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Surgery > Superficial Lesions > Flashcards

Superficial Lesions Flashcards

1
Q

swelling / pain related to food?

A

salivary calculi

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2
Q

dry eyes/ mouth?

A

sjogrens

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3
Q

features of salivary calculi?

A

recurrent unilateral swelling and pain

worse on eating

red, tender, swollen gland (80% submandibular)

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4
Q

ix of salivary calculi?

A

Plain Xray or sialography

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5
Q

mx of salivary calculi?

A

gland excision

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6
Q

causes of acute parotitis?

A

viral: mumps, coxsackie A, HIV

Bacterial: S aureus

  • assoc w calculi and poor oral hygiene
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7
Q

Salivary Gland neoplasms

most common type/ location

A

80% are in the parotid (80% are superficial)

80% are pleiomorphic adenomas

deflection of ear outwards is classic sign

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8
Q

Pleiomorphic adenoma presentation?

A

commonest salivary gland neoplasm

benign and slow growing

90% occur in parotid

occur in middle age

F>M

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9
Q

histology of pleiomorphic adenoma?

A

shows different tissue types

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10
Q

mx of pleiomorphic adenoma?

A

Superficial parotidectomy

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11
Q

types of benign salivary gland tumours?

A
  1. pleiomorphic adenoma
    2nd: Adenolymphoma (warthins tumour)
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12
Q

Types of malignant salivary gland tumours?

A

1st: mucoepidermoid
2nd: adenoid cystic

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13
Q

Ix of salivary gland tumour??

A

ENT examination

US +/- CT

FNAC

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14
Q

mx of Adenolymphoma (warthins tumour)?

A

Enucleation

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15
Q

features of warthins tumour (adenolymphoma)?

A

benign soft cystic tumour

older men

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16
Q

Features of adenoid cystic salivary gland carcinoma?

A

one of the commonest malignant salivary tumours

highly malignant and often incurable

rapid growth

hard fixed mass

pain

facial n palsy

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17
Q

Complications of salivary gland surgery?

A

Facial n palsy

Salivary fistula

Frey’s Syndrome (gustatory sweating)

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18
Q

What is Frey’s Syndrome?

A

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

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19
Q

congenital thyroid lumps?

A

lingual thyroid

ectopic thyroid tissue

thyroglossal cyst

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20
Q

embryology/ anatomy of thyroid?

A

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

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21
Q

Ix of thyroid lump?

A

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

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22
Q

Differential of diffuse goitre?

A

Graves

Thyroiditis: Hashimotos, De Quervains, Subacute lymphocytic (e.g. post partum)

Simple colloid goitre

  • e.g. iodine deficiency, autoimmune
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23
Q

differential of multinodular goitre?

A

multinodular colloid goitre

multiple cysts

multiple adenomas

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24
Q

differential of solitary nodule in thyroid?

A

dominant nodule in multinodular goitre

adenoma

cyst

malignancy

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25
Q

diffuse painful goitre

preceding viral URTI common

thyrotoxicosis -> hypo -> eu

no iodine uptake

A

de Quervain’s viral thyroiditis

viral: coxsackie common

self-limiting

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26
Q

diffuse, painless goitre

hypothyroidism (may have transient thyrotoxicosis before)

assoc w other autoimmune disease

e.g. T1DM

A

Hashimoto’s

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27
Q

what antibodies are responsible in Hashimotos?

A

anti-TPO (thyroid peroxidase)

anti-thyroglobulin antibodies

anti-thyrotropin receptor

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28
Q

mx of Hashimoto’s thyroiditis?

A

Levothyroxine

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29
Q

Mx of viral de quervains thyroiditis?

A

analgesia

thyrotoxic symptoms can be tx w BBs

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30
Q

Diffuse painless goitre

may occur postpartum

thyrotoxicosis -> hypo-> eu

A

postpartum thyroiditis/ subacute lymphocytic

autoimmune

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31
Q

mx of postpartum (subacute lymphocytic) thyroiditis?

A

hypo -> may need levothyroxine

hyper -> BBs may provide relief

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32
Q

diffuse goitre w bruit

exophthalmos

pretibial myxoedema

thyrotoxicosis

assoc w other autoimmune disease

increased uptake on radionucleotide scan

A

Graves disease

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33
Q

pathology of graves disease?

