A 46-year-old woman is referred to endocrine surgery for a possible thyroidectomy. She has a tender neck swelling. Blood results are as follows:

TSH <0.1 mU/l T4 188 nmol/l Hb 14.2 g/dl Plt 377 * 10^9/l WBC 6.4 * 10^9/l ESR 65 mm/hr Technetium thyroid scan shows decreased uptake globally What is the most likely diagnosis?

A. Sick thyroid syndrome

B. Acute bacterial thyroiditis

C. Hashimoto's thyroiditis

D. Subacute thyroiditis

E. Toxic multinodular goitre

This patient does not need surgery! Subacute thyroiditis is suggested by the tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical. This should resolve without any active intervention.

Thyroiditis Sub acute thyroiditis Subacute thyroiditis (also known as De Quervain's thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism Features

• Hyperthyroidism • Painful goitre • Raised ESR • Globally reduced uptake on iodine-131 scan

Management

• Usually self-limiting - most patients do not require treatment • Thyroid pain may respond to aspirin or other NSAIDs • In more severe cases steroids are used, particularly if hypothyroidism develops

Hashimotos thyroiditis Hashimotos thyroiditis is an immunological disorder in which lymphocytes become sensitised to thyroidal antigens. The three most important antibodies include; thyroglobulin, TPO and TSH-R. During the early phase of Hashimotos the the thyroglobulin antibody is markedly elevated and then declines. Features

• Goitre and either euthyroid or mild hypothyroidism • Progressive hypothyroidism (and associated symptoms)

Management

• During the hyperthyroid phase of illness beta blockers may manage symptoms • As hypothyroidism develops patients may require thyroxine

Theme: Voice disorders

A. Vagus nerve injury B. Thyroid nerve injury C. Superior laryngeal nerve injury D. Unilateral inferior laryngeal nerve injury E. Bilateral inferior laryngeal nerves injuries F. Stroke G. Lacunar infarcts H. None of the above Please select the most likely reason for the scenarios given. Each option may be used once, more than once or not at all.

2. A 42 year old singer is admitted for a thyroidectomy. Post operatively she is only able to make a gargling noise. Her voice sounds breathy.

You answered Superior laryngeal nerve injury The correct answer is Unilateral inferior laryngeal nerve injury This patient has diplophonia which causes a gargling sound. This is associated with dysphagia. This can also be caused by a vagus nerve lesion, but the recurrent laryngeal nerve is more at risk of damage.

3. A 42 year old singer is admitted for a thyroidectomy. Post operatively she is unable to sing high pitched notes.

You answered Vagus nerve injury The correct answer is Superior laryngeal nerve injury Theme from September 2011 Exam SLN lesions cause difficulty in voice pitch.

4. A 42 year old singer is admitted for a thyroidectomy. Post operatively the patient develops dyspnoea and is unable to speak.

You answered Vagus nerve injury The correct answer is Bilateral inferior laryngeal nerves injuries This patient has aphonia due to bilateral damage to the recurrent laryngeal nerve.

Voice production There are 2 main nerves involved: Superior laryngeal nerve (SLN)

• Innervates the cricothyroid muscle

Since the cricothyroid muscle is involved in adjusting the tension of the vocal fold for high notes during singing, SLN paresis and paralysis result in: a. Abnormalities in pitch b. Inability to sing with smooth change to each higher note (glissando or pitch glide) Recurrent laryngeal nerve (RLN)/Inferior laryngeal nerve

• Innervates intrinsic larynx muscles

a. Opening vocal folds (as in breathing, coughing) b. Closing vocal folds for vocal fold vibration during voice use c. Closing vocal folds during swallowing

Theme: Nasal diseases

A. Ethmoid sinus cancer B. Maxillary sinus cancer C. Ethmoid adenoma D. Maxillary adenoma E. Ethmoidal fracture F. Nasal polyps G. Sphenoid osteoma H. Ethmoidal sinusitis I. Maxillary sinusitis Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.

