Superficial lesions Flashcards
Key points in a lump examination
SSSCCCCTTTTFPS
Completion: 3
-
S
- site
- size
- shape
-
C
- Colour
- Consistency
- Contour
- Cough impulse
-
T
- Tenderness
- Temperature
- Translumination
-
Tethering deep/superficial
- is it intradermal or subcutaneous?
- Intraderma: cannot draw skin over lump
- sebaceous cyst, neurofibroma, dermatofibroma
- Subcutaneous; can move lump independently from skin
- lipoma, ganglion, LN
- Intraderma: cannot draw skin over lump
- is it intradermal or subcutaneous?
-
FPS
- Fluctuance assess with prest test
- Pulsatile assess for bruits/bowel sounds
- Spreaaaaads (LN)
Completion:
- examine draining LN!
- Examine neurovascular function distral to lump!
- Look for similar lumps elsewhere!
Lump history Qs; 3 headings
- Onset
- When and why did you notice it?
- Any predisposing event: e.g. trauma?
- Continued Symptoms
- What symptoms does it cause: e.g. pain?
- How has it changed?
- Have you noticed other lumps?
- Treatments and Cause
- What treatments have you tried?
- What do you think the cause is?
Lipoma
- Pathology:
- Features:
- Inspection:
- Palpation:
- ‘Viva’-Syndromes: 4
- Management: 2
Lipoma
- Pathology: benign tumour of mature adipocystes. Sarcomatous change probably doesn’t occur.
- Liposarcomas arive de novo in; older pt/deeper tissues of lower limbs
- Features:
- Inspection: occur anywhere where fat can expand ie. not scalp or palms incl spermatic cord and submucosa
- Palpation: soft + subcutaneous + imprecise margins + fluctuant
- ‘Viva’-Syndromes: 4
- Dercum’s disease/ adiposis dolorosa:
- multiple, painful lipomas
- associated peripheral neuropathy
- obese, postmenopausal women
- familial multiple lipomatosis
- madelung’s disease
- Bannaya-Zonana Syndrome:
- AD, multiple lipomas, macrocephaly, haemangiomas
- Dercum’s disease/ adiposis dolorosa:
- Management:
- non-surgical; leave
- surgical; excise (but recur!)
Sebaceous cyst
- Pathology: 2 types
- Features:
- Inspection:
- Palpation:
- ‘Viva’-Syndromes: 2 + Complications
- Management: 2
Sebaceous cyst
- Pathology: Epithelial-lined cyst containing keratin (Two histological subtypes:)
- 1) Epidermal Cyst - Arise from hair follicle infundibulum
- 2) Trichilemmal Cyst / Wen - Arise from hair follicle epithelium, Often multiple, May be AD
- Features:
- Inspection:Occur at sites of hair growth ie scalp, face, neck, chest, back NOT soles or palms, central punctum
- Palpation: Firm + smooth + Intradermal
- ‘Viva’
- Complications: Infection (pus discharge) + ulceration + calcification
- Syndromes:
- Cock’s peculiar tumour: large ulcerating trichilemmal disease on scalp, resemble SCC
- Gardener’s syndrome = FAP + Thyroid Tx + Osteomas + Dental abnormalities + Epidermal cysts (Garden TOAD)
- Management:
- non-surgical
- Surgical
Ganglion
- Pathology:
- Features:
- Inspection:
- Palpation:
- ‘Viva’-Differential
- Management: 2
Ganglion
- Pathology: cystic swelling related to synovial-lined structures: joint, tendon. Myxoid degeneration of fibrous tissue. They contain thick gelatinous material
- Features:
- Inspection: can be found anywhere e.g. dorsum of hand or wrist. There may be a scar from recurrence. May weakly transilluminate
- Palpation: soft + subcutaneous + teathered to tendon
- ‘Viva’-Differential
- Bursae
- cystic protrusion from synovial cavity of arthritic joint
- Management:
- non-surgical: aspiration followed by 3 wks of immobilisation
- surgical excision: 50% recurrence + risk neovasc damage
Seborrhoeic Keratosis
- Pathology: 3
- Features: 3
- Management: 2
Seborrhoeic Keratosis
- Pathology: benign hyperplasia of basal cell layer
- hyperkeratosis: coneum thickening
- acathosis: spinosum thickening
- hyperplasia of basal cells
- Features:
- stuck on appearance + dark brown + greasy
- Management:
- non-surgical
- surgical: superficial shaving or cautery
Neurofibroma
- Pathology:
- Features:
- Inspection:
- Palpation:
- Extras:
- Viva: syndrome
- Management: 1
Neurofibroma
- Pathology: benign nerve sheath tumour arising from schwann cells
- Features: Numerous small violaceous nodules present on the back and forwarm in no particular distribution; neurofibromas
- Inspection: solitary or multiple, pedunculated nodules
- Palpation: fleshy consistency + pressure can -> paraesthesia
- Extras: examine:
- skin: cafe au lait spots
- eyes: lisch nodules
- Acilla: freckles
- CN: 8 (NF2 schwannoma)
- BP: phaeochromocytoma/RAS
- Viva: NF 1
- AD Chr 17
- cafe au lait spots >6 >15mm + freckling + neurofibromas + lisch nodules (iris)
- Management:
- surgical excision ONLY indicated is malignancy suspected
- local regrowth = common!