A

autoimmune (T2 hypersensitivity)

anti-TSHR antibodies

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34
Q

mx of graves disease?

A

BB e.g. propranolol for symptomatic relief

carbimazole (or propylthiouracil) - block binding to Iodine

Radioiodine

Thyroidectomy

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35
Q

diffuse painless goitre

mass effects: dysphagia, stridor, SVC obstruction

usually euthyroid , may -> hypo

iodine deficiency is common cause

A

simple goitre

mx: thyroxine, total or subtotal thyroidectomy if pressure symptoms

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36
Q

Multinodular goitre

thyrotoxicosis

uneven iodine uptake with hot nodule

A

toxic multinodular goitre

(Plummers)

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37
Q

mx of toxic multinodular goitre

A

carbimazole

radioiodine

total/ subtotal thyroidectomy

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38
Q

features of Riedel’s thyroiditis?

A

firm, fixed, irregular thyroid mass (dense fibrosis)

mass effects

assoc w fibrosis and infiltration by IgG4 secreting plasma cells

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39
Q

mx of riedel’s thyroiditis?

A

prednisolone

surgical relief of compression symptoms

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40
Q

Risk factors for malignancy in thyroid nodules?

A

Solitary

 Solid

 Younger

 Male

 Cold

 Radiation exposure

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41
Q

most common type of thyroid malignancy?

A

papillary cancer

80%

common in 20-40

assoc w irradiation

origin: follicular cells

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42
Q

thyroid tumour marker?

A

thyroglobulin

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43
Q

presentation of thyroid cancer?

A

Non-functional (cold)

Painless neck mass

Cervical mets

Compression symptoms

  • Dysphagia
  • Stridor
  • SVC obstruction
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44
Q

Indications for thyroid surgery?

A
  • *M**echanical obstruction
  • *M**alignancy
  • *M**arred beauty: cosmetic reasons
  • *M**edical Rx failure: thyrotoxicosis
  • *M**ediastinal extension: can’t monitor changes
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45
Q

Pre-op thyroid surgery ?

A

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

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46
Q

Medullary thyroid cancer features?

A

5% of total thyroid malignancy

30% familial e.g. MEN2 (young)

sporadic (40-50)

origin: parafollicular C cells

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47
Q

tumour markers of medullary thyroid ca?

A

CEA and calcitonin

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48
Q

Mx of medullary thyroid ca?

A

Do phaeo screen pre op

thyroidectomy + node clearance

consider radiotx

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49
Q

follicular thyroid ca features?

A

10% of total malignancy

40-60yo

follicular cells origin

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50
Q

tumour marker thyroglobulin suggests which subtypes of thyroid malignancy?

A

papillary

follicular

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51
Q

mx of follicular thyroid ca?

A

total thyroidectomy + T4 suppression + radioiodine

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52
Q

Anaplastic thyroid ca features?

A

undifferentiated follicular cells

rare

rapid growth

aggressive spread

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53
Q

mx of anaplastic thyroid ca?

A

usually palliative

may try thyroidectomy + radiotx

54
Q

mx of papillary thyroid ca?

A

total thyroidectomy

+/- node excision +/- radio iodine

T4 to suppress TSH

55
Q

MALToma in thyroid?

A

assoc with Hashimoto’s thyroiditis

56
Q

late complications of thyroid surgery?

A

hypothyroidism

recurrent hyperthyroidism

keloid scar

57
Q

Early complications of thyroid surgery?

A

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

58
Q

mx of haematoma after thyroid surgery?

A

can -> airway obstruction

call anaesthetist + remove wound clips

evacuate haematoma and re-explore wound

59
Q

features of hypocalcaemia following thyroid surgery?

A

presents 24-48h post surgery

tingling in fingers and lips

wheeze/ stridor -> airway obstruction

Chvostek’s

Trousseau’s

60
Q

what is Trousseau’s sign?

A

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)

61
Q

what is Chvostek’s sign?

A

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.

62
Q

mx of hypocalcaemia following thyroid sx?

A

10 ml 10% calcium gluconate IV

63
Q

Mx of thyroid storm?

A

propranolol

antithyroid drugs (carbimazole/ propylthiouracil)

Lugol’s iodine

hydrocortisone sodium succinate

64
Q

what is a hypertrophic scar?

