Superficial Lesions Flashcards
swelling / pain related to food?
salivary calculi
dry eyes/ mouth?
sjogrens
features of salivary calculi?
recurrent unilateral swelling and pain
worse on eating
red, tender, swollen gland (80% submandibular)
ix of salivary calculi?
Plain Xray or sialography
mx of salivary calculi?
gland excision
causes of acute parotitis?
viral: mumps, coxsackie A, HIV
Bacterial: S aureus
- assoc w calculi and poor oral hygiene
Salivary Gland neoplasms
most common type/ location
80% are in the parotid (80% are superficial)
80% are pleiomorphic adenomas
deflection of ear outwards is classic sign
Pleiomorphic adenoma presentation?
commonest salivary gland neoplasm
benign and slow growing
90% occur in parotid
occur in middle age
F>M
histology of pleiomorphic adenoma?
shows different tissue types
mx of pleiomorphic adenoma?
Superficial parotidectomy
types of benign salivary gland tumours?
- pleiomorphic adenoma
2nd: Adenolymphoma (warthins tumour)
Types of malignant salivary gland tumours?
1st: mucoepidermoid
2nd: adenoid cystic
Ix of salivary gland tumour??
ENT examination
US +/- CT
FNAC
mx of Adenolymphoma (warthins tumour)?
Enucleation
features of warthins tumour (adenolymphoma)?
benign soft cystic tumour
older men
Features of adenoid cystic salivary gland carcinoma?
one of the commonest malignant salivary tumours
highly malignant and often incurable
rapid growth
hard fixed mass
pain
facial n palsy
Complications of salivary gland surgery?
Facial n palsy
Salivary fistula
Frey’s Syndrome (gustatory sweating)
What is Frey’s Syndrome?
gustatory sweating
Redness and sweating skin over parotid area
Occurs in relation to food (inc. thinking)
Auriculotemporal branch of CN V3 carries sympathetic fibres to sweat glands over parotid area and parasympathetic fibres to the parotid
Reinnnervation of divided sympathetic nerves by fibres from the secretomotor branch of auriculotemporal branch of CN V3
congenital thyroid lumps?
lingual thyroid
ectopic thyroid tissue
thyroglossal cyst
embryology/ anatomy of thyroid?
Thyroid migrates from its origin at the foramen caecum at the base of the tongue.
- passes behind the hyoid bone
- lies anterior to 3-4th tracheal rings in the pretracheal fascia
leaves behind the thyroglossal cyst which atrophies
persistence -> thyroglossal cyst
ectopic thyroid tissue can be found anywhere along this descent
Ix of thyroid lump?
Bloods: TFTs, antibodies (TSH, anti-TPO), FBC, Ca, LFTs, ESR
imaging:
CXR- mets?
Radionucleotide scan
Histology:
FNA, biopsy
Laryngoscopy:
important pre op to assess vocal cords
Differential of diffuse goitre?
Graves
Thyroiditis: Hashimotos, De Quervains, Subacute lymphocytic (e.g. post partum)
Simple colloid goitre
- e.g. iodine deficiency, autoimmune
differential of multinodular goitre?
multinodular colloid goitre
multiple cysts
multiple adenomas
differential of solitary nodule in thyroid?
dominant nodule in multinodular goitre
adenoma
cyst
malignancy
diffuse painful goitre
preceding viral URTI common
thyrotoxicosis -> hypo -> eu
no iodine uptake
de Quervain’s viral thyroiditis
viral: coxsackie common
self-limiting
diffuse, painless goitre
hypothyroidism (may have transient thyrotoxicosis before)
assoc w other autoimmune disease
e.g. T1DM
Hashimoto’s
what antibodies are responsible in Hashimotos?
anti-TPO (thyroid peroxidase)
anti-thyroglobulin antibodies
anti-thyrotropin receptor
mx of Hashimoto’s thyroiditis?
