Section B - Work Book

Section : B: Head and Neck, Thyroid and Breast
Acknowledgement for this section - B

Dr. Balasubramanian.R, Final Year MBBS, Jawaharlal Nehru Medical college, Belagavi
RRM’S SURGERY SIXER APP BASED WORKBOOK 1

Chapter 1. HEAD and NECK LESIONS
Chapter 1a. Oral cavity
Ulcers in oral cavity
Painful Ulcers Painless Ulcers

• Aphthous ulcer • Cancer – lateral margin of tongue
• Dental ulcer – lateral margin of tongue • Gummatous ulcer – syphilis- anterior
• TB – tip of tongue 2/3rd of tongue in midline
Figure: Gummatous Ulcer
Syphilis oral lesions:
Primary Secondary Tertiary

• Chancre ( painless) • Gumma
• Glossitis ( premalignant)

Figure: snail track ulcers in Syphilis
Conditions associated with malignant transformation:
High risk Medium risk (3S) Low risk ( equivocal risk)

• Erythroplakia ( speckled • Discoid lupoid
> homogenous) erythematosis
• Proliferative verrucous • Oral lichen planus
leukoplakia • Discoid keratosis
• Chronic hyperplastic congenita
candidiasis
1. Leukoplakia
• White patch/ plaque
• M/c in smoking
• m/c premalignant lesion

• specked variant – increased risk – 2.4% malignant
• management- stop smoking and laser
2. Erythroplakia
• 17 times malignant potential

• Highest risk
3. Chronic hyperplastic candidiasis
• Invasive
• Treat with oral antifungal drugs
4. Oral submucous fibrosis
• Betel nut produces – arecoline
• Causes submucous fibrosis
5. Sideropenic dysphagia (plummer Vinson or Paterson Kelly syndrome)

• Females
• 20-40 yrs
• Koilonychias + iron deficiency anemia
• D/t iron deficiency – they have epithelial atrophy – which is premalignant
• Iron supplement – heals epithelial atrophy
Etiological factors
• Smoking – m/c – 1.5-2% risk
• Tobacco
• Arecoline
• Pan masala
• Alcohol
• Dietary- deficiency in antioxidant ( Vit A,C,E)
• Environmental – UV light and sunlight ( for Ca lip)

• Immunocompromised patients
• Infections- HIV 1,2, HPV 16,18 and Syphilis
• Genetic mutation
o P53- m/c
o Plummer Vinson
o Fanconi anemia
o Li Fraumeni syndrome
Pathology
• 90% SCC
• Field cancerisation : entire oral cavity is exposed to carcinogen- therefore we can get 2nd Ca
anywhere
o Synchronous - < 6 months
o Metachronous - > 6months ( Most common – 80%)
o 15% chances of 2nd cancer
Lymph node metastasis
o Systematic way – level I – II- then III
o Skip mets is seen in tongue Ca ( poorest prognosis)
Oral cancers- M/C is SCC

• Lips – M/C western – best prognosis
• Buccal mucosa – M/C India
• Tongue – M/C world – worst prognosis( skip mets)

• Alveolus
• Retromolar trigone
B/L lymph node enlargement is seen in CA

• Lower lip
• Soft palate
• Supra glottis
TNM staging – AJCC 8th edition

• T1-
• T2-
• T3-
• T4
a. Involvement of skin of face, inferior alveolar nerve, floor of mouth
b. Pterygoid plates, carotid sheath, masticator space, internal carotid artery
• N1 - <3cm ( single Node)
• N2 – 3-6 cm
a. Single
b. Multiple ipsilateral
c. Multiple bilateral
• N3:
a. >6 cm size
b. Extranodal extension +
• M1 – distant mets
Stage grouping:
I- T1N0
II- T2N0
III- T3NO; any T N1 ( node starts in III)
IV-
a. T4a; any T N2
b. T4b; any T N3
c. Mets +

• Modifications in 8th edition AJCC:
1. DOI is added to T staging
2. Extra nodal extension is N3b
3. Extrinsic muscle invasion is removed from T4
Investigations
• Oral ulcer – to be evaluated if following are seen:
✓ > 3 weeks
✓ > 3 weeks swelling in oral cavity/ neck

✓ Swallowing difficulty
✓ Trismus +
✓ Sore tongue
• Wedge edge biopsy- with base towards lesion ( 2% toludene blue to enhace lesion)
• To do T& N staging –
❖ MRI of oral cavity ( short Tau Inversion Recovery) ( STIR – MRI)- NEET SS
question
❖ Gadolinium – suppression techniques and variation in image sequence
acquisition is noted
• M/C distant mets : Lungs – CT thorax before surgery
• PET – CT- used only for non-surgical patients – to plan where all we have to give
radiotherapy
• If neck node seen- USG guided FNAC
• CT facial Bones – to look for bony invasion
Tongue cancer:
C/F
• m/c painless ulcer
o Pain – if infiltrating nerve
• Trismus- infiltration of pterygoid plates
• Bony invasion( mandible) – bony pain
Investigation of choice to look for mandible or bone invasion : CT scan Mandible/ Facial bones
• T1- <2cm – 1cm margin excision and approximate cut edge
• T2 – 2-4cm – hemiglossectomy + reconstruction

• T3 - >4cm – hemiglossectomy + reconstruction
• T4 – cross midline – total glossectomy
Reconstruction of tongue
1. RFFF ( Radial Forearm Free Flap)
• M/c used
• Based on radial artery
2. PMMC flap ( Pectoralis Major Myocutaneous flap)
• ….
• ….
3. Delto pectoral flap ( DP flap)
• Can be used in females
• Based on internal mammary artery

Figure: Radial Forearm free Flap
• CT scan
o Abutting mandible – marginal mandibulectomy ( inner table of mandible is removed)
o Infiltrating mandible – segmental mandibulectomy and reconstruct with radius bone.
Cancer Lip
• 90 % are lower lip
o MC type is SCC
o Lower lip cancer – B/L lymph nodes+
• Upper lip
o MC is BCC ( along tear flow area)

o SCC
o Verrucous Ca
• Management:
o Remove tumor with 1cm margin
▪ If Defect <1/3rd gap – close it by primarily
▪ If Defect >1/3rd gap- reconstruction with flaps
• JOHANSSEN STEP LADDER FLAP
• KARPANDAZIC FLAP- Huge defects
• BERNARD FLAP
• ABBES FLAP- Centre of lip
• ESTLANDER FLAP – Angle of lip

CA BUCCAL MUCOSA
• Wide local excision with 1cm margin 3 dimensionally
• With reconstruction using flap
o PMMC in males
o DP flap in females
CA Retromolar Trigone / FLOOR OF MOUTH
• Split mandible approach – VISOR approach
• All cancers are SCC
o Surgical management
▪ Preferred
▪ 1cm margin 3 dimensionally
▪ Reconstruction
o Interstitial radiotherapy/ Brachytherapy

▪ Contraindicated in alveolar cancer ( since it can lead to osteo radio necrosis)
o Either of them can be used to treat
NECK NODES: Levels and Dissections
7 levels of Neck nodes:
1. Submental and Submandibular nodes

2. Upper jugular Extend from base of skull to hyoid bone
3. Middle Jugular Extend from hyoid bone to cricoid cartilage
4. Lower Jugular
5. Supraclavicular or Posterior Group
6. Pre laryngeal/ Pre tracheal Extend from Hyoid bone to sternal notch
( Schwartz says- prelaryngeal as Delphian nodes)
7. Upper mediastinal nodes

Figure: Neck Nodes
If nodes are positive – neck dissection operation is required.
Radical Neck Dissection (RND) Modified Radical Neck Dissection COMMANDO

(mRND)
CRILE’S OPERATION BOCCA’S OPERATION
Removed : • Com- combined
• Level I – V • Man – mandible
• Fat • Nd – Neck dissection
• Fascia • O - operation
• Strap muscles
SIS - removed Indication:
• S- Sternocleidomastoid Oral cavity cancer infiltrating
• I – Internal jugular vein mandible also
• S- Spinal accessory
nerve
Removed: Remove:
• Submandibular gland • Cancer + mandible +
• Part of parotid gland nodes
NOT REMOVED:
• Carotid artery
• Vagus nerve
• Lingual nerve

• Hypoglossal nerve
• Phrenic nerve
• Cervical branch of facial
nerve
NOTE:
• while performing B/L
RND – preserve at least
one IJV.
Supra omohyoid Neck dissection:

