
PS CNs = CNIII, CNVII, CNIX & CNX
- Ciliary ganglion (CNIII/EWN) innervate sphincter pupillae & ciliary muscles allowing pupillary constriction & accomodation
- Pterygopalatine ganglion (CNVII sup. salivatory nucleus) travel w/ greater petrosal n. & n to pterygoid hitch-hiking on CNVb providing secretomotor to lacrimal/mucus glands, nasopharynx & palate
- SM ganglion (CNVII sup. salivatory nucleus) carried within chorda tympani hitchhiking along lingual CNVc to provide secretomotor to SM/SL glands
- Otic ganglion (CNIX from inf. salivatory nucleus) travel w/ lesser petrosal & along auriculotemporal n to provide secretomotor to parotid gland
- Dorsal vagal motor nucleus (CNX) targets PS to organs e.g. RT & GIT
Please describe the anatomy of the muscles of facial expression; their actions & supply.
Develop from 2nd pharyngeal arch so supplied by CNVII
Temporal branch: frontalis to raise eyebrow
Zygomatic: orbicularis oculi to close eyes
Buccal: buccinator to puff out cheeks
Marginal mandibular: depressor anguli oris & mentalis allow symmetry of mouth/lip
Cervical: platysma which lowers corners of mouth & tenses skin of neck
What is the anatomy of CNV?
Originates across four nuclei extending from midbrain to medulla with sensory and motor components -> trigeminal ganglion in Meckels cave -> sensory Va-c but motor as well to CNVc
CNVa provides sensation to upper head, FES sinuses, upper eye/conjunctiva, cornea, lacrimal gland, dorsum of nose & meninges via:
- Recurrent tentorial branch (tentorium cerebelli)
- Frontal (supra-orbital & supra-trochlear)
- Lacrimal
- Nasociliary branches (ant/post ethmoid, infratrochlear & long ciliary)
CNVb innervates lower eyelid/conjunctiva, inf nasal cavity, cheeks, maxillary sinus, lateral nose & upper mouth via
- Sup. alveolar
- Infraorbital
- Zygomatic
- Sup. labial.
- Nasopalatine
- Greater/lesser palatine
- Middle meningeal
- Pharyngeal branches
CNVc innervates muscles of mastication & sensory to lower 1/3rd of face, inferior teeth & tongue via:
- Auriculotemporal
- Buccal
- Inf alveolar -> mylohyoid n to mylohyoid and ant. digastrics & mental n
- Lingual
Please briefly describe the anatomy of the ear.
EXTERNAL EAR
Consists of auricle, EAM & TM
Innervation: greater auricular & lesser occipital to auricle skin, auriculotemporal to auricle skin & EAM then CNVII/CNX to deeper aspect
Blood supply: ECA branches post. auricular, sup. temporal, occipital & maxillary with venous drainage following
LN: sup. parotid, mastoid, upper deep cervical & superficial cervical
MIDDLE EAR
Contains IAM
Borders: petrous temporal bone (R), jugular wall (F), TM (L), inner ear (M), thin plate with auditory tube & tensor tympani seperating ICA (A) & mastoid wall (P)
Bones: MIS
Muscles: tensor tympani (CNVc) & stapedius (CNVII)
Innervation: tympanic n (CNIX)
INNER EAR
Contains bony (vestibule, SCCs & cochlea) & membranous labyrinth (cochlear duct inc. organ of Corti, saccule/utricle & SCDs) separated from middle by oval and round windows
Blood supply: ant. tympanic (maxillary), petrosal (middle meningeal) & stylomastoid (post. auricular) & labyrinthine (inferior cerebellar a)
Venous drainage: labyrinthine vein into sigmoid or inf. petrosal sinus
Innervation: CNVIII
What is the anatomy of the eustachian tube briefly?
Functions: middle ear aeration, secretion clearance & middle ear protection
Arises from anterior middle ear wall sloping down/forward to reach nasopharynx and its lined with ciliated columnar epithelium with goblet cells but then changes to ciliated pseudostratified at the pharynx emtpying into inferior meatus of nasal cavity
Muscles that open it: tensor veli palatini, levator veli palatini, salpingopharyngeus & tensor tympani
Supply:
- Maxillary a & ascending pharyngeal a
- Pterygoid venous plexus
- CNIX/X supply upper portion whereas CNVb/c supply lower portion
- LNs draining include retropharyngeal, deep jugular & intra-parotid
Briefly explain the anatomy of the eye.
7 bones of the orbit;
Frontal
Zygomatic
Maxillary
Ethmoid
Sphenoid
Lacrimal
Palatine
Foramen:
1. Optic canal
2. SOF
3. Inferior orbital fissure (CNVb zygomatic branch, inf. opthalmic vein & sympathetic ns)
4. Supra/infra-orbital canals
5. Nasolacrimal canal
7 muscles:
LPS, sup/inf rectus, medial rectus & inferior oblique (CNIII)
Superior oblique (CNIV)
Lateral rectus (CNVI)
Blood supply:
- Opthalmic a
- Sup/inf opthalmic veins
What is the difference between horners and CNIII palsy?
CNIII palsy = full ptosis, down/out eye + mydriasis due to paralysis of LPS and unopposed orbicularis oculi
Horners damages sympathetic trunk = partial ptosis, miosis & anhidrosis - potential causes include pancoast tumour, aortic aneurysm or thyroid carcinoma
What are the symptoms of a CNIV palsy?
Vertical diplopia
Head tilt
Where does lacrimal gland empty? What is its supply?
Empties into inferior meatus of nasal cavity
Somatic sensory: lacrimal n (CNVa)
PS: pterygopalatine ganglion (CNVII) stimulates secretions
S: sup. cervical ganglion inhibits secretions
Please describe the anatomy of the paranasal sinuses.
4 paired sinuses: maxillary, frontal, sphenoid & ethmoid lined by ciliated pseudostratified columnar epithelium with goblet cells
Functions: lighten head, immune defence, humidify inspired air & resonance of voice
Drainage:
All drain into middle meatus semilunar hiatus except sphenoid (sphenoethmoidal recess sup. to superior concha) & post. ethmoid sinus (sup. meatus)
Supply:
Frontal ->supraorbital n from CNVa + ant. ethmoidal a from ICA
Sphenoid -> post. ethmoidal n. from CNVa & maxillary a blood supply via pharyngeal branches
Ethmoid -> ant/post ethmoidal branches of nasociliary (CNVa) & CNVb + ant/post ethmidal a’s
Maxillary -> CNVb & branches of maxillary a
Please describe the anatomy briefly of the nasal cavity.
Function: warms/humidifies air, smell, traps pathogens/particulate matter & drains/clears paranasal sinuses/lacrimal ducts
3 conchae + 3 meatuses + sphenoethmoidal recess
Blood supply:
ICA -> opthalmic -> ant/post ethmoidal
ECA -> sphenopalatine, greater palatine, sup. labial
= Kiesselbach plexus of epistaxis
Venous supplies follows into pterygoid plexus, facial vein or cavernous sinus
Innervation:
Special sensory = CNI
Somatic sensory = nasociliary (CNVa), nasopalatine (CNVb) & external skin by CNV too
Please describe the anatomy of the parotid gland including its supply.
Produces serous saliva rich in enzymes transported to oral cavity by Stensens duct which traverses masseter, pierces buccinator then opens into oral cavity near 2nd upper molar tooth
Deep/superficial lobes separated by facial nerve and its branches (TZBMC) - other relations:
- Post. auricular a of ECA before terminal branches maxillary & sup. temporal given off
- Retromandibular vein (sup. temporal + maxillary)
Anatomy: zygomatic arch (S), mandible (I), masseter (A) & external ear (P)
Innervation:
Sensory: auriculotemporal n (gland) & great auricular n (fascia)
PS: CNIX otic ganglion increases saliva
S: sup. cervical ganglion inhibits saliva
LNs: deep/superficial parotids to upper deep cervical
What are the post-operative complications of parotidectomy?
- Freys syndrome: PS from auriculotemporal nerve are damaged so there is aberrant reinnervation by the sympathetics causing gustatory sweating
- Salivary fistula
- CNVII palsy
- Greater auricular nerve damage -> numbness to ear lobe
What is the surface anatomy of parotid gland and duct?
Gland: tragus to centre of mastoid bone down along posterior border of masseter to 2cm below/behind angle of mandible to mastoid process
Duct: middle 1/2 of line passing between lower tragus to chelion
Please describe the anatomy of the submandibular gland.
