Thyroid + Triangles of Neck + Airway Obstruction Flashcards
What are the boundaries of the anterior triangle
Midline of neck to anterior border of SCM
What are the contents of the anterior triangle
CCA - internal + external Internal jugular vein Facial vein and artery Vagus nerve Hypoglossal nerve Glossopharyngeal nerve Laryngeal nerve nerve Submandibular and submental node
What are the boundaries of posterior triangle of the neck
External jugular vein Cervical neck plexus Lymph nodes Occipital artery Accesory nerves
Anatomy of thyroid gland
Attached to individual framework so moves up and down when you swallow
2 lobes
Joined by isthmus
What is a thyroglossal cyst
Dilatation of thyroglossal duct remnant
Thyroid formed when foramen caecum from tongue drops down
If connection still exist then cyst forms
What are the features of a thyroglossal cyst and how do you Dx
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
How do you Dx and Rx thyroglossal cyst
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
What are complications of thyroid surgery
Recurrent laryngeal damage
Bleeding
Hypocalcaemia due to damage to parathyroid
Who are thyroid lumps common in
Middle age = 10% malignant
If in the young then 50% malignant
What can a solitary nodule in the thyroid be
Cyst Adenoma Carcinoma Lymphoma Prominent nodule in multi-nodular goitre
What is 1st line investigation
USS to risk stratify and look for malignant cervical LN
+- FNAC
FNAC if suspicious
- Can Dx papillary
- Cannot distinguish between follicular adenoma and carcinoma
How do you DX thyroid cancer
Thyroid function test
MRI
CT but try to avoid due to radiation
What does results of USS / FNAC determine
If nothing = reassure and discharge
If suspicious need to remove thyroid for histological Dx as FNAC can’t differentiate between adenoma and carcinoma
How do you grade result
1 - non diagnostic 2 - normal 3 - borderline 4 - concerning, most likely cancer 5 - cancer
Concerning features
- Solid hypochenic
- Microcalcification
- Irregular
- LN
What are types of thyroid cancer in order of commonest
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
What are the symptoms of thyroid cancer
Painless lump in front of the neck Swollen glands - cerivcla Patient usually euthyroid Unexplained hoarseness Sore throat Dysphagia
What are RF for cancer
Women Thyroiditis Goitre FH Radiation exposure Obesity Acromegaly FAP
What is the investigation process + treatment
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
What is a goitre
Swelling in the neck due to enlarged thyroid
Diffuse = whole gland
What are types of goitre
Simple colloid
Multi-nodular
Neoplastic
Inflammatory
What is a colloid goitre
Benign non-cancerous enlargement of thyroid gland
What causes
Iodine deficiency
Puberty
Pregnancy
Lactation
What can it cause / never cause
Compressive neck symptoms
No bruit
No hormonal abnormalities
What causes multi-nodular goitre
Grave’s
Toxic
What are symptoms of multi-nodular goitre and toxic
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
How do you investigate
Bloods / TFT
Consider FBC
Thyroid USS +- FNAC
CT scan of neck and chest if concern over retrosternal expansion
When is thyroidectomy
Airway obstruction Malignancy Thyrotoxicosis Cosmesis Restrosternal extension
What are complications
Bleeding which can cause respiratory compromise as tight space = stridor Voice hoarsness Thyroid storm Infection Hypoparathyroid HYpothyroid
What are compressive neck symptoms due to neck lump
Dysphagia
Stridor if trachea compressed
SOB on exertion
Retrosternal goitre
How do you test for retrosternal goitre
Find it difficult to reach up arms without choking
What are the central lines used for
Measuring central venous pressure Drug administration Cardiac pacing Blood sampling Fluid resus Haemodialysis IV nutrition
What are complications of central lines
Pneumothorax Haematoma Cardiac tamponade Air embolism Thrombosis Sepsis Line blockage
When is a tracheostomy indicated
Airway obstruction
Airway protection
Poor ventilation due to reduced dead space
What does tracheostomy require
Suctioning
Humidifcation
Long term care
What is stridor
High pitch wheezing
Usually on inspiration
Clinical sign of airway obstruction
What is late sign / worrying / what should you look for
Child not crying Swallowing difficulty Drooling Pallor or cyanosis Use of accessory muscles Tracheal tug All suggest impending obstruction
What causes stridor
Croup Epiglottitis Obstruction Foreign body Tumour Smoke in inhalation Neck surgery Laryngomalacia Vocal cord palsy = rare
What is Laryngomalacia
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
How do you Rx
Maintain sats + feed
Surgery if FTT
Tracheostomy is rare
How do you recognise and Rx croup
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
What is stertor
Noisy breathing due to obstruction above larynx
From pharynx
Sounds like snoring
How do you recognise and Rx epiglottis
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
What causes inspiratory noise
Laryngeal origin
Above vocal cord / glottis
What causes expiratory noise
Tracheobronchial / lung
Typically wheeze
What causes biphasic noise
At Glottis
What is an emergency after head and neck surgery
Stridor
What causes acute airway obstruction in children
FB
Infection - croup / epiglottitis
Congenital - laryngomalacia
Anaphylaxis
What causes acute airway obstruction in adults
Infection - supra glottis and deep neck infection / abscess / epiglottis
Neoplastic - tongue, oropharyngeal, laryngeal
Anaphylaxis
What are complications
Respiratory arrest
Beware in children as will decompensate quickly
How do you manage
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
What do you do after initial management
Investigation for case
What does a FB in pharynx or oesophagus tend to be
Children
- Coin
- Beware battery as look the same on X-ray
Adults
- Food bolus
- Is there any bone in food = important
Why are bone / battery important
Battery can corrode oesophagus = perforation
Bone can just cause perforation
How does FB present
Dysphagia
Odynophagia
Drool
How do you manage
X-ray
Battery / bone = immediate removal
Can allow food to pass
May require OGD
How do deep neck infections present
Pain Trismus Dysphagia Dysphonia Stridor Drooling Typially look very unwell with fever
What causes
Usually bacterial
Commonly from poor dental hygiene
How do you manage
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