5. A 56 year old man presents with symptoms of nasal pain, anosmia and rhinorrhea. He has been well until recently and has worked as a wood carver for many years.

You answered Maxillary adenoma The correct answer is Ethmoid sinus cancer Theme from September 2012 Exam Nasopharyngeal cancer is strongly associated with wood work. Most cases require an occupational exposure of greater than 10 years and are adenocarcinomas on histology. Most cases are ethmoidal in origin (Hadfield E. Ann R Coll Surg Engl. 1970 June; 46(6): 301319)

6. A 32 year old female presents with recurrent episodes of rhinorrhoea, the discharge is watery. She has a medical history of asthma and intolerance of aspirin. On examination she has multiple soft, semi- transparent polyps within her nasal cavity.

Nasal polyps The combination of nasal polyps and atopy is well described. Some cases will respond favourably to systemic steroids and avoid surgery.

7. A child is brought to casualty complaining of a headache and a sensation of pressure between the eyes. On examination she is febrile with a smooth swelling overlying the superomedial aspect of the right eye. The eye is

uncomfortable and there is a purulent discharge from the inner canthus.

Ethmoidal sinusitis Ethmoidal sinusitis may spread to the periorbital tissues resulting in periorbital cellulitis. The superomedial distribution makes a maxillary sinusitis less likely.

Diseases of nose and sinuses Benign Tumours

• Simple papillomas may be an incidental finding or present with obstructive symptoms. Excision under general anaesthesia is sufficient management.

• Transitional cell papillomas may be more extensive and produce obstructive symptoms. Erosion of local structures is a recognised complication. These lesions may rarely undergo malignant transformation and therefore careful and complete excision is required, some cases may require partial or total maxillectomy.

• Pleomorphic adenomas of the maxillary sinuses are reported but are extremely rare, their symptoms typically include nasal obstruction and pain if the sinus is obstructed. Treatment is by complete surgical excision, the diagnosis is not infrequently made post operatively.

• Benign osteomas may develop in the paranasal sinuses, the frontal sinus is the most frequent location of such lesions. Symptoms include; pain, rhinorrhoea and anosmia. Most osteomas may be observed if asymptomatic, sphenoid osteomas should be resected soon after diagnosis as enlargement may compromise visual fields. Many sinus osteomas can now be resected endoscopically, complete surgical resection is required.

• Nasal polyps are benign lesions of the ethmoid sinus mucosa. Many patients may also have asthma, cystic fibrosis and a sensitivity to aspirin. Symptoms include watery rhinorrhoea, infection and anosmia. The polyps are usually a semi transparent grey mass. They are rare in childhood. Treatment is either with systemic steroids or surgical resection. The latter should be combined with antral washout. Low dose, nasal, steroid drops may reduce the risk of recurrence.

Malignant disease

• Malignancies encountered in the nose and paranasal sinuses include, adenoid cystic carcinoma, squamous cell carcinoma and adenocarcinoma.

• Adenocarcinoma of the paranasal sinuses and nasopharynx is strongly linked to exposure to hard wood dust (after >10 years exposure).

• Adenoid cystic carcinoma usually originate in the smaller salivary glands.

• The majority of cancers (50%) arise from the lateral nasal wall, a smaller number (33%) arise from the maxillary antrum, ethmoid and sphenoid cancers comprise only 7%.

• Signs of malignancy on clinical examination include loose teeth, cranial nerve palsies and lymphadenopathy.

• Nasopharyngeal cancers are most common in individuals presenting from China and Asia and are linked to viral infection with Epstein Barr Virus. Radiotherapy and chemotherapy are the most commonly used modalities.

Maxillary sinusitis

• Common symptoms include post nasal discharge, pain, headache and toothache.

• Imaging may show a fluid level in the antrum. • Common organisms include Haemophilus influenzae or Streptococcus

pneumoniae. • Treatment with antral lavage may facilitate diagnosis and relieve symptoms.

Antimicrobial therapy has to be continued for long periods. Antrostomy may be needed.

