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Surgery Review 3
SR 3: Head and Neck, Pituitary, Adrenal, Thyroid, Parathyroid, Inflammation
| Question | Answer |
|---|---|
| What is the anterior neck triangle? | SCM, sternal notch, inferior border of digastric muscle – contains carotid sheath |
| What is the posterior neck triangle? | SCM, trapezius, and clavicle – contains spinal accessory nerve and brachial plexus |
| Where are level I cervical lymph nodes located? | Submental area |
| Where are level V cervical lymph nodes? | Posterior triangle |
| Where are level VI cervical lymph nodes located? | Anterior triangle |
| What is the relationship between the scalene muscles in the neck? | Brachial plexus and subclavian artery pass between anterior and middle scalenes, phrenic nerve and SCV pass anterior to anterior scalene |
| What type of fluids do the following glands secrete: parotid, submandibular, sublingual | parotid – mostly serous fluid, sublingual – mostly mucin, submandibular – 50/50 serous and mucin |
| What is Frey’s syndrome? | Injury of auricuotemportal nerve after parotidectomy that then cross-innervates with sympathetic fibers to sweat glands of skin causing gustatory sweating |
| What is a painless hard mass on the roof of the mouth? | Torus – congenital bony exotosis, midline of palate |
| What is the difference between a radical neck dissection and a modified radical neck dissection? | Radical neck takes CN XI, SCM, IJ. Modified spares some combination of those structures (CN XI is most morbid) |
| Which has a greater risk for cancer, leukoplakia or erythroplakia? | Erythroplakia |
| What is Plummer-Vinson syndrome? What type of cancer is increased? | Triad of dysphagia (due to esophageal webs), glossitis, and iron deficiency anemia. Increased risk of esophageal/tongue Ca |
| What is the most common type of lip cancer? | Epidermoid carcinoma. Lower > upper due to sun exposure |
| What is the usual presentation of nasopharyngeal carcinoma? | 50% presesnt late (as neck mass). Drain to posterior (deep) cervical neck nodes, a/w EBV |
| What is the treatment of lip cancer? | Resect, primary closure if <1/2 of lip, otherwise flaps. Radical neck dissection if node+ |
| What is a verrucous ulcer? What is the treatment? | Well-differentiated tumor of the cheek; tx – full cheek resection +/- flap, no MRND |
| What are the most common malignant salivary gland tumors? | 1 - Mucoepidermoid carcinoma; 2 - Adenoid cystic carcinoma (number 1 of submandibular and minor glands) |
| What are the most common benign salivary gland tumors? | Pleomorphic adenoma (number 1 overall, 5% malignant degeneration), Warthin tumor |
| What is the treatment for a benign salivary gland tumor? | Superficial parotidectomy (spare CNVII). If malignant take whole parotid. If high grade or SCCA need radical neck dissection |
| What is the general treatment for different stages of head and neck SCCa? | Stage I+II(up to 4cm, no nodes) – Rx with single modality (surgery or RT), Stage III+IV get combined modality |
| What is included in a MRND for laryngeal Ca? | Take ipsilateral thyroid lobe |
| What is the treatment for glottic Ca? | If small and cords not fixed, then XRT or laser; If cords fixed, need surgery (laryngectomy) and RT |
| What is the most commonly injured nerve with parotid surgery? | Greater auricular nerve - numbness over lower portion of auricle |
| What is the most common salivary gland tumor in children? | hemangioma |
| What 3 structures must you identify while performing a submandibular gland resection? | mandibular branch of facial nerve, hypoglossal nerve, and lingual nerve |
| What is the treatment for ear SCCA? | 20% metastasize to parotid, so parotidectomy with MRND for +nodes or large tumors, and XRT |
| What is a cholesteatoma? What is the presentation and treatment? | epidermal inclusion cyst of ear – slow growing but erode as they go – present with conductive hearing loss and clear drainage from ear – treat with surgical excision |
| What is the treatment for Stensen’s duct laceration? | Repair over catheter stent as ligation can cause painful parotid atrophy and facial asymmetry |
| What is the cause of suppurative parotitis? | dehydration in elderly – staph is most common organism |
| What is sialoadenitis? What is the treatment? | acute inflammation of the salivary gland (80% submandibular and sublingual) related to a stone in the duct; tx – incise duct and remove stone |
| What is the workup of epidermoid CA found in cervical node without known primary? | Panendoscopy with random biopsies, then CT scan; ipsilateral MRND and tonsillectomy with bilateral XRT if still can’t find primary |