Papilloma
- Pathology: 1
- Features: 3
- Management: 1
Papilloma
- Pathology: overgrowth of all layers of the skin with a central vascular core
- Features: Skin tage/fibroepithelial polyp, pedunculated, flesh coloures
- Management: excision + diathermy to control bleeding
Pyogenic granuloma
- Pathology:
- Features:
- Inspection:
- Palpation:
- Viva: ?association
- Management: 2
Pyogenic granuloma
- Pathology: rapidly growing capillary haemangioma, neither pyogenic nor granuloma!
- Features:
- Inspection:
- most commonly hands, face, gums, lips
- bright red hemispherical nodule
- may have seous/purulent discharge
- Palpation: soft + bleed easily
- Inspection:
- Viva: ?association
- previous trauma? more common in preg
- Management:
- non-surgical: regression is uncommon
- surgical: curretage and diathermy of base
Dermoid cyst
- Pathology: congenital vs acquired
- Features:
- Inspection:
- Palpation:
- Viva: ?association
- Management: 2 (C/A)
Dermoid cyst
- Pathology: epidermal lined cyst deep to the skin
- congenital/inclusion cyst: developmental inclusion of epidermis along lines of skin fusion e.g. midline of neck and nose, medial and lateral ends of eyebrows
- aquired/implantation cyst: Implantation of epidermis in dermis. often secondary to trauma e.g. piercing
- Features:
- Inspection:
- smooth spherical swelling
- sites of embryological fusion
- scar from recurrence
- Palpation: soft, non-tender, subcutaneous
- Inspection:
- Viva: ?association
- congenital: child/young adult
- acquired: adult- ask re trauma
- Management: 2 (C/A)
- congenital; CT to establish extend and surgical excision
- Aquired: surgical excision
Dermatofibroma
- Pathology:
- Features:
- Inspection:
- Palpation:
- Viva: differential
- Management: 1
Dermatofibroma
- Pathology: benign neoplasm of dermal fibroblasts
- Features:
- Inspection:
- can occur anywhere, mostly on lower limbs of younf to middle aged women
- small brown pigmented nodule
- Palpation: Firm + woody feel = characteristic, Intradermal + mobile over deep tissue
- Inspection:
- Viva: differential: malignancy e.g. melanoma, BCC
- Management: Excision and HISTOLOGY!
Kerato-acanthoma
- Pathology:
- Features: 3
- Management:
Kerato-acanthoma
- Pathology: benign overgrowth of hair follicle cells, cytologically similar to well-differentiated SCCs
- Features:
- fast growing
- Dome shaped with keratin plug
- Intraderma;
- Management:
- regress w/i 6 wks
- excise to reduce scarring and obtain histology
Thyroid examination
prep/gen inspection/hands/eyes/neck(IPA)/legs/complete
-
Preparation Ensure exposure down to the clavicles + Position pt. away from a wall
-
Qs:
- Are you comfortable: not too hot or cold?
- Hoarse voice: recurrent laryngeal nerve palsy
-
Qs:
-
General Inspection
- Nervous/agitated or slow/lethargic
- Body habitus
- Sweaty
- Skin and hair condition
-
Hands
- Thyroid acropachy
- Palmar erythema
- Temperature, sweating
- Fine tremor: piece of paper on out-stretched hands
- Pulse: rate and rhythm (AF in thyrotoxicosis)
-
Eyes
- Sympathetic Overstimulation
- Lid Retraction: sclera between iris and upper lid
- Lid Lag
- Graves:
- Oedema: periorbital and chemosis
- Exophthalmos: inspect from above and side
- Ophthalmoplegia: esp. upgaze palsy
- Sympathetic Overstimulation
-
Neck
- Inspect: from front and side.