Frontoethmoidal sinusitis

• Usually presents with frontal headache, nasal obstruction and altered sense of smell.

• Inflammation may progress to involve periorbital tissues. Ocular symptoms may occur and secondary CNS involvement brought about by infection entering via emissary veins.

• CT scanning is the imaging modality of choice. Early cases may be managed with antibiotics. More severe cases usually require surgical drainage.

• Which of the following statements relating to branchial cysts is untrue?

A. The greater auricular nerve may be divided during excision

B. They typically occur in young adults

C. They move upwards on swallowing

D. They are rare over the age of 40 years

E. They are usually located in the anterior triangle of the neck

Nerves at risk during branchial cyst excision: Mandibular branch of facial nerve, greater auricular nerve and accessory nerve.

• They do not move on swallowing. They should be diagnosed with caution in those aged >40 years, as lumps in this age group may in fact be metastatic disease from ENT malignancy.

• Neck lumps •

The table below gives characteristic exam question features for conditions causing neck lumps:

Reactive lymphadenopathy

By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness

Lymphoma Rubbery, painless lymphadenopathy The phenomenon of pain whilst drinking alcohol is very uncommon There may be associated night sweats and splenomegaly

Thyroid swelling May be hypo-, eu- or hyperthyroid symptomatically Moves upwards on swallowing

Thyroglossal cyst More common in patients < 20 years old Usually midline, between the isthmus of the thyroid and the hyoid bone Moves upwards with protrusion of the tongue May be painful if infected

Pharyngeal pouch More common in older men Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles Usually not seen, but if large then a midline lump in the neck that gurgles on palpation Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough

Cystic hygroma A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side Most are evident at birth, around 90% present before 2 years of age

Branchial cyst An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx Develop due to failure of obliteration of the second branchial cleft in embryonic development Usually present in early adulthood

Cervical rib More common in adult females Around 10% develop thoracic outlet syndrome

Carotid aneurysm Pulsatile lateral neck mass which doesn't move on swallowing •

A 22 year old female attends clinic after noticing a painless neck lump. On examination she is noted to have bilateral thyroid masses and multicentric nodes near the base of the thyroid. Her corrected Ca is 2.18. What is the most likely diagnosis?

A. Sporadic medullary carcinoma of the thyroid

B. Medullary carcinoma of the thyroid associated with multiple endocrine neoplasia

C. Follicular thyroid carcinoma

D. Anaplastic thyroid carcinoma

E. Toxic nodular goitre

Medullary thyroid cancer is a tumour of the parafollicular cells of the thyroid. Less than 10% of thyroid cancers are of this type. Patients typically present in children or young adults. Diarrhoea occurs in 30% of cases. Toxic nodular goitre are very rare. In sporadic medullary thyroid cancer, patients typically present with a unilateral solitary nodule and it tends to spread early to the neck lymph nodes. In association with multiple endocrine neoplasia (MEN) syndromes, medullary thyroid cancers are always bilateral and multicentric. It may be the presenting feature in MEN 2a and 2b; almost all MEN 2a patients develop medullary thyroid carcinoma.

Thyroid malignancy Papillary carcinoma

• Commonest sub-type • Accurately diagnosed on fine needle aspiration cytology • Histologically they may demonstrate psammoma bodies (areas of

calcification) and so called 'orphan Annie' nuclei • They typically metastasise via the lymphatics and thus laterally located

apparently ectopic thyroid tissue is usually a metastasis from a well differentiated papillary carcinoma.

Follicular carcinoma

• Are less common than papillary lesions • Like papillary tumours they may present as a discrete nodule. Although they

appear to be well encapsulated macroscopically there invasion on microscopic evaluation.

• Lymph node metastases are uncommon and these tumours tend to spread haematogenously. This translates into a higher mortality rate.

• Follicular lesions cannot be accurately diagnosed on fine needle aspiration cytology and thus all follicular FNA's will require at least a hemi thyroidectomy.

