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Superficial structures > Thyroid and Neck unit > Flashcards

Thyroid and Neck unit Flashcards

1
Q

What does the term ‘Adam’s Apple’ refer to?

A

Laryngeal prominence

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2
Q

List the 4 strap muscles and where are they?

A

sternohyoid, sternothyroid, thyrohyoid, and omohyoid. located anterior to the thyroid

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3
Q

Where is the longus coli muscle?

A

posterior to the thyroid (forming the posterior border)

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4
Q

Where is the sternocleidomastoid muscle?

A

lateral and more superficial to the strap muscles

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5
Q

Where are the scalene muscles?

A

posterior and lateral in the neck

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6
Q

How can you differentiate a possible mass from a muscle in the neck?

A

look in sag and transverse, if you cant see it in both planes, its a muscle

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7
Q

What side of the thyroid is the esophagus seen on?

A

left side of the neck

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8
Q

Where is the basic location of the parathyroid glands?

A

typically 4 parathyroids, 2 superior and posterior to the mid/upper thyroid, and 2 inferior and posterior to the lower thyroid

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9
Q

Neck segments: describe 1A, 1B and what is seen in 1B?

A

1A: submental
1B: submandibular area, contains the SMG

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10
Q

Neck regions: What is seen in 2A? Where is 2B?

A

2A contains the jugulodigastric node and IVJ

2B is posterior to the IVJ

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11
Q

Neck regions: What does level 3 contain a part of? What does level 4 contain?

A

Level 3 contains a portion of the SCM

Level 4 contains the medial supraclavicular nodes

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12
Q

Describe the difference in location for 5A and 5B, and what does 5B contain?

A

5A is the superior portion, 5B is the inferior portion

5B contains the lateral supraclavicular nodes

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13
Q

Neck regions: Where is level 6 and where is level 7?

A

Level 6 is superior to level 6/suprasternal notch

Level 7 is in the suprasternal notch of the neck

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14
Q

What is the thyroid gland and what does it do?

What does the thyroid control?

A

it is an endocrine gland and it synthesizes, stores and secretes hormones (directly into bloodstream)
- controls the BMR: basal metabolic rate (rate at which the body uses energy at rest to keep organs going)

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15
Q

What are the 3 hormones secreted by the thyroid gland?

A

T3: triiodothyronine
T4: thyroxine
Calcitonin

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16
Q

Which cells secrete calcitonin and what role does it play?

A

secreted by the parafollicular cells

lowers blood calcium level (inhibits calcium release from the bone)

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17
Q

What cells secrete T3 and T4?

A

follicular cells

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18
Q

What does the regulatory system involve?

A

hypothalamus, pituitary gland and the thyroid gland

- maintains T3 and T4 levels

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19
Q

What is thyrotropin also known as? What is it regulated by?

A

same as thyroid stimulating hormone (TSH) and is released from the pituitary gland
- regulated by T3, T4 and thyrotropin releasing hormone (TRH)

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20
Q

Describe the negative feedback loop of the thyroid gland

A 
1- decrease in thyroid hormone decreases the BMR
2- decrease in the BMR stimulates TRH
3- TRH induces the release of TSH
4- thyroid releases T3 and T4
5- BMR returns to normal
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21
Q

What is the average size of the thyroid gland? What is it covered by?

A

4-6cm in length, 1.3-1.8cm AP

covered in a fibrous capsule

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22
Q

How much does the thyroid gland weigh?

A

15-20g in adults

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23
Q

Explain the blood flow of the thyroid

A

2 superior thyroid arteries arising off the ECA
2 inferior thyroid arteries arising from thyrocervical trunk of the subclavian artery

possible thyroid IMA artery (variation that typically supplies the isthmus)

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24
Q

Explain the venous drainage of the thyroid gland

A

2 superior thyroid veins, 2 middle thyroid veins, 2 inferior thyroid veins

superior and middle drain into IJV
inferior drains into BCV

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25
Q

What is the most severe thyroid variation?