- Look for collar scars
- Ask pt. stick out tongue and swallow water
- Look in mouth for lingual thyroid
- Palpate: from behind
- Palpate masses: can you get under it?
- Repeat the swallow and protrusion test
- Lymphadenopathy
- Check for tracheal deviation.
- Percuss: for retrosternal extension
- Auscultate: thyroid bruits (Graves’)
- Inspect: from front and side.
-
Legs
- Pretibial myxoedema: brown swelling above lat. malleoli
- Proximal myopathy: ask pt. to stand from chair (Graves)
- Ankle reflexes: kneel on chair
- Slow relaxing: hypothyroidism
- Brisk: hyperthyroidism
-
Completion
- Observation chart
- History
Exophthalmos differential:
- Orbital cellulitis
- Trauma
- Masses: meningioma, glioma
- Carotid cavernous fistula: pulsatile exophthalmos
- Idiopathic orbital inflammatory disease
- Graves
Goitre differential
Diffuse: smooth/nodular
Solitary
Diffuse Enlargement
- Smooth
- Simple colloid goitre
- Graves
- Thyroiditis: Hashimoto’s, de Quervain’s, Riedel’s
- Nodular
- Multinodular goitre
- Multiple adenomas
Solitary Nodule
- Dominant nodule of a multinodular goitre
- Adenoma
- Malignant
- 1O: papillary, follicular, medullary, anaplastic
- 2O: breast
- Cyst
Commentest causes of
hyperthyroidism 2
hypothyroidism 3
Hyperthyroidism
- Graves’ (~2/3)
- Toxic Multinodular Goitre ( = Plummer’s)
Hypothyroidism
- Primary atrophic
- Hashimoto’s thyroiditis
- Iodine deficiency: commonest Worldwide
Thyroid Qs 3
- Thyroid status
- Compression symptoms: dysphagia, difficulty breathing
- Previous thyroid medications or surgery
Goitre investigations
Nlood/imaging/hisology/laryngoscopy
Bloods
- TFTs: TSH, fT3, fT4
- Other: FBC, Ca2+, calcitonin, ESR
- Antibodies: anti-TPO, TSH
Imaging
- CXR: goitre and mets
- High resolution US
- CT
- Radionucleotide (Tc or I) scan: hot vs. cold
Histology or cytology
- FNAC (can’t distinguish adenoma vs. follicular Ca)
- Biopsy
Laryngoscopy: Important pre-op to assess vocal cords
Features of multinodular diffuse goitre
- Commonest goitre in UK
- Progression of simple diffuse goitre to nodular enlargement.
- Middle-aged women
- Positive family Hx
- Over-activity in parts may → mild thyrotoxicosis
- Plummer’s Syndrome
- Malignant change occurs in 5% of untreated MNGs
Management of multinodular diffuse goitre
n.b. most pts do not require intervention
nonsurg vs surg
- Most pts. don’t require intervention*
- *Non-Surgical**
- Thyroxine → regression in 50-70% (Suppress TSH)
- Toxic Multinodular Goitre
- Propranolol + carbimazole
- Radioiodine
Surgical
- Indications: 5 Ms
- Mechanical obstruction
- Malignancy
- Marred beauty: cosmetic reasons
- Medical Rx failure: thyrotoxicosis
- Mediastinal extension: can’t monitor changes
- Procedure
- Total thyroidectomy
- Removes risk of malignant change in thyroid remnant.
Plumbers Vs graves
- age
- Nod or diffuse?
- extra?
- AF?
- AI features?