• Removal of level I, II, III + submandibular gland = Supra omohyoid neck dissection
• Indicated in N0 cases and selected N1 cases
Complications:
• Carotid blow out- loss of blood vessel supplying tunica adventitia
- Prevented by PMMC/ DP flap
Named incisions in oral cavity::

o Weber ferguson incision
▪ Maxillary CA
▪ Hard palate Ca
o Shobinger incision – FOR RND
o Mc fee incision – FOR RND

BENIGN LESIONS
1. Submandibular space infection – LUDWIG’S ANGINA
• Group A streptococci
• c/f-
i. pain , swelling, tongue pushed backward
ii. odynophagia
iii. trismus
iv. airway obstruction
• spreads to parapharyngeal space
• treatment – broad spectrum antibiotics and I&D

2. EPULIS
• Benign tumor of gums
3. Odontogenic cyst
• Dental cyst
• Dentigerous cyst
Dental cyst Dentigerous cyst

Arises from erupted tooth
d/t infected root
Inflammatory etiology
a/k/a radicular cyst**
Middle age
Lined by stratified squamous non keratinized epithelium

Painless
m/c in upper jaw
REMOVE BOTH
• Odontogenic keratocyst/ keratocystic odontogenic tumor
o Only cyst which enlarges without causing bony expansion**
o D/t enzymatic erosion
o Grow anterio- posteriorly

Figure: Dentigerous Cyst
Chapter 1B. SALIVARY GLANDS
PAROTID GLAND
o Superficial lobe and deep lobe

o Separated by Patey’s facio venous plane= retromandibular vein+ facial nerve
o Drains via Stenson’s duct
▪ 5cm in length
▪ Opens opposite to upper 2nd molar

▪ Koplik’s spots in measles are also found here
Facial nerve trunk identification:
Anterograde method
• Conley’s pointer ( tragal pointer)**

o Junction of bony and cartilaginous EAC – points downward 1cm inferior
• Posterior belly of digastic insertion ( above this)
• Stylomastoid foramen
• Facial nerve monitors
Retrograde method:
• Tracked backwards ( eg. From buccal branch – trace backwards towards trunk)
Nerve supply of parotid:
1. Parasympathetic
• Salivary nucleus – via glossopharyngeal nerve ( crossing Tympanic membrane) – relay
in Otic ganglion – post ganglionic fibres Via auriculotemporal nerve ( branch of
trigeminal nerve) supply parotid

• Leads to increased salivary secretion
• Serous discharge
2. Sympathetic supply
• Increase blood flow to gland
Frey’s syndrome (Gustatory sweating syndrome)
• Injury to Auriculotemporal nerve ( post ganglionic parasympathetic nerve injury)
• Sympathetic fibres overgrow, join with auriculotemporal nerve and reach skin
• c/f- pain, erythema and sweating over face on just seeing food
• Presents – 2-3 months after parotidectomy operation
• Prevented by:
o SCM flap
o Temporalis muscle flap
o Membrane
• IOC: starch iodine test
• Treatment – latest Botox injection at areas of reinnervation appearing as Erythema on
Starch Iodine test
o Old – cut the glossopharyngeal nerve at Tympanic membrane – JACOBSON’S
NEURECTOMY

Figure: Starch Iodine test
Submandibular gland
• 2 lobes separated by mylohyoid muscle
• Wharton’s duct
o 5cm
o Opens under the surface of tongue on either side of frenulum
o Lingual nerve and hypoglossal nerve are closely related to duct
• Mucinous secretion
• Flow of saliva is non-dependent

• Rich in amylase and lipase
• m/c gland to develop stones- radio opaque on xray
• Management of stones:
o Old concept:
✓ stone distal to lingual nerve- lay open duct and remove stone
✓ stone proximal- submandibular gland excision

Extra Mile Points:
• 800 minor salivary glands

• Sublingual salivary gland
o Ducts of Rivinus
o Ducts of Bartholin
Most common site for ectopic salivary gland- angle of mandible
o Called as STAFNE BONE CYST (radioluscent bony expansion)
Most common ectopic salivary gland tumor- hard palate
ECTOPICS:
❖ Salivary :
❖ Sebaceous gland :
❖ Stomach :
❖ Pancreas :
❖ Spleen :
❖ Thyroid :
❖ Testis :
❖ Pregnancy : ampulla of fallopian tube
o If happens in ovary – SPIGELBERG CRITERIA
o If happens in cervix – RUBIN’S CRITERIA

TUMORS IN SALIVARY GLAND:
BENIGN MALIGNANT
PAROTID 80%
SUBMANDIBULAR 50%
MINOR GLANDS 10%
As the gland becomes smaller malignancy increases.
Types of epithelial tumors:
Benign :
❖ Pleomorphic adenoma
❖ Warthin’s tumor
Malignant:
❖ Mucoepidermoid
❖ Adenoid cystic
❖ Acinic cell tumor
❖ Pleomorphic adenocarcinoma
❖ Adeno cancer
❖ Squamous cell cancer
Most commons:
Adults:
• m/c benign tumor- in parotid and submandibular- PLEOMORPHIC ADENOMA
• m/c malignant tumor
o Parotid- mucoepidermoid cancer
o Submandibular – adenoid cystic cancer
Children: -35 % are malignant
• m/c tumor: hemangioma

• m/c benign epithelial tumor- pleomorphic adenoma
• m/c malignant tumor – mucoepidermoid cancer
Explanation of benign tumors:
Pleomorphic adenoma Warthin’s tumor

a/k/a mixed tumor
(has epithelial and mesenchymal tissue)
m/c benign tumor of parotid, Submandibular

gland and minor salivary glands
Seen in tail of parotid
3 classical features
• Lift the ear lobule
• Curtain sign positive
• Obliteration of retromandibular groove
Bi digitally palpable+
Tonsil pushed medially (if deep lobe is enlarged)
Pathology:
• Rarely capsule+ - not well defined capsule
• Pseudopod extension into normal gland
Only Parotidectomy is TOC
C/f :
All salivary gland tumors are most common in
females.
High yield Points in Warthin’s:
• Multi centric and multifocal
• 10% bilateral
• h/o smoking – risk factor
• Tc99m scan – hot spot
GODWIN’S TUMOR- benign lymphoepithelioma of parotid
Figure: Huge Pleomorphic adenoma
Investigations:
• FNAC- IOC to confirm diagnosis
• Avoid incision biopsy- can lead to seeding of tumor

• CT scan – in deep lobe tumor
• Tc99m scan- warthin’s and oncocytoma
• MRI – best investigation for salivary gland tumor.
FEATURES SUGGESTIVE OF MALIGNANCY IN PAROTID SWELLING:
• Facial nerve paralysis
• Sudden enlargement of gland
• Severe pain ( usually painless otherwise)
• Satellite nodule/ ulcer in skin
• Cervical node palpable
Mucoepidermoid cancer Adenoid cystic cancer a/k/a cylindroma

High or low grade variants High or low grade variants
m/c malignant tumor of parotid m/c malignant tumor of submandibular gland
Perineural infiltration +
Base of skull extension
30% LN enlargement No LN mets
( Increased LN mets)
Acinic cell tumor
o Only low grade tumor
o 3% B/L
o 2nd most common tumor in children
SURGICAL ASPECTS:
❖ LAZY S INCISION/ MODIFIED BLAIR INCISION/ SISTRUNK INCISION
1. Simple parotidectomy
• Only Superficial lobe removed
• Deep lobe and Facial nerve preserved
• Done in benign tumors
2. Total conservative parotidectomy
• Superficial + deep lobe removed
• Facial nerve is preserved
• Done in deep lobe benign tumors
3. Radical parotidectomy:

• superficial + deep lobe + facial nerve removed
• done in malignant
o mucoepidermoid
o adenoid cystic tumor
o During surgery
o Use only bipolar cautery ( monopolar causes lateral spread)
o If nerve injured ( especially buccal branch) – reconstruct with greater auricular nerve
o Buccal branch is very important and must be reconstructed if injured.
Post op complications:
1. Nerve injuries
• m/c nerve injured- any branch of facial nerve
✓ Bell’s phenomenon
✓ Deviation of mouth
✓ Loss of nasolabial fold
• m/c cutaneous nerve injured- greater auricular nerve**
✓ Paraesthesia in shaving area
• Auriculotemporal nerve( post ganglionic parasympathetic injury) – Frey’s syndrome
2. flap necrosis
3. Infection
4. keloid formation
5. Sialocele
6. Parotid fistula
• Stenson’s duct not identified property and tied
• Require –SEABROOKE OPERATION
SUBMANDIBULAR STONES
• Thick mucinous secretion
• Non-dependent secretion
• Mostly radio opaque stones
• Causes for obstruction of Submandibular duct**
o m/c stones
o 2nd - strictures
• If stone causes complete obstruction – MEAL TIME SYNDROME**
o Rapid swelling in submandibular region immediately

o Pain + ( d/t pressure)
o Pain disappear in 1-2 hours gradually
• If stone causes incomplete obstruction- only mild discomfort
• Treatment: new concept
o Stone <4mm and mobile – remove by scopy with DORMIA BASKET
o Stone >4cmm : INTRA DUCTAL LITHOTRIPTER – break stone and remove
Parotid Duct Stones:
• Parotid gland stones are rare
• If present they are radiolucent