Within submandibular triangle bordered by mandible, anterior & posterior belly of digastrics with superficial & deep lobes seperated by mylohyoid
Mucus secretion entering oral cavity via Whartons duct opening bilaterally either side of lingual frenulum
Relations:
1. Lingual n (CNVc)
2. CNXII
3. Marginal mandibular branch (CNVII)
Blood supply:
- Submental a (facial) & sublingual a (lingual)
- Venous drainage via facial (IJV) and sublingual (lingual & IJV)
Innervation:
PS: CNVII submandibular ganglion
S: superior cervical ganglion
More likely to get stones due to torturous length, thick mucus secretions ascending against gravity
Please describe the anatomy of the sublingual gland.
In sublingual triangle of neck deeper to SM gland draining mucus secretions into minor ducts of Rivinus
Blood supply:
- Sublingual (lingual) & submental (facial) (ECA)
- Venous drainage follows (IJV)
Innervation:
PS: SM ganglion from CNVII
S: superior. cervical ganglion
What is the anatomy of the palate? What are the muscles of the palate and their innervation?
Superiorly in nasal cavity = resp. epithelium
Inferiorly in oral cavity = oral mucosa & salivary glands
Hard palate foramen: incisive anal (nasopalatine n & descending palatine a), greater palatine foramen (n/a/v) & lesser palatine (n)
Soft palate:
Tensor veli palatini - tenses
Levator veli palatini - elevates
Muscularis uvulae - shorts uvula
Palatopharyngeus - tenses & draws pharynx anteriorly on swallowing
Palatoglossus - brings towards tongue
All CNX except TVP which is CNV
Sensory: greater palatine & nasopalatine (CNVb) innervate hard palate whilst lesser palatine (CNVb) innervates soft palate
Bloody supply: greater palatine a’s & anastomosis between lesser palatine a & ascending palatine a
Venous drainage: pterygoid venous plexus
What is the innervation of the oral cavity?
Sensory: CNVb + CNVc split into half
Posterior sensory: CNIX
Motor: CNX
Gag reflex = CNIX + CNX
Please briefly describe the anatomy of the TMJ.
Articulation of mandibular fossa (temporal) & articular tubercle (squamous temporal bone) and head of mandible
Bi-arthrodial hinge (synovial) joint separated by articular disc so there are 2 cavities lined by synovial membrane with fibrocartilage separated by articular surfaces
Lateral, sphenomandibular & stylomandibular ligament stabilise joint
Movements: protrusion (lateral pterygoid), retraction (temporalis), elevation (all mastication muscles bar lateral) & depression (gravity) - also side-to-side (medial pterygoids)
Neurovasculature supply:
Sup. temporal branch (ECA)
Auriculotemporal and massteric branch (CNVc)
Please briefly describe the intracranial pathway of the optic nerve. Why is this clinically relevant?
Optic nerves unite to form optic chiasm -> medial fibres cross over to C/L side whilst lateral fibres remain ipsilateral -> L/R optic trct -> lateral geniculate nucleus -> upper and lower optic radiation
Upper: fibres from superior retinal quadrants corresponding to INFERIOR visual field quadrants -> parietal lobe to visual cortex
Lower: fibres from inferior retinal quadrants corresponding to SUPERIOR visual field quadrants -> temporal lobe via Meyers loop to reach visual cortex
Clinical relevance: optic chiasm compression from pituitary tumour causing bitemporal hemianopia (> superior) due to upwards compression whereas craniopharyngioma would cause the same but > inferior due to downward compression
Where do the different CNs originate from in the brainstem?
CNI - olfactory placode (thickening of ectoderm layer)
CNII - from optic vesicle at outpocketing of the forebrain (why it has meninges surrounding it and you can see papilloedema)
CNIII & CNVI - midbrain
CNV - midbrain to medulla = 4 nuclei (3 sensory and 1 motor)
CNVI & CNVII - pons
CNVIII - pons & medulla - cerebellopontine angle
CNIX, CNX, CNXI & CNXII - medulla
Please briefly describe what the CNIII supplies.
Motor: extraocular muscles LPS, sup. rectus, inferior rectus, medial rectus & inferior oblique
PS: sphincter pupillae & ciliary muscles of eye via ciliary ganglion from inferior branch
S: none but sympathetics to supply superior tarsal run with the nerve
What is the only cranial nerve that decussates peripherally?
CNIV
Where can CNVI be compressed in raised ICP?
Against clivus from spheno-occipital synchrondrosis
Please summarise what CNV supplies. How would you test it?
Sensory: skin, mucous membranes & sinuses of face - cotton tip to 3x areas B/L
Motor: mastication, anterior belly of digatric, mylohyoid, tensor veli palatini & tensor tympani - clench jaw and palpate temporalis and masseter and ask for side-to-side movement of jaw
PS: post-ganglionic neurones from PS ganglia travel with branches but not directly e.g. pterygopalatine ganglion (CNVII) travel with CNVb zygomatic branch to supply lacrimal gland
Test corneal reflex - CNVa is sensory & CNVII is motor
Summarise the supply of CNVII. What is its route?
Derivative of 2nd pharyngeal arch
Motor: muscles of facial expression, posterior digastric, stylohyoid & stapedius
Sensory: concha of external ear
Special sensory: anterior 2/3rd tongue taste via chorda tympani
PS: SM/SL glands, nasal/palatine & pharyngeal glands + lacrimal glands via pterygopalatine ganglion
IC part starts in pons with a motor and sensory root -> IAM -> facial canal -> roots fuse and the nerve forms the geniculate ganglion -> greater petrosal n (PS to mucous/lacrimal glands forming n. to pterygoid canal & synapsing with pterygopalatine ganglion), n. to stapedius & chorda tympani (PS to SM/SL glands via lingual n. hitchhiking) are given off -> exits facial canal via stylomastoid foramen
EC part turns superiorly to run anterior to outer ear in infratemporal fossa giving off post. auricular n -> motor to post. digastric & stylohyoid -> motor root continues into parotid where it terminates into TZBMC
How to different bells palsy vs UMN stroke?
In bells palsy forehead is not spared whereas in stroke only the lower half of the face is affected due to B/L supply of the upper half from the brain
How does vestibular neuritis present vs labryinthitis?
Vestibular neuritis = vertigo, nystagmus, loss of equilibrium & N+V
Labyrinthitis = sensorineural hearing loss & tinnitus as the cochlear branches are also impacted
Please summarise the supply of CNIX.
Derivate of 3rd pharyngeal arch
Sensory: oropharynx, carotid body/sinus, post. 1/3rd of tongue, middle ear & eustachian tube
Special sensory: taste to post. 1/3rd of tongue
PS: PS to parotids (otic gangion via lesser petrosal n hitchhike on auriculotemporal nerve to parotid)
S: stylopharyngeus
Terminates by diving into lingual, tonsil and pharyngeal nerves
Gag reflex = sensory (CNIX) & motor (CNX)
Please summarise the supply of CNX.
Sensory: EAM skin (auricular), laryngopharynx (ILN), & visceral sensation to heart & abdominal viscera
Special sensory: taste to epiglottis & root of tongue
Motor: motor to muscles of pharynx via pharyngeal branches (pharyngeal constrictors, palatopharyngeus & salpingopharyngeus), larynx via RLN (all laryngeal muscles except cricothyroid) & ELN (cricothyroid), palatoglossus of tongue & soft palate muscles
PS: SM of respiratory, GIT and regulates heart rhythm via SAN/AVN (60-80bpm)
How do the CNXs differ from right to left?
Right: anterior to subclavian a - forms post. vagal trunk
Left: inferiorly between L CCA and L subclavian - forms ant. vagal trunk
In neck, pharyngeal branches, SLN & R RLN arise
R RLN hooks underneath R subclavian then ascends to larynx
In the thorax, the L RLN arises and hooks under aortic arch ascending to the larynx
Ant/post trunks enter abdomen via oesophageal hiatus & terminate by dividing into branches supplying oesophagus, stomach & bowels up to splenic flexure
What is the function and anatomical course of CNXI?
Purely somatic motor innervating SCM & trapezius
- Spinal: from upper spinal cord C1-6 run superiorly to enter foramen magnum to jugular foramen where it briefly meets cranial portion before exiting skull, descends along ICA to reach SCM then to posterior triangle to supply trapezius
- Cranial: leaves via jugular foramen and combines with CNX
SCM: lateral flexion/rotation of neck (U/L) or extension (B/L) - runs from mastoid process of temporal bone to manubrium (sternal head) & medial 1/3 of clavicle (clavicular head)
Trapezius: elevate and rotate scapula during abduction, retraction & pulling it downwards - runs from base of skull to spinous processes C7-T12 to lateral 1/3rd of clavicle + scapula acromion
What are the lobes of the brain and their overiding function?
- Frontal: higher intellect, personality & mood - Broca’s area + precentral gyrus (primary motor cortex)
- Parietal: control of language & visuospatial functions - Wernicke’s area + postcentral gyrus (somatosensory cortex)
- Temporal: memory & language - location of primary auditory cortex
- Occipital: vision
Please describe the cavernous sinus. Why is it clinically relevant?