Simple colloid goitre (smooth)
causes
Treatment
Hyperplasia of gland 2O to ↑TSH release
Causes
- Iodine deficiency: commonest worldwide
- ↑ physiological demand: pregnancy, puberty
- Goitrogens: e.g. Li, uncooked cabbage
Rx
- Not usually required
- Thyroxine or ↑ dietary iodine
Graves disease
epidemiology
- Prevalence:
- XX% of cases of thyrotoxicosis
- Sex:
- Age:
- Prev: 0.5%
- 60% of cases of thyrotoxicosis
- Sex: F>>M=9:1
- Age: 40-60yrs
Graves disease: features
- Diffuse goitre c¯ bruit
- Triggers: stress, infection, child-birth
- Ophthalmopathy
- Oedema: periorbital and chemosis
- Exophthalmos → exposure keratopathy
- Ophthalmoplegia: esp. upgaze palsy
- Optic neuropathy: ↓ acuity and RAPD
- Dermopathy: pre-tibial myxoedema
- Acropachy: periosteal reaction (clubbing is soft tissue
Pathology of grave’s eye disease:
exophthalmost
+
Lid-lag
- Exophthalmos
- Retro-orbital inflammation and lymphocytic infiltration → orbital oedema
- 2O to anti-TSH abs
- Lid-lag
- Not Graves’ specific
- Sympathetic overstimulation → restrictive myopathy of LPS
Grave’s disease associations: (3)
- T1SM
- Vitiligo
- Pernicious anaemia
Grave’s disease
treatment
- medical: propranolol + carbimaxole
- Radioiodine
- surgical: subtotal or total thyroidectomy
Grave’s vs thyroiditis (and 4 example)
uptake?
Graves; high uptake
thyroiditis: low uptake e.g.
- hashimoto’s
- de Quervain’s
- Subacute lymphocytic: post-partum
- Riedel’s
Follicular adenoma (benign solitary thyroid nodule)
Features
Management
Follicular adenoma (benign solitary thyroid nodule)
- Features:
- 2-4cm mass
- +/- thyrotoxicosis
- Indistinguishable from follicular Ca on FNAC- need excision histology to confirm Dx
- Management
- Hot:
- <3cm: radioiodine
- >3cm: surgical excision
- COLD: excision!
- Hot:
thyroid cyst (benign solitary thyroid nodule)
Features
Management
- Features:
- true cysts= RARE
- Mostly colloid degeneration, necrosis of H’gge wi benign or malignant tymours
- Only benign if abolished by aspiration!
- Management
- cytology can be false negative in 30%!
- <4cm: aspirate and reciw in 4/12
- surgical excision if:
- >4cm
- blood stained aspirate
- recurrence after aspiration
Malignant solitary thyroid nodule
Papillary
Frequency:
Age:
Cell origin:
Spread:
Mx:
- Frequency: 80%, associated with irradiation
- Age: 20-40 yrs
- Cell origin: follicular cells (thyroglobilin Tx marker)
- Spread:
- nodes and lung
- JDG (JUGULODIAGASTRIC) node = lateral abberrant thyroid
- may be multifocal
- Mx:
- total thyroidectomy
- T4 to suppress TSH
- +/- node excision
- +/-radioiodine
>95% 10 yrs
Malignant solitary thyroid nodule
Follicular
Frequency:
Age:
Cell origin:
Spread:
Mx:
- Frequency: 10%, F>M
- Age: 40-60 yrs
- Cell origin: follicular cells, thyroglobulin TMarker
- Spread: Bone-> blood + lung
- Mx:
- total thyroidectomy
- _ T4 syppresion
- radioiodine
>95% 10yr
Malignant solitary thyroid nodule
Medullary
Frequency:
Age:
Cell origin:
Mx:
- Frequency: 5%, 30% = FAMILIAL! e.g. MEN2
- Age:
- sporadic = 40-50
- MEN2 = young
- Cell origin: parafollicular C cells - CEA + Calcitonin = Markers
- Spread: //
- Mx:
- phaeo screen preop
- thyroidectomy
- node clearance
- +/- radiotherapy
Malignant solitary thyroid nodule
Anaplastic
Frequency:
Age:
Cell origin:
Spread:
Mx:
- Frequency: rare, F>M 3:1
- Age: >60
- Cell origin: undifferentiaed follicular cells
- Spread: rapid growth
- aggressive: local + LN + blood
- Mx:
- usually palliative
- may try thyroidectomy + radiotherapy
- <1% 10 yrs
Thyroid Nodule Facts
quick facts! (5)
- F>M = 4:1
- 4th and 5th decades
- 10% malignant in middle aged
- 50% malignant in young and elderly
- FNAC is most important Ix
Investigation of thyroid nodule?