• M/c site: duct crossing masseter
• Treatment: sialography ( since radiolucent on xray)
o <4mm- endoscopy
o >4mm – remove gland itself
RANULA
• Mucous extravasation cyst from sublingual salivary gland
• Develop form floor of mouth ( remember it’s not retension cyst)
• Surgery: excision of cyst and affected gland ( not marcupilisation)
Figure: Ranula
Plunging ranula:
❖ Retention cyst of submandibular and sublingual gland
❖ Presents as swelling in oral cavity and submandibular region
❖ Bidigtally palpable
❖ Fluctuation +
❖ Cross fluctuation +
❖ Treatment : intra oral resection of plunging ranula
▪ ( old concept: incision over neck )

Chapter 1C. NECK SWELLINGS
TRIANGLES OF NECK
Anterior Triangles Posterior Triangles

• Carotid • Sub occipital
o Posterior belly of digastric a. SCM
o Superior belly of omohyoid b. Inferior belly of omohyoid
o SCM c. Anterior border of trapezius
• Submental • Supraclavicular
o Between the 2 anterior belly of a. SCM
digastric b. Inferior belly of omohyoid
o Hyoid bone c. clavicle
• Muscular
o Hyoid bone
o Superior belly of omohyoid
o SCM
o Imaginary midline
• Submandibular
o Anterior belly of digastric
o Posterior belly of digastric
o mandible
Most common swelling in neck – lymph node enlargement**

Figure: Triangles of Neck
Carotid triangle Posterior triangle

Solid type Carotid body tumor
Liquid type Branchial cyst
Air Filled swelling Laryngocele
Carotid body tumor

• Carotid body : chemo receptor – located posterior medial surface of bifurcation of
common carotid
• Hypoxia stimulates carotid body – results in tachypnes
• Persistent hypoxia – carotid body tumor
o High altitude
o Cyanotic congenital heart disease
• Other names-Chemodectoma, Potato tumor, Non chromaffin paraganglioma
• Clinical Features:
o m/c middle age female
o U/L
o Firm +
o Movement : “ fontaine sign” – only horizontal movement + , no vertical
movement
o Swelling in carotid triangle
o Transmitted pulsation- keep 2 fingers- fingers get lifted but not separated
o Incidence – 0.5%
o Malignancy in 5-10%
o Shamblin classification:
▪ Type I - <25% adherent
▪ Type II – 50% adherent
▪ Type III- encasing the vessel
• IOC to diagnose :
o Angiography
▪ Vessels are splayed out (LYRE SIGN)
o FNAC AND BIOPSY ARE CONTRAINDICATED – Bleeds torrentially
o Duplex scan
• For type I and II- Excise the tumor with vessel control
• For type III- Require resection and prosthesis

Complications of Surgery:
• m/c nerve injured: superior laryngeal nerve
• FIRST BITE SYNDROME:
✓ Sympathetic nerves are damaged
✓ Leads to parasympathetic reinnervation
✓ As we start chewing – pain in neck +
✓ Opposite to frey’s syndrome
• Preop radio therapy should not be given
• Post op RT can be given in malignant tumor, disease recurrence, incomplete resection
CERVICAL RIB and TOS

Types:
• Partial rib
• Fibrous cord
• Full rib
• Partial rib with fibrous extension
Clinical features
• Bilaters in 50 % cases
• Young to middle age females ( 70%)
• Scalene triangle:
• Cervical rib occupies scalene triangle- compression of structures leads to thoracic outlet
syndrome

Figure: Scalene Triangle and TOS
Thoracic outlet syndrome
Neurogenic Vascular
C8T1 (Lower trunk) Subclavian artery compression
Ulnar nerve
M/C in Cervical rib
Pain along medial side of arm + forearm Vascular- claudication
(as you start working – blood supply decrease –
pain develop – makes you stop work)
Ulcer in hand
Gangrene in finger
Tinel’s sign: Subclavian artery steal syndrome-
Tap on brachial plexus – shooting pain + Collateral between vertebral artery and
subclavian artery
Leads to giddiness on starting to use hand

Figure: Cervical rib with TOS
Tests for TOS:

These tests bring out occult cases to be diagnosed by manuevers
Adson Test Roos test** Halstead test

• Extend arm • Abduct arm • standing in military
• Look opposite side • Flex elbow position cause pain
• Take a deep breath • Open and close fist for 5
• Radial artery dynamicity min
decreases ( not pulse rate) • Claudication pain develops
• Patient puts hand down
Investigations:
• Xray – cervical rib
• CT thorax and neck- surrounding vessel compression
• Angiogram – to look for SCA compression
NOTE:
• Post stenotic aneurysm of subclavian artery may develop.
• Cervical rib is palpated in posterior triangle ( just above the clavicle)
OTHER CAUSES OF TOS:

CONGENITAL OSSEUS:
o Cervical rib (m/c)

o Long C7 transverse process
o Abnormal 1st rib
Soft tissue:
o Anomalous scalene insertion
o Scalene muscle hypertrophy
o Congenital bands and ligaments
Postural:
o Heavy breast
o Sagging shoulder
OSSEUS:
ACQUIRED o Fracture clavicle/ 1st rib
o Exostosis/ tumor
Soft tissue:
o Scalene muscle injury
o Previous surgery scar
o Soft tissue tumor
o Direct brachial plexus injury
Branchial cyst and Branchial fistula( Sinus)

• 6 pharyngeal arches – 5th degenerate on both sides
• 2nd arch fuses with 6th arch encompassing 2nd pouch between them
• Persistence of pouch between 2nd and 6th is known as branchial cyst

• Failure to fuse – cleft – brachial sinus
• External opening – lower 1/3rd of SCM anteriorly

• Presents at 15-25 years ( though congenital)
• 1st arch remnant – preauricular sinus
• 3rd arch remnant- clavicular / suprasternal sinus
• 2nd arch remnant – most common

Figure: Branchial Arches
BRANCHIAL CYST BRANCHIAL SINUS/ FISTULA

Upper 1/3rd of SCM
Swelling +
Transillumination negative
Thick content)
(contain cholesterol crystals- also seen in
Hydrocele)
Lined by squamous epithelium**
Persistence of 2nd pouch
Complication:
• Acquired branchial sinus
• Branchiogenic carcinoma- Can have
squamous or columnar epithelium
Treatment:
Complete excision of cyst

Acquired branchial cyst:
• Complication of infected branchial cyst/ surgeon thinks it as abscess and does I&D
• But opening is at upper 1/3rd
IOC: branchial fistulogram
TOC: complete excision of cyst and sinus.
CYSTIC HYGROMA – on posterior triangle of neck

❖ M/c in new born
❖ Associated turner’s syndrome, trisomy 21, 18

❖ Occurs d/t congenital sequestration of lymphatics
❖ C/f- swelling in posterior triangle
o Transillumination +
❖ Earliest neck swelling in humans
o As early as manifesting as obstructed labor

❖ Complications:
o Respiratory difficulty
o Infection
o Spontaneous resolution is also seen
❖ Management:
o Conventional: conservative neck dissection ( unnecessary)
o Latest :
▪ Injection sclerosant – PICIBANIL (OK 432) or INJ. BLEOMYCIN

▪ No CHEMO / RADIO THERAPY REQUIRED.