Anaplastic carcinoma

• Less common and tend to occur in elderly females • Disease is usually advanced at presentation and often only palliative

decompression and radiotherapy can be offered.

Medullary carcinoma

• These are tumours of the parafollicular cells ( C Cells) and are of neural crest origin.

• The serum calcitonin may be elevated which is of use when monitoring for recurrence.

• They may be familial and occur as part of the MEN -2A disease spectrum. • Spread may be either lymphatic or haematogenous and as these tumours are

not derived primarily from thyroid cells they are not responsive to radioiodine.

Lymphoma

• These respond well to radiotherapy • Radical surgery is unnecessary once the disease has been diagnosed on biopsy

material. Such biopsy material is not generated by an FNA and thus a core biopsy has to be obtained (with care!).

Theme: Parotid gland disorders

A. Sialectasis B. Pleomorphic adenoma C. Bacterial parotitis D. Viral parotitis E. Sjogren's syndrome F. Adenoid cystic carcinoma G. Mucoepidermoid carcinoma H. Warthins tumour Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.

10. A 40 year old lady with longstanding rheumatoid arthritis presents with a dry mouth and parotid gland swelling. Her symptoms transiently improved following administration of a course of steroids for her rheumatoid disease.

Sjogren's syndrome Theme from April 2012 Exam Sjogrens syndrome is linked to other autoimmune conditions such as rhematoid disease. A transient improvement may be seen with steroid administration. Most patients are treated with artificial saliva.

11. A 77 year old lady presents with facial pain and on examination is found to have clinical evidence of a facial nerve palsy and a parotid mass. Following surgical excision of the lesion the histological report comments on extensive perineural invasion.

You answered Mucoepidermoid carcinoma The correct answer is Adenoid cystic carcinoma Extensive perineural invasion is most commonly seen in patients with adenoid cystic carcinoma. Both Warthins tumours and mucoepidermoid carcinoma rarely show such marked perineural infiltration.

12. An 18 year old boy presents with pancreatitis. He has bilateral painful parotid enlargement.

You answered Sialectasis The correct answer is Viral parotitis In a young adult with parotid swelling and pancreatitis/orchitis/reduced hearing/meningoencephalitis suspect mumps.

Parotid gland clinical Causes of bilateral parotid enlargement

• Mumps: Associated with meningoencephalitis, pancreatitis, orchitis, or deafness

• Parotitis • Sialectasis - especially if related to eating • Sjogren's syndrome: dry eyes or mouth, connective tissue disease • Sarcoidosis • Tuberculosis • Alcoholism • Myxoedema • Cushing's disease • Diabetes/insulin resistance • Liver cirrhosis • Gout • Bulimia nervosa • Drugs • Severe dehydration • Malnutrition

Causes of unilateral parotid enlargement

• Salivary calculus • Tumour

Parotid gland tumours

• Pleomorphic adenomas are the most common. • Incisional biopsy of parotid masses is not recommended, so superficial

parotidectomy is the usual procedure of choice. • Signs of facial nerve palsy and a parotid mass should raise suspicion of

malignancy. • Warthins tumours are relatively benign lesions that are slow growing and

occur most commonly in elderly male smokers. • Adenoid cystic carcinoma have a tendency for perineural invasion.

Theme: Neck lumps

A. Dermoid cyst B. Thyroglossal cyst C. Sjogren's syndrome D. Mikulicz's syndrome E. Pleomorphic adenoma of the parotid F. Carcinoma of the parotid G. Cystic hygroma H. Branchial cyst I. Pharyngeal pouch Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.

13. A dentist treating a women with rheumatoid arthritis for recurrent episodes of dental sepsis notices that both parotid and submandibular glands are symmetrically enlarged.

Sjogren's syndrome Sjogren's is associated with autoimmune disorders. Mikulicz's is similar but there is no sicca or arthritis.

14. A patient presents with a facial nerve palsy. This occurred following repeat

excision of a facial lump. The histology report remarks on the biphasic appearance of the lesion and mucinous connective tissue.

