Head & Neck

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esmond
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163477
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Head & Neck
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2016-03-08 04:57:34
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Head neck
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General Head & Neck FRCS
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  1. Chyle leak
    • Chyle
    • - 2-4L/day, sim to tissue lymph
    • - fat, protein, electrolytes, and lymphocytes
    • - triglyceride rich chylomicrons and long-chain (>10 carbon atoms) esterified fats
    • Chylomicrons = lipoprotein particles, consist of triglycerides, phospholipids, cholesterol, proteins
    • -Thoracic duct = conduit for lymph and dietary fat to reach venous bloodstream
    • Lymphoscintigraphy if unable to identify source
    • Complications - hyponatremia, hypochloremia, hypoproteinemia and lymphopenia, chylothorax, infection
    • Treatment
    • - medium chain triglyceride diet
    • >600mls conservative managment unlikely to be successful
    • - total parentaral nutrition
    • - re-exploration >500ml for > 1 week
    • - embolisation
    • - transthoracic ligation
    • - Octreotide
  2. Radiotherapy patients oral care
    • Benzydamine rinse before,during,3/52 post rx
    • Pilocarpine if not CI if salivary gland functioning
    • Caphosol -  calcium phosphate solution
    • Gelclair
  3. Retrophargeal space
    • Anteriorly visceral fascia of middle deep cervical fasicia
    • Posteriorly alar fascia of internal deep cervical fascia
    • Inferiorly T2 where visceral & alar fascia fuse
    • Laterally  carotid sheath
    • Superiorly skull base
  4. Prevertebral space
    • between prevertebral fascia & vertebral bodies
    • Lateral border Prevertebral fascia attachment to tranverse processes
    • Skull base to coccyx
  5. Danger space
    • Between alar and prevertebral fascia
    • Skull base to mediastinum
    • Lateral limit fascial attachment to transverse processes
  6. Submandibular space
    • Superiorly – floor of mouth mucosa
    • Inferior – external deep cervical fascia of hyoid bone
    • to mandible
    • Posteriorly – continuous with parapharyngeal space
    • Laterally -mandible

    Divided into sublingual and submyelohoid spaces by myelohyoid
  7. Parapharyngeal space
    • Superiorly - Skull base(temporal&sphenoid bones incl  carotid canal,jugular foramen,hypoglossal foramen)
    • Inferiorly - Greater cornua of hyoid,posterior digastric, stylohyoid muscle 
    • Posteriorly carotid sheath(sep from retropharyngeal space), Internal deep cervical fascia
    • Anteriorly Submandibular space, Interpterygoid fascia ,pterygomandibular raphe(medial ptergoid hamulus to post mylohyoid line of mandible)
    • Lateral - External layer of the deep cervical fascia overlying the mandible, medial pterygoids , parotid
    • Medially - pharyngeal fascia around constrictor and tensor & levator muscles  palatini and styloglossus, retropharyngeal space

    Divided into pre & post styloid by fascia fro styloid to tensor veli palati

    • Prestyloid internal maxillary artery,ascending pharyngeal artery, auriculotemporal nerve, deep lobe parotid
    • Post styloid - ICA,CN 9,10,11,12, cervical sympathetic plexus
  8. Masticator space
    • contains masticator muscles – medial and lateral pterygoid, masseter, temporalis
    • consists of temporal and infratemporal fossa
  9. Partial Open Laryngectomy
    • Vertical laryngectomy
    • -<1 cm subglottic extension,mobile affected cord, unilateral lesion, no cartilage/extra laryngeal soft tissue/post commissure invasion
    • - resectoion includes lower half false cord to sup margin of cricoid, arytenoid if necessary, +/- cartilage
    • - reconstruction strap/septum/epiglottis

    • Horizontal laryngectomy
    • Supraglottic indication - above ventricle,mobile cords,no cartilage/ artenoid/ postcricoid/ pyriform fossa/tongue base past circumvalate papillae invasion
    • -cricohyoidoepiglottopexy [CHEP] or cricohyoidopexy [CHP]) indication - 1cm below cords, mobile cords, t2 prev radiotherapy for t2
  10. Partial pharyngeal reconsruction
    Need leave strip of mucosa, improved swallowing outcomes