Levothyroxine
Mx of viral de quervains thyroiditis?
analgesia
thyrotoxic symptoms can be tx w BBs
Diffuse painless goitre
may occur postpartum
thyrotoxicosis -> hypo-> eu
postpartum thyroiditis/ subacute lymphocytic
autoimmune
mx of postpartum (subacute lymphocytic) thyroiditis?
hypo -> may need levothyroxine
hyper -> BBs may provide relief
diffuse goitre w bruit
exophthalmos
pretibial myxoedema
thyrotoxicosis
assoc w other autoimmune disease
increased uptake on radionucleotide scan
Graves disease
pathology of graves disease?
autoimmune (T2 hypersensitivity)
anti-TSHR antibodies
mx of graves disease?
BB e.g. propranolol for symptomatic relief
carbimazole (or propylthiouracil) - block binding to Iodine
Radioiodine
Thyroidectomy
diffuse painless goitre
mass effects: dysphagia, stridor, SVC obstruction
usually euthyroid , may -> hypo
iodine deficiency is common cause
simple goitre
mx: thyroxine, total or subtotal thyroidectomy if pressure symptoms
Multinodular goitre
thyrotoxicosis
uneven iodine uptake with hot nodule
toxic multinodular goitre
(Plummers)
mx of toxic multinodular goitre
carbimazole
radioiodine
total/ subtotal thyroidectomy
features of Riedel’s thyroiditis?
firm, fixed, irregular thyroid mass (dense fibrosis)
mass effects
assoc w fibrosis and infiltration by IgG4 secreting plasma cells
mx of riedel’s thyroiditis?
prednisolone
surgical relief of compression symptoms
Risk factors for malignancy in thyroid nodules?
Solitary
Solid
Younger
Male
Cold
Radiation exposure
most common type of thyroid malignancy?
papillary cancer
80%
common in 20-40
assoc w irradiation
origin: follicular cells
thyroid tumour marker?
thyroglobulin
presentation of thyroid cancer?
Non-functional (cold)
Painless neck mass
Cervical mets
Compression symptoms
- Dysphagia
- Stridor
- SVC obstruction
Indications for thyroid surgery?
- *M**echanical obstruction
- *M**alignancy
- *M**arred beauty: cosmetic reasons
- *M**edical Rx failure: thyrotoxicosis
- *M**ediastinal extension: can’t monitor changes
Pre-op thyroid surgery ?
Render euthyroid pre-op w antithyroid drugs:
- Stop 10 days prior to surgery (they ↑ vascularity)
- Alternatively just give propronalol
Check for phaeo pre-op in medullary carcinoma
Laryngoscopy: check vocal cords pre- and post-op
Medullary thyroid cancer features?
5% of total thyroid malignancy
30% familial e.g. MEN2 (young)
sporadic (40-50)
origin: parafollicular C cells
tumour markers of medullary thyroid ca?
CEA and calcitonin
Mx of medullary thyroid ca?
Do phaeo screen pre op
thyroidectomy + node clearance
consider radiotx
follicular thyroid ca features?
10% of total malignancy
40-60yo
follicular cells origin
tumour marker thyroglobulin suggests which subtypes of thyroid malignancy?
papillary
follicular
mx of follicular thyroid ca?
total thyroidectomy + T4 suppression + radioiodine
Anaplastic thyroid ca features?
undifferentiated follicular cells
rare
rapid growth
aggressive spread
mx of anaplastic thyroid ca?
usually palliative
may try thyroidectomy + radiotx
mx of papillary thyroid ca?
total thyroidectomy
+/- node excision +/- radio iodine
T4 to suppress TSH
MALToma in thyroid?
assoc with Hashimoto’s thyroiditis
late complications of thyroid surgery?
hypothyroidism
recurrent hyperthyroidism
keloid scar
Early complications of thyroid surgery?
reactionary haemorrhage -> haematoma
-> airway obstruction
laryngeal oedema
damage during intubation or surgical manipulation
can -> airway obstruction
recurrent laryngeal n palsy
right RLN more common (oblique ascent)
damage to one -> hoarse voice
damage to both -> obstruction needing trache
hypocalcaemia
usually parathyroid dysfunction but may be permanent if parathyroids removed
thyroid storm
severe hyperthyroidism
mx of haematoma after thyroid surgery?