Paired dural venous sinuses in middle cranial fossa on either side of sella turcica of sphenoid bone connected by intercavernous sinuses - recieves drainage from opthalmic veins, central retinal vein, sphenoparietal sinus, sup. middle cerebral vein & pterygoid plexus then empties into petrosal sinuses & IJV
Borders: SOF (A), petrous temporal bone (P), body of sphenoid (M), dura mater (L/R/F)
Travels passing through lateral wall:
Oculomotor (CNIII)
Trochlear (CNIV)
Opthalmic (CNVa)
Maxillary (CNVb)
Carotid a. (internal)
Abducens (CNVI)
Clinical relevance: facial vein anastomoses with sup. opthalmic vein so extracranial route of infection spread to intracranial via nasolabial triangle of danger -> thrombosis can occur causing headache, periorbital oedema, proptosis, photophobia & CNVI palsy -> can progress to meningitis
Please explain the anatomy of the dural venous sinuses.
5 unpaired sinuses:
Sup. sagittal
Inf. sagittal
Straight sinus
Intercavernous sinus
Occipital
Confluence = sup. sagittal, straight (inf. sagittal + great cerebral vein) + occipital -> transverse sinuses
5 paired sinuses:
Sphenoparietal -> cavernous sinuses -> sup. & inf. petrosal sinuses -> transverse
Transverse -> sigmoid -> IJV
Please explain the ventricular system of the brain.
CSF acts to protect the brain, give buyoancy & chemical stability
It is produced by choroid plexus in lateral ventricles -> foramen of Monro -> 3rd ventricle -> cerebral aqueduct of sylvius -> 4th ventricle -> foramen of Magendie (medial) & Luschka (lateral) to spinal canal -> subarachnoid cisterns where it is reabsorbed by arachnoid granulations draining it into DVCs
Please describe the circle of willis.
Anastomosis of vertebral arteries & ICA
ICA;
1. Opthalmic a
2. Post. communicating
3. Ant. choroidal a
4. ACA (ant. communicating between)
Continues as MCA
Vertebral:
1. Meningeal branch (falx cerebelli)
2. Ant/post spinal a’s
3. PICA
Converge to form basilar a with pontine branches -> PCA
Please briefly describe the anatomy and components of Waldeyers ring.
- Phayngeal tonsil
- Tubal tonsils x2
- Palatine tonsils x2
- Lingual tonsil
All receive some supply from CNIX
All are classified as MALT containing T/B cells & macrophages
What are the layers of the neck?
Superficial cervical fascia containing NV supply & LNs blending with platysma (originate from deltoid/pec major fascia then fuse with facial muscles inserting into mandible)
Deep cervical fascia
Investing layer
Pretracheal layer (muscular & visceral components)
Prevertebral layer
Carotid sheath is lateral + has contributions from last 3 layers containing CCA, IJV, CNX & cervical LNs
Space between posterior visceral pretracheal fascia (buccopharyngeal) & prevertebral fascia is the danger space which allows infection to descend to posterior mediastinum
What is the blood supply coming off of the arch of the aorta?
Right brachiocephalic trunk -> R CCA + R Subclavian
Arch of aorta -> L CCA + L subclavian
CCA bifurcates @ C4
What are the branches of the ECA? What nerve passes anterior to it?
ECA (Some Angry Lady Found Out PMS)
Superior thyroid
Ascending pharyngeal
Lingual
Facial
Occipital
Post. auricular
Maxillary (-> middle meningeal)
Sup. temporal
CNXII passes anterior to it
What are the branches of the subclavian arteries?
VIT C&D
Vertebral
ITA
Thyrocervical trunk
Costocervical
Dorsal scapular
What is the venous drainage of the head & neck?
EJV receives tributaries from post. auricular & retromandibular vein (sup. temporal + maxillary) -> subclavian vein = drains face
Ant. jugulars drain anterior neck -> subclavian vein
Sigmoid sinus -> IJV drains intracranial cavity, fascia & neck organs -> subclavian to form brachiocephalic
What is the lymph drainage of the head/neck briefly?
Superficial vessels drain lymph from scalp, face & neck into superficial LNs inc. occipital, mastoid, pre-auricular, parotid, submental, SM, facial & superficial cervical
Deep lymphatic vessels of head/neck arise from deep cervical LNs inc. prelaryngeal, pre tracheal, jugulodigastric & supraclavicular (Virchows) -> L/R jugular lymphatic trunk
L combines with thoracic duct @ neck root emptying via L subclavian vein
R forms R lymphatic duct at neck root emptying via R subclavian
Please describe the anterior triangle of the neck.
Bordered by mandible (S), SCM (L) + midline (M), investing fascia (R) & visceral fascia (F)
Split into:
1. Carotid: post. digastric (S), SCM (L) & superior omohyoid (S) - contains CCA + bifurcation, carotid sinus/body, IJV, CNX (carotid sheath) & ansa cervicalis
2. Submental: hyoid (I), anterior digastric (L) & midline of neck (M) & mylohyoid (F) - contains LNs + SL gland
3. SM/digastric: mandible body (S), anterior + posterior digastric - contains SM gland, LNs, facial a/v & CNXII
4. Muscular: hyoid (S), midline of neck, sup. omohyoid (S/L) & SCM (I/L) - contains infrahyoids, pharynx, thyroid, parathyroid glands & EJV
Please describe the posterior triangle of the neck.
SCM (A), trapezius (P) & middle 1/3rd of clavicle (I), investing layer (R) & prevertebral fascia inc. splenius capitis, levator scapulae & scalenes (F)
Contains:
Omohyoid inferior belly splitting it into 2 (occipital + subclavian below)
Scalene
EJV -> subclavian vein (CVC)
Branches of cervical plexus: Transverse cervical, supraclavicular, great auricular & lesser occipital
3rd past of subclavian a
CNIX (upper 2/3rd of SCM -> lower 1/3rd of trapezius)
Cervical plexus -> phrenic n (C3-5)
Brachial plexus trunks x3
Supraclavicular & occipital LNs
List the suprahyoid vs infrahyoid muscles. What is their supply?
Supra:
1. Stylohyoid (CNVII)
2. Digastric (ant by mylohyoid n from inf. alveolar n of CNVc whilst post by CNVII): ant. belly from digastric fossa of mandible + post. from mastoid process of temporal bone
3. Mylohyoid (inf. alveolar n of CNVc): from mylohyoid line of mandible to hyoid
4. Geniohyoid (CNXII C1 nerve roots): from inferior mental spine of mandible to hyoid
Action: elevate hyoid in swallowing
Blood supply: facial artery
Infra:
Superficial:
1. Omohyoid: sup. belly from hyoid + inf. belly from scapula to clavicle by deep cervical fascia
2. Sternohyoid
Deep:
3. Thyrohyoid (just C1 supply)
4. Sternothyroid
Innervation: Ansa cervicalis supply via C1-3
Function: depress the hyoid & larynx during swallowing/speaking
Blood supply: thyroid arteries
What does the greater auricular nerve (C2-3) supply?
Skin over angle of mandible
Skin over parotid duct
Skin of lower 1/3 of auricle
What is the carotid body vs sinus?
Body is @ posterior CCA bifurcation & has chemoreceptors spending to pH change
Sinus is dilated area @ ICA base just superior to bifurcation containing baroreceptors for maintaining BP
Please briefly explain the anatomy of the pharynx.
Muscular tube connecting oral & nasal cavity to larynx & oesophagus beginning at C6
Composed of:
1. Nasopharynx: base of skull to soft palate lined with respiratory epithelium conditioning inspired air & propagating it
2. Orophraynx: to epiglottis involved in swallowing
3. Laryngopharynx: to C6 (inferior border of cricoid cartilage) continuous inferiorly with oesophagus
Circular & longitudinal muscles (CNX) except stylopharyngeus (CNIX - also does sensory):
1. Sup/middle/inf constrictors (circular) to propel food bolus
2. Stylo/palato/salpingo-pharyngeus (longitudinal) acting to shorten/widen/elevate it in swallowing
Blood supply: ECA branches ascending pharyngeal, facial, lingual & maxillary
Venous drainage: pharyngeal plexus -> IJV
What is a pharyngeal diverticulum?
Inferior constrictor split into thyropharyngeus & cricopharyngeus with the area between the 2 being a weak area - pouch can form due to raised pressures
Please briefly describe the anatomy of the larynx.