    • Pectoralis major
    • Radial forearm
    • Lat dorsi
    • Anterlateral thigh flap
  11. Total pharyngeal reconstruction
    • Gastric pullup - one anstomosis, good lower clearance(skip lesions), reflux
    • Jejunum - donor site morbidity, not if upper oesophageal involvement
    • ALT
  12. Nutritional assessment
    • Patient generated subjective global assessment tool(PG-SGA)
    • - History 7 items
    • - Examination 4 items
    • - rated as well nourished, moderately (or suspected of being) malnourished, or severely malnourished.
  13. HPV
    • HPV 16 increase risk oropharyngeal cancer X10 general pupulation, X30 non smoker low drinker population
    • E6 & E7 = proteins produced by viral infected cells
    • HPV 16 >90% cases, others = HPV  18,31,33,35 
    • Past smoking negatively influences HPV+ve  prognosis
  14. Melanoma sentinal node biopsy
    • Multi centre selective lymphadenectomy trial
    • Intermediate thickness melanoma
    • SLNB + neck dissection for +ve v wait and neck dissect +ves
    • Improved disease free survival for SLNB,not overall survival
    • SLNB is normally considered for patients with melanoma 1+ mm, when about 20% are positive;however, the risk of a positive SLNB in a melanoma< 1 mm is still 5%

    5% it is not possible to identify the sentinel node

    • unfiltered99m Tc sulfur colloid
    • In the nuclear medicine department, 2-16 hours before the operation, the patient is injected intradermally around the site of the primary tumor or biopsy scar

    Vital blue dye (1-2 mL) is injected intradermally around the primary tumor or biopsy site after the patient is prepared and draped using sterile technique

    70-80% of patients (range 58-92%) have no further disease identified
  15. Parapharyngeal space approaches
    • Trans oral
    • Trans cervical
    • Trans parotid
    • Via mandulotomy
    • Infratemporal fossa
  16. Squamous Cell Carcinoma
    • Classic type
    • Variants 15% - Verrucous ,basaloid, exophytic(papillary), spindle cell, small cell, neuroendocrine

    HPV type lack keratinisation and basaloid features
  17. Oral verrucous carcinoma
    • well-differentiated squamous cell carcinoma
    • grows slowly and locally, invasive in nature and unlikely to metastasise
    • painless, thick white plaque resembling a cauliflower
    • closely resembles verrucous hyperplasia(?early stage of disease)
    • Surgery +/-radiotherapy=treatment of choice
  18. Radiotherapy
    • Produces free radicals which cause DNA damage
    • Post op radiation >20% risk recurrence
    • Start no later 6/52 post op
    • Absolute indications - +ve/close margins, 2+ nodes, extracapsular spread, soft tissue invasion neck

    • Types 
    • Conventional - fluoroscopic planning, 1-4 rectangular fields
    • 3D Conformal - CT planning, multileaf collumater to shape beams
    • Intensity modulated -

    • five radiobiological principles which determine the outcome of RT for tumour and normal tissues. These are known as the 5 ‘Rs’ of radiobiology and comprise;
    • (i) Repair of RT-induced DNA damage;
    • (ii) Redistribution of cells into radiosensitive phases of thecell cycle;
    • (iii) Repopulation of tumour cells following RT-induced cell kill
    •  (iv) Reoxygenation of tissues duringa course of RT;
    • (v) the inherent radio responsiveness of individual tumours
  19. Unknown primary
    • Cystic neck mets 40% false negative FNA
    • PET increases detection unknown primary 1/3
    • Total mucosal irradiation - no difference overall survical
    • 70% disease control rates
    • 10-15% recurrence at primary site
  20. Chemoradiation
    • If resectable  40% 5yr survival, unresectable & radiotherapy 20% 5yr survival
    • Chemo - radiosensitiser, destroys radioresistant clones,works on  hypoxic tissue, reduces tumour bulk, eradicate micro mets
    • Pignon Metanalysis concomitant v neoadjuvant v adjuvant - Cisplatin 11% survival advantage at 5yrs
    • Bonner 2006 Cetuximab & radio v radio 10% OS benefit
    • Indications - unresectable disease, organ prservation

