clinical- neck discussion (Qs and As)

D.D. neck swelling

D.D. neck swelling?

1- Midline swellings: thyroid (solid & moves with swallowing only) & thyroglossal cyst (cystic +move with prot.tongue & swallowing) & L.N. (pre-laryngeal & pre-tracheal)

2- Ant. Triangle: Chemodectoma (= carotid body tumor solid), Branchial cyst, cold abscess (=collar stud abscess = T.B. L.N. complication) & L.N.

3- Within sternomastoid: sternomastoid tumor (hematoma)

4- Post. Triangle: Pharyngeal pouch (reducible), Cystic hygroma (cystic), L.N.

5- Parotid region: Endemic parotitis, parotid ts, obstructing stone

       [+ swelling from skin & SCT: lipoma, sebaceous cyst, dermoid cyst]

OSCE advanced Qs

Thyroglossal cyst: aetio, diagnostic signs, investig., ttt?

Def: Remnant patent part of throglossal tract (attached to foramen cecum of tongue) → moves with protrusion of tongue & swallowing

Signs: +ve paget & transillumination

Inv.: clinical diagnosis +/- U/S or Ct for extent to tongue

ttt: Cis-trunk oper. = excision with all tract to base tongue & middle part of hyoid bone

Branchial cyst or sinus or fistula: aetio, diagnostic signs, investig., ttt?

Def.: Remnants of 2^nd pharyngeal arch (lack fusion 2^nd * 3^rd arch), in young adult

Signs: +ve paget & transillumination

- Sinus= blind end tract lined by epith. Or granulation tissue

- Fistula= abnormal tract connecting 2 epithelial surfaces

        Clinically both (sinus & fistula) are considered sinus

Inv.: clinical diagnosis + FNAC→ cholesterol

Ttt: complete excision

Chemodectoma (Carotid body t.) (potato t.): aetio, diagnostic signs, investig., ttt?

Def: Benign t. at carotid bifurcation infront sternomastoid

Signs: Pulsatile itself or transmits pulsation underlying carotid arteries, usually bilat.

Inv.: Angiography (goldstandard), U/S or CT (for extent)

Ttt: small & bilat. → observe

       Enlarging or invasive → excision or radiotherapy

Cold abscess: aetio, diagnostic signs, investig., ttt?

Sternomastoid t. : aetio, diagnostic signs, investig., ttt?

Pharyngeal pouch: aetio, diagnostic signs, investig., ttt?

Def.: Herniation of pharyngeal mucosa through ms coat between thyropharyngeus & cricopharyngeus (Kellian dehiscence) → asymptomatic or dysphagia

Signs: palpation → squelching sound

Inv.: Ba swallow (diagnostic) (can be done routin befor any UGIE) or endosc: if t.

Complic.: aspiration → chest inf & rarely neoplasia(1%)

Ttt: if small, asympt.→ conservative,  otherwise → excision open or endoscopic

Cystic hygroma: aetio, diagnostic signs, investig., ttt?

Def.: cong. Cystic lymphatic malformation

Signs: +ve cross fluctuation & transillumination

Inv.: CXR, CT, MRI (for extent)

Complic.: obstructed delivery (at birth), dyspnea or dysphagia (later)

Ttt: aspiration or excision (partial or complete)

Thyroid

How to differentiate between thyroid swelling & thyroglossal cyst?

By protrusion of tongue & swallowing:

1- Thyroid swelling: does not move with protrusion tongue & moves with swallowing

2 Thyroglossal cyst: moves with protrusion of tongue & swallowing

Why thyroid swelling moves with swallowing? Attachment to pretracheal fascia

Why thyroglossal cyst move with swallowing & protrusion tongue? Attachment to foramen cecum at base tongue

Do we have to test every swelling by protrusion of tongue? NO, if butterfly swelling → not thyroglossal cyst, do only swallowing to confirm it is thyroid

What Qs to ask pt. about thyroid status?

Intolerance of hot weather (hyperthyroidism) or col weather (hypothyroidism)

بتحب الصيف و لا الشتا

Why hyperthyroid pt. (thyrotoxic pt.) have tachycardia?

Because thyroid H. ↑ effect of catecholamines on heart

Why thyroid swelling moves up & down with deglutition (swallowing)?