A

athyrosis

  • associated with cretinism
  • congenital absence of the gland
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26
Q

Thyroid variations: What is a thyroglossal tract?

A

traces of epithelial cells that normally solidifies and should ultimately atrophy

-where the thyroid descends during development

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27
Q

What is the most common thyroid variation?

A

pyramidal lobe: typically extends upwards from the isthmus, or from either lobe

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28
Q

Where is the most common location for an ectopic thyroid gland?

A

can be at any level along the duct but most commonly lingual (sublingual?)

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29
Q

What does the parathyroid glands produce?

What do they look like

A

produce parathyroid hormone

oval/almond shaped measuring up to 5mm

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30
Q

What is the primary source of production of the parathyroid hormone? (PTH)

What does PTH regulate?

A

chief cells

  • blood calcium levels and phosphorus levels
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31
Q

What organs is PTH important for?

A

bones, kidneys and intestins

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32
Q

Describe the parathyroid feedback loop

A

increase in calcium levels prevents further PTH secretion

- when blood calcium levels become low, PTH secretion increases

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33
Q

What tests are done when looking at parathyroid levels?

A

lab tests that are usually fasting to test the PTH and calcium levels in the blood

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34
Q

List some anatomic variations of the parathyroid glands

A

accessory glands, absence of one or more
can be ectopic (in 15-20%): most commonly in anterior mediastinum
can be intrathyroidal, and tends to remain symmetrical even when ectopic

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35
Q

What is the purpose of the thymus gland?

A

plays a role in immune function, releases thymosin (necessary for T cell production)

largest in children and is replaced by fat after puberty

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36
Q

What provides the diagnosis between benign or malignant thyroid pathology?

A

FNA cytology

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37
Q

What is another term for hyperthyroidism and what is it?

A

thyrotoxicosis

- hypermetabolic state caused by elevated levels of free T3 and T4

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38
Q

What is primary hyperthyroidism?

A

excess thyroid hormone that is synthesized and secreted by the thyroid gland
- TSH is increased

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39
Q

What is secondary hyperthyroidism?

A

less common and caused from an outside source such as an TSH secreting pituitary adenoma
- TSH is decreased

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40
Q

What is the most common cause of thyrotoxicosis?

A

hyperthyroidism (type of thyrotoxicosis)

-you can have thyrotoxicosis without hyperthyroidism

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41
Q

What is the most common cause of hyperthyroidism and describe what it is

A

Graves disease, is an autoimmune disease that can occur at any age (*40-60s) with female predominance

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42
Q

What is the etiology of graves?

A

can be hereditary, from the immune system, age, gender or stress related

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43
Q

What is the classic triad of graves disease?

A

diffuse thyroid enlargement (goiter)
ophthalmology (protrusion of the eyes)
graves dermopathy (pretibial myxedema)

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44
Q

What are the clinical manifestations of hyperthyroidism and graves disease?

A

tachycardia at rest, excessive sweating, heat intolerance, weight loss

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45
Q

What is the sonographic appearance of hyperthyroidism/graves?

A

normal or enlarged in size
heterogenous when enlarged
hypervascularity is common (thyroid inferno)

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46
Q

What is the most common thyroid function disorder and describe what it is

A

hypothyroidism, is a decrease in thyroid hormone production

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47
Q

What is the most common type of hypothyroidism?

A

primary: intrinsic abnormality

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48
Q

Describe what secondary hypothyroidism is

A

the pituitary or hypothalamus is being affected in a way that results in failure to stimulate normal thyroid function
- related to damage or disease to those glands (adenomas, tumours, meds etc)

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49
Q

What is the most common cause of primary hypothyroidism world wide?
- in iodine deficient areas?

A

iodine deficiency

chronic autoimmune thyroiditis/ Hashimoto’s (75%)

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50
Q

What is primary hypothyroidism associated with?