    Adjuvant - extracapsular spread,+ve margins, T4 disease, multiple nodal leveal, LN>3cm & PS 0-1
  21. Pharyngeal pouch
    Endoscopic technique 10% recurrence

    Classification 

    • Lahey system
    • Stage I: A small mucosal protrusion is present.
    • Stage II: A definite sac is present, but the hypopharynx and esophagus are in line.
    • Stage III: The hypopharynx is in line with diverticulum, and the esophagus is indented and pushed anteriorly.

    • Morton system
    • Small sacs are less than 2 cm in length.
    • Intermediate sacs are 2-4 cm in length
    • Large sacs are greater than 4 cm in length.

    • van Overbeek system
    • Small sacs are less than 1 vertebral body in length.
    • Intermediate sacs are 1-3 vertebral bodies in length
    • Large sacs are greater than 3 vertebral bodies in length.
  22. Suspicious Thyroid mass US features
    • Hypoechoicity
    • High vascular supply
    • Indisinct margins
    • Irregular capsule
    • Microcalcification
    • Lymphadenopthy

    If doing CT dont use contrast with in 3/12 of RAI
  23. Radioiodine
    RAI 3.7 gbq bq=bequerel=radioactivity unit
  24. Beahrs triangle - carotid, trachea, inf thyroid artery
    If not there non recurrent
  25. Early laryngeal cancer
    Supraglottis - need preserve 2/3 - cricoartenoid joints, epiglottis for swallow rehabilitation

    European Laryngological Society Classification Supraglottic Carcinoma

    • Limited excision
    • Type 1 - superficial tumour

    • Medial supraglottic laryngectomy with partial resection of pre-epiglottic space
    • Type IIa Tumours of laryngeal surface of epiglottis located above the hyoid bone: resection includes the suprahyoid epiglottis
    • Type IIb Tumours extending below the hyoid: resection includes a total epiglottectomy

    • Medial supraglottic laryngectomy with resection of the pre-epiglottic space
    • IIIa Tumours extending to petiole of epiglottis: resection must include the pre-epiglottic space
    • IIIb Tumours of the infrahyoid epiglottis extending to the ventricular fold: resection includes ventricular folds dissected from the thyroid cartilage

    • Lateral supraglottic laryngectomy
    • IVa Tumors of the threefolds’ region: resection of free edge of the epiglottis, the aryepiglottic fold, the pharyngo-aryepiglottic fold and the ventricular fold
    • IVbTumour extending to arytenoids: resection includes the arytenoids and inner/medial or anterior wall of the pyriform fossa
  26. Human Papilloma Virus
    • papillomaviridae
    • non-enveloped and contain a circular double stranded DNA
    • Exerts effects via p53 & pRb
    • p53=tumour suppressor gene, if dna damage - repair or apoptosis
    • retinoblastoma protein = tumour suppressor, regulates progression G1 to S
    • HPV tumours nonkeratinising, basaloid morphology
    • Early T stage, advanced N stage presentation

    Tests - need demonstarted HPV biological activity

    • HPV DNA tests
    • PCR E6 protein
    • Chromogenic in situ hybridisation

    • Tests HPV activity
    • PCR cDNA E6 & E7
    • Surrogate markers - overexpression p16
  27. Neurofibromatosis type 2
    • < 18 years, isolated meningioma or vestibular schwannoma has a 20% and 10% risk of having NF2 respectively.
    • Management aim = maintain function quality of life whilst managing the tumour load.
    • majority tumours demonstrate significant growth,
    • growing by at least 5mm/year in over 80% of patients
    • surgery more difficult, facial preservation rate lower
    • Stereotactic radiosurgery controls tumour growth in 60-92% of cases over a five-year period, 33-57% chance of preserving serviceable hearing over a five-year period, up to 10% facial weekness but ?malignant transformation poorer outcomes after salvage surgery