Due to attachment to pre-tracheal fascia

Where to feel carotid pulsation? Anterior to sternomastoid ms in carotid triangle in ant.triangle of neck

دايما تلاقى قدامه كوب ماء و زجاجة و رزمة ورق    thyroid      حالة

What is normal relation between cornea & eyelid?

Normal eye: upper 1/5 cornea covered & lower edge just touching lower lid (no rim)

What is n. supply of LPS ms? Only ocular ms with Dual n. supply

1-    Somatic: occulomotor

2-    Sympathetic:

What is difference between exophthalmos & Proptosis? Not imp.

What are eye signs in hyperthyroidism? Fix head while examining

Staring look

Infrequent blinking

Lid retraction: rim above cornea (due to spasm of Muller part of Levator pulpeprae superioris (LPS) due to ↑ sympathetic tone)

Apparent exophthalmos: rim below cornea & above = sclera visible allaround (due to eyeball protrusion)

Lack Wrinkling (Joffroy’s sign): when eyeball look upward (due to exophthalmos not need to wrinkle to extend field)                                                         

Lid Lag (VonGrave’s sign): upper lid lags while eyeball looks down (as lid retraction)

Lack convergance (Mobiu’s sign):  (due to weakness of med. rectus = converging ms)

Exophthalmos examination from behind while extending head (Naffziger’s)

     [Naffziger test replaces the obsolete ophthalmometer to detect mild exophthalmos] 

NO ophthalmoplegia = no  (examine if asked) cover contralat. Eye & follow my index

Normal Visual acuity = optic n. not infiltrated (examine if asked)

What is diagnosis of Thyroid case? Example

Thyroid status: Pt. not warm, hands not sweaty, no fine tremors, no tachycardia, no water hammer pulse, no pretibial myxedema, no lidlag, no apparent exophthalmous

 Thyroid: butterfly swelling infront lower neck in ant. triangle 5X7 cm, does not move with protrusion of tongue & moves with swallowing, edge well defined surface nodular, firm consistency, not attached to skin or sternomastoid ms, no L.N. enlargement or carotid displacement or infiltration

Case of thyroid enlargement with euthyroid status, propably simple nodular goiter

D.D. Thyroid swelling (Goitre)?

Diffuse: Non-toxic→ Simple colloid goitre

                               → Thyroiditis (Hashimoto, Riedle's, De Quervain)

              Toxic → Grave's disease

Nodular:   Solitary Nodule

                 Multi-nodular goiter (M.N.G.)

Any of above may be toxic or malignant or undergo changes

How to investigate case thyroid enlargement?

Lab.: TSH, T3, T4 & routine Lab for oper.

Neck U/S: → Solid or Cystic

FNAC: if cystic, if malign. cyst→ total thyroidectomy

+/- Thyroid scan: (for solitary nodule) → Cold or Hot

+/- CXR: (for retrosternal extension)

Ask pt. Q to suspect malignancy? How long have the swelling? If Long → benign

How to prepare pt. for thyroidectomy?

Inderal (either stop gradually before oper. or continue)

Carbimazole = neomercazole

Why some of eye signs not +ve? Because pt. may be on medical ttt

What is medical ttt hyperthyroidism?

1-    Inderal: ↓ effect of thyroid H. on heart

2-    Neomercazole: ↓ synthesis thyroid Hs (T3, T4)

OSCE advanced Qs

Simple colloid goitre: aetio, investig., ttt? Commonest cause

Aetio.: hyperplasia of gl. To meet demands Thyroid h.

1-      I deficiency

2-      ↑ demand: puberty, preg, lactation

3-      Goitrogens (Lithium & antithyroid)

4-      ↓ Thyroid h. production (rare)

Inv.: no (except if suspect toxic, malign., retrosternal ext)

Ttt: conservative  

Grave's disease: aetio, investig., ttt? Common in female 9:1

Aetio.: Ab (Ig) against TSH receptors → persistent stmulation → ↑ thyroid hs

Ccc: thyroid eye ds, pretibial myxedema, other autoimmune ds (IDDM, pernicious anemia)

Inv.: as above

TTT: medical: inderal & neomercazole → Radioactive I (if failed medical)

         Surg.: (failed medical) Bilat. Subtotal thyroidectomy (leave 4-10gms for T3,4 and PTH)

Multi-nodular goiter (M.N.G.) : aetio, investig., ttt?