You answered Carcinoma of the parotid The correct answer is Pleomorphic adenoma of the parotid The histological features are as described with a classic biphasic (mixed stromal and epithelial elements), although benign local recurrence can complicate incomplete excision. As this is a benign lesion direct extension into the facial nerve is unlikely to occur. Facial nerve injury can happen during repeat parotid surgery.

15. A patient is recovering from a Sistrunk's procedure, what lesion was treated with this operation?

Thyroglossal cyst This is the procedure for excision of the cyst and its associated track. Excision must be complete and thus a small segment of the hyoid bone is removed to gain access to the upper part of the cyst tract.

Neck lumps The table below gives characteristic exam question features for conditions causing neck lumps:

Reactive lymphadenopathy

By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness

Lymphoma Rubbery, painless lymphadenopathy The phenomenon of pain whilst drinking alcohol is very uncommon There may be associated night sweats and splenomegaly

Thyroid swelling May be hypo-, eu- or hyperthyroid symptomatically Moves upwards on swallowing

Thyroglossal cyst More common in patients < 20 years old Usually midline, between the isthmus of the thyroid and the hyoid bone Moves upwards with protrusion of the tongue May be painful if infected

Pharyngeal pouch More common in older men Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles Usually not seen, but if large then a midline lump in the neck

that gurgles on palpation Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough

Cystic hygroma A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side Most are evident at birth, around 90% present before 2 years of age

Branchial cyst An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx Develop due to failure of obliteration of the second branchial cleft in embryonic development Usually present in early adulthood

Cervical rib More common in adult females Around 10% develop thoracic outlet syndrome

Carotid aneurysm Pulsatile lateral neck mass which doesn't move on swallowing A 44 year old lady presents with epistaxis. From which of the following regions is the bleeding most likely to originate?

A. Posterior nasal space

B. Alar rim

C. Kisselbach's plexus

D. Cribriform plate

E. None of the above

Kisselbachs plexus has an arterial supply derived from both the internal and external carotid arteries and is the commonest area for bleeding in idiopathic epistaxis.

Epistaxis Usually trivial and insignificant but severe haemorrhage may compromise airway and pose a risk to life. Anatomy: Arterial supply

• From internal and external carotid • An arterial plexus exists at Little's area and is the source of bleeding in 90%

cases • Major arterial supply is from the sphenopalatine and greater palatine arteries

(branches of the maxillary artery) • The facial artery supplies the more anterior aspect of the nose

• Ethmoidal arteries are branches of the ophthalmic artery. They supply the posterosuperior nasal cavity

Venous drainage follows the arterial pattern Classification

• Primary idiopathic epistaxis accounts for 75% of all cases • Secondary cases arise as a result of events such as anticoagulants, trauma and

coagulopathy • Classification into anterior and posterior epistaxis may help to locate the

source and becomes more important when invasive treatment is required

Management

• Resuscitate if required • Subject should sit upright and pinch nose firmly • Nasal cavity should be examined using a headlight • Simple anterior epistaxis may be managed using silver nitrate cautery. If

difficult to manage then custom manufactured packs may be inserted • Posterior packing or tamponade may be achieved by passing a balloon

tamponade device and inflating it. This is indicated where anterior packing along has failed to achieve haemostasis.

• Post nasal pack patients should receive antibiotics • Failure of these methods will require more invasive therapy. Where a vascular

radiology suite is available consideration may be given to angiographic techniques. Direct ligation of the nasal arterial supply may also be undertaken. Of the arterial ligation techniques available the endo nasal sphenopalatine arterial ligation procedure is most popular.

A 56 year old man presents with a painless swelling in the upper part of the anterior triangle of his neck. On examination a mass lesion involving the sub mandibular gland is identified. On CT scanning this is shown to be a solid lesion. There is no regional lymphadenopathy. Two fine needle aspirates have failed to be diagnostic. Which of the following is the most appropriate management option?

