Head & Neck Surgery 2024 Summary PDF

# Head & Neck Surgery 2024 Summary ## Chapter 1: Thyroid Gland Introduction - Extension of lobe from oblique line of thyroid cartilage above to 6th tracheal ring below. - Isthmus overlies tracheal rings number 2 to 4. ### Zuckerkandl nodule: - **Def:** lateral hump in Middle of the thyroid lobe...

# Head & Neck Surgery 2024 Summary ## Chapter 1: Thyroid Gland Introduction - Extension of lobe from oblique line of thyroid cartilage above to 6th tracheal ring below. - Isthmus overlies tracheal rings number 2 to 4. ### Zuckerkandl nodule: - **Def:** lateral hump in Middle of the thyroid lobe - **Importance:** hides recurrent laryngeal nerve (RLN) behind it, making its dissection more difficult. ### Arterial Supply 1. **Superior thyroid artery:** from external carotid artery (ECA). - Accompanied by external laryngeal nerve. 2. **Inferior thyroid artery (ITA):** from thyrocervical trunk, of first part of the subclavian artery. - It is The main arterial supply. - The ITA is closely related to the RLN 3. Esophageal and tracheal branches. 4. **Thyroidea ima artery:** 3% of people arises from the aortic arch - Enters the gland through the lower border of its isthmus. ### Venous Drainage: | Vein | Location | |---|---| | Superior thyroid vein | internal jugular vein (IJV). | | Inferior thyroid vein | left innominate vein | | Esophageal and tracheal branches | left innominate vein | | Thyroidea ima vein | | ### Lymphatic Drainage - LN in region VI and VII, III, IV, V, II and lastly I. ### Three deep fasciae: - **Pre-tracheal fascia:** directly envelopes the thyroid gland - Cause why thyroid gland moves with deglutition. - Helping factor in retro-sternal extension → superior mediastinum - **Berry's ligament:** postero-medial part is very tough and anchors the thyroid lobe into the trachea. It is called Berry's ligament. - **Importance:** hides RLN behind it just before entry of larynx. - carries a small artery and vein carefully controlled ## Nerves: 1. **External laryngeal nerve:** branch of superior laryngeal nerve of vagus. - **Site:** It is located in Joll's triangle. - **Supply:** cricothyroid muscle only intrinisic laryngeal muscle outside laryx. - **Injury:** while ligating the superior thyroid vessels - **Effect of injury:** Paralysis of ipsilateral cricothyroid (Tensor of vocal folds) - A. Fatigability of his voice. - B. Loses ability to produce high pitched sounds 2. **Internal laryngeal nerve:** a branch of superior laryngeal nerve. - **Supply:** Pure sensory nerve of larynx above vocal folds. 3. **Recurrent (inferior) laryngeal nerve (RLN):** Branch of vagus nerve. - **Supply:** mixed nerve. - A. motor to intrinsic laryngeal muscles except cricothyroid muscle. - B. Sensory to interior of the larynx below vocal folds - **Injury of RLN** |Injury|Partial|Unilateral|Bilateral|Complete| |---|---|---|---|---| |Dyspnea|Stridor|||| |||||hoarseness of voice|Aphonia| ## Imaging ### INVESTIGATIONS 1. Plain X-ray neck and upper chest: Soft tissue shadow (retrosternal goiter-RSG) 2. Ultrasound (US) neck (the most important). - Diagnose cystic from solid nodules, detect clinically impalpable nodules, 3. Computed tomography (CT) neck: RSG, + cervical LNs. ### Others 1. Biopsy (FNAC or Tru-cut needle biopsy): in case of suspected malignancy. 2. Indirect Laryngoscopy (for assessment of the vocal cords). ### Common (Routine) Investigations 1. TSH, FT3 and FT4. 2. Thyroid auto-antibodies, if Hashimoto"s thyroiditis is to be excluded. 3. US + FNAC. 4. Thyroid tumor markers: Calcitonin for medullary cancer ## Chapter 2 ## Clinical Approach to Goiter - **Def:** enlarged thyroid gland irrespective of the cause or function. ### Characteristic Clinical Features of a Thyroid Swelling 1. **Anatomical site:** - Lower anterior part of the neck, deep to the sternomastoid muscle. 2. **Shape:** Butterfly; however, enlargement may be unilateral or asymmetrical. 