A

other autoimmune diseases (Sjogren’s, lupus, Rh arthritis)

- also genetic predisposition, high iodine intake (Wolff-chaikoff), selenium deficiency, smoking and chronic hep C

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51
Q

Describe what the Wolff-Chaikoff effect is

A

an auto-regulatory phenomenon
- excess iodine interrupts the normal production of thyroid hormones and is usually temporary, but in patients with underlying thyroid disease the suppressive action can persist and result in iodine-induced hypothyroidism

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52
Q

What are the key clinical manifestations of hypothyroidism?

A

weakness/fatigue, dry skin, cold intolerance, hoarseness, weight gain, constipation, menstrual irregularities, and decreased sweating

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53
Q

What is the sonographic appearance of Hashimoto’s?

A

can look similar to graves, diffusely heterogenous
moderately enlarged, lobular without calcs or necrosis
often hypervascular

if in late stages it can appear ill defined and atrophic

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54
Q

What is the most common presentation of thyroiditis? (what condition can it come
from)

A

hypothyroidism or thyrotoxicosis followed by hypothyroidism

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55
Q

What is the possible cause for subacute thyroiditis?

What else can subacute thyroiditis be referred to as?

A

possibly from a viral cause

also De Quervain Disease or granulomatous thyroiditis

56
Q

What are the clinical presentations of subacute thyroiditis?

when does it resolve and when is recovery

A

neck pain that can radiate to upper jaw, throat and ears
unilateral or bilateral enlargement of the gland

usually a temporary condition that resolves in 2-6weeks with spontaneous recovery of function in 6-8weeks

57
Q

What are the sonographic appearances of subacute thyroiditis?

A

enlargement, hypoechoic, normal/decreased vascularity, and nodularity

58
Q

What are 15-25% of solitary thyroid nodules? (sono appearance)

What is the treatment for benign vs malignant?

A

either cystic or mostly cystic (due to degeneration or hemorrhage)

benign: percutaneous ethanol injection
malignant: surgically removed

59
Q

What are the types of complex thyroid cysts? (not spongiform)

A

colloid cysts and hemorrhagic cysts

both have low malignant suspicion

60
Q

What is the cause of colloid cysts?

A

they are irregularly enlarged follicles containing abundant colloid
they may have multiple echogenic foci with comet tail artifacts or calcifications

61
Q

Explain what a hemorrhagic cyst is

A

may contain blood and debris
it may have complex internal echoes, septa, and debris (layered debris at dependent portion is highly characteristic of hemorrhage)

62
Q

What increases the frequency of getting thyroid nodules, what decreases the frequency?

A

frequency increases with age, it decreases with iodine intake

63
Q

What is a hot nodule?

A

hyperfunctioning/autonomous: area of dense collection of activity on nuclear med imaging
approx 5-10%

64
Q

What is a cold nodule?

A

non functioning nodule: area of decreased or absent activity on nuc med images
approx 80-85% of patients are cold, 10-15% of these nodules are malignant

65
Q

What is a thyroid adenoma?

What can it produce and cause?

A

it is a benign neoplasm that is slow growing with a fibrous capsule and usually solitary
incidence increased with age 50-60%
they are rare and can produce thyroid hormones and can cause hyperthyroidism

66
Q

What are most thyroid adenomas derived from?

A

follicular cells

67
Q

What is the sonographic appearance of a thyroid adenoma?

A

variable appearances
most common appearance is solitary, well circumscribed and oval/circular
rim calcifications, complete/incomplete halo
spoke wheel colour doppler appearance

68
Q

What is goiter?

What is a reliable marker?

A

enlargement of the thyroid gland, can be variable in side
can be toxic or non toxic, simple or multinodular and more common in women

reliable marker is an isthmus >1cm

69
Q

What is the symptoms of goiters?

A

dysphagia, inspiratory stridor (high pitch turbulent sound when you breath from compression of the vocal cords)
venous congestion and hoarseness

70
Q

Explain what non-toxic goiter is
Endemic goiter?
Sporadic goiter?