A. Sub mandibular gland excision

B. Incisional biopsy of the mass

C. Manage conservatively and repeat the CT scan in 6 months

D. Sub mandibular gland excision and radical neck dissection

E. Diagnostic excision of the superficial lobe of the submandibular gland

There is a 50% risk that this lesion is malignant (in some series up to 70%). Therefore the gland should be excised entirely. At this stage a radical neck dissection is not justified.

Submandibular glands- disease Physiology The submandibular glands secrete approximately 800- 1000ml saliva per day. They typically produce mixed seromucinous secretions. When paraympathetic activity is dominant the secretions will be more serous. The parasympathetic fibres are derived from the chorda tympani nerves and the submandibular ganglion, they travel to the glands via the lingual nerves. Sialolithiasis

• 80% of all salivary gland calculi occur in the submandibular gland • 70% of the these calculi are radio-opaque • Stones are usually composed of calcium phosphate or calcium carbonate • Patients typically develop colicky pain and post prandial swelling of the gland • Investigation involves sialography to demonstrate the site of obstruction and

associated other stones • Stones impacted in the distal aspect of Whartons duct may be removed orally,

other stones and chronic inflammation will usually require gland excision

Sialadenitis

• Usually occurs as a result of Staphylococcus aureus infection • Pus may be seen leaking from the duct, erythema may also be noted • Development of a sub mandibular abscess is a serious complication as it may

spread through the other deep fascial spaces and occlude the airway

Submandibular tumours

• Only 8% of salivary gland tumours affect the sub mandibular gland • Of these 50% are malignant (usually adenoid cystic carcinoma) • Diagnosis usually involves fine needle aspiration cytology • Imaging is with CT and MRI • In view of the high prevalence of malignancy, all masses of the submandibular

glands should generally be excised.

A 36-year-old woman who presented with a goitre is diagnosed with autoimmune thyroiditis. Which one of the following types of thyroid cancer is she predisposed to developing?

A. Anaplastic

B. Lymphoma

C. Medullary

D. Follicular

E. Papillary

Hashimoto's thyroiditis is associated with thyroid lymphoma Rarely, a patient with Hashimotos thyroiditis may develop a lymphoma of the thyroid gland. The exact aetiology of thyroid gland lymphoma is unknown. Hashimotos thyroiditis is a definite risk factor. It is possible that the lymphoma may represent the exapnsion of a clone of immortalised intrathyroidal lymphocytes. Lymphoma of the gland is characterised by rapid thyroid growth despite T4 therapy. Whilst adenocarcinoma of the thyroid may occur in association with thyroiditis there are no studies, to date, showing a correlation between these two conditions. The commonest sequelae of thyroiditis is hypothyroidism.

Thyroiditis Sub acute thyroiditis Subacute thyroiditis (also known as De Quervain's thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism Features

• Hyperthyroidism • Painful goitre • Raised ESR • Globally reduced uptake on iodine-131 scan

Management

• Usually self-limiting - most patients do not require treatment • Thyroid pain may respond to aspirin or other NSAIDs • In more severe cases steroids are used, particularly if hypothyroidism develops

Hashimotos thyroiditis Hashimotos thyroiditis is an immunological disorder in which lymphocytes become sensitised to thyroidal antigens. The three most important antibodies include; thyroglobulin, TPO and TSH-R. During the early phase of Hashimotos the the thyroglobulin antibody is markedly elevated and then declines. Features

• Goitre and either euthyroid or mild hypothyroidism • Progressive hypothyroidism (and associated symptoms)

Management

• During the hyperthyroid phase of illness beta blockers may manage symptoms • As hypothyroidism develops patients may require thyroxine

Which of the following are not typical of papillary carcinoma of the thyroid?

A. Haematogenous metastases are common.

B. It has an overall mortality rate of 11%.

C. Histology typically shows 'orphan Annie-eyed' nuclei.

D. They are seldom encapsulated.

E. They are more common in females.

Haematogenous metastasis is rare. Hence the low mortality rate. Lymphatic spread is more common.