A

scar confined to wound margins

across flexor surfaces and skin creases

appears soon after injury and regress spontaneously

any age: commonly 8-20 yrs

65
Q

features of a keloid scar?

A

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

66
Q

mx of hypertrophic/ keloid scars?

A

non surgical:

mechanical pressure therapy

topical silicone gel sheets

intralesional steroid and LA injections

surgical:

revision of scar w closure by direct suturing

67
Q

key features to note about cervical lymphadenopathy?

A

consistency

number

fixation

symmetry tenderness

68
Q

what other examinations are relevant w cervical lymphadenopathy?

A

face and scalp for infection/ neoplasm

chest

breast

ENT

rest of reticuloendothelial system

69
Q

hx relevant in cervical lymphadenopathy?

A

FLAWS

symptoms from lumps?

e.g. alcohol induced pain

systemic disease? (PMH, previous ops)

social hx - HIV risk factors

70
Q

causes of cervical lymphadenopathy?

A

lymphoma/ leukaemia

infection

sarcoidosis

tumours

71
Q

ix of neck lumps?

A

triple assessment

clinical assessment

imaging: US

cyto/ histo: aspiration or biopsy

72
Q

what makes up the anterior triangle of the neck?

A

anterior margin of SCM

midline

ramus of mandible

73
Q

lumps in anterior triangle?

A

pulsatile:

carotid artery aneurysm

tortuous carotid artery

carotid body tumour

non-pulsatile:

branchial cysts

laryngocele

goitre

parotid tumour

74
Q

what is the submandibular triangle?

A

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.

75
Q

causes of lumps in the submandibular triangle?

A

salivary stone

sialadenitis

salivary tumour

76
Q

what is the posterior triangle of the neck?

A

posterior margin of SCM

anterior margin of trapezius

mid 1/3 of clavicle

77
Q

causes of lumps in posterior triangle of neck?

A

LNs

cervical ribs

cystic hygromas

pancoast tumour

pharyngeal pouch

78
Q

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

A

Branchial cyst

(embryological remnant of 2nd branchial cleft)

79
Q

mx of branchial cyst?

A

medical:

abx for infection

sclerotherapy may be used

Surgical excision:

definitive tx

may be difficult due to proximity of carotids

80
Q

Small opening in lower 3rd of neck on ant. margin of SCM

Between tonsillar fossa and ant. border of SCM
May discharge mucus

A

branchial sinus/ fistula

81
Q

Cystic dilatation of the laryngeal saccule

Congenital or acquired

Exacerbated by blowing

A

laryngocele

82
Q

features of carotid body tumour (chemodectoma)?

A

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)

83
Q

Ix of carotid body tumour?

A

doppler or angio: splaying of bifurcation

84
Q

features of dermoid cyst?

A

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
85
Q

features of thyroglossal cyst?

A

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

86
Q

mx of thyroglossal cyst?

A

sistrunks operation: excision of cyst and thyroglossal duct

87
Q

what is a cervical rib?

A

Overdevelopment of transverse process of C7

88
Q

features of cervical rib?

A

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

89
Q

what is pharyngeal pouch?

where is a weak spot?

A

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

90
Q

what is Killian’s dehiscence?

A

a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus of the inferior constrictor of the pharynx

91
Q

swelling on left side of neck (posterior triangle)

regurgitation and aspiration

halitosis

gurgling sounds

food debris -> pouch expansion -> oesophageal compression -> dysphagia

A

pharyngeal pouch

92
Q

ix of pharyngeal pouch?

A

barium swallow

93
Q

mx of pharyngeal pouch?

A

excision and cricopharyngeal myotomy

endoscopic stapling

94
Q

lump in lower part of posterior triangle but may extend to axilla

infants

increases in size when child coughs/ cries

transilluminates

A

cystic hygroma

95
Q

mx of cystic hygroma?

A

excision or hypertonic saline sclerosant

may recur

96
Q

features of malignant melanoma?

A

Asymmetry

Border: irregular

Colour: non-uniform

Diameter >6mm

Evolving / Elevation

97
Q

risk factors of malignant melanoma?

A

Sunlight: esp. intense exposure in early years.

Fair skinned (low Fitzpatrick skin type)

↑ no. of common moles

+ve FH

↑age

Immunosuppression

98
Q

types of malignant melanoma?

A

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
99
Q

Breslow depth?

A

melanoma

thickness of tumour to deepest point of dermal invasion

100
Q

clarks staging of malignant melanoma?

