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ENT > Thyroid + Triangles of Neck + Airway Obstruction > Flashcards

Thyroid + Triangles of Neck + Airway Obstruction Flashcards

1
Q

What are the boundaries of the anterior triangle

A

Midline of neck to anterior border of SCM

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2
Q

What are the contents of the anterior triangle

A 
CCA - internal + external
Internal jugular vein
Facial vein and artery
Vagus nerve
Hypoglossal nerve
Glossopharyngeal nerve 
Laryngeal nerve nerve
Submandibular and submental node
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3
Q

What are the boundaries of posterior triangle of the neck

A 
External jugular vein
Cervical neck plexus
Lymph nodes
Occipital artery
Accesory nerves
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4
Q

Anatomy of thyroid gland

A

Attached to individual framework so moves up and down when you swallow
2 lobes
Joined by isthmus

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5
Q

What is a thyroglossal cyst

A

Dilatation of thyroglossal duct remnant
Thyroid formed when foramen caecum from tongue drops down
If connection still exist then cyst forms

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6
Q

What are the features of a thyroglossal cyst and how do you Dx

A

Lump in midline of neck - mobile, non-tender, soft and fluctuant
Grows with age
Moves upwards on tongue protrusion as connected to foramen caecum
Can become infection and discharge with risk of discharging sinus formation

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7
Q

How do you Dx and Rx thyroglossal cyst

A

USS prior to ensure functioning thyroid tissue as would leave patient hypothyroid
+- FNAC
May reoccur
Need to remove hyoid bone first for surgery
Only Rx if complication e.g. infection

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8
Q

What are complications of thyroid surgery

A

Recurrent laryngeal damage
Bleeding
Hypocalcaemia due to damage to parathyroid

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9
Q

Who are thyroid lumps common in

A

Middle age = 10% malignant

If in the young then 50% malignant

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10
Q

What can a solitary nodule in the thyroid be

A 
Cyst
Adenoma
Carcinoma
Lymphoma
Prominent nodule in multi-nodular goitre
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11
Q

What is 1st line investigation

A

USS to risk stratify and look for malignant cervical LN
+- FNAC
FNAC if suspicious
- Can Dx papillary
- Cannot distinguish between follicular adenoma and carcinoma

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12
Q

How do you DX thyroid cancer

A

Thyroid function test
MRI
CT but try to avoid due to radiation

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13
Q

What does results of USS / FNAC determine

A

If nothing = reassure and discharge

If suspicious need to remove thyroid for histological Dx as FNAC can’t differentiate between adenoma and carcinoma

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14
Q

How do you grade result

A 
1 - non diagnostic
2 - normal 
3 - borderline
4 - concerning, most likely cancer
5 - cancer

Concerning features

  • Solid hypochenic
  • Microcalcification
  • Irregular
  • LN
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15
Q

What are types of thyroid cancer in order of commonest

A

Papillary - most common

  • <40F
  • Lymph mets to cervical LN
  • RF = RT

Follicular

  • Tend to be more middle age
  • RF = iodine deficiency
  • Blood mets - brain, bone, lung liver

Medullary

  • Originate parafollicular C cells
  • Middle age
  • MEN 2A or 2B
  • Can do genetic screen for RET mutation and check urine metanephrine prior to surgery for pheochromocytoma prior to any surgery

Anoplastic

  • Aggressive - rapidly enlarging neck mass over 2-3 months
  • Elderly
  • Local spread
  • Dx requires biopsy and Rx most likely palliative

Lymphoma

  • Diffuse large B cell
  • RF = hashimoto
  • Dx = biopsy
  • Rx = chemo / RT as per lymphoma oncology team
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16
Q

What are the symptoms of thyroid cancer

A 
Painless lump in front of the neck
Swollen glands - cerivcla
Patient usually euthyroid 
Unexplained hoarseness
Sore throat 
Dysphagia
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17
Q

What are RF for cancer

A 
Women 
Thyroiditis
Goitre
FH
Radiation exposure
Obesity
Acromegaly
FAP
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18
Q

What is the investigation process + treatment

A

USS to look at size, LN and mets
Non contrast CT / MRI may be needed if neck nodes
Cold nodules on schintogrpahy

Surgery

  • Thyroid lobectomy
  • Total thyroidectomy - if >1cm or high risk follicular
  • Neck dissection if established mets in LN

RAI

  • Used in papillary and follicular
  • No use in medullary as tumour from neuroendocrine cells NOT follicular

Other
External RT and chemo
Replacement thyroxine as suppress gland + prevent recurrence +- calcium may be needed after

Follow up

  • Thyroglobulin at 6 weeks (tumour marker)
  • USS +-FNAC
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19
Q

What is a goitre

A

Swelling in the neck due to enlarged thyroid

Diffuse = whole gland

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20
Q

What are types of goitre

A

Simple colloid
Multi-nodular
Neoplastic
Inflammatory

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21
Q

What is a colloid goitre

A

Benign non-cancerous enlargement of thyroid gland

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22
Q

What causes

A

Iodine deficiency
Puberty
Pregnancy
Lactation

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23
Q

What can it cause / never cause

A

Compressive neck symptoms
No bruit
No hormonal abnormalities

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24
Q

What causes multi-nodular goitre

A

Grave’s

Toxic

25
Q

What are symptoms of multi-nodular goitre and toxic

A 
Neck lump
- Moves on swallowing
- Can be one dominant nodule 
Pressure Sx if large - SOB / dysphagia 
Pain and acute swelling if ruptures
If toxic 
Increased hormone production
Tend to be elderly
AF due to thyrotoxicosis 
Bruit
No eye signs
26
Q