3. **Mobility with deglutition:** A goiter moves up & down with deglutition. - NB: Move upwards with protrusion of the tongue: Thyroglossal cyst ### Clinical Types of Goiter (Causes of Thyroid Enlargement) | Type | Description | |---|---| | Simple Goiter | - Diffuse: <br> a) Physiological <br> b) Colloidal) <br> - Multinodular <br> - Solitary Nodule <br> - Recurrent Nodular. | | Toxic Goiter | - Diffuse (1) = Grave's Disease <br> - Multinodular (2) = Marine Lenhart Syndrome. <br> - Solitary Nodule = Plummer's Disease. <br> - Recurrent Nodular. | | Special Goiter | - Thyroiditis. <br> - Neoplastic: <br> a) Benign: Adenoma. <br> b) Malignant: 1 or 2. <br> - Autoimmune. <br> - Congenital (dyshormogenesis). | ### HISTORY-TAKING ### Personal History (Personal Data) - **Age:** - Young Age - Between 25-40 y - Between 30-45 y - Elderly - Physiologic goiter, papillary carcinoma. - SNG - 1 thyrotoxicosis. - 2 thyrotoxicosis. - Cancer of the thyroid. - **Gender:** - Females are more commonly affected with goiter than males. - Males are more affected with retro-sternal goiter and malignant solitary thyroid nodule. ### Symptoms (Complaints) - **A. Symptoms due to thyroid swelling** - 1 **Sudden appearance or rapid in size may be due to:** - A. Hemorrhage in a cyst or a necrotic nodule. - B. Rapidly growing carcinoma, or subacute thyroiditis. - 2 **Pain** = same causes of rapid enlargement - **B. Pressure symptoms:** - On 2 tubes (esophagus/trachea), 2 nerves (RLN/sympathetic trunk) & 2 vessels (carotid artery/IJV): - 1. **Dysphagia:** Because the thyroid has to be pulled upwards during swallowing. - 2. **Dyspnea:** pressure over trachea, (Retro-sternal or malignant) - 3. **Hoarseness of voice:** (RLN) affection in cancer. - 4. **Horner's syndrome:** cancer thyroid. - 5. **Dizziness & fainting attacks** (rare). - 6. **Congestion of the face**. ### Present History - **B) Progress** - Slowly-progressing - Rapidly-progressing - Self-limiting (within 1-3 m) - Restricted mobility - Harder in consistency - **Past History** - Similar condition: SNG may turn 2 ry toxic or malignant. - Intake of goitrogens e.g. drugs (Thiocyanates) or food (cabbage) - Previous irradiation of the neck: predispose to cancer thyroid. - Previous thyroid operation (Recurrence or fixation / limited mobility). - Family History: Goiter + deafness in Pendred's disease = hereditary goiter. ### CLINICAL EXAMINATION 1 **Heart rate and rhythm** | Condition | Description | |---|---| | Thyrotoxicosis | Tachycardia persists during sleep <br> < 90/min = mild, <br> 90-110/min = moderate. <br> > 110/min = severe | | Neurosis | Disappear during sleep | 2. **Temperature:** elevated in thyrotoxicosis. 3. **Blood pressure:** Systolic hypertension & ↑ pulse pressure in thyrotoxicosis 4. **Respiratory rate:** Dyspnea at rest: toxic heart failure or retro-sternal goiter. 5. **Head and Neck** - **Scalp and face:** Malar flush & scanty dry head hair (myxedema) 6. **The Eyes** - Horner's syndrome (ptosis, myosis, and enophthalmos) in thyroid cancer with infiltration of the cervical sympathetic trunk. - Look for signs of toxicity 1. Lid retraction (Dalrymple's sign) - Upper eyelid is higher than normal + No exophthalmos 2. Stellwag's sign - Staring look due to infrequent blinking 3. Lid lag (Von Graefe's sign) - The upper lid does not move downward with the moving eyeball. 4. Lack of convergence (Moebius sign) 5. Joffroy's sign: look upwards without wrinkling of the forehead). 6. Exophthalmos - The sclera becomes visible below or all around the iris. - **How to test???? Naffziger's Method:** - A. Stand behind the seated patient & tilt his head backwards.. - B. Eyeball appear before super-ciliary ridges. 7. Chemosis, Ophthalmoplegia and dilated congested conjunctival blood vessels, in severe thyrotoxicosis. 8. Tremors of the eyelids in semi-closed eyes. - **- Dullness over the manubrium (percussion) ………….. Retro-sternal goiter.** - **The Hands** - Moist and warm in thyrotoxicosis. - Fine tremors in thyrotoxicosis: - **Test:** Ask the patient to hold her arms out in front of her, elbows and wrists straight, fingers straight and separated. - **Lower Limbs** - Peri-tibial myxedema: Pitting with orange chins at the beginning, but becomes non-pitting later on, with deep purple chins - **What is Berry's Sign?