| What is the cause of unilateral nasal obstruction and recurrent epistaxis in a teen male? What is the treatment? | Juvenile Nasopharyngeal Angiofibroma - benign but locally agressive vascular tumor of nasal cavity. Embolize (internal maxillary artery), then extirpate |
| What hormones does the anterior pituitary secrete? | ACTH, FSH, LH, TSH, GH, and prolactin |
| What hormones does the posterior pituitary secrete? | ADH and oxytocin |
| What is the classic vision change with pituitary mass effect? | Bitemporal hemianopsia - vision missing in outer half of both right and left visual fields |
| What is the most common pituitary adenoma? What are the symptoms? | Prolactinoma galactorrhea, irregular menses, infertility, decreased vision |
| What is Sheehan syndrome? | postpartum lack of lactation and persistent amenorrhea caused by necrosis of pituitary from blood loss during/after childbirth |
| What is the treatment for a prolactinoma? | Bromocriptine or transphenoidal resection |
| What is Nelson's syndrome? What is the treatment? | Rapid enlargement of a pituitary adenoma that occurs after bilateral adrenalectomy (10%) – increased CRH/ACTH, muscle weakness, pigmentation (from melatonin stimulating hormone (beta-MSH) – a byproduct of ACTH), vision changes; tx - steroids |
| What is the cause of DM, HTN, and gigantism with a pituitary mass? What is the treatment? | Acromegaly – increased growth hormone - confirm with IGF-1 and GH >5-10; tx – transphenoidal resection, XRT and bromocriptine as primary or secondary therapy |
| What is Waterhouse Friderichsen syndrome? | adrenal hemorrhage a/w meningococcal sepsis |
| Describe the blood supply to the adrenal gland | Superior adrenal artery off inferior phrenic, middle directly off of aorta, inferior off renal artery; left adrenal vein goes to left renal vein whereas right goes directly to IVC |
| What are the surgical indications for an adrenal mass? | >4 cm, ominous radiologic characteristics (non-homogenous), functioning, or enlarging |
| What is the workup of an adrenal mass? | Check serum K, urine VMA / metanephrines / catecholamines, CXR, colonoscopy, mammogram; serum renin and aldosterone if HTN or decreased K |
| What are the zones of the adrenal cortex and what hormones does each secrete? | Glomerulosa – aldosterone, fasciculata – glucocorticoids, reticularis – androgens / estrogens |
| What is the most common cause of congenital adrenal hyperplasia? | 21-hydroxylase deficiency – salt wasting, hypotension, increased testosterone (precocious puberty in males, virilization in females) |
| What is the treatment for congenital adrenal hyperplasia? | Cortisol and genitoplasty |
| What is Conn's syndrome? | hyperaldosteronism = 80% adenoma, 20% bilateral hyperplasia - HTN, low K, high Na |
| What is Addison's disease? | low aldosterone and glucocorticoids = low Na, high K, hypoglycemia. Crisis presents similar to sepsis with hypoTN, fever; steroids are diagnostic and therapeutic |
| What is Cushing's disease? | Excessive secretion of ACTH from the anterior pituitary, usually from a pituitary adenoma. Causes 70% of non-iatrogenic Cushing's syndrome. |
| What is the most common cause of Cushing syndrome? | iatrogenic |
| What is Cushing's syndrome? | hormone disorder with high levels of cortisol - symptoms include characteristic weight gain (truncal obesity, moon face, buffalo hump), purple striae, hirsutism, polyuria, htn, insulin intolerance |
| How do you determine the type of Cushing syndrome? | Dexamethasone suppresion test + ACTH levels: Pituitary - high ACTH, cortisol suppressed with steroids Adrenal - low ACTH, not suppressed Ectopic - high ACTH, not suppressed |
| What is the most sensitive test for Cushing’s syndrome? | 24hr urine cortisol |
| What is the medical therapy for ectopic ACTH? | Ketoconazole and metyrapone (inhibit steroid formation), aminoglutethimide (inhibit cholesterol formation), and Op-DDD (mitotane – adrenal-lytic – used for metastatic disease) |
| What enzyme converts norepinephrine to epinephrine? | PNMT - Phenylethanolamine N-methyltransferase – only found in adrenal medulla |
| What are the common characteristics of a pheochromocytoma? | 10% are: malignant, bilateral, in children, familial, extra-adrenal |
| What is the most common extra-adrenal location for a pheochromocytoma? | Organ of Zuckerkandl at aortic bifurcation |
| What is the pre-operative management for a pheochromocytoma? | fluid replacement, alpha-blockers (phenoxybenzamine) first, then beta-blockers if tachycardic |
| How is the diagnosis of pheochromocytoma made? | screen with urine VMA (most sensitive) and metanephrines; MIBG can localize |