Aetio.: progression from simple diffuse goiter, Family history +ve,

Inv.: if suspect toxic, malign., retrosternal ext. (as above)

Ttt: conservative (if not toxic, no pr. S/S & not malignant, no cosmetic)

       If toxic→ medical →(fail)→radio I →(fail)→ Bilat. Subtotal thyroidectomy

       If pr. S/S → Bilat. Subtotal thyroidectomy

       If malign. → Total thyroidectomy (as below)

Solitary thyroid Nodule: aetio, investig., ttt?

Aetio.: middle age female

1-      nodule in M.N.G.

2-      adenoma (follicular)

3-      cyst (rarely pure but mostly hge into necrotic nodule) → FNAC

4-      carcinoma

5-      thyroiditis

inv.: all of above

ttt: according to cause as M.N.G. (cold nodule is considered carcinoma till proved otherwise).

Why FNAC not differentiate follicular adenoma from carcinoma? Because no capsule presented

Difference between Grave's ds & toxic M.N.G.?

Grave's ds: young, eye signs, associated with autoimmune ds

toxic M.N.G.: old, no eye signs, not  associated with autoimmune ds, AF is common

What are causes Hyperthyroidism? Grave's ds, toxic M.N.G. & functioning adenoma

What are causes Hypothyroidism? 1ry myxedema & Hashimoto thyroiditis

What is benign thyroid tumor? Follicular adenoma (not differentiated from carcinoma by FNAC)

Compare types thyroid malignancy?

Papillary	Follicular	Anaplastic	Medullary	Lymphoma
75%	10%	5%	8%	2%
Young	Middle age	Old age	90% sporadic, 10% familial (MEN II)
Lymph spread	Bl. spread	Direct spread	From parafollic. cells
total thyroidectomy	total thyroidectomy	Debulking+radio +chemotherapy	total thyroidectomy	Chemotherapy

What is Pemberton sign?

Elevation arms 3 mins above head → face congestion & dizziness = retrosternal extension

How test myopathy with hyperthyroidism? Squat then stand up

Why ENT examinat. Before thyroidectomy? Medicolegal (unilat. Cong. Paralysis 2-5%)

How test n. inj. after thyroidectomy?    قول الحمد لله RLN→ hoarsness & SLN→ weak voice

Cause Exophthalmos? Retro-orbital cell deposition & edema

Cause congested neck vs with goiter? Retrosternal extension

Which ms first affected by ophthalmoplegia? Sup. Rectus (up) & Inf.Obl. (up & out)

What is chemosis? Edema of conjunctiva

Complications of thyroidectomy?

Hge & Hematoma → airway obst. (clip remover beside bed)

Hoarsness (RLN inj.) or weak voice (SLN inj.)

Hyperthyroidism (thyroid storm)

Hypothyroidism

Hypoparathyroidism → Hypocalcemia

Wound: inf, hypertrophic scar or keloid

Parotid Gland

What is nerve supply of masseter ms? Mandibular branch of trigeminal

What does facial nerve supplies?

Ms of face: Occiptofrontalis by Temporal branch

                   Orbicularis occuli by Zygomatic br.

                   Buccinator by Buccal br.

                   Orbicularis oris by mandibular br.

 platysma by cervical br.

post. Belly of digastric

Stapedius

Chorda tympani (taste to ant. 2/3 of tongue)

How to diagnose case of parotid enlargment? Example:

Swelling in parotid region bilaterally measure 4X4 cm, edge well defined, smooth surface, soft consistency, ↑ with clenching teeth, cervical L.N.s not felt, facial n. intact, superficial temp. a. pulsation felt bilaterally

Case of bilateral parotid gland enlargment

Ask pt. some questions about his case (Parotid swelling)?

How long you have this swelling: if long → benign

You have CLD, Bilhariziasis, alcoholic?

You took radio- or chemotherapy?

How this swelling is affecting your life?

What is D.D. of this swelling?

skin & SCT: lipoma, sebaceous cyst

ms: masseter hypertrophy

L.N.: preauricular

Gl.: parotid enlargement

What are causes (D.D.) of parotid enlargement?