** - Displacement of the carotid artery backwards and outwards by goiter. ### Signs of Retro-sternal Extension: - **History:** Postural dyspnea, stridor, cough, wheezing, choking, dysphagia, etc. - **Physical examination:** - 1. Dilated veins in front of the neck and sternum. - 2. Enlarged thyroid with non-visible lower border on swallowing (inspection). - 3. Impalpable lower border on palpation. - 4. Dullness on percussion over the manubrium sterni. - 5. Flushing of the skin & dilatation of the EJV during raising the arms or hyperextension of the neck (= Positive Pemberton' Sign). - 6. **Investigations** - a) Plain X-ray. - b) CT scan. - c) Thyroid scan. ### Point of difference | Feature | 1ry thyrotoxicosis | 2ry thyrotoxicosis | |---|---|---| | Age | Young adults | Older age groups | | Onset of toxic symptoms | Simultaneous with the swelling | Follows the swelling | | Eye signs | +++ | + | | Nervous manifestations | +++ | + | | Cardiovascular symptoms | +++ | + | | GIT manifestations | +++ | + | | Increased BMR | +++ | + | | The gland | Diffuse and smooth, symmetrical bilateral and fleshy | Nodular, asymmetrical and may be unilateral | ### Criteria | Feature | 1 Toxic (Grave's) | Colloid Goiter | Thyroiditis | |---|---|---|---| | Size | Slight to moderate | Moderate to gross | Small or moderate | | Surface | Smooth | Bosselated | Smooth | | Consistency | Soft-Fleshy | Fleshy | Hard | | Tenderness | - | - | - | | Bruit | + | - | - | ### Complications of multinodular goiter: 1- Toxicity 2- Malignancy 3- Retrosternal extension 4- Pressure 5- Cyst formation 6- Calcification 7- Hemorrhage 8- Infection is rare due to the extensive vascularity. ## Criteria of malignant transformation: | Criteria | Description | |---|---| | **Glandular criteria:** | | | Rapid growth | | | Fixation | | | Consistency is hard | | | Edge is ill-defined | | | Onset of pain | | | **Extraglandular criteria:** | | | Pressure (more evident) | | | Vocal cord paralysis (RLN) | | | Horner syndrome | | | Cervical lymph nodes | | | Unequal carotid pulsations | | | Distant metastases | | ## Chapter 3 ## Thyroid Tumors ### BENIGN TUMORS OF THE THYROID ### Pathological Classification: | Tumor Type | Description | |---|---| | **Epithelial Tumors** | | | Papillary adenoma (fetal or microfollicular adenoma). | | | Follicular adenoma (cystadenoma or colloid adenoma). | | | **Mesenchymal Tumors** | | | Lipoma | | | Leiomyoma | | | Hemangioma | | | **Other Tumors** | | | Teratoma (mainly in children). | | ### MLIGNANT TUMORS OF THE THYROID ### When to be Suspected? - enlarging painless lesion with one or more of the following: - Radiation exposure - Male gender, older age, younger age - Rapid ↑ in size - Previous thyroid cancer - Lymphadenopathy - Evidence of local invasion (vocal cord paralysis, dysphagia or firm, fixed nodules) ### Familial syndromes. ### Familial syndromes: Familial non-medullary thyroid cancer | Syndrome | Thyroid cancer | Description | |---|---|---| | Gardner syndrome | PTC | Intestinal polyps, osteomas, fibromas, lipomas | | Cowden syndrome | PTC - FTC | Breast cancer, hamartomas, pigmented adrenal nodules, Schwannoma | | Carney syndrome | PTC | Myoma, pituitary adenomas, testicular tumors | ### Incidence | Tumor Type | Incidence | |---|---| | Papillary | 80% | | Follicular | 15% | | Medullary | 2-10% | | Anaplastic | 5-15% | | Lymphoma | rare | | Metastatic | rare | ### Classification - **Differentiated tumors of follicular origin (90-95%):** Papillary carcinoma, follicular carcinoma, Hürthle cell carcinoma - **From parafollicular cells (2-10%):** Medullary thyroid carcinoma (MTC) - **Poorly differentiated (5-15%):** Anaplastic thyroid carcinoma (ATC) ### Oncogenes associated with Thyroid Carcinoma 1. RET oncogene: Papillary (PTC) & MTC. 2. Mutated RAS oncogene: Follicular thyroid carcinoma (FTC) 3. Mutated p53 gene: Anaplastic thyroid carcinoma (ATC). ### Incidence ### PAPILLARY THYROID CARCINOMA (PTC) - The most common histological variety of thyroid malignancy (80%) - Predominant thyroid cancer in children. - May be due to radiation exposure of the neck. - Age: Peak incidence is in the third decade of life. - Gender (Female: male = 3:1) ### Pathology - Complex papillary projections with a fibrovascular core. - **The hall mark** - A. Psammoma bodies (laminated calcified spheres) - B. Orphan Annie eye Nuclei or ground glass nuclei (nuclei that contain finely dispersed chromatin, optically clear or empty appearance) - The incidence of multi-focality is 80% - Spread to LNs in 30-50% of patients, → No effect on survival. - Hematogenous spread is late to