A

typically euthyroid (normal thyroid function), can be simple or multinodular

endemic: due to iodine deficiency in food, water and soil in an area
sporadic: occurs spontaneously in euthyroid patients in iodine sufficient areas, peak incidence 35-60yo

71
Q

What are probable causes of sporadic non toxic goiter?

A

thought to be due to ingestion of certain drugs/meds that or hereditary factors

72
Q

What can toxic goiter induce?

A

thyrotoxicosis

is typically multinodular

73
Q

Explain multinodular goiters

A

multi-lobulated, asymmetrical enlargement, be unilateral or bilateral, can extend below the clavicle/sternum (plunging)
can be nontoxic or toxic

74
Q

What is the sonographic appearance of multinodular goiters?

A

heterogenous, lobulated and multinodular

75
Q

What is the most common thyroid carcinoma? Second most common?
What % of thyroid nodules are malignant?

A

1st: papillary
2nd: follicular

5-6.5%

76
Q

What increases the incidence of thyroid carcinoma?

A

radiation exposure

77
Q

What are the sonographic appearances of thyroid carcinomas?

A

typically solid and hypoechoic, microcalcs are one of the most specific features of malignancy**
taller than wide shape, ill defined margins, central hypervascularity

*lymph node mets are highly suspicious thyroid malignancy

78
Q

What is the most common type of thyroid cancer? Explain how aggressive this is and the peak incidence

A

papillary carcinoma (75-85%)
is the least aggressive thyroid ca with great prognosis
peak incidence 20-50

79
Q

What is the clinical presentation of papillary carcinoma?

A

painless palpable lump
palpable nodule with enlarged cervical lymph nodes
enlarged cervical nodes without a palpable nodule

80
Q

What is the sonographic appearance of papillary carcinoma?

What can be seen if there is mets to the lymph nodes?

A

hypoechogenicity (90%)
microcalcs, hypervascular with disorganized vessels
punctate microcalcs may appear in the affected lymph nodes if mets are present

81
Q

What is the second most common thyroid cancer? Explain the incidence rates

A 
follicular carcinoma (10-20%)
peak incidence 40-50yo, increased in areas of dietary iodine deficiency
82
Q

What are the clinical presentations of follicular carcinoma?

A

slow growing painless nodule

mets occur in the bone, liver or lungs (NOT in the neck lymph nodes)

83
Q

What is the sonographic appearance of follicular carcinoma?
Is FNA helpful or not?
What are the features of malignancy, although rare?

A

appearance looks like follicular adenomas
- FNA cant tell the difference between the two, needs cytology smear

irregular margins, thick irregular halo, hypervascularity

84
Q

Describe medullary carcinoma

what does it not respond to

A

makes 5% of thyroid cancers, from parafollicular cells (c-cells), is a more aggressive type that does not respond to chemo or radiation, and is more common in females (slightly)

85
Q

What is the clinical presentation of medullary carcinoma?

A

mass in the neck that can cause dysphagia or hoarseness
patients often suffer a number of symptoms that are related to endocrine secretions ( carcinoid syndrome: serotonin, and Cushings)

86
Q

What is the sonographic appearance of medullary carcinoma?

A

similar to papillary with local invasion and mets to cervical nodes (more common in patients with medullary ca)

87
Q

Describe anaplastic thyroid carcinoma

Survival rate?

A

makes 5% of thyroid ca, is aggressive with poor prognosis and widespread mets, there is no effective treatment
less than 10% of patients survive more than 5 years due to the wide spread mets

88
Q

What is the clinical presentation of anaplastic thyroid ca?

A

rapidly enlarging neck mass with symptoms relating to the destruction of local structures

89
Q

What is the sonographic appearance of anaplastic thyroid ca?

A

large, solid, hypoechoic mass with demonstration of encasing/invading blood vessels and possible invasion of other nearby structures

90
Q

What is Hurthle Cell ca? How is it classified?

A

3% of thyroid ca, is an aggressive form with poor prognosis, MORE IN MALES
-either benign Hurthle cell adenoma OR malignant Hurtle cell carcinoma (based on histology)

91
Q

What is the clinical presentation and sonographic appearance of Hurthle cell ca?

