Weekly Quiz Questions

Question 1

Describe Posterior cervical triangle borders (4)

Answer 1

1. Posterior border of stenocleidomastoid muscle
2. Anterior border of the trapezius muscle
3. Base of triangle is middle third of clavicle
4. Roof formed by cervical facia

Question 2

What can the posterior triangle be further divided into?

Answer 2

• Occipital triangle
• Supraclavicular triangle

Question 3

Describe the border of the Anterior triangle

Answer 3

1. Inferior border of mandible is tops
2. Anterior border of sternocleidomastoid muscle is lateral side
3. Apex which is the jugular notch
4. Floor, formed by pharynx, larynx and thyroid

Question 4

What can the anterior triangle be further divided into?

Answer 4

Superior to hyoid – submental and submandibular triangles
Inferior to mandible – carotid and muscular triangles formed

Question 5

Clinical features: Feeling hot, increased sweating, weight loss, enlargement of the thyroid gland, rapid heart rate and palpitations, anxiety and restless hyperactivity.
• Describe the laboratory tests that would be used in a patient that presents with the following clinical features.
• Draw possible conclusions as to the cause of these symptoms.
• Describe the most common condition that may cause these symptoms.

Answer 5

Condition: Hyperthyroidism – Graves’ disease
Laboratory test: TSH levels (decreased) and T3 and T4 (increased). This is due to the feedback mechanism not requiring furtherTSH secretion in the prescence of increased T3 and T4 production. . RAIU could also be performed but it is not as specific as hyperthyroidism does not always cause increase in iodine uptake.
Description: Grave’s disease is an autoimmune disease in which antibodies are made against TSH receptors. These are called thyroid-stimulating antibodies which bind to TSH receptors and stimulate thyroid hormone secretion

Question 6

Clinical features: Cold intolerance, facial and extremity oedema, lethargy, weight gain, bradycardia, constipation, hair loss.
• Describe the laboratory tests that would be used in a patient that presents with the following clinical features.
• Draw possible conclusions as to the cause of these symptoms.
• Describe the most common condition that may cause these symptoms.

Answer 6

Condition: hypothyroidism - Hashimoto’s thyroiditis
Laboratory tests: TSH – elevated as it is secreted in response to low T3 and T4. T3 and T4 would also be tested. RAIU could also be performed
Description: Hashimoto’s thyroiditis is an autoimmune disease presents as reduced thyroid function and symptoms of myxedmea due to reduced metabolic rate. Seen more in women than men.
Thyroid prominent and rubbery.

Question 7

Clinical features: Prominent, irregular neck swelling, difficulty in swallowing, occasional neck pain.
• Describe the laboratory tests that would be used in a patient that presents with the following clinical features.
• Draw possible conclusions as to the cause of these symptoms.
• Describe the most common condition that may cause these symptoms.

Answer 7

Condition: Multinodular goitre
Laboratory tests: RAIU, TSH, T3 and T4. However, these will all appear normal if the nodules and non-functioning. If there is a dominant function adenoma, there may be n elevation in RAIU and T3/T4 tests with a reduction in TSH
Description: a Multinodular goitre May present as generalised enlargement of the thyroid or have irregular margins with nodules. There may be a rapid increase in size of a nodule due to internal haemorrhage into one of the nodules. Can cause pain and increase the patients symptoms of dysphagia.

Question 8

Clinical features: History of renal calculi, unilateral (mild) neck swelling.
• Describe the laboratory tests that would be used in a patient that presents with the following clinical features.
• Draw possible conclusions as to the cause of these symptoms.
• Describe the most common condition that may cause these symptoms.

Answer 8

Condition: parathyroid adenoma
Laboratory tests: assess serum calcium and parathormone levels. These would be increased. This rules out malignancy as if there was a malignant change you would see suppressed parathormone levels
Description: Parathyroid adenoma are often small but may enlarge to be palpable. Look for hyperplasia.