Functions: phonation, cough & protection of LRT
Spans C3-6 continuous with trachea inferiorly covered by infrahyroid muscles and lateral thyroid gland lobes - lined by pseudostratified ciliated columnar epithelium except vocal cords which are stratified squamous
3 sections:
1. Supraglottis: epiglottis to vestibular folds/false vocal folds
2. Glottis: contains vocal folds
3. Subglottis: to inferior border of cricoid cartilage
Blood supply:
1. Sup. laryngeal (sup. thyroid) follows internal SLN - veins same draining into IJV
2. Inf. laryngeal (inf. thyroid) follows RLN - veins same draining into L brachiocephalic
Innervation is primarily CNX:
1. RLN: sensory to infraglottis & motor to all muscles except cricothyroid
2. SLN: internal branch supplies sensory to supraglottis + external branch supplies motor to cricothyroid
Please describe the causes and consequences of an RLN palsy.
Causes: apical lung tumour, thyroid Ca, AAA & iatrogenic (thyroid surgery when ligating inf. thyroid a)
Unilateral palsy: hoarseness
B/L full palsy: paralysed between add/ab-duction so cannot phonate
B/L partial palsy: vocal chords paralysed adducted so airway emergency
= Semons law
What are the muscles of the larynx and their functions briefly?
External muscles elevate/depress larynx during swallowing: supra/infra-hyoids & stylopharyngeus
Internal muscles move the individual components allowing breathing and phonation:
- Cricothyroid: stretches/tenses vocal ligament to allow forceful speech & changing tone
- Thyroarytenoid: relaxes ligaments softening voice
- Transverse/oblique arytenoids: adduct arytenoid cartilages narrowing inlet
- Lateral cricoarytenoid: adduction of vocal folds
- Post. cricoarytenoid = SOLE ABDUCTORS of vocal folds
What cartilages make up the larynx?
Unpaired:
1. Thyroid -> laryngeal prominence (C4)
2. Cricoid (complete hyaline ring) = C6 - clinically relevant as Sellicks manouvre involves occluding oesophagus via this structure to prevent regurgitation of gastric contents
3. Epiglottis - makes laryngeal entrance flattening & moving posteriorly on swallowing to prevent aspiration
Paired:
1. Arytenoids: sit on cricoid
2. Corniculate: articulate with apices of arytenoids
3. Cuneiform: within aryepiglottic folds
What are the laryngeal ligaments and folds?
Extrinsic:
1. Thyrohyoid membrane: between thyroid + hyoid pierced by SL vessels & ILN
2. Hyo-epiglottic
3. Cricotracheal
4. Median cricothyroid: anteromedial thickening of cricothyroid ligament
Intrinsic:
1. Cricothyroid: free upper margin forms vocal ligament attaching anteriorly to thyroid and posteriroly to artyenoid cartilage - where cricothyroidotomy is performed (palpate thyroid & go in depression below)
2. Quadrangular: anterolateral arytenoids to lateral epiglottis - lower margin forms vestibular ligament
Folds:
1. Vocal folds: contains vocal ligament, vocalis muscle & Reinke’s space (fluid area of GAGs) - white & avascular
2. Vestibular folds/false vocal cords: vestibular ligament covered by mucous membrane acting to protect larynx - pink
Please describe the anatomy of the thyroid gland.
Endocrine structure located between C5-T1 consisting of L/R lobes connected by isthmus being wrapped around cricoid cartilage & superior tracheal rings
Relations:
A = infrahyoids, sup. omohyoid & sternohyoid
L = carotid sheath
M = larynx, pharynx, trachea & oesophagus + ELN/RLN
Blood supply:
- Sup. thyroid (ECA) close to SLN external branch
- Inf. thyroid (thyrocervical trunk from subclavian) close to RLN + cervical sympathetic chain
3. Thyroid imea (brachiocephalic) in 10%
Venous drainage:
1. Sup/middle thyroid veins -> IJV
2. Inf thyroid vein -> brachiocephalic
Lymph drainage:
1. Paratracheal
2. Deep cervical
Innervation:
1. Sympathetic trunk branches
2. Secretory function by pituitary gland
Please describe the anatomy of the parathyroid glands.
Endocrine glands x4 = 2x superior (4th pouch) & 2x inferior (3rd pouch so can go to sup. mediastinum) on posterior aspect of thyroid gland -> produce PTH which increases Ca
Blood supply: inf. thyroid
Venous drainage: sup/middle/inf thyroid veins
Lymph drainage: paratracheal & deep cervical
Innervation:
1. Thyroid branches of cervical sympathetic ganglia
2. Endocrine secretion under hormonal control
What would happen if parathyroids damaged in thyroid surgery?
Hypocalcaemia (PTH & Ca to be checked post-op)
Symptoms
Tetany
Muscle cramps
Paraestheisa of fingers/toes/mouth
Over long time period -> stones, bones, abdominal groans & psychiatric overtones
What are the scalenes? What is their clinical importance?
3 paired muscles: anterior, middle & posterior in lateral neck acting as accessory muscles of respiratory + perform flexion of neck
- Anterior: ant. tubercle of transverse processes C3-6 to scalene tubercle on 1st rib inner border acts to elevate 1st rib - ipsilateral contraction = lateral flexion but B/L contraction = anterior flexion (ant. rami of C5-6)
- Middle: from post. tubercles of transverse processes C2-7 attaches onto sup. 1dt rib with same function as above (ant. rami of C3-8)
- Posterior: from post. tubercles of transverse processes C5-7 attaching onto 2ND rib elevating it + lateral flexion (ant. rami of C6-8)
Important relations:
Subclavian vein & phrenic n pass anteriorly to anterior scalene
Brachial plexus & subclavian a pass between anterior and middle
Please briefly describe anatomy of cervical plexus.
Posterior triangle 1/2 way up SCM within prevertebral layer & formed by ant. rami of cervical spinal nerves C1-4
Muscular branches:
1. Phrenic (C3-5)
2. N to geniohyoid/thyrohyoid (C1 - travel w/ CNXII)
3. Ansa cervicalis (C1-3): supplies 2x bellies of omohyoid, sternohyoid & sternothyroid
4. Other minor branches to prevertebral muscles & contributing to bigger muscles
Sensory branches (Erbs point for nerve block is at middle posterior border of SCM):
1. Greater auricular (C2-3)
2. Transverse cervical (C2-3)
3. Lesser occipital (C2):
4. Supraclavicular (C3-4)
What is the function and route of the phrenic nerve?
B/L mixed nerve (C3-5)
Motor: diaphragm
Sensory: central diaphragm, pericardium & mediastinal part of parietal pleura
Course: begins in cervical plexus -> lateral border of ant. scalene passing over it deep to prevertebral fascia -> post. to subclavian vein
Right side: passes over lateral right subclavian a, entering thorax via sup. thoracic aperture descending anteriorly along right lung root, along pericardium of RA piercing the diaphragm at caval opening to innervate inferior diaphragm surface
Left side: passes over meal left subclavian a and descends same but crosses aortic arch bypassing CNX coursing along LV
What is the embryology of the thyroid gland? Why is this relevant?
Develops from foramen caecum to pass forward and loop beneath hyoid bone
Incomplete descent: lingual/pyramidal thyroid
Incomplete closure: thyroglossal cyst
Why does the thyroid move up on swallowing?
Berrys ligaments attach it to trachea/pretracheal fascia so when digastrics contract and pull up hyoid bone along with all this
What are the attachments of the vocal cords?
A = thyroid cartilage
P = arytenoid
L = laryngeal muscle
M = free border
What bones form the pterion? Whats its signifiance?
Frontal
Temporal
Parietal
Sphenoid
Site of middle meningeal artery damage and EDH as its weakest point of skull
What muscles open the TMJ and what movement is this?
Protrusion + depression = opening
DLGM =
Digastric
Lateral pterygoid
Geniohyoid
Myohyoid
What are some benign tumours of the posterior cranial fossa?
Acoustic neuroma
Hemangioblastoma
Ependymoma
Ependymoblastoma
Name some causes of lytic skull lesions.
Mets
Pagets
Multiple myeloma
Osteomyelitis
What structures attached to styloid process?
Ligaments = stylohyoid & mandibular
Muscles = stylohyoid/glossus & pharyngeus
What is GCA? What are its pathological characteristics? What are some typical signs/symptoms?
Vasculitis of medium/large vessels of head affecting the branches of ECA specifically the superficial temporal artery affecting the tunica media the most
Pathological characteristics: intimal thickening, medial granulomatous inflammation causing elastic lamina fragmentation, infiltrate of T cells/macrophages i.e. giant cells & skip lesions
Signs/symptoms:
Often occurs in older women with PMR
Pain/tenderness/sensitivity over scalp
Jaw claudication
Visual disturbances -> loss as it can affect ophthalmic artery
Amaurosis fugax
How would you investigate & treat GCA?