A

stratifies depth by 5 anatomical levels

stage 1: epidermis

Stage 5: sc fat

101
Q

mx of malignant melanoma?

A

excision + 2O margin excision depending on Breslow depth

+/- lymphadenectomy

+/- adjuvant chemo

102
Q

features of squamous cell carcinoma?

A

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)

103
Q

What are the premalignant lesions before SCC?

A

Solar/ actinic keratosis -> bowens -> SCC

104
Q

What is Bowen’s Disease?

A

red/ brown scaly plaques

typically on the legs of older women

SCC in situ

105
Q

What are actinic keratoses?

A

irregular crusty warty lesions

pre malignant

tx: cautery, cryotherapy

106
Q

commonest skin cancer

pearly nodule w rolled telangiectatic edge

may ulcerate

typically on face in sun exposed area

A

basal cell carcinoma

  • low grade malignancy -> rarely metastasize

locally invasive

107
Q

mx of Basal Cell Carcinoma?

A

excision

  • Mohs: complete circumferential margin assessment using frozen section histology

Cryo/ radio may be used

108
Q

features of lipoma?

A

palpation: soft, subcutaneous, imprecise margin, fluctuant

occur anywhere fat can expand

109
Q

condition characterized by generalized obesity and fatty tumors in the adipose tissue.

multiple, painful lipomas

assoc peripheral neuropathy

A

Dercum’s disease aka Adiposis dolorosa

110
Q

autosomal dominant condition characterized by multiple lipomas on the trunk and extremities.

A

Familial Multiple Lipomatosis

111
Q

rare disease characterized by abnormal diffuse lipomatosis in proximal upper limbs and neck.

A

madelung’s disease

112
Q

macrocephaly + multiple lipomas + haemangiomas?

A

Bannayan-Zonana Syndrome

113
Q

what is a sebaceous cyst?

A

epithelial lined cyst containing keratin

  1. epidermal cyst
    - arise from hair follicle infundibulum
  2. trichilemmal cyst
    - arise from hair follicle epithelium
    - often multiple
114
Q

features of sebaceous cyst?

A

occur @ sites of hair growth

scalp, face, neck, chest and back

NOT soles or palms

central punctum

115
Q

complications of sebaceous cyst?

A

infection: pus discharge

ulceration

calcification

116
Q

Large ulcerating trichilemmal cyst on the scalp

resembles an SCC

A

Cock’s peculiar tumour

117
Q

Familial adenomatous polyposis + thyroid tumours + osteomas + dental abnormalities + epidermal cysts

A

Gardener’s Syndrome

118
Q

cystic swelling related to a synovial lined structures: joint, tendon

myxoid degeneration of fibrous tissue

contains thick, gelatinous material

A

ganglion

119
Q

features of ganglion?

A

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

120
Q

dark brown greasy stuck on appearance

benign hyperplasia of basal epithelial layer

hyperkeratosis: keratin layer thickening
acanthosis: prickle layer thickening

A

Seborrheic keratosis

121
Q

skin cancer tumor that looks like a tiny dome or crater.

dome shaped w keratin plug

intradermal

A

Keratoacanthoma

Benign overgrowth of hair follicle cells

Cytologically similar to well- differentiated SCCs

122
Q

Mx of Keratoacanthoma?

A

Regress within 6 wks

Excision + histology

123
Q

features of neurofibroma?

A

Benign nerve sheath tumour arising from schwann cells.

soliary/ multiple pedunculated nodules

fleshy consistency

pressure can -> paraesthesia

assoc w NF1

124
Q

Features of Neurofibromatosis type 1?

A

Auto dom, Chr 17

cafe au lait spots (>6)

freckling

neurofibromas

Lisch nodules (iris)

125
Q

what is a papilloma?

A

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

126
Q

what is a pyogenic granuloma?

A

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

127
Q

Pyogenic granuloma assoc w?

A

previous trauma

more common in pregnancy

128
Q

mx of pyogenic granuloma?

A

regression is uncommon

surgical: curettage w diathermy of bases

129
Q

types of dermoid cyst?

A

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
130
Q

mx of dermoid cyst?

A

congenital:
CT to establish extent

surgical excision

acquired:

surgical excision

131
Q

what is a dermatofibroma?

A

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

Surgery (17 decks)

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