Figure: Cystic Hygroma
LARYNGOCELE
❖ CAUSES:
o Weakness in thyrohyoid membrane ( Bilateral)
o And laryngeal mucosa comes out of it

❖ Seen in trumpet players/ nathaswaram players
❖ Laryngocele can be internal / external

❖ c/f:
o Presents as swelling in carotid triangle

o Resonant on percussion
o Cough impulse +
o Valsalva maneuver – more prominent
o Moves with deglutition
❖ Treatment :
o Resect and repair thyrohyoid membrane
CLINICAL PEARLS:
❖ Swelling that moves with deglutition:
❖ Cricothyroid membrane : used for emergency needle tracheostomy

❖ Tracheostomy : between in 2nd and 3rd ring
Pharyngeal pouch
▪ Old men
▪ Left side
▪ Posterior triangle swelling
▪ Clinical features-
o Dysphagia
o Halitosis
o Compress- swelling reduces with gurgling sound

▪ False diverticulum
▪ IOC: Barium swallow
▪ TOC:
o Diverticulectomy or
o DOHLMAN’S Procedure ( endoscopic stapling operation).

Chapter :2 Thyroid Gland
2a. Introduction
Anatomy of thyroid gland

• Butterfly shaped organ
• Derived from thyroglossal tract (originating from foramen caecum) which comes down and
divides into thyroid bud.
• Ultimobranchial body give rise to parafollicular cells
Arterial supply:
• Superior Thyroid Artery arises from External carotid. Enters the gland and then divides into
branches.
• Inferior Thyroid artery arises from Thyrocervical trunk of Subclavian artery and divides into
multiple branches before entering the gland.

• Inferior Thyroid artery – Supplies all 4 parathyroid glands
• Rarely- One more artery-from arch of Aorta- Arteria Thyroidea ima** is seen
Ligation of STA and ITA:
• Old Concept- Ligate STA close to gland to prevent injury to ELN, ITA ligated away from
gland to prevent injury to RLN.
• New Concept- to prevent Hypocalcemia due to parathyroid loss of Blood supply- Now we
ligate the ITA very close the gland as individual vessels. ( Remember both STA and ITA are
ligated close to gland)
Most common site of ectopic thyroid: LINGUAL THYROID ( failure to descend from Foramen Cecum
of Tongue)
Venous Drainage:
• STV- drains to IJV
• ITV drains to Brachiocephalic vein
• There is MTV ( But MTA)- drains into IJV
• 4th vein- Kocher’s vein drains into IJV or Brachiocephalic vein

Recurrent Laryngeal Nerve course:
• RLN arises from Vagus nerve as it descends down it gives the branches- Right and Left RLN
• RLN Hooks and comes back
• Right RLN hooks around Right Subclavian Artery (Errata in App**)

• Left RLN hooks around Ligamentum arteriosum
• RLN is non recurrent in 5% cases.
• RLN is both motor and sensory.
o Motor- all muscles of vocal cord including posterior crioco arytenoid
▪ Helps in abduction of vocal cord( opening)
▪ Also called safety muscle of larynx
o Sensory – below the mucosa of vocal cord
Injuries to nerves:
• ILN:
• ELN:
• U/L RLN :

• B/L RLN:
External Laryngeal nerve injury:
• Most common nerve injured :
Classification of ELN course in relation to superior pole of thyroid. – CERNEA Classification
I- >1cm from the superior pole
II- < 1cm from the superior pole
a. Above the gland
b. On the gland – hence has high chance of damage.
Recurrent laryngeal nerve – concepts from Bailey 27th Edition:
• Most common site of injury BEAHR’S triangle.
o Laterally-
o Medically-
o Superiorly-
• Tubercle of Zuckerkandl= most posterior lateral portion ( not Posteromedial – errata in app)
part of thyroid, also known as Pointing tip towards RLN.
o Close to berry’s ligament- which is a condensation of pretracheal fascia
▪ Connecting thyroid to trachea
▪ Reason for movement of thyroid with deglutition.

Injury of RLN- Management:
• U/L Injury: hoarseness – recover within 3 months
• B/L injury: Stridor post op--- 1st sign due to B/L nerve going for Cadaveric position
Stridor Management:
• Step 1- Immediate Reintubation
• Wait for 24-48 hours (Many neuropraxias will recover with steroids)
• Extubate with entire team ready for Tracheotomy.
• If there is stridor again- and Both nerves not functioning Tracheostomy done.
• After few months if it is a permanent damage we must go for some special procedures:
o Advice Arytenoidectomy/ Lateralisation of cord ( Types of thyroplasty)
Nutshell: Anatomy
• Lingual thyroid – m/c site of ectopic thyroid—
o d/t undescended thyroid located in formen caecum
o c/f-deglutition problems.
• 3 arteries- STA, ITA, ARTERIA THRYOIDEA IMA – Ligate close to gland
• 4 veins : STV, MTV, ITV, KOCHER’S VEIN
• ELN- M/C nerve injury- CERNEA Classificaiton
• ILN- Paroxysomal nocturnal cough
• RLN- M/C INJURED IN BEAHR’S triangle ( Between TE groove, CCA and ITA Postero
Laterally
Physiology:
• RDA for I2 – 0.1 – 0.15 mg/ day
Steps in synthesis. ( Mnemonic- TOBC)
• Trapping
• Oxidation ( iodine to iodide via thyroid peroxidase)
• Binding iodide with thyroglobulin ( to form mono iodothyroglobulin (MIG) Or Di

iodothyroglobulin( DIG).
• Coupling
▪ MIG +DIG = T3 – t half= 24 hrs
▪ DIG +DIG= T4 – t half = 7 days.
▪ T3 is the active form.
▪ Peripherally T4 is converted to T3.

Diseases related to physiology:
• Deficiency of iodine: m/c cause of hypothyroidism in the world
• Congenital thyroid peroxidase deficiency – PENDRED SYNDROME

o Sensory Neural Hearing Loss
o Congenital Hypothyroidism
• Hashimoto thyroiditis: inhibitory antibody against
o TPO – MCC
o THYROGLOBULIN
o TSH-R
o MCC OF HYPOTHYROIDISM IN WESTERN COUNTRIES**
• GRAVE’S DISEASE:
o Stimulatory antibody to TPO, TG and TSH- R which results in increased T3 and T4
production
Thyroid Function Tests:
Thyroid profile
▪ Free T3- 3-9 micro mol/l
▪ Free T4 – 8-24 n mol/l
▪ TSH - <3 mU/l
▪ TPO Value- >25 U/ml
▪ Anti TG >1:100

Hypothyroidism:
▪ Free T3- N/ decreased
▪ Free T4- N/ decreased
▪ TSH- INCREASED
Hyper thyroidism:
▪ TSH- DECREASED
▪ FT3 – N/ increased
▪ FT4- N/ increased
• Most sensitive IOC for hypo/hyper thyoidism- TSH value.

• Subclinical cases- Free T3
• Refetoff syndrome – increased T4 along with normal or increased TSH. Due to peripheral T4
resistance syndrome
Other investigations:
1) USG – neck:
• Helps to identify if it is thyroid / not
• Consistency ( solid / cystic)
• Lymph node
TIRADS- grading system (Thyroid Imaging Reporting and Data System)
2) FNAC/ FNNAC( FINE NEEDLE- NON ASPIRATION CYTOLOGY)
o FNNAC- Tissue is collected in needle hub (no negative pressure created)
o After that take gas in syringe and push it on glass slide
o BETHESTDA classification - based on FNNAC/FNAC
o Thy1 –
o Thy 1c –
▪ Completely disappear

• Non recurrent/< 3 times recurrence
• Recurrent>3 times - surgery
▪ Incompletely disappear – surgery is treatment of choice
o Thy 2 –
o Thy 3 –
o Thy 4 –
o Thy 5-
3) IDL scopy: 3% patients have occult vocal cord paralysis
o Document for medicolegal purpose
4) Radio Active Iodine Uptake Study: (RAIU)
▪ Mixed with milk and taken orally)
o I131 :
o I123 :
o I132 :
o Tc99m : t ½- 6 hrs
• Gland traps RAI and Emits beta radiation.- used for diagnostic and therapeutic
purposes.
• Caught on Gamma cameras- to see for uptake- called as THYROID SCAN.
Diagnostic uses: (m/c used is low dose I123 ) Therapeutic uses:

( MC used is I131)
1. <16% uptake – hypothyroidism Treatment of choice for

>48% uptake – hyperthyroidism 1. Grave’s disease
1-48 % uptake- Normal 2. To destroy thyroid
2. Warm nodule- increased activity than the surrounding cancer mets
tissue
5% are malignant.
Cold nodule- Decreased activity than the surrounding
tissue
20% are malignant.
3. To locate ectopic thyroid
4. Thyroglossal cyst:
▪ IOC in adults: USG NECK
▪ IOC in children : RAIU study – to rule out if
this is the only functioning thyoid tissue