Ix
Bloods: Routine but specifically ESR
Definitive/invasive: temporal artery biopsy & stained with H&E
Mx
Methylprednisolone IV immediately if evolving visual loss/amaurosis fugax
Prednosolone 60mg PO tapering down over 2 years
What are steroids? What are some side effects of steroid therapy?
Medications used to reduce inflammation & suppress the immune system acting as glucocorticoid agonists altering gene expression of cell by down-regulating pro-inflammatory genes and up-regulating anti-inflammatory genes
Side effects:
Cushings syndrome (moon face, truncal obesity, bruising & proximal muscle wasting)
Osteoporosis
AVN
Diabetes
HTN
What are the causes of parotid swellings?
U/L
Benign growths = 85% e.g. pleomorphic adenoma, Warthins in smokers, ductal papillomas & oncocytoma
Malignant growths = 15% e.g. mucoepidermoid carcinoma, adenoid cystic carcinoma, acinic cell carcinoma & SCC
Duct obstruction due to calculus
Parotitis
B/L
Local e.g. mumps
Systemic e.g. sarcoidosis or TB
Drugs e.g. COCP
Define a pleomorphic adenoma. Is there a genetic element?
Benign tumours consisting of micture of ductal epithelium and myoepithelial cells showing both epithelial & mesenchymal differentiation = histologically diverse
Genetics = BRCA1/2
What are the clinical signs of a malignant parotid neoplasm?
CNVII involvement
Rapid increase in size
Associated nodes/distant mets
Fixity to underlying skin
Lack of differentiation = anaplasia
How would you investigate & manage a salivary gland growth?
Ix
Routine bloods
Viral serology
Sialogram if stone was suspected
USS -> FNAC/tru-cut if suspicious for IHC/receptor status
CT/MRI/PET if malignant
Mx
If benign superficial parotidectomy
If malignant, total parotidectomy, radiotherapy +/- neck dissection
Frozen section intra-op can determine status of tumour
If in submandibular gland total excision with incision 2 finger bredths below angle of mandible to avoid CNXII, marginal mandibular (CNVII), lingual (CNVc) & greater auricular nerve
What are some features of malignant cells?
- Increased irregular mitotic rate
- Anaplastic features such as high nuclear to cytoplasmic ratio & hyperchromatic nuclei
- Ischaemic necrosis where they outgrow blood supply
- Invasion of surrounding structures
Define the statistical terms specificity, sensitivity, PPV, NPV
Sensitivity = ability of test to correctly classify someone as having the disease = low false negative rate - TP/TP+FN
Specificity = ability to test to correctly classify someone as not have the disease = low false positive rate - TN/TN+FP
PPV = chance of patient having condition if test is positive - TP/FP+TP
NPV = chance of patient not having disease if testing negative - TN/FN+TN
How to handle needle stick?
- First aid: encourage bleeding & wash w/ soap/water covering with impermeable dressing
- Assess incident risk: based on injury, whether needle was contaminated or not & age of sharps
- Assess source: BBVs or risk factors? Get blood tests - if high risk may need PEP
- Inform occupational health for advice & document
What are the advantages & disadvantages of FNAC vs Tru-Cut biopsy?
FNAC
Adv: less invasive & cost effective
Disadv: cannot differentiate in situ vs invasive as can only perform cytology not histology
Tru-cut
Adv: more reliable & avoids need for excision biopsy
Disadv: more invasive & expensive
Define metastasis. Name the steps of pathological invasion of carcinoma and how it can spread distantly.
Survival & growth of tumour cell at site distant from origin
Steps of spread:
1. ECM is invaded by loosening of tumour-cell interactions, degradation & attachment to novel components
2. Direct extension via BM breach & intravasation into lymph*, blood vessels or body cavities (transcolemic)
3. Transport into circulation of tumour cells + extravasation into capillary beds at secondary sites
4. Growth + angiogenesis in secondary sites
*cancer cells & tumour-associated macrophages secrete GFs e.g. VEGF to induce lymphangiogenesis in primary tumour & draining sentinels & immunomodulators e.g. exosomes that cause immunosuppression
Define carcinoma.
Type of cancer developed from epithelial cells
What is the mechanism of radiotherapy? What are the ways to measure it?
Damages DNA of cancerous tissue via base damage, single/double stranded breaks & crosslinks to protein
This leads to cellular death
Measured via:
Coloumb/kg = exposure
Gray = dose
Sievert = dose equivalent
Becquerel = activity
What are risk factors for nasopharyngeal carcinoma?
Non-modifiable: males, Chinese/Phillipino/Malyasian, genetics factors & EBV
Modifiable: consumption of salted fish (nitrosamines), tobacco & alcohol
Where can nasopharyngeal carcinoma spread to?
Locally to:
Sphenoid/cavernous sinuses (S)
Base of skull/clivus, nasal cavity, orbit, & middle ear (L)
Oropharynx/C1 (I)
Via lymphatics
What are the common lymph node tumours and how do you invesigate them?
Lymphoma (Hodgkins/NHL)
Leukaemia
Metastatic
Ix
Biopsy w/ FNAC/excisional/sentinel sent for histopathology or IHC
Imaging via USS, CT, MRI or PET
What is the most common brain tumour in the elderly? How may they present?
Mets
High grades:
Glioblastoma multiforme
Medulloblastoma
Low grades:
Meningiomas
Acoustic neuromas
Signs/symptoms:
General: headache, N&V, seizures & papilloedema
Specific: focal neurology e.g. CN palsy or neurological deficit of UL/LL, personality change/disinhibition (frontal lobe) or dysarthria (parietal)
Define hyperplasia & hypertrophy.
Hyperplasia: Increase in NUMBER of cells in a tissue/organ in response to stimuli
Hypertrophy: Increase in SIZE of cells in a tissue/organ in response to stimuli
What would you see microscopically in hyperplasia of the parathyroid glands?
Chief cell hyperplasia involving glands in diffuse or multinodular pattern
Water clear cells
Oxyphil islands
Poorly developed fibrous strands enveloping the nodule
What is an insulinoma? How does it present?
Tumour of B-cells of islets of langerhans demonstrating high insulin levels and insulin-to-glucose ratio
Symptom triad: Confusion/stupor/LoC, hypoglycaemia <2.5mmol/L that is precipitated by fasting/exercise & relieved by feeding/glucose administration
Gene mutations:
1. MEN1
2. Loss of function of TSGs e.g. PTEN/TSC2 activating mTOR signalling pathway
3. Inactivating mutations in ATRX & DAXX which maintain telomeres normally
Name some causes of unresonsive hypoglycaemia.
Abnormal insulin sensitivity
Diffuse liver disease
Inherited glycogenoses
Ectopic insulin production by RP fibromas/fibrosarcomas
What is the two-hit hypothesis?
Loss of function mutations of TSG are often recessive so for a cell to become cancerous both TSGs must be mutated
What is a telomere?
Region of repetitive nucleotide sequences at end of each chromosome protecting the ends from deterioration or fusion with other chromosomes
How would you investigate a thyroid nodule?
RBs + TFTs
USS + FNAC
IHC: localises specific antigens based on Ab-Ag recognition via complement fixation - Abs linked to fluorescent dye meaning the Ag can be seen once bound under the microscope
What is a medullary thyroid cancer? How to manage it?
Cancer of parafollicular C cells showing amyloid deposits + staining positive for calcitonin
Mx: total thyroidectomy with block neck dissection
What is TNM staging for thyroid cancer?
Tx - cannot be assessed
T0 - no evidence of primary
T1 <1cm
T2 <4cm
T3 >4cm
T4 extends beyond capsule
N1 - regional node metastasis
M1 - mets present
What is phaeochromocytoma? How do you investigate it? How do you manage it?
Neuroendocrine tumours of adrenal medulla secreting catelcholamines
Ix
Urine: fractionated/total metanephrines, catelcholamines & VMA
Plasma: free metanephrines, catelcholamines & catelcholamine stimulation test
Imaging: USS, CT, MRI & PET
Mx:
MDT
A-blockers & B-blockers before adrenalectomy
What are the MENs syndromes?
Autosomal dominant multiple endocrine neoplasias
MEN1 = MENIN gene on Ch 11
3Ps = parathyroid adenoma, pituitary adenoma (e.g. prolactinoma) & pancreas tumour (islet cell tumours)
Presents with hypercalcemia symptoms
MEN2a = RET oncogene on Ch 10
HyperPTH + medullary thyroid Ca + phaochromocytoma
MEN2b = as above
MEN2a + marfanoid body habitus + mucosal neuromas
What are some causes of hypercalcaemia?
What are the symptoms? How do you treat it?
HyperPTH
Malignancy
RF
Symptoms/signs:
Reflux & ulcers due to increased gastric + HCl
Renal tract stones
Abdominal pain
Psychiatric moans
Mx: hydration, forced diuresis, bisphosphonates (IV pamidronate) & calcitonin
How can you localise the parathyroud glands?