can -> airway obstruction
call anaesthetist + remove wound clips
evacuate haematoma and re-explore wound
features of hypocalcaemia following thyroid surgery?
presents 24-48h post surgery
tingling in fingers and lips
wheeze/ stridor -> airway obstruction
Chvostek’s
Trousseau’s
what is Trousseau’s sign?
hypocalcaemia
BP cuff inflated -> occlude brachial artery ->
wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct.
aka main d’accoucheur (hand of obstetrician)
what is Chvostek’s sign?
hypocalcaemia
When the facial nerve is tapped in front of tragus the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcemia with resultant hyperexcitability of nerves.
mx of hypocalcaemia following thyroid sx?
10 ml 10% calcium gluconate IV
Mx of thyroid storm?
propranolol
antithyroid drugs (carbimazole/ propylthiouracil)
Lugol’s iodine
hydrocortisone sodium succinate
what is a hypertrophic scar?
scar confined to wound margins
across flexor surfaces and skin creases
appears soon after injury and regress spontaneously
any age: commonly 8-20 yrs
features of a keloid scar?
scar extends beyond wound margins
earlobes, chin, neck, shoulder, chest
appears months after injury and continue to grow
puberty to 30 yrs
F>M
black and hispanic
mx of hypertrophic/ keloid scars?
non surgical:
mechanical pressure therapy
topical silicone gel sheets
intralesional steroid and LA injections
surgical:
revision of scar w closure by direct suturing
key features to note about cervical lymphadenopathy?
consistency
number
fixation
symmetry tenderness
what other examinations are relevant w cervical lymphadenopathy?
face and scalp for infection/ neoplasm
chest
breast
ENT
rest of reticuloendothelial system
hx relevant in cervical lymphadenopathy?
FLAWS
symptoms from lumps?
e.g. alcohol induced pain
systemic disease? (PMH, previous ops)
social hx - HIV risk factors
causes of cervical lymphadenopathy?
lymphoma/ leukaemia
infection
sarcoidosis
tumours
ix of neck lumps?
triple assessment
clinical assessment
imaging: US
cyto/ histo: aspiration or biopsy
what makes up the anterior triangle of the neck?
anterior margin of SCM
midline
ramus of mandible
lumps in anterior triangle?
pulsatile:
carotid artery aneurysm
tortuous carotid artery
carotid body tumour
non-pulsatile:
branchial cysts
laryngocele
goitre
parotid tumour
what is the submandibular triangle?
located underneath the body of the mandible. It contains the submandibular gland (salivary), and lymph nodes. The facial artery and vein also pass through this area.
Superiorly – body of the mandible.
Anteriorly – anterior belly of the digastric muscle.
Posteriorly – posterior belly of the digastric muscle.
causes of lumps in the submandibular triangle?
salivary stone
sialadenitis
salivary tumour
what is the posterior triangle of the neck?
posterior margin of SCM
anterior margin of trapezius
mid 1/3 of clavicle
causes of lumps in posterior triangle of neck?
LNs
cervical ribs
cystic hygromas
pancoast tumour
pharyngeal pouch
age < 20 yrs
lump on ant margin of SCM at junction of upper and middle 3rd
may become infected-> abscess
may be assoc w branchial fistula
contain cholesterol crystals
lined by squamous epithelium
Branchial cyst
(embryological remnant of 2nd branchial cleft)
mx of branchial cyst?
medical:
abx for infection
sclerotherapy may be used
Surgical excision:
definitive tx
may be difficult due to proximity of carotids
Small opening in lower 3rd of neck on ant. margin of SCM
Between tonsillar fossa and ant. border of SCM
May discharge mucus
branchial sinus/ fistula
Cystic dilatation of the laryngeal saccule
Congenital or acquired
Exacerbated by blowing
laryngocele
features of carotid body tumour (chemodectoma)?
