How do we divide the neck?
Into 2 triangles
Ant - From midline to ant border of SCM
Post - From post border of SCM to ant border of Trapezius
Whats contained in the anterior triangle?
- Facial art/vein
- Submental/Submandibular lymph nodes
- Cr Ns 9->12
Whats contained in the post triangle?
- External Jugular Vein
- Lymph nodes
- Occipital Art
- Accessory Nerve (CN XI) and cervical nerve plexus
The ext carotid branches in the neck, what are its branches?
Post -> Sup:
- Sup Thyroid
- Asc Pharyngeal
- Posterior Auricular
- Superficial Temporal
Order is not certain so don’t worry about it just a rough guide.
Where does the Common carotid divide?
Where do we insert a cental line?
Into the subclavian vein
When would we use a central line?
- Central Venous pressure
- Blood sampling
- Cardiac Pacing
- Fluid Resus
- IV nutrition
Complications of a central line?
- Air Embolism
- Cardiac Tamponade
- False Passage
- Line Blockage
How does neck lymph drain?
Into deep cervical lymph nodes
Then into left and right jugular lymphatic trunks
Then into thoracic and right lymphatic ducts respectively.
How do we describe lymph nodes in the neck?
By group, covered in Yr 1 By level: 1 - Submental/Submandibular region 2-4 - The SCM is split into 3rds starting at the top 5 - Posterior triangle 6 - Midline
Where do the various groups of neck lymph nodes drain?
What does the thyroid gland and parathyroid glands do?
- Thyroid hormone
- Calcitonin (Lowers Ca and raises Phosphate)
Regulate ca & phosphate levels
Describe the structure of the thyroid and parathyroid glands?
Thyroid gland is two lobes connected by an isthmus.
4 parathyroid glands are located posteriorly to the thyroid poles
What is a thyroglossal cyst?
The thyroglossal duct from the back of the tongue to the thyroid gland persists (should be lost during embryological development)..
It the dilates froming a cyst which appears in the midline and grows with age.
You must do an US then excise or drain the cyst.
How do we divide thyroid masses?
How do we tell if a mass is thyroid in nature on exam?
Itll move with the thyroid on swallowing
What could cause a solitary thyroid nodule?
They’re more common in women and the middle aged with malignancy more likely amongst younger sufferers
How do we investigate if there is a single nodular thyroid mass?
Fine needle aspiration cytology (FNAC).
However it doesnt tell us about the masses capsule so it cant differentiate adenoma vs carcinoma.
Therefore, if you suspect cancer youll require a thyroid lobectomy and histology
What are the types of thyroid cancer?
Papillary - usually metastesisses to lymph nodes
Follicular - spreads through blood
Medullary - 10% show a familial associated. Arise from parafollicular C cells so a raised calcitonin is an indicator
Anaplastic - Spreads locally, very aggressive and poor prognosis
What causes a diffuse thyroid enlargement?
Which is a benign overgrowth of the thyroid gland often due to hyperplasia, iodine deficiency or hormonal changes in puberty, pregnancy or lactation.
Can also be Grave’s disease
What is grave’s disease?
An auto-immune condition where auto-antibodies attack thyroid stimulating hormone receptor triggering hyperthyroidism
This leads to
- thyroid eye disease
- diffuse enlargement
- Acropachy (Soft tissue swelling of the hands and clubbing)
- pre-tibial myxoedema (waxy/red orange peel appearance to skin)
Who gets grave’s disease and how do we treat it?
Its most common in women and the middle aged
Treat with anti-thyroids, beta blockers, radio-iodine and surgery.
What could cause multi-nodular goitre?
Could also be Grave’s disease
But also Toxic Goitre
What is toxic goitre?
A hyperthyroidism due to iodine deficiency
(Iodine deficiency -> Low thyroid hormones -> Thyroid hyperplasia -> Hyperthyroidism).
Its commoner in the old. Can cause Afib but unlike graves doesnt cause thyroid eye disease
When would you perform a thyroidectomy?
- Causing an airway obstruction
- If you suspect malignancy
- Thyrotoxicosis (excess thyroid hormones increasing rate of metabolism)
- Cosmesis (Fix an aesthetic problem)
- Retrosternal extension (i.e. it enlarges down into the chest)
Complications of a thyroidectomy?
Bleeding Hoarseness Infection Hypoparathyroidism Hypothyroidism Thyroid storm (hugely excess thyroid hormones causing HR/BP/Temp to soar dangerously)
What are the manifestations of parathyroid disease?
Think stones - Bones - Psychic Moans - Abdo Groans
- Renal calculi, polyuria, renal failure
- Bone pain, osteoporosis, pathological fracture
- Abdo pain, constipation, weight loss, pancreatitis, peptic ulceration
- Anxiety/depression, confusion, paranoia
How do we test for parathyroid disease?
U&E - Creatinine, Ca Phosphate Parathyroid hormone Bicarbonate Vit D US/CT/MRI Isotope scan of glands
How do we treat parathyroid disease?
Surgery if theres hyperparathyroidism
Usually down to adenoma, hyperplasia or malignancy
What does stridor tell us about an airway obstruction?
Inspiratory its a laryngeal obstruction
Expiratory its probably tracheobronchial
Biphasic its probably glottic/sub-glottic
What is a branchial cyst?
Either a remnant cleft from failure of the branchial arches to fuse
Or cystic degeneration of a lymph node.
They grow slowly and can become inflamed.
Most commonly ant to SCM between upper & middle 3rds.
Must be excised to prevent further infection
What is a pharyngeal pouch?
A herniation of the pharyngeal mucosa through the inferior constricter (between thyro- & crico-pharyngeus muscles) of the pharynx forming a pouch which can trap food.
They present with hoarseness, regurg, dysphagia, weight loss and aspiration pneumonia.
How do we treat a pharyngeal pouch?
Barium swallow to spot
Then we can excise the pouch.