Sestamibi scan (pre-op)
Frozen section (intra-op) - pathological lab procedure to perform rapid microscopic analysis of a specimen where the surgeon will fix specimen to a metal disc, secured in chuck & frozen to -20-30 degrees, embedded in gel medium called OCT (not parrafin as it takes a week to embed) then cut with microtome portion of cryostat then stained w/ H&E
May need to look down to superior mediastinum as 3rd branchial arch can drag it down in development
Whats the histology of a parathyroid adenoma? How do you treat it?
Uniform polygonal chief cells
Small central nuclei
Nests of larger oxyphil cells
Rim of compressed non-neoplastic PT tissue separated by fibrous capsule
Mx: excision
Please describe the 3 types of hyperparathyroidism.
Primary: most due to solitary adenoma & usually asymptomatic or patient will have symptoms of hyperCa
Hormonal changes = raised PTH/Ca & low Ph
Secondary: due to PT hyperplasia from low Ca often in CRF & may develop bone disease e.g. osteitis fibrosa cystica & soft tissue calcifications
Hormonal changes = raised PTH/Ph, Ca low & reduced vitamin D
Tertiary: ongoing hyperplasia of all 4 glands after correction of underlying renal disorder causing metastatic calcification, bone pain/#, nephrolithiasis & pancreatitis
Hormonal changes = raised PTH/ALP, Ca high & Ph/vitamin D low
What are the characteristic features of a BCC?
Pearly papule with central ulcer
Granulation tissue on base
Rolled inverted edges
Telangiectasia surrounding (dilated subepidermal blood vessels)
Indolent slow progression
Locally destructive but limited potential to metastasize
LN spread via permeation of embolization
What are the management options for a BCC?
Topical
- Photodynamic therapy e.g. delta-aminolevulinic acid in 20% emulsion allows tumour to become photosensitive & undergo destruction when exposed to light
- Topical fluorouracil 5%
- Topical imiquimoid 5%
Radiotherapy
Surgery
- Curettage & electrodissection
- Cryotherapy
- Excision with primary closure (margin of 4mm is aimed for) - grafts/flaps may be used
- Mohs micrographic surgery - serial tangential horizontal sections taken & examined until margins cleae
How do you manage MRSA?
Outpatient: oral clindamycin, amoxicillin & tetracyline
Inpatient: IV vancomycin to target levels for 7-14 days or clindamycin/linezolid
Decolonisation with mupirocin nasal or chlorhexidine
I+D if abscess
+ normal infection control protocols + patient in single room, PPE when managing patient & waste/linen to be treated as contimated/infected
FNAC of lymph node showing lymphocytes, PMNL, histiocytes & cells with bilobed nuclei. Whats the diagnosis?
Reed sternberg cells (owl eye appearance due to 2 lobes) -> Hodgkins lymphoma
What is a malignant melanoma? List some risk factors.
Malignant neoplasm of melanocytes arising in lower epidermis of skin - develops in younger people anywhere in the body appearing as a asymmetrical mole with irregular borders & multicoloured
Risk factors:
Non-modifiable - xeroderma pigmentosum, albinism, fitzpatrick skin type 1, multiple naevi & genes BRAF/NRAS/NF1/KIT/BRCA1/CDK2
Modifiable - UV exposure (intermittent) & sun bed use
What is important in the pathology report of a skin lesion?
Size
Breslow thickness: mm from top of stratum granulosum to deepest point of tumour involvement
Clarks level: depth of invasion
Ulceration
Mitosis
Lymphovascular invasion
IHC staining
What are the characteristic features of an SCC?
Cancer of upper epidermal layer with keratin pearl formation causing hyper-keratotic lesion on sun-exposed areas usually due to continuous exposure often around oral cavity & near body orifices - affects older patients especially those immunosuppressed & can appear as scaly patch, non healing sore or red bump which may bleed, ulcerate or crust over
How to manage malignant melanoma?
Excision & safety margin based on breslow thickness:
<0.76mm thick = 1cm margin
<1mm = 2cm margin
1mm = 3cm margin
Frozen section + Mohs surgery can aid in getting correct margins
If regional lymphadenopathy perform FNAC + CT to explore mets
How to treat DVT? What about PE?
Parenteral anticoagulation e.g. LMWH
Maintain on this for 6 months if precipitated -> INR 2-3 on Warfarin is aim 1-10mg/day
Catheter directed thrombolysis if <14 days old/acute phelgmasia ceruleans otherwise clot becomes organised + its not effective - monitor fibrinogen then warfarin for 6 months
SVC filter if other treatment modalities fail/contra-indicated or in pre-surgical prophylaxis
If suspected PE -> CTPA, SC LMWH if stable or thrombolysis/embolectomy if unstable
What is virchows triad?
- Endothelial injury
- Hypercoagulable state
- Stasis of blood
= risk factors for clot formation
What infections and malignancies are associated with inguinal lymphadenopathy?
Infections:
Cellulitis of LL
Venereal infections e.g. syphilis, HSV, chancroid, & lymphogranuloma venereum
Malignancies:
Lymphomas
Metastatic melanomas from LL
SCC from genitals
List some types of malignant melanoma.
- Superficial spreading (most common): grows out first to form irregular pattern and uneven colour
- Nodular: lumpy, blue/black, faster growth spreading downwards
- Lentigo maligna: elderly peoples faces
- Acral: palms of hands, soles of feet & nail beds
- Desmoplastic: rare marked by non-pigmented lesions on sun exposed areas
Epitheloid melanomas occur in superficial spreading & nodular types - composed of large and round epitheloid cells with abundant eosinophilic cytoplasm, prominant nuclei & large nucleoli
What is a satellite lesion?
Local spread of melanoma by contiguity & continuity leading to pigment flooding surrounding area within 2cm
List some examples of gram negative vs position diplococci.
Gram -ve:
Neisseria
Haemophilus
Gram +ve:
S. Pneumoniae
Enterococcus
What is SIRS?
Systemic inflammatory response syndrome including 2 or more of:
Temp <36/>38
HR >90
RR >20
WCC <4/>12 or greater than 10% immature neutrophils
Hyperglycaemia in absence of DM
Altered mental state
When and what time frame do you do a CT head for trauma?
High risk criteria - CT within 1 hour
GCS <15 2h post-injury
Suspected open/depressed skull #
Basilar skull # signs e.g. haemotympanum, racoon eyes, battles sign & CSF rhinor/otorrhoea
> 2 vomitus
Age >65
Any head injury if anticoagulated
Medium risk - CT within 8 hours
Retrograde amnesia to event >30mins
Dangerous mechanism
What is the normal ICP?
7-15 (supine)
-10 (standing)
What are the indications and ways to measure ICP?
Indications: TBI, haemorrhages, hydrocephalus or CNS infections
- Intraventricular catheter = gold standard
Allows drainage to lower ICP + calibration possible but invasive, infection rate & difficult procedure - Intraparenchymal probe
Low infection rate but measures local pressure + drifts from zero over time - Subarachnoid probe
Low infection rate as no brain penetration but limited accuracy, high failure rate & need periodic flushing - Epidural probe
Low infection rate as extradural & easy insertion but limited accuracy & delicate - Lumbar CSF pressure
Extracranial procedure but inaccurate ICP reflection + is dangerous when oedema is present due to risk of coning - TM displacement & transcranial doppler
Non-invasive but not precise
What is the cushings reflex?
Physiological nervous system response where mixed vagal and sympathetic stimulation to elevated ICP causes a triad consisting of:
1. HTN to elevate CPP
2. Bradycardia
3. Irregular respiration
Please explain the monro-kellie doctrine.
Skull is a fixed vault containing brain (80%), blood (10%) & CSF (10%) - increase in volume of 1 component may cause compensatory decrease of other to prevent ICP rise but once its reached 25mmHg the brain can no longer compensate and herniation is a risk
This explains the lucid interval in EDH because you get a TBI, collapse then recovery but the condition deteriorates as the brain fails to compensate and ICP rises
How do you calculate CPP?
CPP = MAP - ICP
MAP = diastolic + 1/3 (systolic-diastolic)
MAP autoregulation range is between 50-150mmHg to maintain constant cerebral blood flow - if this is disrupted cerebral ischaemia can ensue
What are the indications to intubate someone?
GCS <8
Risk of raised ICP due to agitation i.e. sedation required
Bleeding into mouth/airway
B/L fractured mandible or severe facial injuries
How do you manage raised ICP?