Just anterior to upper 3rd of SCM.
Pulsatile
Move laterally but not vertically
May be bilateral
Pressure may → dizziness and syncope
Mostly benign (5% malignant)
Ix of carotid body tumour?
doppler or angio: splaying of bifurcation
features of dermoid cyst?
developmental inclusion of epidermis along lines of skin fusion
common <20 yr
found at junctions of embryological fusion
- neck midline
- lateral angles of eyebrow
- under tongue
contains ectodermal elements
- hair, sebaceous glands
mx: excision
features of thyroglossal cyst?
Fluctuant lump that moves up w tongue protrusion
Can become infected → thyroglossal fistula
Cyst formed from persistent thyroglossal duct
- Path of thyroid descent from base of tongue
mx of thyroglossal cyst?
sistrunks operation: excision of cyst and thyroglossal duct
what is a cervical rib?
Overdevelopment of transverse process of C7
features of cervical rib?
Mostly asymptomatic
Hard swelling
↓ radial pulse on abduction and external rotation of arm
Can → vascular symptoms
Compresses subclavian A
Raynaud’s
Subclavian steal
↓ venous outflow → oedema
Can → neurological symptoms
Compresses lower trunk of brachial plexus, T1 nerve root or stellate ganglion.
Wasting of intrinsic hand muscles
Paraesthesia along medial border of arm
what is pharyngeal pouch?
where is a weak spot?
Herniation of pharyngeal mucosa through its muscular coat at its weakest point.
Killian’s dehiscence: represents a potentially weak spot.
a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus of the inferior constrictor of the pharynx
what is Killian’s dehiscence?
a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus of the inferior constrictor of the pharynx
swelling on left side of neck (posterior triangle)
regurgitation and aspiration
halitosis
gurgling sounds
food debris -> pouch expansion -> oesophageal compression -> dysphagia
pharyngeal pouch
ix of pharyngeal pouch?
barium swallow
mx of pharyngeal pouch?
excision and cricopharyngeal myotomy
endoscopic stapling
lump in lower part of posterior triangle but may extend to axilla
infants
increases in size when child coughs/ cries
transilluminates
cystic hygroma
mx of cystic hygroma?
excision or hypertonic saline sclerosant
may recur
features of malignant melanoma?
Asymmetry
Border: irregular
Colour: non-uniform
Diameter >6mm
Evolving / Elevation
risk factors of malignant melanoma?
Sunlight: esp. intense exposure in early years.
Fair skinned (low Fitzpatrick skin type)
↑ no. of common moles
+ve FH
↑age
Immunosuppression
types of malignant melanoma?
Superficial spreading (80%)
- irregular borders, colour variation
- grow slowly, metastasize late = better prognosis
Lentigo maligna melanoma
- often elderly pts
- face/ scalp
acral lentiginous
- asians/ black
- palms, soles, subungual
nodular melanoma
- all sites
younger age, new lesion
- invade deeply and metastasize early = poor prognosis
amelanotic
- atypical appearance -> delayed dx
Breslow depth?
melanoma
thickness of tumour to deepest point of dermal invasion
clarks staging of malignant melanoma?
stratifies depth by 5 anatomical levels
stage 1: epidermis
Stage 5: sc fat
mx of malignant melanoma?
excision + 2O margin excision depending on Breslow depth
+/- lymphadenectomy
+/- adjuvant chemo
features of squamous cell carcinoma?
ulcerated lesion w hard, raised everted edges
sun exposed areas: scalp, face, ears, lower leg
may arise in chronic ulcers: marjolins ulcer
xeroderma pigmentosa (increased risk)
What are the premalignant lesions before SCC?