    • Medical therapy
    • Bevacizumab, an anti-vascular endothelial growth factor monoclonal antibody

    • auditory brainstem implantation
    • electrode in brainstem cochlear nucleus, provide aid to lip reading, implant even if unilateral disease to maintain neural plasticity
    • MRI 1.5 tesla & head bandage
    • Spinal schwannomas and meningiomas may require excision if they are causing compressive symptoms

    • Screening
    • children start at 10 mri/audiology up age 40
    • Once diagnosed annual MRI head, 3yrly spine if spinal tumour, otherwise 5 yearly
  28. Voice
    • Changes caused by 
    • Mass changes - alter pitch(fundamental frquency)
    • Poor closure - breathy/weak voice
    • Changes vibration/tension vocal cord - harshness

    • Disorders
    • Inflammatory
    • Neurogenic
    • Neoplastic
    • Muskulosketal

    rate of each cycle of vibration of the folds determines the fundamental frequency (pitch) and the amplitude ofthe wave (its loudness).

    • Stroboscopy observations
    • Symmetry 
    • Periodicity (the regularity of apparent successive cycles of vocal fold vibration)
    • Amplitude (the extent of horizontal excursion of the vocal folds)
    • Presence of stiffness or adynamic (non-vibratory segments) on the vocal fold
    • Pattern of closure.

    • Laryngeal biomechanics (pattern of closure)patterns
    • Glottic - posterior chink due to posterior cricoartenoid, seen with nodules
    • Supraglottic - lateral squeeze, often compensating for underlying glottic insuifficiency
    • Supraglottic - ant - post squeeze
    • Supratentorial - vocal cords abducted for phonation but normal for laughing, coughing,whistling

    High seed video - aphonic voice,children

    Kymography - digital technique for high-speed visualization of vibration at one point along vocal cords, 8000f/sec

    •  Voice quality measurement
    • Subjectively -Voice handicap index(VHI-10)
    • Objectively - GRBAS Grade(overall),Roughness, Breathiness, Asthenia and Strain. 0 = normal, 1 = mild, 2= moderate, and 3 = severe
    • Quantitively - voicel analysis software, laryngograph
  29. PET scanning
    • rectus muscles of orbit (esp medial rectus), mylohyoid muscle, palatine and lingual tonsils and major salivary glands can all display increased SUV(standardised uptake values) compared to surrounding tissues.
    • Also brain and renal tract- FDG-glucose not reabsorbed
    • Fast 4hrs pre scan so normal tissues metabolising free fatty acids
    • Lie still 45 mins after injection so muscles do not use glucose

    • Unknown primary
    • CT/MR identify 80% primaries
    • PET 1/3 of remainder

    • Mets
    • Advanced disease changes management plan 10-20%

    • Treatment planning
    • Better at estimating gross tumour volume than CT

    • Disease response surveillance
    • overall sensitivity of 94% and specificity of 82% following chemo-radiotherapy or radiotherapy, and 89% and 74% respectively for laryngeal tumours.

    Neck disease - normally upstages

    Other uses - melanoma, lymphoma
  30. Neck dissections
    • Comprehensive - levels 1-5
    • - Radical
    • - Modified radical
    • - Extended more levels or non lymphatic structures
    • Selective

    • Indications
    • - Therapeutic
    • - Elective - occult nodes, if >20% chance occult mets
  31. Poor prognostic indicators
    • Carotid invasion 10% 5yr survival
    • Skin invasion 15% 5 yr survival
    • Salvage surgery following recurrence post neck dissection <5%
  32. Thyroid investigations
    • 5% solitary nodules malignant on US, 10% palpable
    • Malignancy in MNG 5-20%
    • Thyrotoxicosis 2-5%