5. After total thyroidectomy for malignancy- look for
metastasis
▪ Not done before thyroidectomy as uptake will
be only in thyroid tissue.
Side effects of RAI
Immediate( usually recover) Long term tumours Long term damage

Neck pain Leukemia Infertility
Thyroiditis Papillary CA of thyroid Abortion
Sialadenitis Anaplastic CA of thyroid Pulmonary fibrosis
Cerebral oedema Breast CA Bone marrow suppression
Vocal cord paralysis Gastric CA Ovarian / testicular failure
Bone marrow supression Lung CA Hypo parathyroidism
Salivary tumours
Bladder Ca
After RAI I 131

• Isolate patient for 8 days
• Don’t spit/ urinate/ kiss in public

RAIU is also used to know the cause for hyperthyroidism
Excessive T3& T4 production : increased RAIU Normal production but increased release : N/
decreased RAIU
o Thyroiditis (in acute inflammatory
phase – increased release of hormone)
o Thyrotoxicosis factitia ( excessive
thyroxine tablet taken)
o Hamberger toxicosis ( south Americans
eat thyroid of Cow in burger)
Extra Edge Points:
Thyroid doesn’t extent superiorly because?
o Pretracheal fascia extends from hyoid bone to arch of aorta ( in superior
mediastinum).
o Therefore thyroid swelling goes only retrosternally.

Post RAI – What happens to Physiology?
o After RAI ablation :most grave’s disease patient becomes euthyroid in 2
months.
o After 6 months : 50 % remain euthyroid
o Remaining 50 % becomes hypo/ hyper thyroid.
o Contraindication for RAI
2b. Benign Thyroid Disorders
Diffuse Nodular Inflammatory Neoplastic

Physiological Colloid goitre Hashimoto’s Papillary Ca
Grave’s disese Solitary nodular Reidel’s Follicular Ca
Colloid goiter Multinodular Dequervain Medullary Ca
Anaplastic Ca
Clinical features:
Hypothyroidism Hyperthyoridism
Obese Slim
Less intake Increased intake
Cold intolerance Heat intolerance
Constipation Diarrhea( increased bowel movement)
Menorrhagia--- amenorrhoea( anemia) Oligomenorrhoea
Tendon reflex – decreased Tendon reflex – increased
Pseudo myotonic reflex/ hungup ankle reflex- Fine tremors
delayed ankle jerk
• Loss of eye brow Eye signs- exophthalmos ( early)
• Macroglossia • Pretibial Myxoedma – deposition of
• Mask like faces mucopolysaccharides in front of tibia
• Depression • Acrobachy – subperiosteal bone resoprtion
of fingers- look like clubbing

Both are late features
Cause: Cause:
Cretinism ( paediatrics) Grave’s disease( 1’ toxicosis)
Myxodema ( adults) Plummer’ s disease (2’ toxicosis) due to
MNG > SNT ( for exams)
Grave’s Plummer’s
1’ 2’
Diffuse enlargement Long standing Solitary
with simultaneous Nodular thyroid
toxic features suddenly go for toxic
features.
Affect: Affect:
CNS+ Old guys
EYE SINGS+ CVS+:
1. Sinus atrial
tachycardia( mc)
2. Atrial extra systole
3. Atrial fibrillations
4. Congestive cardiac
failure
5. Thyroid storm
6. Lerman scratch
sound( systolic
scratch sound in
Left 2nd ICS on
expiration)- rub
between pleura and
pericardium
Treatment:
50-100 micro gram tab. Thyroxine
(supplement dose)
MCC:
▪ Iodine deficiency : India
▪ Hashimoto : western

Grave’s disease
• MCC of hyperthyroidism.
• Autoimmune disease : HLAB8, HLADR3, HLADQ1
• Diffuse enlargement , soft consistency, highly vascular
o Palpation: thrill in superior pole
o Auscultation:
▪ arterial bruit
▪ Venous hum+ ( d/t increased sympathetic activity causing hyperdynamic
circulation)
Figure: Pretibial Myxedema in Graves disease
• Clinical tests in thyroid: ( All clinical examination videos will be showed in Clinical
Examination Section)
▪ Examined from behind.
▪ Short neck- PIZZILO’S METHOD. (hand behind neck & hyperextension of neck)
▪ Retrosternal goiter – Pemberton sign( to look for svc compression- lift both arm with
arm touching ears- look for facial congestion)
▪ Lahey’s test: 4 finger examination ( push on one side and palpate with 4 fingers)
▪ Criles test- for doubtful nodule( using only thumb- ask patient to swallow- feel for
nodule)
▪ Trail’s sing- prominent SCM muscle ( thyroid swelling pushes trachea)
▪ Berry’s sign- non palpable carotid artery against vertebrae ( d/t engulfment of the
tumour)

Figure: Pizzilo’s Test
Figure: Pemberton Sign
Figure: Lahey’s test

Figure: Crile Test
Tests for toxicosis:
CNS CVS Eye signs

▪ Increased reflexes Sleeping Pulse rate Exophthalmos
▪ Tremors- fine ( CRILE’S GRADING)
▪ Fasciculations in METHOD
tongue (with
▪ Give
tongue
tab. P Phenobarbitone night dose and measure.
inside mouth)

Figure: Eye Signs in Thyrotoxicosis
Eye signs:
Mild exophthalmos – due to only sympathetic activity
1. Von grafe’s lig lag sign- ask patient to follow vertical movement- lid lags behind
2. Dalymples sign/lid retraction sign- visible upper sclera
3. Stellwag’s sign- starring look
Moderate – due to retroorbital accumulation
4. Joffroy’s sign- absence of forehead wrinkle on looking up
Ask patient to look the ceiling (patient eye is already out)
Severe – due to intraocular accumulation and paralysis of muscle
5. Mobius sign- Inability to converge ( paralysis of intraocular muscle)
Malignant – though treatment given- exophthalmos increases
• Epiphora
• Congestion
• Redness
Other signs:
Jellwek’s sing- pigmentation in upper eyelid
Naffziger’s sign- see through supraorbital ridge – normally eyes not seen
o If seen it is exophthalmos or proptosis
Gifford test ( eversion of upper eye lid to differentiate exophthalmos and proptosis)

o Exophthalmos- muller muscle spasm + - inability to evert upper eyelid
o Proptosis – pathology behind eye ball - able to evert upper eye lid.
Diagnosis:
▪ T3,T4 increased, TSH decreased
▪ RAIU increased
▪ Autoimmune antibodies increased: Anti TG, Anti TPO – 75% cases
▪ LATS- Long Acting Thyroid Stimulator is elevated in 90 % cases. Also Known as Thyroid
stimulating Antibody or TSH-R stimulating Ab
▪ FNAC is not beneficial.

- Haemorrhagic aspirate.
- Therefore not advised in grave’s disease.
Management of Grave’s disease:
Preparation of the thyrotoxic patient to euthyroid state
Surgery
Radioactive iodine ablation
Therapy
Gold standard
Preparation of the thyrotoxic patient to euthyroid state
• If not done properly - thyroid storm ( MC cause is inadequate preparation to Surgery)
Anti thyroid drugs Quick preparation Lugol’s iodine

Inhibit Mechanism:
• Trapping of iodine • Decrease vascularity of
• Oxidation of iodine the gland
• Peripheral conversion • Makes the gland firm
T4 to T3
Carbimazole – leads to 5% iodine

reversible agranulocytosis- +
Ask h/o sore throat 10% KI
1st sign of decreased wbc count 10 drops TDS
Methimazole – 10-30 mg TDS

Propylthiouracil- used in
pregnancy – don’t cross
placental barrier
Take for 3- months to become LAST 10 DAYS BEFORE
euthyroid. SURGERY
Block and Replacement therapy:
Antithyroid drugs – high dose
carbimazole + thyroxine
Last dose of carbimazole given Note :Continue beta blocker 7

night before surgery days post op including Intraop
period**
After patient is prepared: RAIU
I 131: 8-12 mci
Mixed with milk
Isolate them for 8 days.
Contraindication for RAI
▪ Severe ophthalmopathy
▪ Pregnancy and lactation
▪ Children
▪ Nodules +
▪ Smoking females
Surgery is indicated in these cases.
After RAI ablation :most grave’s disease patient becomes euthyroid in 2 months.
After 6 months : 50 % remain euthyroid
Remaining 50 % becomes hypo/ hyper thyroid.