Conservative:
Elevation of bed to 30 degrees
Good neck alignment in neutral position + dont use restrictive neck collars to immobilise C spine
Ensure tapes holding tube do not compress neck veins
Hyperventilate
ICP monitoring with serial head scans
Medical:
Mannitol
Furosemide
Hypertonic saline
Anticonvulsants if seizing
Surgical:
Extraventricular drain
Decompressive craniectomy
Urgent evacuation is needed if there is coma, neurological deterioration, clot thickness >10mm or midline shift of 5mm
What is the advantage of a tracheostomy?
Less dead space
Helps weaning from ventilator
May allow swallowing, eating & drinking
Better tolerated long-term
What is GCS?
Neurological scale that gives a reliable + objective way of recording concious state of person
Eyes: 1 (not opening), 2 (open to pain), 3 (open to voice) & 4 (open spontaneously)
Verbal: 1 (not talking), 2 (sounds), 3 (words), 4 (confusion) & 5 (orientated)
Motor: 1 (not moving), 2 (extension to pain), 3 (abnormal flexion to pain), 4 (flexion to pain), 5 (localises to pain) & 6 (obeys commands)
What is calcium bound to in the body and what are its main functions?
99% in bone as hydroxyapatite
1% in body fluid:
50% unbound/ionized - acidosis will increase this (hyper) and alkalosis will decrease (hypo)
45% bound to plasma proteins
5% with anions
Functions:
1. Neuromuscular transmission
2. Smooth & skeletal muscle contraction
3. Co-factor for blood coagulation
4. Mineralization of bone
Please give an overview of calcium homeostasis.
- Ca low so PTH is released:
- Increased osteoclastic activity & bone resorption to release Ca/Ph
- Increased renal excretion of Ph but reduces Ca losses
- Stimulates 1a-hydroxylase in kidneys increasing calcitriol - Vitamin D3 (calcitriol):
- Increases Ca and calcification of bone matrix
- Increases Ca/Ph reabsorption in kidneys and gut - Ca low so Calcitonin released:
- Inhibits osteoclasts and bone resorption
- Stimulates renal excretion of Na, Cl, Ca + Ph
How is vitamin D formed?
When UVB hits the skin 7-dehydrocholesterol is converted to vitamin D3
Some is also ingested in diet
In the liver then kidneys hydroxylase specifically 1a-hydroxylase enzymes convert it to its active form calcitriol which has 3 hydroxyl groups
Once active, it stimulates RANKL expression which causes osteoclast/osteoblast maturation + enhances gut absorption of Ca/Ph
What are the symptoms and signs of hypocalcaemia? How do you treat it?
CATS go Numb
Convulsions
Arrythmias
Tetany - if occurs in larynx will get laryngospasm
Spasms & stridor
Numbness in fingers
Chovsteks sign: twitching of facial muscles on tapping facial nerve anterior to tragus
Trousseau sign: spasm of hand upon tapping median nerve following BP cuff induced arm ischaemia
Mx:
Cardiac monitoring
10ml of 10% Ca gluconate IV followed by 10-40ml in saline infusion over 4-8h
Please explain the HPA axis with regards to thyroid hormone.
- Hypothalamus released thyrotropin releasing hormone (TRH)
- This stimulates anterior pituitary to produce TSH
- TSH stimulates thyroid gland to produce thyroxine which can negatively feedback to both hypothalamus and pituitary
How is T3/T4 produced?
- Iodide enters thyroid follicular cell by active pumping and is converted to iodine via thyroid peroxidase (TPO) enzyme
- Iodine combines with tyrosine to form monoiodotyrosine (MIT) and diiodotyrosine (DIT)
- MIT + DIT = T3 - more biologically active & less protein binding ability
- DIT + DIT = T4 - inactive in vitro with more protein binding capacity
What are the causes of hypothyroidism? What are the signs/symptoms?
Primary = T4 low but TSH high
Iatrogenic
Autoimmune (Hashimotos) - may also cause pernicious anaemia due to anti-parietal cell Abs leading to lack of IF
Iodine deficiency
Idiopathic
Secondary = both T4 and TSH low
Pituitary or hypothalamic failure
Signs/symptoms:
Weight gain
Cold intolerance
Myxoedema
Constipation
What biochemical patterns would you see in primary & secondary hyperthyroidism, sick euthyroid syndrome, poor compliance with thyroxine & steroids?
Primary hyperthyroidism = high T4 & low TSH
Secondary hyperthyroidism = high T4 & TSH
Sick euthyroid syndrome = both T4/TSH low
Poor compliance with thyroxine = T4 normal but TSH high
Steroids = TSH low but T4 normal
What considerations should be taken into account when operating on a hypothyroid patient with poor compliance?
Pre-operative risks include anaemia + increased risk of IHD
Intra-operative risk of bradycardia, hypotension & hypothermia
Post-operative risk of myxoedema coma, delayed recovery & poor wound healing
Involves anaesthetists, surgeons & endocrinologists in care
Increase compliance via:
Simplifying regime
Discuss patient their reasons & ensure they understand the consequences if not compliant
Medical/GP follow-ups
What is a steroid? What advice would you give to patients commencing them?
Organic compound containing characteristic arrangement of 4 cycloalkane rings joined together
Advise:
Not to be stopped suddenly
Medical alert bracelet to be worn
Increased infection risk
Do not take NSAIDs due to PUD risk
Warn of all side effects
What are the layers of the adrenal gland and what do they produce?
GFR - salt sugar then sex (from out to in)
Zoma glomerulosa -> aldosterone:
- Na reabsorption/K excretion in DCT/CD
- Salt/water retention
- Metabolic alkalosis
Zona fasiculata -> cortisol
- Anti-insulin + stimulates gluconeogenesis so increases blood glucose
- Stimulates protein synthesis + lipolysis
- Anti-inflammatory + immunosuppressant affect
- Bodies stress response
Zona reticularis -> sex hormones
Medulla -> catelcholamines
Please explain the HPA axis with regards to cortisol.
- Hypothalamus released CRH
- This stimulates anterior pituitary to produce ACTH
- ACTH stimulates adrenal cortex to produce cortisol which can negatively feedback to both hypothalamus and pituitary
What is an addisonian crisis? How do you manage it?
Acute reduction of circulating steroids due to addisons disease primarily as the adrenal supply of cortisol cannot meet body requirements or can be secondarily due to trauma, surgery, infection or sudden cessation of exogenous steroids
Features:
Abdominal pain
N+V
Unexplained shock
HypoNa + hyperK
Mx:
Prevent by increasing steroids and convert to IV if having surgery/unwell if they are on >10mg/day
A-E as per CCRISP if in crisis giving immediate IV steroid bolus of 100mg hydrocortisone then 200mg infusion following over 24h
Rapid IVF bolus 1L then further bags as required
Adjust metabolic disturbances
What is SIADH? Name some causes. How do you investigate and manage it?
Excessive secretion of ADH from posterior pituitary causing water retention, dilution of blood and hyponatraemia but high urinary sodium
Causes:
Brain injury
SCLC
Drugs e.g. carbamazepine
Hypothyroidism
Signs/symptoms:
Reduced volume of concentrated urine
Nausea & headache
Muscle cramps & confusion
Seizures & coma
Signs of fluid overload e.g. oedema
Ix:
Urine Na + osmolality
Plasma Na + osmolality
TFTs & cortisol
CXR/CT
Mx:
Treat cause
Fluid restriction
Note: the opposite syndrome of low ADH is DI and you get large volumes of dilute urine - can be neurogenic/nephrogenic in cause, diagnosed with fluid deprivation test & desmopressin can help manage
How do you perform a FNAC?
- Draw up heparinized saline into 10ml syringe with green needle going up and down then expelling it
- Clean skin over lesion and pass needle in pulling plunger back with thumb
- Multiple passes are needed to collect sufficient sample and once removed, there should be small amount in green portion of needle
- Pre-marked slides should be used and the aspirate should be smeared on one and the other one to be smeared over the top - one will be air dried and the other one will be sprayed with fixing spray
- Remaining aspirate to be placed in pot with saline to be spun down for analysis
What are the signs/symptoms of a pituitary adenoma? How do you investigate and manage?
Can be functional or non-functional (mass-effect)
If functional may have:
Cushingoid symptoms
Acromegaly - prominant brow, macroglossia, enlargement of hands/feet & CTS
DI
Bitemporal hemianopia due to medial compression of optic chiasm
Diplopia
Amenorrhoea/galactorrhoea
Pituitary apoplexy can cause rapid increase in size, haemorrhage + necrosis
Ix:
Endocrine test/hormonal profile
CT head
MRI
Mx:
Dopamine agonists e.g. bromocriptine if prolactinoma
Radiation
Surgery e.g. transphenoidal
Can just be under surveillance
What are the signs/symptoms of a skull base fracture? How do you investigate and manage?