    • US feaures suggestive of malignancy
    •  hypoechogenicity, irregular margins, absence of through transmission, micro-calcification and nodule size greater than 3cm
  33. Salivary gland malignancy
    • Molinary et al 1993 Meta-analysis 23% local control benefit with post op radiotherapy
    • Chemotherapy useful for palliation of symptoms
    • Accuracy for frozen section malignnt tunours 80%
    • FNA high false negative rate 14-48%
    • several malignant histologic tumour types lack unequivocal cytological parameters indicating malignancy
    • MR if suspicion of malignancy
    • Adenocystic carcinoma - most common SMG,lingual,MSG
  34. Parapharyngeal space neoplasms
    • Paragangliomas/nerve sheath tumours can be managed conservatively
    • Radiotherapy option for paragangliomas, reduced CN complications c/w surgery
    • Surgery complications CN 10-20%, sympathetic - horners and first bite syndrome(pain)
    • Post styloid - nerve related or paraganglioma
    • Prestyloid parotid
  35. Benign salivary gland disease
    IgG4 sclerosis - commonest site = pancreas may respond to steroids

    Bilateral salivary gland swelling - autoimmune(sjogrens, RA), endocrine(diabetic),nutritional, drugs, alcohol, infection(hiv,tb) sarcoid, amyloid, neoplastic
  36. Chemotherapy
    RECIST criteria - complete response, partial response, stable disease, progressive disease

    Veterans Administration Cooperative Study randomised 332 patients with Stage III or IV glottic or supraglottic carcinoma to receive laryngectomy and postoperative radiotherapy or 3 cycles of neaodjuvant cisplatin and 5FU chemotherapy followed by definitive radiotherapy in responders. Larynx preservationwas possible in 64% of patients randomized to the neoadjuvant chemotherapy arm without detriment to overall survival.

    • RTOG91–11,
    • 3 arm study comparing neoadjuvant chemotherapy followed by radiotherapy versus concurrent chemoradiotherapy versus radiotherapy alone. There was no difference in the survival rates, but the rates of laryngeal preservation were higher in the groups assigned to either concurrent chemotherapy or neoadjuvant chemotherapy.

    Neoadjuvant chemo - cisplatin/5-fu 5–6 days via an intravenous infusion every 3 weeks. Usually 2–6 cycles

    EORTC 22931 trial randomised 334 patients to receive either post-operative concurrent chemoradiotherapy or radiotherapy alone. Concurrent treatment has improved the 3 year disease free survival from 41% to 59% and the 3 year overall survival from 49% to 65%. There is no difference in the rate of metastatic relapses.This benefit is at the cost of increasing acute radiotherapy toxicity (grade 3 and above) from 21% to 41%. Concurrent CRT should be considered for high risk postoperative cases (for instance, those with positive margins or extracapsular extension in nodal disease).
  37. Parotidectomy complications
    • Scar
    • Infection
    • Bleeding
    • Numbness
    • Facial nerve
    • cosmetic deformity
    • frey's syndrome
    • Saliary fistula/sialocoele aspirat, botox if persistent, fistula manage conservatively
    • recurrence 1%
  38. Pleomorphic adenoma
    • malignant transformation up to 5% over 20 years
    • If >4cm dont treat conservatively, increased risk malignancy
  39. PARSPORT trial
    • RCT pharyngeal SCC IMRT v CRT
    • significantly less xerostomia, no significant difference survival
  40. Hyperfractionated radiotherapy
    EORTC 22791 trial were randomised to receive conventional treatment or 80.5Gy given in twice daily fractions of 1.15Gy per fraction over 7 weeks. Hyperfractionation resulted in an increase in tumour control from 40% to 59% with no increase in late normal tissue toxicity.
  41. Radioactive iodine
    • specifically uptaken by thyroid, some salivary gland uptake & lactating breast
    • Half life 8 days
    • beta(tissue damage) and gamma radiation(detectable)