Question 9

Briefly describe embryonic development of thyroid

Answer 9

• 1st endocrine gland to form
• Appears in 4th embryonic week as a median endodermal thickening in the pharynx which forms thyroid diverticulum
• Developing thyroid descends through the thyroiglossal duct which breaks down at the end of the 5h week
• Isolated thyroid continues descend
• Reaches final resting place inferior to cricoid cartilage by 7th week
• Only remanant of the thyroglossal duct is normall the foremen caecum of tongue

Question 10

What are the advantages of fine need aspiration (FNA)

Answer 10

minimal materials (usually a very simply procedure)
inexpensive
quickly performed
local anaesthetic often not used
minimal discomfort (usually)
small bruise only (usually)

Question 11

What are the disadvantages of fine needle aspiration (FNA)

Answer 11

sample may be inadequate ( reduced if pathologist is present to check sample )
false positive/false negative/equivocal aspirates
dependence of cytopathology expertise
specific tissue-related potential pitfalls.

Question 12

What are the advantages for core biopsy

Answer 12

inexpensive
relatively atraumatic
may obviate the need for open biopsy
higher diagnostic yield (though there is some varying opinion about this)

Question 13

Disadvantages of core biopsy

Answer 13

greater chance of local haemorrhage due to larger bore needle used
tracheal perforation and other complications as there is probably reduced control of the needle depth with this procedure compared to FNA.
potential for facial nerve damage
possibility of tumour seeding, but very little evidence.

Question 14

Describe the ultrasound appearances of a parathyroid adenoma

Answer 14

-Usually affects only one gland but may be multiple.
-They are typically discrete and oval.
-Usually small, 8-15 mm, but have been known to be up to 5cm in diameter.
A large adenoma may become complex in appearance when large due to cystic degeneration,internal haemorrhage and/or necrosis.
-Rarely are calcifications present.

Question 15

Describe the ultrasound appearances of a Parathyroid cysts

Answer 15

More common in women and usually occurs in one of the inferior glands.
Well-defined and thin-walled with anechoic centre. Some may have some internal debris orseptae.

Question 16

Describe the ultrasound appearances of Parathyroid hyperplasias

Answer 16

• It is not possible on ultrasound to differentiate between primary and secondary parathyroid hyperplasia as in both cases the glands have increased as a compensatory mechanism
• All four glands are symmetrically and equally enlarged.
• Hypo-echoic, usually, but may be iso-echoic compared to the thyroid gland.
• Calcifications may be present.
• Whilst oval in shape, hyperplastic parathyroid glands are typically more spherical than adenomas.
• Usually hyperplastic glands are quite vascular with arterial internal flow.

Question 17

Describe the ultrasound appearances of Parathyroid carcinoma

Answer 17

• Usually affects only one gland and is quite rare.
• They are usually hypo-echoic when compared to the thyroid gland.
• Carcinoma may be lobulated and heterogenous due to necrosis.
• Local invasion may be noted and adjacent lymphadenopathy.
• Calcifications may be present.

Question 18

Describe the ultrasound appearances that favour benign (8)

Answer 18

1.Internal consistency
Solid, this is variable as malignant nodules may also be solid.
Cystic, many benign nodules undergo cystic degeneration or internal haemorrhage and therefore have cystic components, though some malignant lesions have cystic varieties and may also undergo necrosis.
“Comet-tail‟ artefacts within a mixed or cystic mass are generally associated with benign colloid nodules

2.Echogenicity: Hyper-echoic nodules are more likely to be benign, then iso-echoic.

3.Margination: usually well-defined, smooth and sharp.

4.Calcification: If present, they are usually coarse and irregularly distributed, or have a peripheral (“egg shell‟) pattern.

5.Peripheral anechoic halo: A complete, thin halo is more common in benign lesions. The halo is caused either by the capsule of the nodule or compressed thyroid vessels.

6.Co-existing multinodularity: Multiple nodularity used to be an indicator for benign disease, but benign and malignant disease can co-exist, though this is not common.
Solitary nodules are statistically going to be benign due to the low incidence of thyroid carcinoma.