- CSF rhinorrhoea
- CSF otorrhoea
- Haemotympanum - conductive hearing loss
- Battle sign
- Bump
Ix: CT trauma, audiometry & ENT R/V
Mx: ATLS, conservative management of symptoms or reconstructive surgery
What are the signs and symptoms of anterior cranial fossa lesion? What are some causes? How to manage?
Anosmia (CNI)
Decreased visual acuity (CNII)
Lateral gaze palsy (CNVI)
Decreased memory
Causes: meningioma, olfactory neuroblastoma or sinonasal malignancies
Mx: CT/MRI, stereotactic biopsy, neuro-onc MDT & then proton beam radiotherapy/surgery
How do you perform an AMTS assessment?
Ask patient:
Give address of 42 West Street at beginning
Their age
DoB
Home address
The time
Current year
Whats my job? Whats her job?
Year of WWI (1914)
Current president (Keir Starmer)
Count backwards from 20 to 1
Ask to recall address given earlier
A score of <6 is indicative of issue
How do you perform a CN exam?
WIPE
CNI - any change to smell?
CNII: visual acuity with snellen* (or crudely by asking them to read some writing), isihara for colour, pupils (direct/consensual reflex, swinging light test & accomodation) & visual fields
CNIII/IV/VI: H eye movements slowly
CNV: sensory to 3 areas of face, muscles of mastication & offer corneal reflex
CNVII: ask patient to raise eyebrows, squeeze eyes shut, puff out cheek & grin/bare teeth - any change to taste?
CNVIII: crudely by whispering number whilst distracting other ear then ask to repeat,
Webers & Rinnes & Rombergs
CNIX/X: open mouth and say Ah, cough & offer gag reflex - any problems with swallowing?
CNXI: shrug shoulders against resistance (trapezius) & turn head to one side against resistance (SCM)
CNXII: stick tongue out
To complete my exam i’d perform fundoscopy (for papilloedema/haemorrhage), otoscopy & LL/UL neurological exam
*recorded as chart distance over number of lowest line read
What are some causes of bitemporal hemianopia?
Optic chiasm lesion
Mass pressing on it e.g. pituitary adenoma, pineal tumour or thalamic tumour
Craniopharyngioma from above -> inferior quadrantopia
If pressing from below -> superior quandratopia
How do you perform otoscopy?
Pull pinna up & back held in right hand for right ear holding it like pencil and rest hand on cheek advancing it under direct vision
Looking for:
Wax
Erythema
Discharge
Foreign bodies
TM for colour/bulging, perforation, light reflex or scarring
What are the signs and symptoms of a posterior cranial fossa lesion? What are the possible causes? How would you investigate and manage?
DANISH due to affect on cerebellar ataxia
Dysdiadokinesia
Ataxia
Nystagmus
Intention tremor
Staccato speech
Hypotonia
DDx: mets, trauma, CVA or MS
Post. cranial fossa lesions: cerebellar astrocytoma, medulloblastoma, brainstem gliomas & ependydoma
Ix:
Plain X-ray of skull
MRI/CT
Guided biopsy
CT scan of body if expecting tumour elsewhere
Mx: excision
How do you perform a cerebellar exam?
WIPE
1. Gait: stance, stability, heel-to-toe walking & rombergs
2. Head: speech (“British Constitution”) & nystagmus (H test)
3. Arms: pronator drift, rebound phenomenom, tone & reflexes
4. Coordination: finger to nose test creating moving target, intention tremor by asking them to take pen & dysdiadokinesia
5. Legs: tone, reflexes, reflexes & coordination
To complete my exam I’d perform CN exam & UL/LL neurological exam
How do you perform a thyroid exam?
WIPE
1. End of bed looking for comfort, rashes, skin or hair changes
2. General
- Hands for dry skin & palmar erythema
- Tremor with paper
- Radial pulse
3. Face/eyes:
- Face: asymmetry/rashes/neck veins
- Eyes: exopthalmos from above, lid lag & H test
4. Neck inspection: Assess lump by 6s - site, size, shape, symmetry, overlying skin & scars then ask patient to protrude tongue & swallow water
5. Palpate from behind for tenderness, temp, surface, edge, consistency, fixity, pulsatility - then feel below + ask them to protrude tongue/swallow water whilst feeling it
6. LN examination: submental, SM, pre-auricular, post-auricular, superficial/deep cervical chain, occipital & supraclavicular
7. Percuss sternum
8. Auscultate with bell for bruits
9. Legs for pretibial myxoedema, LL reflexes & proximal myopathy (stand from sitting with arms crossed)
To complete my exam, I’d perform triple assessment with a history, bloods for TFTs and arrange USS + potentially FNAC of lump
What are some differentials for a thyroid lump? How would you manage?
DDx:
- Simple goitre (euthyroid)
- Toxic multinodular goitre e.g. Graves
- Neoplasm: benign or malignant
- Inflammatory: autoimmune (Hashimotos), granulomatous (De Quervains thyroiditis), infective (bacterial) or amyloid
If neoplastic: MDT and work up for total or hemi-thyroidectomy
If not:
- Antithyroid drugs e.g. Carbimazole but long-term Tx needed and not always successful
- Radioiodine but patient must be quarantined after from kids/pregnancy
- Surgery with subtotal thyroidectomy is long-term cure but thyrotoxicosis can recur, hypoparathyroidism, nerve injury & scar can result
How do you examine the parotid & submandibular glands?
WIPE
1. Inspect with 6S’s: site, size, shape, symmetry, skin changes & scar comparing with C/L side then inspect stensons duct at the level of 2nd upper molar tooth
2. Test CNVII via raising eyebrows, squeezing eyes shut, puffing checks & grinning teeth
3. Palpate from behind with teeth clenched for surface, consistency, fixity, edges & pulsatility on both sides
4. LN exam
5. Palpate stensons duct + perform bimanual palpation with gloves both sides
SM gland the same except you inspect Whartons duct either side of lingual frenulum, marginal mandibular nerve only by asking to show teeth, CNXII and sensory to anterior 2/3rd of tongue (lingual n)
How would you investigate and manage a gland lump?
Ix:
USS + FNAC
CT/MRI
Sialogram if stone suspected - can also be therapeutic
Mx:
MDT if neoplastic
Conservative with analgesia, Abx, good hydration & gland massage if infection/stone
Duct can be laid open and stone retrieved
Sialendoscopy to retrieve stone
SM gland excision or superficial/total parotidectomy if neoplasm
How would you do a general lymph node examination?
WIPE
1. Start with neck ones as before in both triangle of neck
2. Axillary + epitrochlear nodes
3. Inguinal
What are some causes of generalised lymphadenopathy? How would you investigate?
Generalised = >2 non-contiguous LN groups so more likely due to serious infection/disease/malignancy
Viral: HIV
Bacterial: TB
Autoimmune: SLE
Malignancy: leukaemia/lymphomas
Ix:
Infection swabs
FBC, U&Es, LFTs & CRP/ESR
Viral titres/BCs/autoab screen
CXR
USS
CT/MRI
FNA
Excisional biopsy is gold standard
How is lymphoma staged?
Ann arbor
1 = single LN region
2 = 2 or more LN groups on same side of diaphragm
3 = LNs on both sides of diaphragm
4 = involvement of 1 or more extralymphatic organ e.g. liver, bone marrow, pleura or CSF
What are the main stages of assessing any lump?
Inspect for 6 S’s - site, size, shape, symmetry, overlying skin & scars
Palpate for temperature, tenderness, size, edges/margins, surface, consistency, reducibility, compressibility, pulsatility, fluctuation, fixity to skin/deeper structures & transillumination
Auscultate for bruit
Regional LN exam
Slip sign positive in lipoma
What is a lipoma? What are some other differentials? How to investigate and manage?
Benign tumour of fat (the most common soft tissue tumour in adults) - can be anywhere except palms, soles, brain & tongue
Dangerous if in mucosa of intestines, thecal/spinal cord or on vocal cords
Other DDx: sebaceous cyst, abscess, soft tissue tumour or vascular malformations
Ix: US, CT/MRI +/- biopsy (FNAC/excisional)
Mx:
Can be left alone or
Excision or liposuction - can be done under GA, local or nerve block/regional
Where to place incision for superficial parotidectomy?
Posterior to mandible but to inferior to tragus of ear
What constitutes a radial neck dissection?
LN levels I-IV removed
+ SCM + IJV + CNXI
Please summarise the findings, investigations and management of a branchial cyst.
Congenital remnant of branchial cleft commonly due to incomplete involution of the 2nd cleft during embryonic development - they can get recurrent infections, abscesses, cause mass effect & can undergo malignant transformation
Ix
USS + sinograms can be used
FNA may show cholesterol granules
CT/MRI can be used pre-operatively
Mx
Surgical excision is generally recommended due to complications