    • No indication
    • Favourable histology
    • Papillary <1cm, Follicular no vascular invasion <2cm
    • No extension beyond capsule

    • Definite indication
    • Distant mets
    • Incomplete resection
    • >10 lymph nodes
    • >3 lymph nodes extracapsuar spread


    • Probable indication
    • Thyroid remnant
    • Lymph nodes not assessed at surgery
    • Tumours 1-4cm
    • Multifocal tumours
    • Unfavourable histology

    • Pre treatment
    • Low iodine diet, non contrast imaging(3/12)
    • Raised TSH
    • Pregnancy test
    • Breast feeding stop 1/12 before treatment
    • Need medical physics assessment prior d/c
    • Defer conception 6/12 M 4/12 F

    • Toxicity
    • Hypothyroidism
    • Acute - taste, sialoadenitis, neck discomfort/swelling
    • Chronic - miscarriage 1yr,Sailadenitis/dry eyes,dry mouth,secondary cancer 0.5%

    HiLo study - lower dose(1.1v3.7GBq) RAI as effective, Thyrogen as effective as thyroid withdrawal

    • 50% metastatic disease takes up iodine
    • If no uptake survical >3yrs rare
    • tyrosine kinase studies underway but side effects
    • doxyrubicin 20% respone, side effects
  42. Thy
    • Thy1c 4% risk malignancy
    • Thy2 false -ve <1%
    • Thy2c
    • Thy3a rpt fna, if thy3 surgery, 90%benign f/u
    • Thy3f - 30% malignant
    • Thy4 - 70% malignancy
    • Thy5 -
  43. Ranula
    • Sublingual gland - no capsule, between FOM & mylohyoid
    • Lesser sublingual gland - always present with 15-30 small glands with short duct of Rivinus passes to Plica sublingualis
    • Greater sublingual gland sometime present, then unilateral, between lesser gland(antlat) and whartons duct(medially), Bartholins duct from greater gland to Whartons duct or curuncula sublingualis

    • Ranula=extravasation from sublingual gland
    • Sublingual gland = spontaeous secretor

    • Treatment - need stop extravasation of gland
    • Options
    • Excision gland or ranula
    • Marsupalisation
    • Micromarsupalisation with silk suture through ranula
    • Injection OK432
    • Botox
  44. Locally invasive differentiated thyroid cancer
    Extra thyroid spread reduces 10 yr survival 50%

    Principles - remove all gross tumour, preserve functioning and vital structures, balance tumour control & fuction, use adj treatment

    • Strap muscles - resect at attachments
    • RLN - try and preserve if working
    • Trachea involvement
    • Shin classification - I= perichondrium only - can shave II = Invades cartilage, III = Cartilage & submucosal involvement, IV = full thickness with mucosal disease
    • Full thickness resection
    • - wedge or window if isolated
    • - sleeve rescetion - up to 5 tracheal rings with suprahyoid release , upper limit >1cm below subglottis, < 3cm no mobilisation required, can resect ant cricoid

    • Larynx - partial/total laryngectomy
    • Oesophagus - if muscle only dissect off mucosa, if intraluminal partial oesophagectomy
  45. Thyrotoxicosis
    • Causes
    • Graves disease - only cause of eye disease
    • Toxic MNG - Rx Surgery RAI
    • Toxic adenoma
    • Drugs - amiodarone

    • Preop considerations - 
    • lugols iodine - reduce vascularity, 2/52 get rebound effect
    • B blocker
    • try control with carbimazole

    Graves Opthalmopathyy - RAI causes small deterioration, Surgery 71% get improvement

    • Medical treatment
    • Thionamides e.g. carbimazole - SE agranulcytosis itching, teratogenic 18/12 course - 65% long term remission

    • RAI
    • 90% remission, 85% hypothyroid at 10 years
    • increase small bowel & thyroid cancer, decrease other patients

    • Surgery
    • increased haematoma rate
    • thyroid storm
  46. Melanoma BAD 2010 Guidelines
    • Stage 1,2,3a - no imaging
    • Stage 3b+ - CT body
    • PET scan if considering metastectectomy
    • Bone scan if suspicious symptoms