Total thyroidectomy- advised in grave’s disease
Indications:
Thyroid storm:
MCC- Inadequate preparation of thyroid patient

OTHER CAUSES-
▪ Illness
▪ Stress
▪ Amiodarone
Characterised by:
CNS problems – agitation/ depression
CVS problems – dysfunction- CCF
10% mortality
Clinical features:
• Tachycardia
• Hyperpyrexia
• Dehydration
• CCF( symptoms+)
• Hyperexitability
• Atrial fibrillation
Treatment of thyroid storm:

Basic life support Antithyroid drugs Special drugs
O2 IV propranolol Steroids – hydrocortisone
200mg- ( adrenal is exhausted)
Tepid sponging Lugol’s iodine Diazepam ( they are
hyperexcitable)
IV fluids PTU Diuretics- ( they have CCF)
Glucose Carbimazole Digoxin – ( if in AF)
KI – in IV
Secondary Toxicosis
▪ Solitary nodule
▪ Multinodular- Plummer’s disease ( some books mention as SNT with toxicosis also)
▪ Old patient
▪ CVS manifestation are MC** than Eye signs and CNS manifests.
▪ Eye signs may be present- lig lag+ and lid retraction+
Treatment of choice:
▪ Prepare them to euthyroid state
▪ Surgery- subtotal/ total thyroidectomy (as nodule presence is a contraindication for RAI)
Thyroiditis
• Mc in females 30-40 yrs
• Inflammation of thyroid gland
Hashimoto Reidel( fibrosis) Dequervain’s Acute

Mc type Mc in children
a/k/a chronic lymphocytic/ Associated with • a/k/a post viral or • Bacterial
autoimmune thyroiditis • Invasive fibrosing subacute(after few weeks of infection
thyroiditis viral infection) • Mc-
• Dupuytren’ s • Associated with streptococcu
contracture HLAB35 s
• Retroperitoneal fibrosis • NO HLA
association
Abs: (inhibitory) Persistent
• TPO- MC pyriform sinus
• TG fistula-
• TSH-R important cause
of recurrent
acute bacterial
thyroiditis

FNAC: FNAC: cannot be done-
• Hurthle cells/ woody hard- mimics cancer
Ashkenazy cells Do trucut biopsy ( done in
(Abdundant cytoplasm with anaplastic and reidel)
varying size of nucleus)
• Lymphocytes+
C/F: ▪ ALWAYS ▪ Predominantly ▪ Severe neck
▪ Pain + HYPOTHYROID**- hyperthyroid with pain pain+
▪ Thyrotoxicosis( d/t produce compressive for long period odynophagia
increased release not symptoms ▪ Later become ▪ Increased
production) hypothyroid ESR
▪ Burn out leading to ▪ Increased
hypothyroidism DD: Grave’s- increased RAIU WBC
▪ When patient Dequervain-
presents- painless ▪ Decreased RAIU
enlarged thyroid ▪ Increased ESR
with
hypothyroidism.
Complications:
▪ Hypothyroidism ▪ Laryngitis
▪ Compressive ▪ Perichondrit
symptoms is
▪ Premalignant- ▪ Sepsis
lymphoma and ▪ Tracheal
papillary Carcinoma rupture
▪ Esophageal
rupture
▪ IJV
thrombosis
Treatment:
▪ Tab thyroxine ▪ Tab . thyroxine ▪ Analgesics ▪ Antibiotics
▪ Painkiller for pain ▪ Steroids ▪ steroids ▪ Remove
Surgery is not advised ▪ Antiestrogen- pyriform
except in compressive tamoxifen sinus fistula
symptoms ▪ Mycophenolate
mofetil
Retro sternal goiter:
Why Goitre extends Downwards?

• Pretracheal fascia – attaches from hyoid to aortic arch (superior mediastinum)
• SCM prevent upwards movement.
Types :
Primary Mediastinal: Secondary Mediastinal: ( Retrosternal Goitre)

▪ Arising from ectopic thyroid ▪ Typical retrosternal extension –
gland present inside chest 99% patients
▪ Blood supply from thoracic ▪ Blood supply from superior and
vessels inferior thyroid artery
▪ Sternotomy is required ▪ Approach through neck
incision- put finger and hook it
= TOBOGANN maneuver
▪ Pemberton sign+ - ( hands on
ear- flushing of face)
Managament:
▪ Investigation of choice: ( COMPULSORY) CECT THORAX /NECK
Elderly: asymptomatic – wait and watch
Indications for sternotomy:
Thyroglossal cyst (congenital):
• Persistence of tract
• c/f:
o 5-25 yrs (though congenital)
o Females
o Moves with protrusion of tongue
o Mc site- sub hyoid

• Complications:
o Infection- m/c
o Rupture / I&D –leads to TG fistula= Acquired
o Malignancy- papillary Ca
• IOC: USG Neck
• Paediatric case: RAIU study
o If this is the only thyoid- wait till child becomes adult
o If normal thyroid gland is present : SISTRUNK OPERATION
▪ Remove whole tract + central hyoid bone
NOTE:
Sistrunk operation : lymphadema of limbs
Sistrunk incision : parotid surgery
Thyroid cyst
• Patient presents with nodule
• On FNAC – clear fluid aspirate- BETHESDA thy1c
Indications for hemithyroidectomy:
2c. Thyroid Malignancies

DUNHILL CLASSIFICATION:
DIFFERENTIATED MEDULLARY UNDIFFERENTIATED

Papillary Ca – 80% 2.5% Anaplastic – 5%
Follicular Ca – 10% Lymphoma ( NHL) – 2.5%
Hurthle cell Ca
Sequence Based Question: Papillary > follicular> anaplastic > medullary=lymphoma
Predisposing factors:
▪ Long standing Multinodular goiter: follicular Ca
▪ Irradiation : papillary Ca
▪ Hashimoto’s : NHL and Papillary CA

▪ Thyroglossal cyst: papillary ca
▪ Genetic mutation and syndromes
o RET ongogene: Medullary Ca
o RAS oncogene: follicular > papillary
o PTEN : follicular ca
o P53: Anaplastic ca
• Syndromes:
o COWDEN SYNDROME
o FAMILIAL ADENOMATOUS POLYPOSIS
o MEN 2A AND MEN 2B
o CARNEY’S triad
o Mc Cune Albright Syndrome
MEN 2A (SIPPLE SYNDROME) MEN 2B

Medullary Ca thyroid
Pheochromocytoma
Hyperparathyroidism
Hirschsprung disease
Prophylactic thyroidectomy done for Both Patients
< 5years <1year
Staging of thyroid CA:
T Staging:
o T1a: < 1cm

o T1b: 1-2 cm
o T 2: 2-4 cm

o T3: >4 cm , muscle /soft tissue+
o T4a: Removable Structures: RLN/ Trachea/ larynx/ esophagus
o T4b: Non Removable Structures: carotid vessels/ medistinum/ prevertebral
fascia
Nodes:
o N1a: Level VI ( Delphic nodes)
o N1b : More than Level VI
Papillary Carcinoma Follicular Carcinoma

MC thyroid cancer
Pathology •
• Multifocal- one lobe many foci
• Multicentric – B/L
• May or may not have capsule
Spread:
Lymph node mets
“lateral aberrant thyroid”
Metastatic node from an occult papillary ca.
Distant mets: lungs

FNAC: (3p) •
• Psammoma bodies( concentric calcification)
• Pale empty orphan annie eye nucleus
• Papillary projections
Predisposing factors:
• Irradiation
• Hashimoto’s
• Thyroglossal cyst
Prognosis:
Excellent: 95% 10 yr survival
Treatment: Management:
Total thyroidectomy+ modified radical neck • If >4cm – do total thyroidectomy directly
dissection ( if nodes +ve) • If Thy 3 ( <4cm)
Hemithyroidectomy

cut and send for HPE ( not frozen- miss
malignancy)
result in 2-3 days

Based on Result:
o if benign: discharge patient
o if malignant: on day 3- do
completion total thyroidectomy.
After Total thyroidectomy in differentiated Cancers- Post op protocol:

Post op:
1. Look for mets - RAIU study

o Mets+ - do RAI Ablation therapy with higher doses
o No mets – follow up with tumour marker thyroglobulin
o When TG rises- do RAIU Study and look for mets.
2. TSH dependent tumour – papillary Ca of thyroid-

o Give suppression dose of thyroxine (only for papillary Ca) – 0.3 mg
o Give substitution dose after total thyroidectomy in Follicular cancer– 0.2 mg
Scoring system for prognosis: AGES, AMES, MACIS
Low risk High risk