Ix: Triple Assessment
- Clinical examination
- US
- FNAC
Isotope scan: used if pt. is hyperthyroid
MEN1: Wermer syndrome
- Pituitary adenoma
- Parathyroid hyperplasia or adenoma
- Pituitary endocrine tumour
MEN2 syndrome
Men 2
- Medullary thyroid Ca
- Phaeochromocytoma
- A: hyperparathyroidism
- B: marfanoid habitus
Complications of thyroid surgery
early/late
Early
- Reactionary haemorrhage → haematoma
- Recurrent laryngeal nerve palsy
- Hypocalcaemia
- Thyroid storm
Late
- Hypothyroidism and hypoparathyroidism
- Recurrence of disease
- Keloid scar
Practicalities of Thyroid Surgery
- Render euthyroid pre-op c¯ antithyroid drugs
- Stop 10 days prior to surgery (they ↑ vascularity)
- Alternatively just give propranolol
- Check for phaeo pre-op in medullary carcinoma
- Laryngoscopy: check vocal cords pre- and post-op
Neck examination
(prep/inspect neck, mouth, eyes/palpate/percuss/ausc/other/complete)
- *Preparation:** Ensure exposure down to the clavicles + Position pt. away from wall
- *Inspect**: Scars, Sinuses, Masses
- Neck
- Look very carefully for scars: collar incision
- Look for masses: which triangle?
- Does mass move on swallowing or tongue protrusion?
- Mouth
- Lingual thyroid
- Ranula (ruptured salivary gland → mucocele)
- Eyes
- Thyroid eye disease
Palpate
- Best from behind the pt.
- Palpate while pt. swallowing and protruding tongue
- Assess for lymphadenopathy
- Tracheal deviation
- *Percuss** Retrosternal extension
- *Auscultate**
- Listen over lump for bruits.
- Gurgle of pharyngeal pouch
If no obvious masses / skin lesions
- Check neck pulses and listen for bruits
- Test sensation and neck movements
Completion
- If goitre → asses thyroid status
- Lump history
Quick differential for neck lumps
anywhere
midline: solid/cystic
ant triangl: solid/cystic
Post triangle: solic/cystic
Investigation of neck lump; 3 special to think of
- US: shows consistency
- FNAC or core Bx
- Consider CT/MRI to define relations
Key neck Hx Qs
onset/continued Sx/Rx and causes
-
Onset
- When and why did you notice it?
- Any predisposing event: e.g. trauma?
-
Continued Symptoms
- What symptoms does it cause: e.g. pain?
- How has it changed?
- Have you noticed other lumps?
-
Treatments and Cause
- What treatments have you tried?
- What do you think the cause is?
Midline and anterior triangle: 3 key differentials
- Thyroglossal cyst
- Branchial cyst
- Chemodectoma
Posterior triangle lumps: 3 key differential
- cystic hydroma
- pharyngeal pouch
- cervical rib
Thyroglossal cyst
pathology
presentation
Pathology
- Persistence of any part of the thyroglossal duct which marks the developmental descent of the thyroid from the foramen caecum
- Ectopic thyroid tissue can be found anywhere along this path of descent.
- Cysts may contain thyroid tissue which can undergo malignant change → papillary Ca
Presentation:
- Young pt.
- Fluctuant midline neck lump
- Usually subhyoid
- Protrusion of tongue → elevation
- Swallowing → elevation
- May see opening of a thyroglossal sinus
- Following removal there will be a transverse incision just above the thyroid cartilage.
Thyroglossal cyst
differential
epidemiology
complications
- *Differential**
- Thyroid nodule and masses
- Dermoid / epidermal cysts
- Subhyoid bursa
- *Epidemiology**
- Rare
- M=F
- 40% in 1st decade
- *Complications**
- Infection
- Sinus formation
- Development of Ca
- Recurrence post-op
Surgical management of thyroglossal cyst
- *Sistrunk’s Operation**
- Inject patent tract c¯ dye at start
- Excise cyst and patent tract
- Need to resect central portion of hyoid as tract runs through it.
Branchial cyst
pathology
presenation
-
Pathology:
- Failed fusion of 2nd and 3rd branchial arches
- Lined by squamous epithelium
- Contain “glary” fluid c¯ cholesterol crystals
-
Presentation:
- Young pt.