    • Sentinal lymph node biopsy 1B+
    • 1.2-3.5 mm thickness 5 yr survival - +ve=75% -ve=90%
    • No proven therapeutic value
    • 5% unable to identify node

    Excise down to fascia of muscle

    • Metatatic recurrence - consider metastectomy
    • Multiple dermal recurrence - CO2 laser
    • Enter clinical trials for chemotherpay
    • Radiotherpy painful lesions

    Post comprehensive neck dissection - 16-32% recurrence

    LDH prognostic stage 4 disease

    • Chemotherapy no proven benefit
    • Radiotherapy - 15% local control improvement, no overall survival benefit

    Neck dissections for lesions above parotid - include parotid
  47. Cutaneous SCC
    • Over all metastatic rate 5%, up to 50% poor prognostic indicators - perineural invasion, poor differentiation,>4mm thickness
    • Metastatic nodal disease - 35% 5yr survival
    • Tumours >2cm = X2 local recurrence,X3 mets

    • Low risk tumours 4mm margin=95% clearance
    • > 2 cm, moderately, poorly or undifferentiated tumours extending into the subcutaneous tissue and those on the ear, lip, scalp, eyelids or nose should be removed with a wider margin (6 mm or more)
  48. Multinodular goitre
    • Radioactive iodine treatment
    • 40% volume reduction @ 1year
    • 50-60% @ 3-5 years
    • 2/3 hypothyroid at 18 months
    • Risks acute thyroiditis,malignancy
  49. Well differentiated thyroid cancer
    • Papillary >1cm & high risk Follicular - total thyroidectomy, majority receiving RAI
    • TSH suppresiion <0.1m U/L, low risk <0.5 mU/L
    • TSH suppression risks = AF,osteoporosis
    • Thyroglobulin >2 ng/ml after TSH stimulation suggestive of residual disease
    • Thyroglobulin <10 ng/ml good prognosis, distant disease unlikely
    • TSH high normal range = increased risk of malignancy pre dx
  50. Lower lip reconstruction
    • <1/3 - Wedge V,W,Pentagonal
    • 1/3 - 2/3 - Abbe/Estlander flap
    • 2/3 - 3/3 - Gillies fan flap,Karapandzic flap, McHugh flap (cheek advancement flap)

  51. Dysphagia
    • Neurological
    • Structural
    • Psychogenic

    • Treatment strategies
    • Diet modification
    • Postural changes
    •  - Chin tuck - improves airway protection
    •  - Head turn - to close pyriform fossa
    •  - Head tilt -  to good side for unilateral pharyngeal weakness
    • Swallowing therapy
    •  - Thermal stimulation
    •  - Supraglottic swallow - hold breath prior to swallow
    •  - Mendlesson manoevre
    •  - Super super glottic swallow
    •  - Shaker exercise
  52. Voice restoration after laryngectomy
    • Oesophageal speech
    • Tracheo-oesophgeal  puncture
    • Artificial larynx(servox) through vibration
  53. Thyroplasty
    • Type 1 Medialisation
    • Type 2 Lateralisation
    • Type 3 Shortening vocal cords (lower pitch)
    • Type 4 Increasing tension vocal cords(elevate pitch)

  54. Mikulicz's disease = Kuttners tumour
    • lacrimal and salivary gland swelling that is not associated with other systemic conditions
    • self-limiting and most often, the diagnosis is a clinical one
  55. Immunoglobulin G4-related disease (IgG4-RD)
    • unknown etiology comprised of a collection of disorders that share specific pathologic, serologic, and clinical features
    • majority of patients respond to glucocorticoids
    • 2 main presentations
    • type 1 autoimmune pancreatitis
    • salivary gland disease - salivary gland enlargement or as sclerosing sialadenitis
  56. Vocal cord palsy SLT
    • Voice & swallow
    • Thickened fluids
    • Turn head to side to improve voice & swallow
    • Glottic tapping
    • Bilabial plosive babbling
  57. Endoscopic phonosurgery
    • Materials
    • Teflon - granuloma
    • Gelfoam - lasts 3/12
    • Fat
    • Bioplastque - up to 7 years