A

variable depending on size/extent, and widely variable

92
Q

What is the clinical presentation of thyroid lymphoma? How is it treated?

A

rapidly growing mass and symptoms of airway obstruction with a hx of long standing thyroiditis/hashimotos

radiation and chemo

93
Q

What is the sonographic appearance of thyroid lymphoma?

A

large, solid, hypoechoic mass
infiltration of thyroid parenchyma and even encasement of neck vessels, lobulations and cystic areas (possibly)
non specific Doppler, can be hypovascular or have chaotic blood vessel distribution

94
Q

What forms thyroid lymphoma?

A

thyroid lymphocytes that turn into cancer cells

95
Q

Describe thyroid mets

Where are they most commonly from?

A

very uncommon, occurs in late disease progression of another cancer
more commonly spread by blood rather than lymphatic routes

  • melanoma, breast, lung, RCC
96
Q

What causes thyroid disease in pregnancy?

A

hormonal and physiological changes

- a common sign is an increase in thyroid size in about 15% of women

97
Q

What is the most common type of thyroid disease in/from pregnancy?

A

postpartum thyroiditis in post delivery women

- can occur after abortion or miscarriage, risk is increased with type 1 diabetes or patients with previous hx of PPT

98
Q

When do you not treat a thyroid nodule as spongiform?

A

if cystic components are less than 50%, or if other features such as peripheral calcs or microcalcs are present

99
Q

When can a nodule be considered almost completely solid?

A

when the cystic components are less than 5% of the nodule

100
Q

What is a very hypoechoic nodule considered in relation to?

A

the surrounding muscles

101
Q

What is considered large comet tail artifact?

A

larger than 1mm and V shaped (is not concerning)

102
Q

What defines a macrocalc?

A

greater than or equal to 2mm

103
Q

What are the complications of FNA?

A

risk of bleeding or infection, voice hoarseness or seeding of cancer (although rare)

104
Q

When is FNA effective? (for what nodules)

A

papillary, medullary and anaplastic

NOT follicular, Hurthle cell ca or lymphoma

105
Q

What are the major paired salivary glands? What is their purpose?

A

Submandibular, parotid and sublingual

they secrete enzymes for chewing and digestion

106
Q

Which is the largest salivary gland and explain its composition

A

parotid, located in the parotid space

has superficial and deep lobes separated by the facial nerve, with a fibrous capsule

107
Q

In what salivary gland are tumours and neoplasms most common?

A

paroritd

108
Q

What is the sonographic appearance of the parotid gland?

A

homogenous, increased echogenicity compared to muscles, and intraparotid nodes are common

fatty infiltration can occur with age

109
Q

What is a Warthins Tumour?

What is it associated with?

A

benign tumour most commonly in the tail of the parotid gland, bilateral in 10-15% of cases
associated with smoking and irradiation

110
Q

What is the sonographic appearance of a Warthins Tumour?

A

well defined ovoid lesion with multiple irregular cystic areas, larger ones have more cystic components
hypervascular

111
Q

What is a pleomorphic tumour?

Where is it most commonly located?

A

also a benign mixed tumour, is the most common salivary gland tumour
most commonly in the parotid and associated with prior neck irradiation

112
Q

What is the sonographic appearance of a pleomorphic tumour?

A

hypoechoic mass with possible posterior enhancement

113
Q

How is a pleomorphic tumor treated?

A

surgery (either partial or total) due to risk of malignant transformation

114
Q

What is the Duct of Rivinus? What is the major sublingual duct?

A

collection of smaller excretory ducts that drain the sublingual glands

Bartholin duct

115
Q

What secretes saliva into the Whartons Duct?

A

submandibular gland, produces the majority of the saliva in the mouth with a fibrous capsule

116
Q

What is the most common salivary gland disease?

A

sialolithiasis: stones in the ducts or parenchyma of the salivary glands
most common in the SMG, more common in males aged 30-60

117
Q

What is the clinical presentation of sialolithiasis?

