Neck Flashcards
What are the anatomical content of the neck?
- Arteries
- Veins
- Nerves
- Lymph nodes
- Lymphatic channels
- Thyroid gland
- Parathyroid glands
- Muscles
- Trachea
What is the superior boundary of the neck?
Mandible
What is the anterior boundary of the neck?
Anterior midline
What is the inferior boundary if the neck?
Clavicle
What is the posterior boundary of the neck?
Trapezius
What is the anterior and posterior boundary of the anterior triangle?
- Anterior: midline of the neck
- Posterior: anterior border of sternocleidomastoid
What is the anterior and posterior boundary of the posterior triangle?
Anterior: posterior border of sternocleidomastoid
Posterior: anterior border of trapezius
What are the contents of the anterior triangle?
- Common carotid artery
- External carotid artery
- Facial artery
- Hypoglossal nerves
- Vagus nerves
- Glossopharyngeal nerves
- Submadibular nodes
- Submental nodes
- Internal carotid artery
- Internal jugular vein
- Facial vein-Accessory nerves
- Laryngeal nerves
What are the contents of the posterior triangle?
- Accessory nerve
- Occipital artery
- Lymph nodes
- Cervical nerve plexus
- External jugular vein
What is the main artery supplying the head and neck?
Common carotid artery
At what vertebral level does the common carotid artery divide?
C4
What is the only artery with branches in the neck?
External carotid artery
What are the branches of the external carotid artery?
-Superior thyroid
-Ascending pharyngeal
Lingual
-Occipital
-Facial
-Posterior auricular
-Maxillary
-Superficial temporal
Give examples of indications for central lines.
- Central venous pressure
- Drug administration
- Cardiac pacing
- Blood sampling
- Fluid resuscitation
- Haemodialysis
- Intravenous nutrition
What are the possible complications of central lines?
- Pneumothorax
- Haematoma
- Cardiac tamponade
- Air embolism
- Chylothorax
- False passage
- Thrombosis
- Sepsis
- Line blockage
How many lymph nodes are there in the head and neck?
600
What do the lymph nodes receive?
- Lymph
- Tissue waste product
Where do the lymph nodes of the head and neck drain to?
Cisterna chyli then drain to thoracic duct on left
How are lymph nodes described?
In groups and levels
How are the lymph nodes described in terms of levels?
- I and IV anterior to sternocleidomastoid muscle
- II, III and IV down the sternocleidomastoid muscle
- V posterior to the sternocleidomastoid muscle
What do the parotid lymph nodes drain?
- Scalp
- face
- Parotid gland
What do the occipital nodes drain?
Scalp
What do the superficial cervical nodes drain?
- Breast
- Solid viscera
What do the deep cervical nodes drain?
Final drainage pathway to thoracic duct
What do the submandibular nodes drain?
- Tongue
- Nose
- Paranasal sinuses
- Submandibular gland
- Oral cavity
What do the submental nodes drain?
- Lips
- Floor of mouth
What do the supraclavicular nodes drain?
- Breast
- Oesophagus
- Solid viscera
What are the 3 categories of causes of lymphadenopathy?
- Infective
- Inflammatory
- Malignant
What type of gland is the thyroid gland?
Endocrine
What is the structure of the thyroid gland?
2 lobes joined by isthmus
What does the thyroid gland produce?
- Thyroid hormone
- Calcitonin
What does calcitonin do?
Acts to lower calcium and raise phosphate
Thyroglossal cyst
Dilatation of thyroglossal duct remnant
What can happen to a thyoglossal cyst?
Can become infected
How does a thyroglossal cyst appear?
- Midline
- Grows with age
- Moves on tongue protrusion
What is needed before removal of a thyroglossal cyst?
Ultrasound scan to ensure functioning thyroid tissue elsewhere
What may a thyroid mass be?
- Solitary nodule
- Diffuse enlargement
- Multi-nodular goitre
What may a solitary thyroid nodule be?
- Cyst due to localised haemorrhage
- Adenoma (benign follicular tissue)
- Carcinoma
- Lymphoma
- Prominent nodule in multi-nodular goitre
What is the prevalence of solitary thyroid nodules?
- F>M
- 30-40 years
- 10% malignant in middle-aged
- 50% malignant in young
How should a solitary thyroid nodule be investigated?
- Fine needle aspiration cytology
- Ultrasound
What can FNAC not distinguish between?
A follicular adenoma and a follicular carcinoma
How is a tissue acquired for histological diagnosis of solitary thyroid nodule?
Thyroid lobectomy
How does papillary thyroid cancer present?
Lymphatic metastasis
How does follicular thyroid cancer present?
Haematogenous metastasis
How do medullary thyroid cancers present?