7.Vascularity: peripheral flow with little internal flow, if at all. There will be no flow in septae.
Functioning adenomas may have increased internal flow, so need to be correlated with an isotope scan as they should be “hot‟.

8.Surrounding structures: No invasion of the margins of lesion or local spread should be seen.
There should be no associated adjacent lymphadenopathy, unless inflammatory in nature.

Question 19

Describe the ultrasound features that favour malignancy

Answer 19

1.Internal consistency: Usually have a solid appearance, but may be mixed and/or cystic (for example, papillary carcinoma).

2.Echogenicity: Hypo-echoic or iso-echoic.

3.Margination: irregular and poorly-defined.

4.Calcification: Punctate, fine scattered (for example, psammoma bodies in papillary carcinoma) calcifications are often found, but those with medullary carcinoma may be more coarse.

5.Peripheral anechoic halo: A partial, thick halo may be present or no halo seen.

6.Co-existing multinodularity: Malignant lesions are usually solitary (though papillary carcinoma may be multi-centric).

7.Vascularity: variable flow patterns, increased peripheral flow, multiple vascular poles and chaotic, internal flow, within septae.

8.Surrounding structures: Invasion of any capsule of the lesion is common. Local invasion, that is, involvement of the strap muscles (as seen by a loss of fascial planes between the strap muscles and the thyroid gland with ill-defined muscle outline), involvement of the trachea, oesophagus and recurrent laryngeal nerve).
Associated lymphadenopathy is also common.

Question 20

Where could a thyroglossal duct cyst form

Answer 20

Anywhere along the course followed by the thoroglossal duct during the descend of the thyroid from the tongue.
The thyroglossal duct using atrophies and disappears during embryonic development.
Most costs found in anterior neck just inferior to hyoid bone or below tongue.

Question 21

Describe the intranodal vascularity of normal / reactive lymph nodes

Answer 21

no flow (due to the low flow velocity or low number of red blood cells ) or a few intranodal dots; and
hilar flow with or without peripheral branches from the longitudinal hilar vessels.

Question 22

Describe the vascularity patterns of malignancy lymph nodes

Answer 22

Most malignant nodes are more likely to have the following vascular appearances:
displacement of the hilar vessels;
aberrant vessels;
missing intranodal flow signals;
sub-capsular or peripheral flow; and
chaotic flow patterns of the Doppler traces;
These patterns are subject to variations and are by no means 100 percent accurate. They do, though, help raise the suspicion of malignancy.

Question 23

List some localised inflammatory diseases of the thyroid

Answer 23

Acute / chronic sialdentitis
Acute viral inflammation
Sialectasis
Sjogren syndrome
Sarcoidosis
Post radiotherapy of the neck

Question 24

Definition of Acute/chronic sialadenitis

Answer 24

Definition: Acute sialadenitis is the sudden inflammation of the salivary glands, while chronic sialadenitis refers to a long-lasting or recurrent inflammation of the salivary glands.

Question 25

Cause of Acute/chronic sialadenitis

Answer 25

Commonly caused by bacterial infections, viral infections, autoimmune diseases and duct obstruction by a calculi

Question 26

Ultrasound appearances of Acute/chronic sialadenitis

Answer 26

• enlarged and hypoechoic.
• heterogenous (this may be due to microabscesses, duct dilatation and/or retention cysts).
• Abscess formation may follow (supporative sialadenitis) , ill-defined hypoechoic mass, frank fluid may be detected and hyperechoic foci due to gas bubbles.
• There is no mass effect, i.e. displacement of the duct and vessels.
• Ultrasound-guided abscess drainage may be useful to aid treatment.

Question 27

Presentation of Acute/chronic sialadenitis

Answer 27

Acute: sudden pain, swelling, and tenderness in the affected salivary gland, while
chronic sialadenitis: recurrent swelling, intermittent pain, and dryness of the mouth.