- Ant. margin of SCM at junction of upper and middle thirds
- Firm, fluctuant ovoid swelling
- Opaque on transillumination
- May be opening from branchial sinus
Branchial cyst
COmplication
Management; surgical/medical
- *Complications**
- Infection
- Sinus formation
- Recurrence post-op
- *Surgical Excision**
- Bonney’s blue dye can be injected into fistula to allow more accurate excision
- May be difficult due to proximity of carotids
- *Medical**
- Sclerotherapy is an option
Chemodectoma
Pathology
presentation
-
Pathology:
- Very rare
- Tumour of the paraganglion cells of the carotid bodies: measure pH and PaO2 and PaCO2
- Located @ the carotid bifurcation
- Mostly benign (5% malignant)
-
Presentation:
- Ant. triangle @ the angle of the jaw
- Pulsatile
- Moves laterally but not vertically
- Pressure can → syncope
- May be bilateral
Chemodectoma
Investigations
Management: surgical/radiological
- *Ix**
- Duplex US
- Angiography: splaying
- CT / MRI
- *Surgical Excision**
- *Ultrasonic** surgical dissection
- *Radiotherapy**
- Large tumours
- Unfit for surgery
Cytic hydroma
pathology
presentation
complications
management
Pathology: Congenital multicystic lymphatic malformation
Presentation:
Usually paediatric
Lobulated cystic swelling
Soft and fluctuant
Compressible
Transilluminate brilliantly
↑s in size when infant coughs / cries
Look in the oropharynx- Cyst may extend intoretropharyngeal space
- *Complications:**
- Obstruction of swallowing
- Respiratory obstruction
Management:
- Surgical excision
- Hypertonic saline sclerosant
Pharyngeal pouch
pathology
presentation
Herniation of pharyngeal mucosa through its muscular coat at its weakest point.
- Pulsion diverticulum
- *Killian’s dehiscence**
- Between thyro- and crico-pharyngeal muscles that form the inferior constrictor*
Presentation:
- Elderly patient
- Left sided cystic swelling
- Palpation → gurgling
- Hallitosis
Pharyngeal pouch
symptoms
complications
Ix
Management: non surg/surg
- *Symptoms**
- Regurgitation
- Dysphagia
- *Complications**
- Aspiration → pneumonia
- Diverticular neoplasia (<1%)
- *Ix**
- Ba swallow
Management:
- *Non-surgical**
- If small and asymptomatic
- *Surgical**: Dohlman’s Procedure
- Minimally invasive endoscopic stapling
Cervical rib
pathology
presentation (vasc/neuro)
management
-
Pathology:
- Overdevelopment of transverse process of C7
- Occur in 1:150
Presentation: Hard swelling: mostly asymmpto
Can → vascular symptoms
- Due to subclavian A. compression
- Subclavian steal
- Raynaud’s
Can → neurological symptoms
- Compress lower roots of brachial plexus, T1 or stellate ganglion
- Wasting of intrinsic hand muscles
- Paraesthesia along medial arm
management: Surgical excision
Cervical lymphadenopathy
examination
Key features (5) + technique + additional examination!
Key Features
- Consistency
- Number
- Fixation
- Symmetry
- Tenderness
Technique
- Ask pt. to drop chin to relax muscles
- Chin backwards → pre-auricular
- Down anterior cervical chain
- Supra- and infra-clavicular nodes
- Up posterior cervical chain
- Mastoid → occipital nodes
Additional Examination
- Face and scalp for infection or neoplasm
- Chest exam: infection or neoplasm
- Breast examination
- Formal full ENT examination
- Rest of reticuloendothelial system
Lymphadenopathy
key history Qs
- Symptoms from the lumps e.g. EtOH-induced pain
- General symptoms; Fever, malaise, wt. loss
- Systemic disease
- PMH
- Previous operations
- Social history
- Ethnic origin
- HIV risk factors
Causes of cervical lumphadenopathy: I LIST
- Lymphoma and Leukaemia
- Infection
- Sarcoidosis
- Tumours
- ENT
- Breast
- Lung
- Gastric
I= INFECTION
- Bacterial
- Tonsillitis, dental abscess
- TB
- Bartonella henselae (Cat scratch disease)
- Viral
- EBV
- HIV
- Protozoal
- Toxoplasmosis
Investigation of lymphadenopathy
blood/radiological/pathology
Blood
- FBC, ESR, film (atypical lymphocytes)
- TFTs, serum ACE
- Monospot test, HIV test
Radiological
- US
- CT scan
Pathology
- FNAC
- Excision biopsy
Salivary examination
inspect/palpate/complete
Inspection
- Skin changes: swelling, scars, sinuses
- Swelling / discrete lump
- Parotid or submandibular?