1-    unilat.: acute inflammation (bac: strept, staph & viral), obstructing stone, pleomorphic adenoma & other as bilat. (see below)

2-    bilat.: chrذonic inflammation = endemic parotiditis due to debilitating ds (CLD, Alcohol (worldwide), Bilhariziasis (Egypt), mumps, autoimmune ds (Sjogren, Mickulciz ds)

What are ccc Sjogren ds? Parotid enlargement & eye inflamm. & dry secretions +/- CT disorder (arthritis) + high incidence of B-cell lymphoma

What are types of Sjogren ds? 1ry (no CT disorders) &2ry (CT disorders)

What are ccc Mickulciz ds?   Parotid & lacrimal gl. enlargement & dry secretions (dry eye & dry mouth) due to sarcoidosis, lymphoma or T.B.

How to surely identify facial nerve? Nerve stimulation

OSCE advanced Qs

What are Types, investing. & ttt of salivary tumors?

Types:

Benign: Pleomorpic adenoma (mixed t.) & Monomorphic adenoma (commonest is adenolymphoma= Warthin's tumor)

Malignant: Mucoepidermid carcinoma (parotid) & Adenoid cystic carcinoma (submand. & minor gls)

Investig.: FNAC (exclude malign. & MRI (if malign. or huge size to asses deep lobe involvement)

Ttt: Benign + no deep lobe → Superficial conservative parotidectomy (preserve facial n.)

       Benign + deep lobe involved → Total conservative parotidectomy

       Malig. → radical parotidectomy (should include facial n. BUT may try to spare it)

What are causes of facial palsy?

Idiopathic= Bell's palsy

Intracranial: CVA, meningitis, acoustic neuroma

Intratemporal: skull base Fr., O.M., SCC middle ear

Parotid: parotid malignancy

Commonest gl. For stones? Submandibular gl.

Commonest gl. For tumors? Parotid but mostly banign

Complications of parotidectomy? General & Specific →

Wound: hematoma, inf.,

Facial inj.

Salivary fistula

Frey syndrome (auriculotemporal syndrome)= gustatory sweating d.t. regrowth of symp.n. into skin

Greater auricular n.inj. → Loss sensation of pinna

Submandibular Gland vs L.N.

How to differentiate submandibular gl. Enlargement from submandibular L.N.?

History Ask Qs about

1-    You have other swellings: multiple swellings → L.N., Single → submand.gl.

2-    What ↑ the swelling? If ↑ by sour food → submand.gl.

Examination

1-    multiple or single?

2-    Bimanual examination (hand at ts ramus mandible & gloved hand inside)

If felt bimanually → submand.gl.

If not felt bimanually & only rolled from outside → submand. L.N.

Where is the duct of submand.gl.? beside frenulum of tongue

How to surely diagnose submandibular gl. Stone? Sialogram

What type of L.N. biopsy is usually done? Excisional biopsy (NO FNAC)

Do we usually do palpation parotid gl.? NO, bec rare stone, pain, difficult

Why salivary stones more common on submand. Gl. Than parotid gl.?

Bec. Submandib.gl. → thick secretion & duct less dependent

Lymph nodes (esp, Submandibular)

Causes of Lymph node enlargement ? (LIST)

1- Lymphoma / Leukemia

·   Hodgkin’s 

·   Non-Hodgkin’s

2- Infective

·   Nonspecific

·   Bac. : Tuberculosis

·   Viral: IMN (Glandular fever) - Syphilis

·   Protozoal:  Filariasis-  Toxoplasmosis (Cat scratch fever)

3- Sarcoidosis  

4- Tumor

How to investigate enlarged L.N.?

   first look for other L.N.s & for RES (HSM)

1-    FBC (differential count)

2-    Specific tests: IMN (monospot test) & T.B. (…..)

3-    Bone marrow biopsy (Sternal puncture)

4-    Lymph node biopsy: excisional biopsy (if suspect tumor)

       But FNAC recommended in T.B (avoid chr. ulcer) & SCC

N.B. Some surgeons start by FNAC then proceed accordingly (see below)

Name 1 imp. L.N. of deep cervical?  Jugulo-digastric draining ……

OSCE advanced Qs

What are surgical options for excision of cervical lymphadenopathy?

1-      open L.N. excision biopsy

2-      Block dissection of neck & limited block neck dissection

3-      Radical neck dissection

How to proceed according to FNAC of L.N.?

If Lymphoma, adenocarcin. or inflamm.(except T.B.) → excisional biopsy & search for 1ry or cause

If T.B. → ttt T.B.

If SCC → refere to ENT to find 1ry