- Familial association
- 10% arise from parafollicular C cells
How do anaplastic thyroid cancers present?
- Aggressive
- Local spread
- Very old
- Poor prognosis
What may colloid goitre be due to?
- Gland hyperplasia
- Iodine deficiency
- Puberty
- Pregnancy
- Lactation
What may a diffuse thyroid enlargement be due to?
- Colloid goitre
- Grave’s disease
- Thyroiditis
What is the prevalence of Grave’s disease?
F>M
Why does hyperthyroidism occur with Grave’s disease?
Auto-antibodies against thyroid stimulating hormone receptor stimulate receptor
What are the signs of Grave’s disease?
- Thyroid eye disease
- Acropathy/clubbing
- Pre-tibial myxoedema
What is the treatment for Grave’s disease?
- Anti-thyroids
- B blockade
- Radio-iodine
- Surgery
What are the indications for a thyroidectomy?
- Airway obstruction
- Malignancy or suspected malignancy
- Thyrotoxicosis
- Cosmesis
- Retrosternal extension
What are the complications of a thyroidectomy?
- Bleeding (primary or secondary)
- Voice hoarseness
- Thyroid storm
- Infection
- Hypoparathyroidism
- Hypothyroidism
- Scar (keloid/hypertrophic)
What can multi-nodular goitre be due to?
- Grave’s disease
- Toxic goitre
What is the typical patient of multi-nodular goitre due to Grave’s?
- Female
- Middle ages
- Over activity leading to hyperthyroidism
What is the typical patient of multi-nodular goitre due to toxic goitre?
- Older
- No eye signs
- Atrial fibrillation
What investigations should be carried out fro multi-nodular goitre?
- Thyroid function tests
- FNAC
- CXR
How many parathyroid glands do you usually have?
4
What do parathyroid glands do?
Regulate calcium and phosphate levels
Where are the parathyroid glands located?
Posterior to poles of thyroid
When can parathyroid glands be injured?
Neck surgery
What are the signs of parathyroid disease?
- Painful stones
- Aching bones
- Psychic moans
- Abdominal groans
How can parathyroid disease manifest itself in relation to painful stones?
- Renal calculi
- Polyuria
- Renal failure
How can parathyroid disease manifest itself in relation to aching bones?
- Pathological fractures
- Osteoporosis
- Bone pain
How can parathyroid disease manifest itself in relation to abdominal groans?
- Abdominal pain
- Constipation
- Peptic ulceration
- Pancreatitis
- Weight loss
How can parathyroid disease manifest itself in relation to psychic moans?
- Anxiety and depression
- Confusion
- Paranoia
What investigations are important in parathyroid disease?
- U+Es
- Creatinine
- Calcium
- Phosphate
- Parathyroid hormone
- Bicarbonate
- Vitamin D
- US
- CT/MRI to identify ectopic glands
- Isotope scanning to detect disease glands
When is the only time surgery is indicated in parathyroid disease?
Hyperparathyroidism
What can cause hyperparathyroidism?
- Adenoma
- Hyperplasia
- Malignancy (rare)
Why is hyperplasia common in secondary hyperparathyroidism?
Due to low calcium
What is the management for parathyroid disease?
- Medical treatment
- Surgery if patient is fit
- Remove single adenomas
- Remove multiple adenomas
- Remove 3 or 3.5 hyperplastic glands through neck exploration
- Carcinomas removed with thyroid gland and lymph nodes
What are the 4 fascial layers of the neck?
- Pre-tracheal
- Pre-vertebral
- Deep cervical
- Carotid sheath
What are the indications for a tracheostomy?
- Airway obstruction
- Airway protection
- Poor ventilation to reduce dead space
What is needed after a tracheostomy is fitted?
-Suctioning
-Humidification
Long term care
What can the timing of stridor tell you about the site of airway obstruction?
- Inspiratory: laryngeal
- Extrinsic: tracheobronchial
- Biphasic: glottis/subglottic
Stridor
Clinical sign of airway obstruction
How is stridor treated?
-O2
-Nebulised adrenaline
IV Dexamethasone
-Airway management
Brachial cyst
Remnant of fusion failure of branchial arches or lymph node cystic degeneration
Where do branchial cysts occur?
Anterior to sternocleidomastoid at junction between upper and middle thirds
Why are brachial cysts excised?
To prevent further infection
Pharyngeal pouch
Herniation of pharyngeal mucosa between thyropharygeus and cricopharyngeus muscles of the inferior constrictor of the pharynx
What are the signs of pharyngeal pouches?
- Voice hoarseness
- Dysphagia
- Aspiration pneumonia
- Regurgitation
- Weight loss
- Neoplasia
What is the treatment for pharyngeal pouches?
- Barium swallow
- Excision (endoscopic or open)
- Dilate
