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

Thyroid + Triangles of Neck + Airway Obstruction Flashcards

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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

Study These Flashcards
A

Grave’s

Toxic

25
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 ```
26
How do you investigate
Bloods / TFT Consider FBC Thyroid USS +- FNAC CT scan of neck and chest if concern over retrosternal expansion
27
When is thyroidectomy
``` Airway obstruction Malignancy Thyrotoxicosis Cosmesis Restrosternal extension ```
28
What are complications
``` Bleeding which can cause respiratory compromise as tight space = stridor Voice hoarsness Thyroid storm Infection Hypoparathyroid HYpothyroid ```
29
What are compressive neck symptoms due to neck lump
Dysphagia Stridor if trachea compressed SOB on exertion Retrosternal goitre
30
How do you test for retrosternal goitre
Find it difficult to reach up arms without choking
31
What are the central lines used for
``` Measuring central venous pressure Drug administration Cardiac pacing Blood sampling Fluid resus Haemodialysis IV nutrition ```
32
What are complications of central lines
``` Pneumothorax Haematoma Cardiac tamponade Air embolism Thrombosis Sepsis Line blockage ```
33
When is a tracheostomy indicated
Airway obstruction Airway protection Poor ventilation due to reduced dead space
34
What does tracheostomy require
Suctioning Humidifcation Long term care
35
What is stridor
High pitch wheezing Usually on inspiration Clinical sign of airway obstruction
36
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 ```
37
What causes stridor
``` Croup Epiglottitis Obstruction Foreign body Tumour Smoke in inhalation Neck surgery Laryngomalacia Vocal cord palsy = rare ```
38
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
39
How do you Rx
Maintain sats + feed Surgery if FTT Tracheostomy is rare
40
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 ```
41
What is stertor
Noisy breathing due to obstruction above larynx From pharynx Sounds like snoring
42
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 ```
43
What causes inspiratory noise
Laryngeal origin | Above vocal cord / glottis
44
What causes expiratory noise
Tracheobronchial / lung | Typically wheeze
45
What causes biphasic noise
At Glottis
46
What is an emergency after head and neck surgery
Stridor
47
What causes acute airway obstruction in children
FB Infection - croup / epiglottitis Congenital - laryngomalacia Anaphylaxis
48
What causes acute airway obstruction in adults
Infection - supra glottis and deep neck infection / abscess / epiglottis Neoplastic - tongue, oropharyngeal, laryngeal Anaphylaxis
49
What are complications
Respiratory arrest | Beware in children as will decompensate quickly
50
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
51
What do you do after initial management
Investigation for case
52
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
53
Why are bone / battery important
Battery can corrode oesophagus = perforation | Bone can just cause perforation
54
How does FB present
Dysphagia Odynophagia Drool
55
How do you manage
X-ray Battery / bone = immediate removal Can allow food to pass May require OGD
56
How do deep neck infections present
``` Pain Trismus Dysphagia Dysphonia Stridor Drooling Typially look very unwell with fever ```
57
What causes
Usually bacterial | Commonly from poor dental hygiene
58
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 ```

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