How do you investigate

A

Bloods / TFT
Consider FBC
Thyroid USS +- FNAC
CT scan of neck and chest if concern over retrosternal expansion

27
Q

When is thyroidectomy

A 
Airway obstruction
Malignancy
Thyrotoxicosis
Cosmesis
Restrosternal extension
28
Q

What are complications

A 
Bleeding which can cause respiratory compromise as tight space = stridor 
Voice hoarsness
Thyroid storm
Infection
Hypoparathyroid
HYpothyroid
29
Q

What are compressive neck symptoms due to neck lump

A

Dysphagia
Stridor if trachea compressed
SOB on exertion
Retrosternal goitre

30
Q

How do you test for retrosternal goitre

A

Find it difficult to reach up arms without choking

31
Q

What are the central lines used for

A 
Measuring central venous pressure
Drug administration
Cardiac pacing
Blood sampling
Fluid resus
Haemodialysis
IV nutrition
32
Q

What are complications of central lines

A 
Pneumothorax
Haematoma
Cardiac tamponade
Air embolism
Thrombosis
Sepsis 
Line blockage
33
Q

When is a tracheostomy indicated

A

Airway obstruction
Airway protection
Poor ventilation due to reduced dead space

34
Q

What does tracheostomy require

A

Suctioning
Humidifcation
Long term care

35
Q

What is stridor

A

High pitch wheezing
Usually on inspiration
Clinical sign of airway obstruction

36
Q

What is late sign / worrying / what should you look for

A 
Child not crying
Swallowing difficulty
Drooling
Pallor or cyanosis
Use of accessory muscles 
Tracheal tug 
All suggest impending obstruction
37
Q

What causes stridor

A 
Croup 
Epiglottitis 
Obstruction 
Foreign body
Tumour 
Smoke in inhalation
Neck surgery
Laryngomalacia 
Vocal cord palsy = rare
38
Q

What is Laryngomalacia

A

Most common cause of paediatric stridor
Cartilage doesn’t develop properly so epiglottis and larynx falls in when you breath in
Leads to stridor and breathing and feeding difficulty

39
Q

How do you Rx

A

Maintain sats + feed
Surgery if FTT
Tracheostomy is rare

40
Q

How do you recognise and Rx croup

A

Barking cough +- resp distress due to obstruction
95% due to parainfluenza
Give all children a single dose of dexamethasone

If stridor at rest then admit or not settling for 
O2 humidified 
Nebulised adrenaline 
IV dexamethasone 
Heliox gas if breathing difficult 
Reduce swelling
Airway management
41
Q

What is stertor

A

Noisy breathing due to obstruction above larynx
From pharynx
Sounds like snoring

42
Q

How do you recognise and Rx epiglottis

A

Short Hx fever, sore throat, drooling of saliva
Cough is absent
Due to H. Influenza B so rare due to vaccine

Management
Keep upright and do not examine as cause distress
Anaetheist to secure airway 
Nebuliser
Dexamethasone 
IV AX
Steroid
Intubation
43
Q

What causes inspiratory noise

A

Laryngeal origin

Above vocal cord / glottis

44
Q

What causes expiratory noise

A

Tracheobronchial / lung

Typically wheeze

45
Q

What causes biphasic noise

A

At Glottis

46
Q

What is an emergency after head and neck surgery

A

Stridor

47
Q

What causes acute airway obstruction in children

A

FB
Infection - croup / epiglottitis
Congenital - laryngomalacia
Anaphylaxis

48
Q

What causes acute airway obstruction in adults

A

Infection - supra glottis and deep neck infection / abscess / epiglottis
Neoplastic - tongue, oropharyngeal, laryngeal
Anaphylaxis

49
Q

What are complications

A

Respiratory arrest

Beware in children as will decompensate quickly

50
Q

How do you manage

A

Call on call ENT / anaesthetist / or paeds if child
O2
Nebulised adrenaline - 1ml 1:1000 in 4ml saline
Steroids - dexamethasone- nebuliser and IV
Monitor sats, RR and BP
Intubation may be needed

51
Q

What do you do after initial management

A

Investigation for case

52
Q

What does a FB in pharynx or oesophagus tend to be

A

Children

  • Coin
  • Beware battery as look the same on X-ray

Adults

  • Food bolus
  • Is there any bone in food = important
53
Q

Why are bone / battery important

A

Battery can corrode oesophagus = perforation

Bone can just cause perforation

54
Q

How does FB present

A

Dysphagia
Odynophagia
Drool

55
Q

How do you manage

A

X-ray
Battery / bone = immediate removal
Can allow food to pass
May require OGD

56
Q

How do deep neck infections present

A 
Pain
Trismus
Dysphagia
Dysphonia
Stridor
Drooling
Typially look very unwell with fever
57
Q

What causes

A

Usually bacterial

Commonly from poor dental hygiene

58
Q

How do you manage

A 
ABCDE approach 
Secure airway - may need tracheostomy or intubation
Fluid
Broad spec Ax
- Micro results important 
CT used to confirm Dx and neck space 
Surgical drainage

ENT (14 decks)

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