Age <40 yrs
sex Female
Mets Absent
Grade Well differentiated
Size <2cm
extent Confined
Completion of surgery completed
Hurthle cell Carcinoma:

Rare variant of follicular carcinoma
o Malignancy indicated by capsular invasion
o FNAC not useful

Differentiating features:
o From oxyphil cells of thyroid
o Do not take up RAIU
o Multifocal and multicentric
o Lymph node mets +
o Bad prognosis- 20% mortality in 10 years.
Treatment: Total thyroidectomy +m RND+ Central neck node dissection
Central neck node dissection: Removal of level 6 nodes- advised in medullay Ca of thyroid.
Central neck Nodes are seen between
o Hyoid bone superiorly

o Clavicle inferiorly
o SCM laterally
Post op management of Dunhill’s differentiated Ca:

1. Total thyroidectomy followed by RAIU study to look for mets. If mets are present RAI ablation
therapy govem
o RAI dose: 30-100 mci
Indication for RAI ablation therapy
▪ Distant mets+
▪ Extrathyroid spread+
▪ Size >4cm tumour
▪ Lymph node mets are+

▪ Papillary Ca- variants
o Tall cell variant
o Insular variant
o Columnar variant
2. External beam radiotherapy (EBRT) – for follicular Ca
3. Chemotherapy
o Doxorubicin
o Paclitaxel
4. Hormone therapy
Papillary Ca (TSH suppression with thyroxine tablets – 0.3mg)
Medullary Ca of thyroid
• Incidence -2.5%

• Parafollicular c cells- (ULTIMOBRANCHIAL BODY)
• RET oncogene mutation : MEN2A , MEN 2B
SPORADIC FAMILIAL
80% - 20%
M/C TYPE
Unilateral Bilateral- multicentric and multifocal
MEN2A, MEN2B, Familial medullary carcinoma
thyroid syndrome
Properties:
Neuroendocrine tumour (secretory)
o Calcitonin – tumour marker for follow up ( > 0.08ng/ml is significant)
o CEA – for prognosis
o ACTH- cushing syndrome
o Serotonin- diarrhea
o PGE2 AND PGF2 ALPHA
o HISTAMINIDASE
Rule out pheochromocytoma- 24 hr urinary VMA INCREASED. IF PRESENT- OPERATE

Pheochromocytoma first.
FNAC shows- amyloid stroma
Recent advances
EGFR antibodies : Vandetanib
Anti CEA antibodies : Labetuzumab
Treatment: total thyroidectomy + central neck node dissection ( irrespective of node -/+) +
mRND ( if node +)
MC site of distant metastasis – Liver ( like other neuroendocrine)
Prophylactic thyroidectomy :
o MEN2A : <5 yrs
o MEN2B : <1yr
Anaplastic carcinoma – p53 mutation
• Old women

• Aggressive
• Bad prognosis
• In 6 months – they die
• FNAC – cannot be done- stony hard
• Trucut biopsy has to be done
• MCC of death – respiratory obstruction
If a k/c/o anaplastic Ca coming with stridor- LET HIM DIE PEACEFULLY.
Not a k/c/o anaplastic ca with stridor- Isthmectomy / tracheostomy are done
Miscellaneous
1. Mets to thyroid – (post mortem dissection)
• m/c breast – overall
• m/c lungs – in men
2. Lymphoma :
• NHL – ‘B’ cell
• CHOP REGEIMEN
• CYCLOPHOSPHAMIDE
• HYRDROXYADRIAMYCIN
• ONCOVIN
• PREDNISOLONE
Follow up protocol: Thyroid Cancer
2d. THYROID SURGERY
TYPES OF THYROIDECTOMY

• Lobectomy/ hemithyroidectomy – remove isthmus + one lobe
• Subtotal thyroidectomy – leave behind 8 g in each TE groove
• Near total thyroidectomy/ Hartley – Dunhill procedure – 2-4 g is left behind on one side
• Total thyroidectomy – nothing is left behind
Steps in thyroid surgery:
1. Reverse trendlenberg position( head up)- decrease bleeding from neck
2. Neck extended position / dog barking position
3. Skin crease incision
4. Subplatysmal flap- raise above and below
5. Open deep fascia of neck

6. Strap muscle is cut / retracted
7. 1st ligated vessel- MIDDLE THYROID VEIN
8. Then ligate artery near the gland

- superior thyroid artery – prevent ELN injury
- inferior thyroid artery – preserve Parathyroid gland blood supply
9. Place drain for 24 hours- look for bleed
Surgeon finds a yellow tissue with the dissected thyroid. What to do?
o Saline float test – place tissue in normal saline
▪ If sinks – it is parathyroid gland
▪ If floats- it is fat / lymph node
▪ Intra operative – place parathyroid gland in SCM muscle pocket

▪ Post operative- place parathyroid gland in non dominant brachioradioalis as
implant.
Post op complications
1. Stridor – B/L RLN injury/ neuropraxia- reintubate -wait for 48-72 hours by giving steroids
and anti-inflammatory drugs
▪ If stridor disappear – extubate
▪ If persistent stridor –extubate and do tracheostomy

▪ Permanent B/L RLN injury- do lateralization of cord / Arytenoidectomy
2. Life threatening complication in post op-
▪ Hematoma – due to slippage of ligature of superior thyroid artery

▪ Management- remove suture in bed side- then prepare O.T
▪ Nowadays we don’t get it as we have drain-
▪ If bleed is seen in drain- shift patient to O.T and capture the bleed
3. Nerve injuries
▪ U/L RLN: - hoarseness of voice
▪ B/L RLN- Stridor

▪ ELN( MC) – Huskiness of voice ( timber is lost)
▪ ILN – Paraxysomal nocturnal cough/ aspiration
4. Laryngomalacia – after removal of thyroid- the larynx collapses
5. Thyroid storm
6. Respiratory dyspnea
▪ Hematoma
▪ B/L RLN injury
▪ Vocal cord oedema

▪ Laryngomalacia( tracheomalacia)
▪ Laryngismus stridulus (hypocalcemia)
7. Hypocalcemia
Hypocalcemia
• 2-5 days post op
• Due to loss of blood supply to parathyroid gland
• Manifestations: subclinical or overt

Subclinical overt
• On measuring BP- Carpopedal spasm – • Tetany- opisthotonus
trousseau sign • Laryngismus stridulous
• On tapping face- chvostek sign
Management – oral Calcium IV Calcium gluconate
▪ No need to monitor sr. calcium for Looking for Hypocalcemia
▪ Normal Sr. calcium- 8-12 mg/dl.
▪ For a pre op patient with 12 mg/dl – post op value of 8 is also hypo calcemic
though in normal range. So serum calcium is not reliable.

▪ For transient – oral calcium
▪ For severe- iv calcium
▪ Permanent( <10% cases where all 4 parathyroid glands are removed)- oral calcium + vit d3 for
life time
Recent trends-
1. Monitoring of RLN injury
Continuous Intermittent
Electrode on vagus nerve Electrode on vocal cords at ET tube
When we give traction on RLN – it is detected Indicates after vocal cords lie in cadaveric
and we get signal position
Prevents injury Injury is detected ( after palsy)
2. Minimally invasive surgery or BY ROBOTIC surgery
BY various approaches
▪ Axillary approach
▪ Sub mammary approach
▪ Supraclavicular approach
▪ Breast Approach

Chapter : 3 Breast
3a. Triple Assessment of Cancer Breast
ANATOMY:
• 16-20 ducts
• 10-100 lobules
• Breast is held in place with suspensory ligament of Cooper
• Breast lies over pectoralis major muscle and pectoralis fascia
• Sappey’s plexus – sub areolar lymphatic plexus
• Lymphatics of breast are classified based on pectoralis minor

o Level I- ( lateral to pectoralis minor)
o Level II – ( at the level of p minor a/k/a central nodes)
▪ Interpectoral nodes/ Rotter’s nodes
o Level III – ( medial to p minor a/k/a infraclavicular/ apical group)
o Other nodes
o Supraclavicular node= Regional node
o Internal mammary node= seen only in CECT chest
Figure: Axillary Nodes.