| What can falsely elevate urine VMA? | coffe, tea, fruits, vanilla, iodine, alpha + beta blockers |
| What is the blood supply to the thyroid? | 2 arteries, 3 veins: superior thyroid artery off external carotid, inferior thyroid artery off thyrocervical trunk; superior and middle veins drain into IJV, inferior drains into innominate vein |
| What does the superior laryngeal nerve innervate? | motor to cricothyroid muscle (projection and high pitch), sensory to supraglottis |
| What does the recurrent laryngeal nerve innervate? | All muscle of larynx except cricothyroid |
| What is the ligament of Berry? | posterior medial suspensory ligament of thyroid close to recurrent laryngeal nerves |
| What is the function of thyroglobulin? | stores T3 and T4 in colloid |
| What is the effect of propylthiouracil (PTU)? | Peripherally and centrally blocks conversion of T4 to T3 |
| What are side effects of PTU? | crosses placenta - cretinism, aplastic anemia, agranulocytosis, and liver damage |
| What drugs peripherally block conversion of T4 to T3? | PTU, Propanolol, Prednisone (& other steroids) and methimazole |
| What is the Wolk Chaikoff effect? | Reduction in thyroid hormone levels after a large ingestion of iodine - useful in thyroid storm |
| What cells produce calcitonin? | parafollicular C cells - derived from neural crest cells |
| What is the most identifiable cause of a goiter? | iodine deficiency – tx with iodine replacement, if not iodine deficient can try to suppres with thyroxine (T4) |
| What is a lingual thyroid? What is the treatment? | thyroid tissue that persists in the area of the foramen cecum causing dyspnea, dysphonia, and dysphagia – it is the only thyroid tissue in 70% of patients with it; tx – thyroxine (T4) suppression, RAI, or resection if medical therapy fails |
| What is the pathophysiology of Grave’s disease? | IgG antibodies to TSH receptors |
| What disease causes heat intolerance, pretibial edema, exophthalmos, sweating, palpatations, and afib? | Grave’s disease – the most common cause of hyperparathyroidism (80%) |
| What is the pathophysiology of Hashimoto’s thyroiditis? | humeral and cell-mediated autoimmune disease (thyroglobulin antibodies) – pathology shows a lymphocytic infiltrate |
| What is the cause of DeQuervain’s thyroiditis? What is the treatment? | Viral URI; tx – steroids and ASA |
| What is the main limitation of FNA in a solitary thyroid nodule? | Differentiation of benign vs malignant follicular and Hurthle cell neoplasms |
| What do Psammoma bodies bodies on pathology of a thyroid FNA suggest? | Papillary thyroid cancer |
| What is the most common type of thyroid cancer? | Papillary |
| What % of papillary cancer present with positive nodes? | 20% of adults, 80% of children – however, lymphatic spread is NOT prognostic |
| What is the population distribution of papillary thyroid cancer? | F:M ratio is 3:1 1/2 are before age 40 |
| What does amyloid on FNA of a thyroid suggest? | Medullary thyroid cancer |
| What are the indications for radioactive iodine for thyroid cancer? | Only effective for papillary and follicular, given 6 weeks after surgery; give for recurrent or metastatic disease, capsular invasion (extrathyroidal disease), or +nodes in papillary |
| What are the limitations of treatment of thyroid cancer during pregnancy? | No radioactive iodine during pregnancy or breast-feeding; Operate in second trimester if possible |
| What is the difference in metastases between papillary and follicular thyroid cancers? | Papillary – lymphatic spread – lung most common; Follicular – hematogenous spread – bone most common |
| What are the indications for ipsilateral MRND for papillary or follicular thyroid cancer? | clinically positive cervical nodes or extrathyroidal tissue involvement |
| What is the effect from increased calcitonin (as seen from medullary thyroid cancer)? | flushing and diarrhea |
| What is usually the first manisfestation of MENIIa? | medullary thyroid cancer (same for IIa and IIb) |
| What serum level is monitored for recurrence of medullary thyroid cancer? | calcitonin |
| What does amyloid on FNA of a thyroid suggest? | Medullary thyroid cancer |
| What gene is associated with medullary thyroid cancer? | ret proto-oncogene |
| What % of patients with medullary thyroid cancer have MEN2? | 20% (tend to be bilateral, younger, worse prognosis) |
| When do you perform an elective thyroidectomy for a patient with MEN-2A? MEN-2B? Familial medullary carcinoma? | 2A – age 5; 2B – infancy; MTC – age 5 |
| What is the embryologic origin of the parathyroids? | Superior from 4th pharngeal pouch, inferior from 3rd; both receive blood supply from inferior thyroid artery |