A

recurrent pain and swelling in area of affected gland, can cause infections, chronic obstructions can case the gland to undergo fatty atrophy

118
Q

What is sialadenitis?

A 
inflammation of the salivary glands due to either:
acute bacterial sialadenitis
acute viral sialadenitis
chronic sialadenitis
acute sialadenitis
or sialolithiasis (common cause)
119
Q

What is the sonographic features of acute sialadenitis?

chronic?

A

enlarged, hypoechoic, hyperemic, possible duct dilatation

atrophic, diffusely hypoechoic with irregular margins (like a cirrhotic liver)

120
Q

What is Sjogren Syndrome?

A

autoimmune condition of the exocrine glands that produce tears or saliva, more common in females

121
Q

What is the clinical presentation of Sjogren?

A

dry eyes and inflammation, dry mouth, bilateral parotid enlargement

122
Q

What is the sonographic appearance of early stage Sjogren? late stage?

A

normal or enlarged and hypoechoic

atrophic gland with multicystic appearance

123
Q

What is Mikulicz syndrome?

A

used to be called Sjogren’s type 1, considered to be on the IgG4 disease spectrum
is non specific inflammatory enlargement of at least 2 or more of the salivary and lacrimal glands

124
Q

What is the clinical presentation of Mikulicz?

A

bilateral painless symmetrical swelling of the lacrimal and salivary glands, xerostomia (dry mouth) and xeropthalmia (dry eyes)

125
Q

What are the sonographic features of Mikulicz?

A

enlargement of the glands, diffuse and symmetrical with non specific lymph node involvement

126
Q

What is a thyroglossal duct cyst?

A

congenital defect in the thyroglossal duct if it persists beyond development, most are found before age 10

typically more than 3cm in size, and increases the risk of infections

127
Q

What is a branchial cleft cyst?

A

congenital defect, branchial cleft is a thin tract extending from the pharyngeal cavity to an opening near the auricle or neck
abnormalities along this can lead to cysts, sinuses or fistulae (typically singular and unilateral)

128
Q

What is the 1st branchial cleft?
2nd?
3rd?
4th?

A
  • cysts either in the auditory canal (type 1) or submandibular area (type 2)
  • most common, located along upper/anterior part of SCM muscle or adjacent to it
  • rare and located deep to SCM
  • rare with variable location
129
Q

What is a branchial cleft fistula?

A

when the cleft fails to involute

130
Q

What is a cystic hygroma?

A

congenital defect as a result of damage or an error in development of the cervical lymphatic system
has a strong association with chromosomal abnormalities

131
Q

What is the sonographic appearance of a cystic hygroma?

A

multiloculated, septated cystic mass at the posterior lateral aspect of the neck

132
Q

List some other neck pathologies

A

deep neck space infections, hematomas, and cervical lymphadenopathy

133
Q

Explain a deep neck space infection

where is the most common space for an abscess?

A

abscess vs infection/phlegmon, commonly caused by dental infections in adults and tonsilitis in children

submandibular space, retropharyngeal space and parapharyngeal space

134
Q

What is the clinical presentation of a deep neck space infection?

A

recent dental procedures or recent other infections, neck or mouth trauma
pain, difficulty swallowing
can be idiopathic

135
Q

What is the gold standard imaging for a deep neck space infection?
What are the sonographic findings?

A

CT, US is used to describe the appearance in relation to anatomy

abscess: fluid filled (partial or complete), thick walls, can have gas collection
enlarged and reactive lymph nodes in the adjacent areas

136
Q

What are common causes of lymphadenopathy?

A

infections, autoimmune disease and neoplastic causes

generalized is usually from a viral infection

137
Q

What is the sonographic appearance of lymphadenopathy?

What about mets from PTC?

A

round, hypoechoic, absence of the fatty hilum, cystic necrosis within
increasing size on serial exams
mixed vascularity

calcifications in the nodes is common and the node appears hyperechoic

Superficial structures (2 decks)

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