lung & bones. ### Investigations - Ultrasonography (US) - Sonographic features that are helpful are: - 1. Calcifications: Thyroid microcalcifications, = Psammoma bodies - 2. Local invasion + LN metastases - Irregular margins + Heterogeneous echo-texture. - vascularity throughout the LN instead of normal central hilar vessels. - 3. Shape: Taller than it is wide - 4. Vascularity (color or power Doppler US): - The most common pattern: marked intrinsic hyper-vascularity, - 5. Hypoechoic solid nodule. - FNAC (specific and sensitive for PTC, MTC and ATC) - CT/MRI in patients with extensive local or sub-sternal extension ### Surgery - Hemithyroidectomy (lobectomy with isthmectomy): minimal PTC. - Total thyroidectomy if - (1) size >4cm. - (2) age (male >40 y, female >50y) +(3) Angio-invasion - Total thyroidectomy + Neck dissection if: metastatic cervical LNs ### Incidence ### FOLLICULAR THYROID CARCINOMA (FTC) - It is the 2nd common thyroid cancer (10%). - More frequent in I₂ deficiency areas - nodular goiter →neoplasm - Age: Mean age is 50 y - Gender: (Female: male = 3:1) ### The following features should be taken into consideration: 1. Occasional tumors are dominated by cells with abundant granular, eosinophilic cytoplasm (Hürthle cells). 2. Requires extensive sampling of the tumor-thyroid capsule → capsular or vascular invasion. 3. hematogenous spread is more common (bone, lung and liver). ### Diagnosis and treatment: - FNAC not helpful → R: lobectomy and isthmectomy. ### Both scoring systems have identified 2 distinct subgroups; | Feature | Low-risk group | High-risk group | |---|---|---| | Age | younger | older patients | | Metastas | Without distant metastasis | Distant metastasis | | Tumor type | Intra-thyroid follicular / papillary | Extrathyroid papillary/follicular | | Size | Tumors < 4cm in diameter | Tumors >4 cm | ### - Incidence: 3-5% ### HURTHLE CELL THYROID TUMOR - Gender: more in Male. - Origin: Derived from oxyphilic cells of the thyroid gland. - Spreads by lymphatics - Diagnosis: FNAC (20% malignant) - Often multifocal and bilateral. - Treatment: - Total thyroidectomy + Modified radical neck dissection (if with palpable cervical LNs). ### MEDULLARY THYROID CARCINOMA (MTC) - Age: The peak incidence is at 50-60 years - Origin: parafollicular or C cells of the thyroid (neuroectodermal) - Secrets calcitonin (95%); 85% secrets carcinoembryonic antigen (CEA) - Sporadic 90%: Uni-focal, usually at 45y, worse prognosis. - Familial 10%: Multifocal, usually 35 y, better prognosis, associated with: - 1. MEN IIA or Sipples' syndrome - (MTC, hyperplastic parathyroid and pheochromocytoma) - 2. MEN IIB (MTC, pheochromocytoma, ganglioneuromatosis and Marfan's syndrome) - Can secrete: - Calcitonin (95%), СЕА (85%). - SPREAD: - 1. Lymphatics (neck and superior mediastinum) - 2. Blood → liver, bone (osteoplastic) and lung - 3. Local invasion - Diagnosis: Serum calcitonin, CEA, - Treatment - FNAC: characteristic amyloid stroma - Total thyroidectomy - MRND: - Palpable cervical LN, tumor >2cm →chance of 60% nodal metastasis is - o All patients should be screened for pheochromocytoma (MEN II) which - should be resected first. - Follow up: Serum Calcitonin / CEA level - Best → worst prognosis: - Familial non-MEN MTC → ΜΕΝ ΙΙΑ → sporadic cases → MEN IIB ### ANAPLASTIC THYROID CARCINOMA (ATC) - Incidence: An uncommon, affecting older patients - Origin: May arise in a well differentiated thyroid carcinoma - 80% a history of a long-standing goiter with sudden and rapid growth, - Treatment - 1. Tracheostomy and total thyroidectomy are extremely difficult ?? injury to neck structures - NB: Tissue diagnosis is needed to differentiate from lymphoma. - 2. External radiation may temporarily control the local effects of ATC. - 3. Limited effect of systemic chemotherapy (Adriamycin); no hormonal therapy - Prognosis is extremely poor + mean life expectancy of 6-9 months. Death occurs from local invasion of vital cervical structures + airway compression ### THYROID LYMPHOMA - Non-Hodgkin B-cell lymphoma - Hashimoto's thyroiditis is a risk factor - Treatment - 1. Chemotherapy / Radiotherapy - 2. Surgery: It is curative if limited to the thyroid gland only ### - Rare ### METASTATIC CARCINOMA - Hypernephroma is the most common primary site