| What electrolyte abnormalities are present in primary hyperparathyroidism? | Elevated calcium, low phosphate, can get hyperchloremic metabolic acidosis |
| What are the effects of calcitonin? | Decreased serum Ca (osteoclast inhibition), increased urinary Ca and PO4 excretion |
| What disease is associated with osteitis fibrosa cystica? | hyperparathyroidism |
| What % of patients with hyperparathyroidism have a single gland adenoma? | 80%, 15% have diffuse hyperplasia, 4% have multiple adenomas |
| What is MEN I? | Wermer's syndrome - parathyroid, pancreas (gastrinoma most common), pituitary (prolactinoma MC) |
| What is MEN IIa? | Sipple syndrome - Parathyroid, adrenal (pheochromocytoma), and thyroid |
| What is MEN IIb? | Thyroid, adrenal, mucosal neuromas/marfan |
| What is the value of intraop PTH measurement? | Helps determine if causative gland is removed (PTH should go to <1/2 of preop value), PTH half-life is 18 minutes |
| Where do you look for a missing parathyroid gland? | inferiorly in thymus tissue (most common), near carotids, vertebral body, superior to pharynx, and thyroid |
| How do you differentiate between different causes of hypocalcemia postop? | Bone hunger – normal PTH, decreased HCO3; Aparathyroidism – decreased PTH, normal HCO3 |
| What is the treatment of secondary hyperparathyroidism? | Decrease PO4 intake, supplement Ca and vit D. Total parathyroidectomy for bone pain, fractures, or pruritus (80-90% relief), but rarely needed |
| What is tertiary hyperparathyroidism? | Renal disease now corrected with transplant but still overproduces PTH, similar lab values to primary disease |
| What is pseudohyperparathyroidism? | Defect in PTH receptor in kidney causing no response to PTH |
| What do you correct first in MEN-I? MEN-IIa? MEN-IIb? | MEN I – hyperparathyroidism; MEN IIa + IIb – pheo even though is usually benign |
| What are the causes of hypercalcemia? | CHIMPANZEES – Calcium suppl, Hyperparathyroidism, Iatrogenic (thiazides, immobility), Milk alkali syndrome, Paget disease of bone, Acromegaly/Addison’s disease, Neoplasia, Zollinger-Ellison Syndrome, Excessive Vitamin D and A, Sarcoidosis |
| Which growth factor is the key component of tissue repair? | TGF-beta |
| What are the effects of transforming growth factor-beta (TGF-beta)? | stimulates fibroblasts and chemotactic for neutrophils (too much/too long can cause fibrosis) |
| What is the effect of platelet-derived growth factor (PDGF)? | Attracts fibroblasts and increases smooth muscle to speed matrix deposition and collagen formation |
| What is the main source of histamine in blood? | Basophils |
| What is the main source of histamine in tissues? | Mast cells |
| What is the main initial cytokine response to injury and infection? | Release of TNF-alpha and IL-1 |
| What are the largest producers of TNF-alpha? | macrophages |
| What cell type does TNF-alpha recruit and activate? | neutrophils |
| How does TNF cause wasting/cachexia in cancer patients? | Anorexia, glycolysis, and lipolysis |
| What is the source of fever in atelectasis? | alveolar macrophages |
| What is the function of IL-6? | Increases hepatic acute phase proteins (C-reactive protein, amyloid A) and activates lymphocytes |
| Which cytokines are released by lymphocytes and help to inhibit viral replication? | Interferons |
| What electrolyte is required for both classic and alternative complement pathways? | Magnesium |
| Which complements are anaphylatoxins? | C3a, C4a, C5a |
| Which complements make up the membrane attack complex? | C5b-C9b |
| Which complement is used for opsonization? | C3b |
| Which complements are chemotactic? | C3a and C5a |
| What is the source and effects of prostacyclin? | From endothelium – causes vasodilatation, bronchodilatation, and decreased platelet aggregation |
| What is the source and effects of thromboxane? | From platelets – causes vasoconstriction, bronchoconstriction, and increased platelet aggregation |
| How do steroids inhibit inflammation? | inhibit phospholipase, which converts phospholipids to arachidonic acid |
| What cells are the primary mediators in reperfusion injury? | PMNs |
| What is the effect of EDRF (endothelium derived relaxing factor) | vasodilation via cGMP, increased in sepsis; nitric oxide is most common example |
| What is the rate limiting step in adrenal steroidogenesis? | Conversion of cholesterol to pregnenolone |
| High-dose dexamethasone suppression test shows suppression of plasma ACTH level and decreased cortisol level. What is the diagnosis? | Pituitary adenoma |
Created by:
jclanton82
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