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Surgery Review 3

SR 3: Head and Neck, Pituitary, Adrenal, Thyroid, Parathyroid, Inflammation

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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