Thyroid malignancy Papillary carcinoma

• Commonest sub-type • Accurately diagnosed on fine needle aspiration cytology • Histologically they may demonstrate psammoma bodies (areas of

calcification) and so called 'orphan Annie' nuclei • They typically metastasise via the lymphatics and thus laterally located

apparently ectopic thyroid tissue is usually a metastasis from a well differentiated papillary carcinoma.

Follicular carcinoma

• Are less common than papillary lesions • Like papillary tumours they may present as a discrete nodule. Although they

appear to be well encapsulated macroscopically there invasion on microscopic evaluation.

• Lymph node metastases are uncommon and these tumours tend to spread haematogenously. This translates into a higher mortality rate.

• Follicular lesions cannot be accurately diagnosed on fine needle aspiration cytology and thus all follicular FNA's will require at least a hemi thyroidectomy.

Anaplastic carcinoma

• Less common and tend to occur in elderly females • Disease is usually advanced at presentation and often only palliative

decompression and radiotherapy can be offered.

Medullary carcinoma

• These are tumours of the parafollicular cells ( C Cells) and are of neural crest origin.

• The serum calcitonin may be elevated which is of use when monitoring for recurrence.

• They may be familial and occur as part of the MEN -2A disease spectrum. • Spread may be either lymphatic or haematogenous and as these tumours are

not derived primarily from thyroid cells they are not responsive to radioiodine.

Lymphoma

• These respond well to radiotherapy • Radical surgery is unnecessary once the disease has been diagnosed on biopsy

material. Such biopsy material is not generated by an FNA and thus a core biopsy has to be obtained (with care!).

Which of the following does not cause parotid enlargement?

A. Liver cirrhosis

B. Myxoedema

C. Amiodarone

D. Tuberculosis

E. Sjogrens syndrome

Drugs commonly implicated in parotid gland enlargement include: Thiouracil, isoprenaline, phenylbutazone, high oestrogen dose contraceptive pills.

Parotid gland clinical Causes of bilateral parotid enlargement

• Mumps: Associated with meningoencephalitis, pancreatitis, orchitis, or deafness

• Parotitis

• Sialectasis - especially if related to eating • Sjogren's syndrome: dry eyes or mouth, connective tissue disease • Sarcoidosis • Tuberculosis • Alcoholism • Myxoedema • Cushing's disease • Diabetes/insulin resistance • Liver cirrhosis • Gout • Bulimia nervosa • Drugs • Severe dehydration • Malnutrition

Causes of unilateral parotid enlargement

• Salivary calculus • Tumour

Parotid gland tumours

• Pleomorphic adenomas are the most common. • Incisional biopsy of parotid masses is not recommended, so superficial

parotidectomy is the usual procedure of choice. • Signs of facial nerve palsy and a parotid mass should raise suspicion of

malignancy. • Warthins tumours are relatively benign lesions that are slow growing and

occur most commonly in elderly male smokers. • Adenoid cystic carcinoma have a tendency for perineural invasion. • At which of the following time frames is secondary haemorrhage most likely

to occur following tonsillectomy?

A. Between 5 and 10 days after surgery

B. During the first 6 hours after surgery

C. Between 6 and 12 hours after surgery

D. Upon resumption of normal feeding

E. Between 2 and 3 days post operatively

• Haemorrhage in the first 6 hours after surgery is termed reactionary haemorrhage. Feeding does not increase the risk and may actually lower the risks of infection developing.

• Secondary haemorrhage after tonsillectomy •

Haemorrhage is a feared complication following tonsillectomy. Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre. Secondary haemorrhage occurs between 5 and 10 days after surgery, it is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in 3% of all tonsillectomies.

• A 8 year old boy with recurrent attacks of otitis media is suspected of developing a glue ear. If his sound conduction is tested, which of the following is most consistent with a unilateral middle ear effusion?