Solar/ actinic keratosis -> bowens -> SCC
What is Bowen’s Disease?
red/ brown scaly plaques
typically on the legs of older women
SCC in situ
What are actinic keratoses?
irregular crusty warty lesions
pre malignant
tx: cautery, cryotherapy
commonest skin cancer
pearly nodule w rolled telangiectatic edge
may ulcerate
typically on face in sun exposed area
basal cell carcinoma
- low grade malignancy -> rarely metastasize
locally invasive
mx of Basal Cell Carcinoma?
excision
- Mohs: complete circumferential margin assessment using frozen section histology
Cryo/ radio may be used
features of lipoma?
palpation: soft, subcutaneous, imprecise margin, fluctuant
occur anywhere fat can expand
condition characterized by generalized obesity and fatty tumors in the adipose tissue.
multiple, painful lipomas
assoc peripheral neuropathy
Dercum’s disease aka Adiposis dolorosa
autosomal dominant condition characterized by multiple lipomas on the trunk and extremities.
Familial Multiple Lipomatosis
rare disease characterized by abnormal diffuse lipomatosis in proximal upper limbs and neck.
madelung’s disease
macrocephaly + multiple lipomas + haemangiomas?
Bannayan-Zonana Syndrome
what is a sebaceous cyst?
epithelial lined cyst containing keratin
- epidermal cyst
- arise from hair follicle infundibulum - trichilemmal cyst
- arise from hair follicle epithelium
- often multiple
features of sebaceous cyst?
occur @ sites of hair growth
scalp, face, neck, chest and back
NOT soles or palms
central punctum
complications of sebaceous cyst?
infection: pus discharge
ulceration
calcification
Large ulcerating trichilemmal cyst on the scalp
resembles an SCC
Cock’s peculiar tumour
Familial adenomatous polyposis + thyroid tumours + osteomas + dental abnormalities + epidermal cysts
Gardener’s Syndrome
cystic swelling related to a synovial lined structures: joint, tendon
myxoid degeneration of fibrous tissue
contains thick, gelatinous material
ganglion
features of ganglion?
can be found anywhere
90% on dorsum of hand or wrist
dorsum of ankle
May be scar from recurrence
weakly transilluminable
on palpation: soft, suncutaneous, may be tethered to tendon
dark brown greasy stuck on appearance
benign hyperplasia of basal epithelial layer
hyperkeratosis: keratin layer thickening
acanthosis: prickle layer thickening
Seborrheic keratosis
skin cancer tumor that looks like a tiny dome or crater.
dome shaped w keratin plug
intradermal
Keratoacanthoma
Benign overgrowth of hair follicle cells
Cytologically similar to well- differentiated SCCs
Mx of Keratoacanthoma?
Regress within 6 wks
Excision + histology
features of neurofibroma?
Benign nerve sheath tumour arising from schwann cells.
soliary/ multiple pedunculated nodules
fleshy consistency
pressure can -> paraesthesia
assoc w NF1
Features of Neurofibromatosis type 1?
Auto dom, Chr 17
cafe au lait spots (>6)
freckling
neurofibromas
Lisch nodules (iris)
what is a papilloma?
Overgrowth of all layers of the skin w a central vascular core.
skin tag/ fibroepithelial polyp
pedunculated
flesh coloured
mx: excision + diathermy to control bleeding
what is a pyogenic granuloma?
rapidly growing capillary haemangioma
neither pyogenic nor a granuloma
most commonly on hands, face, gums, lips
bright red hemispherical nodule
may have serous/ purulent discharge
soft, bleeds easily
Pyogenic granuloma assoc w?
previous trauma
more common in pregnancy
mx of pyogenic granuloma?
regression is uncommon
surgical: curettage w diathermy of bases
types of dermoid cyst?
congenital:
- developmental inclusion of epidermis along lines of skin fusion
- midline of neck and nose
- medial and lateral ends of eye brows
acquired/ implantation cyst:
- implantation of epidermis in dermis
- often secondary to trauma e.g. piercing
mx of dermoid cyst?
congenital:
CT to establish extent
surgical excision
acquired:
surgical excision
what is a dermatofibroma?
benign neoplasm of dermal fibroblasts
can occur anywhere
mostly on the lower limbs of young to middle aged women
small brown pigmented nodule
on palpation: firm woody feel
intradermal: mobile over deep tissue
