emrcs questions anatomy head neck

1. 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

2. • 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. 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

4. 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

5. 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.

6. • 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.

7. • 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

8. 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.

9. 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.

10. 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

11. 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

12. 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

13. 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

14. • 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

15. 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

16. 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

17. • 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.

18. 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

19. • 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.

20. • 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

21. 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

22. 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

23. 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