A. Negative Rinne's test on the ipsilateral side

B. Positive Rinne's test on the ipsilateral side

C. Positive Webers and Rinnes tests on the ipsilateral side

D. Positive Rinne's test on the contralateral side

E. Negative Webers test only on the contralateral side

• Theme from 2008 Exam Rinne's test will localise to the affected side (i.e. it is negative in conductive deafness). In a positive Rinne's test sound heard by air conduction is better than that conveyed by bone conduction. Reduction of both air and bone conduction in equal measure is a feature of sensorineural hearing loss.

• Hearing Loss •

Hearing loss may be conductive or sensorineural. To determine which is present patients will often require a formal assessment with pure tone audiometry. In the clinical setting Webers and Rinnes tests may be helpful in categorising various types of hearing loss. Webers and Rinnes Tests In a normal patient, the Weber tuning fork sound is heard equally loud in both ears with no one ear hearing the sound louder than the other. A patient with symmetrical hearing loss will hear the Weber tuning fork sound equally well with diagnostic utility only in asymmetric (one-sided) hearing losses. In a patient with assymetrical hearing loss, the Weber tuning fork sound is heard louder in one ear versus the other. This clinical finding should be confirmed by repeating the procedure and having the patient occlude one ear with a finger; the sound should be heard best in the occluded ear.

Rinne Test Weber without lateralisation

Weber lateralises to left Weber lateralises to right

Both ears Normal Sensorineural loss on Sensorineural loss on left

Air>Bone right Left Bone > Air

Conductive loss on left Combined loss on left

Right Bone> Air

Combined loss on right Conductive loss on right

Both Bone > Air

Combined loss on right and conductive on left

Combined loss on left and conductive on right

heme: Head and neck lesions

A. Dermoid cyst B. Thyroglossal cyst C. Sjogren's syndrome D. Mikulicz's syndrome E. Pleomorphic adenoma of the parotid F. Carcinoma of the parotid G. Cystic hygroma H. Branchial cyst I. Pharyngeal pouch Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.

23. The parents of a 2 year old child are concerned after he develops a lump in his neck. On examination there is a swelling in the subcutaneous tissue of the posterior triangle which transilluminates.

Cystic hygroma This is a classical description. Collection of dilated lymphatic sacs which are fluctuant and brilliantly transilluminable. Recurrence is common.

24. A 40 year old female presents with a painless neck lump. There is a mass noted beneath the sternocleidomastoid muscle. There is a long history and somewhat unkindly her husband remarked on her rather noticeable halitosis.

Pharyngeal pouch Usual history of regurgitation of undigested food or coughing at night. Associated with halitosis and throat infections.

25. A 32 year old lady is referred to the clinic with recurrent infections and

abscesses in the neck. On examination she has a midline defect with an overlying scab, which moves upwards on tongue protrusion.

Thyroglossal cyst Thyroglossal cyst is always located in the midline as it is this route that the thyroid takes during its embryological descent. Its connection with the foramen caecum means it will move on tongue protrusion.

Similar theme question in September 2011 exam

Neck lumps The table below gives characteristic exam question features for conditions causing neck lumps:

Reactive lymphadenopathy

By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness

Lymphoma Rubbery, painless lymphadenopathy The phenomenon of pain whilst drinking alcohol is very uncommon There may be associated night sweats and splenomegaly

Thyroid swelling May be hypo-, eu- or hyperthyroid symptomatically Moves upwards on swallowing

Thyroglossal cyst More common in patients < 20 years old Usually midline, between the isthmus of the thyroid and the hyoid bone Moves upwards with protrusion of the tongue May be painful if infected

Pharyngeal pouch More common in older men Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles Usually not seen, but if large then a midline lump in the neck that gurgles on palpation Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough

Cystic hygroma A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side Most are evident at birth, around 90% present before 2 years of age

Branchial cyst An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx Develop due to failure of obliteration of the second branchial cleft in embryonic development Usually present in early adulthood

Cervical rib More common in adult females Around 10% develop thoracic outlet syndrome

Carotid aneurysm Pulsatile lateral neck mass which doesn't move on swallowing