    GA or LA
  58. Tracheostomy
    • Ideal size 75% tracheal diameter
    • Paediatric size age/4 + 4
    • Cuff pressure 20-25mm H2O
    • suction catheter </= .5X internal diameter of the tracheostomy tube  Suction catheter size (Fg) = 2 X (size of tracheostomy tube - 2)
  59. OSA SIGN guidelines 2003
    • Epworth sleepiness score all patients
    • COPD patients/drivers/heavy machinery refer urgently
    • When compared with full PSG,oximetry alone showed a mean sensitivity of 87%  and mean specificity of 65%

    • Management
    • Beghavioural
    • Non surgical - CPAP, intra oral devices mild cases or failed CPAP
    • Surgical - tonsillectomy - large tonsils, tracheostomy, barriatric surgery, madibular & maxilla advancement, hyoid release, nasal surgery
  60. Goitre classification
    • Simple(non toxic)
    • -Diffuse
    • -Solitary nodule
    • -Multi nodular
    • -Recurrent nodule
    • Toxic
    • -Diffuse
    • -Soiltary
    • -Multinodular
    • -Recurrent nodule
    • Neoplastic
    • -Benign
    • -Malignant
    • Inflammatory
    • -Hashimotos
    • -Riedels
    • -De-Quervans
    • Rare
    • -TB
    • -Amyloid
    • -Syphylis
    • -HIV
    • -Lithium
  61. BAETS audit
    • Bleeding after thyroid surgery is largely affected by extent of resection (bilateral subtotal > total > lobectomy) and increasing age.
    •  Early hypocalcaemia is increased by lower age, female gender, Graves’ disease and level VI dissection.
    •  Late hypocalcaemia is largely dependent on level VI dissection, with those other factors that affect early hypocalcaemia becoming much less relevant.
    • Total thyroidectomy post op hypocalcaemia 27%, late hypocalcaemia 12%
  62. Thy FNA outcomes
    • • C5 = 98.2% (329/335)
    • • C4 = 63.4% (184/290)
    • • C3 = 21.5% (416/1,933)
    • • C3 (all neoplasia) = 57.0% (1,102/1,933)
    • • C2 = 7.1% (122/1,714)
    • • C1 = 11.5% (101/880)
  63. Nottingham oncolocy
    • Unknown primary IMRT to tongue base, pyriform fossa, nasopharynx
    • Cetuximab - skin reaction, max age 75
    • Minor cartilage erosion chemorad
    • PET 12 weeks post CRT for all Stage 3,4 disease
    • Neoadjuvant chemo - Stage 3,4 nasopharynx, bulky disease, 2 cycles of 5FU,Taxane,cysplatin
    • Cysplatin dose 200mg/m2 total 6 weekly doses
    • Primary radiotherapy 70Gy
    • Post surgery radiotherapy 60G no worrying features, 66Gy worrying features
    • Palliative radiotherapy 27 Gy in 6 does, X3/week
  64. Bilateral parotid swelling investigations
    • FBC,ESR,CRP
    • U&E,LFT,glucose
    • Anti Rho/La
    • Ca, ACE
    • HIV

    MR,FNA/bx
  65. Muscle tension dysphonia
    • Type I: Glottic/laryngeal isometry features a posterior chink due to simultaneous (and inappropriate) contraction of the posterior cricothyroid muscle and lateral cricoarytenoid muscle during phonation.
    • Type II: Supraglottic/plica ventricularis is A false vocal fold approximation that may be functional or compensatory.
    • Type III: Supraglottic/partial anterior-posterior contraction.
    • Type IV: Supraglottic/complete anterior-posterior contraction in which the petiole of the epiglottis approximates the arytenoids.

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