- Bilateral or unilateral?
- Facial asymmetry
- Inside the mouth c¯ a pen torch
- Stenson’s duct opposite the 2nd maxillary molar
- Wharton’s duct adjacent to the frenulum linguae
- Inflammation, stone, pus
Palpation
- Any tenderness?
- Palpate from behind
- Test muscle fixity: ask pt. to clench teeth
- Palpate for cervical lymphadenopathy
Completion
- Bimanual palpation of parotid and submandibular ducts for stones.
- Bimanual palpation of submandibular gland
- Test CN7
- Perform full ENT examination
Differential for swelling of salivary gland
diffus/localised
Diffuse Swelling of Whole Gland
- Infection: Parotitis
- Autoimmune: Sjogren’s
- Infiltration: Sarcoid
- Systemic: Chronic liver disease, DM, anorexia, bulimia
Localised Swelling
- Calculus
- Lipoma
- Salivary gland neoplasm
- Leukaemia: ALL
Salivary gland: key history Qs
Hx
- Pain or swelling related to food: calculi
- Fever / malaise: mumps
- Dry eyes / mouth: Sjogren’s
- SOB: sarcoid
Salivary gland neoplasm
common types
Common Types
- Benign
- Pleiomorphic adenoma: 80%
- <50yrs
- Adenolymphoma: Warthin’s tumour
- >50yrs
- Smoking is important risk factor
- Pleiomorphic adenoma: 80%
- Malignant
- 1st: Mucoepidermoid
- 2nd: Adenoid cystic
Salivary Gland Neoplasms
Features
80% in the parotid gland
80% benign: 80% are pleiomorphic adenomas
Only 60% of submandibular gland tumours are benign
Malignant Features
- Facial nerve palsy
- Rapid growth and pain
- Hyperaemic, hot skin
- Hard consistency
- Fixity to skin or underlying muscle
Investigation of salivary gland mass
FNA
MRI: determine deep lobe involvement
Salivary gland mass management
benign/malignant
-
Benign
- Superficial: superficial parotidectomy
- Deep: total parotidectomy
-
Malignant
- Total parotidectomy ± adjuvant radiotherapy
Complications of parotidectomy
(immediate/early/late)
-
Immediate
- Facial nerve injury
- Reactionary haemorrhage
-
Early
- Temporary facial weakness: neuropraxia
- Salivary fistula
- Loss of pinna sensation: greater auricular nerve damage.
- Late: Frey’s Syndrome (gustatory sweating)
- Facial sweating while eating
- Re-innervation of divided sympathetic nerves by fibres from the secretomotor branch of auriculotemporal branch of CNV3
Hypertrophic scar
- Scar confined to wound margins
- Across flexor surfaces and skin creases
- Appear soon after injury and regress spontaneously
- Any age: commonly 8-20yrs
- M=F
- All races
Keloid scar
- Scar extends beyond wound margins
- Earlobes, chin, neck, shoulder, chest
- Appear months after injury and continue to grow
- Puberty to 30yrs
- F>M
- Black and Hispanic
Hypertrophic and keloid scar Wound type Associations
- Infection
- Trauma
- Burns
- Tension
- Certain body areas
Hypertrophic and Keloid Scars management
non-surge and surg
Non-surgical
- Mechanical pressure therapy
- Topical silicone gel sheets
- Intralesional steroid and LA injections
Surgical: Revision of scar c¯ closure by direct suturing
Causes of digital clubbing
Gastrointestinal
CLD: esp. PBC
IBD: esp. Crohn’s
Coeliac disease
GI lymphoma
Respiratory
Chronic suppurative lung disease
CF / bronchiectasis
Abscess
Empyema
Malignancy: adenocarcinoma or mesothelioma
Pulmonary fibrosis
Cardiac
Infective endocarditis
Congenital cyanotic heart disease
Fallot’s
Transposition
Atrial myxoma: e.g. in Carney Complex
Miscellaneous
Familial
Thyroid acropachy
Axillary artery aneurysms and brachial AVMs
Pathophysiology of digital clubbing
Exact aetiology unknown
Platelet clumps and megakaryocytes bypass the lungs and impact in digital capillaries.
They release growth factors such as PDGF → clubbing
Stages of digital clubbing
1: bogginess of the nail bed
2: loss of the nail angle
3: ↑ curvature
4: expansion of the distal phalanx