Case discussion of Breast Cancer:
Triple assessment of breast
• Clinical examination
• Radiological examination
• Pathological examination
Positive predictive value of diagnosis of CA breast by this method is 99.9%
Clinical examination:
o Position:
• Sitting
• Sitting and leaning forward- look for chest wall fixity( ribs)
• Arm on hip with alternate contraction and relaxation- look for pectoralis major
fixity
• Arms raised above head – look for Nipple retraction and paeu de orange
• Semi recumbent position- Best position - fat gets dispersed and tumor is well
elicited
o Methods to examine the breast: ( not to miss out areas)
• Circumferential method – palpate from centre to periphery with 4 fingers
• Vertical strip method – to top to bottom from lateral to medial
• Dial clock method – go outside to inside in each clock hour

c TNM (8th edition AJCC):
• C TNM : ( Clinical TNM)
• p TNM : pathological TNM
• y TNM : Post neo adjuvant CT/RT

• Tis: Tumor in situ – Ductal CA in situ, Paget’s disease
(Lobular Ca in situ is removed in 8th Edition as it is a physiological precursor for CA breast)
T staging:
• T1:
• T2 :
• T3:
• T4 :
a. Chest wall fixity – involvement of inter costal muscles, serratus anterior, ribs
b. Skin involvement –
o Paue de orange ( subdermal lymphatics infiltrated)
o Ulcer in skin
o Satellite nodules + on skin
c. Both a+ b
d. Inflammatory breast cancer (worst prognosis)
Things not included in skin involvement are:

o Fixity
o Tethering
o Nipple retraction
o Dimpling
o Puckering
N staging:
N1 : mobile axillary nodes
N2
a:
b: ( By CECT- but comes in c TNM)
N3
a.
b.
c.
Contralateral nodes : always metastatic ( eg. Opposite supraclavicular nodes)
M1: metastatic
o M/c site:
o Lumbar vertebrae ( batson plexus)
o Long bones ( both osteolytic and osteoblastic)

o Liver
o Lungs
NOTE:
• If patient presents with 2 tumors in breast – take the biggest one for T staging**
• IF patient presents with B/L tumors – do separate staging for both breast
STAGING
• Stage I, IIa , IIb – Early breast cancer – do MRM or BCS
• Stage IIIa,b,c – Locally advanced breast cancer – do neoadjuvant chemotherapy followed by
MRM + RT
• Stage IV – Metastatic cancer – palliative therapy – Hormone therapy+ chemotherapy

At the end of clinical examination of Mrs. Kamala- let us assume the stage T4b N2a M0 – stage IIIb
Radiological examination
o USG breast – indicated for females <35 years( due to dense breast)
o Mammography - > 35 years ( less dense breast)
o MRI – In females with silicon implant (to look for capsular rupture – Linguine sign – i.e
floating of ruptured capsule)
Figure: Linguine Sign in MRI

Mammography:
• X ray
• Low voltage and high amplitude
• Bremstrahlung type of X ray ( Not a conventional X ray)
o Dose – 0.1 c Gy = 4 times chest x ray
o No increased risk of cancer
• Screening mammography - >40 YEARS
o Risk of cancer breast related deaths decreased by 30 %
• Views to be taken in mammography

o Cranio-caudal view
o Mediolateral oblique view
o Done always for both breast
Findings on mammography:
1. In cancer breast ;
Figure: Microcalcification in cancer breast
2. In DCIS :

o Micro calcification
o Scattered calcification
o Clustered calcification
Radiological IOC for DCIS is Mammography.
3. LCIS : NO radiological finding.
4. LC invasive type:
o Neighboring calcification
5. Fibroadenoma breast
o Popcorn calcification / macrocalcification
BIRADS grading ( Breast Imaging Reporting And Data System)

0- Inconclusive
1- Benign - followup
2- Benign- followup
3- Benign - followup
4- Probably malignant – advice biopsy**
5- Mostly malignant – take appropriate action
6- Biopsy proven malignancy
Biopsy is advised for BIRADS 4 and above
PIRADS – Prostate
TIRADS – thyroid
Mammography:
o Screening investigation of choice for >40 years** for general public

o IOC for DCIS
MRI Breast (for screening)
Indications:
Age for screening - >30 years in high risk cases**

Other indications of MRI breast
o Scarred breast
o Previous h/o breast conservative surgery
o Silicon implant breast
Let us assume our case:
o On C/E – stage IIIb
o On R/E: BIRADS 4 ( Hence biopsy advised)
Pathological examination
1. FNAC : with 22/24 G needle
2. Corecut Biopsy : 16/18 G needle,
• IOC to diagnose cancer breast- Helps to diagnose Type of cancer and also
Hormone receptor status study
3. Excision biopsy- only with small and inconclusive lesion
Findings:
• Ducts giving cancer– Ductal cancer -90 % ( insitu or invasive)
• Lobules giving cancer – Lobular cancer – 10% ( insitu or invasive)
• Supporting tissue gives cancer – Phyllodes tumor
Ductal Ca – invasive Lobular Ca - invasive

80%
m/c type:
• NST( no specific type) or
• NOS (not otherwise specified) or
• Scirrous
TYPES :
1. MEDULLARY CA
• Triple negative CA
• Soft in consistency
• Bad prognosis
2. Colloid CA
o Mucinous cancer
o Old age
o Best prognosis

3. Tubular CA –Good prognosis
Figure: Indian File Pattern in Lobular Cancer
DCIS LCIS
• India : m/c presentation : painless lump • m/c painless lump
• Western : mammography ( as • no radiological finding
microcalcification)
• Converted to Ductal Ca invasice in • Converted to Ductal Ca invasive ( m/c)
same place and same type Or any cancer and any where
• ANATOMICAL PRECURSOR OF • PHYSIOLOGICAL PRECURSOR OF
MALIGNANCY MALIGNANCY
Classified under Tis Removed form Tis
Types: • Pleomorphic type of lobular ca in situ –
Low grade can be seen on mammography with
• Papillary type calcification
• Cribriform type • Needs resection
High grade
• Solid type
• Comedo type
Management:
• Simple mastectomy ( with sentinel • High risk patients – advise regular
node biopsy) screening

• Breast conservative surgery • With T. tamoxifen
• Tamoxifen given
• RT to remaining breast after BCS/SM
VAN NUY’S grading system: based on
1. Age
2. Grade
3. Size
4. Margin clearance
Molecular classification
Immunohistochemistry done for
• ER +/-
• PR +/-
• HER 2 NEU+/-
o 0 ,+1 – HER 2 NEGATIVE
o +2 – EQUIVOCAL – do FISH to confirm (+/-)
o +3 – HER 2 POSTIVIE
Luminal A ( m/c type) Luminal B( ALL Her 2 Basal type

POSITIVE) (ONLY HER 2 ( ALL NEGATIVE)
POSTIVIE)
ER+ ER- ER-
PR+ PR- PR-
HER 2 + HER 2 + HER 2 -
Poor prognosis Worst prognosis
a/w BRCA 2 MOST COMMON
CANCER IN BRCA 1**
Consolidation:
• MC presentation- Painless lump
• Nipple discharge- Bleeding
• Nipple retraction
o Circumferential – malignant
o Slit like – benign
• Most common quadrant
o Ca breast and fibro adenosis – upper and outer quadrant

o Fibroadenoma – lower quadrants
Risk factors causing Ca breast.
Non modifiable Modifiable Histological risk factor

Reproductive Reproductive • Atypical ductal
• Early menarche (<12yr) • Child birth (>30 yrs) hyperplasia
• Late menopause (>55yr) • Nulliparous • Atypical lobular
• Absent breast feeding hyperplasia
• Atypical epithelial
hyperplasia
Age (With increasing age) Tobacco LCIS (Physiological precursor of

malignancy)
Female sex alcohol
Family history obesity
BRCA 1,2 mutation Night shift work
Li Fraumeni syndrome Lethargic activity
H/o radiation exposure in Hormones :
childhood • OCP: Yes
• HRT (post menopausal) :
Yes
• Young female after B/L
salpingo oopherectomy
on estrogen only pills :
NO
Classification of breast cancer:
1. Sporadic : 60-75%
2. Familial : 20-30 %
• 1st degree relative has 13 % risk
3. Hereditary 5%
• BRCA 1 -45%
• BRCA 2 - 35%
• Li Fraumeni syndrome -1%
• Ataxia telangiectasia -1%
• Muir torre ( lynch II)- 1%
• Cowden- 1%

BRCA 1 BRCA 2
Chromosome 13 q
Well differentiated
Triple + / ER +
Good prognosis
m/c-
• Breast ca ( 80 %)
• Ovarian ca – 20%
• Prostate ca
• Colon ca
• Pancreatic ca
• Gastric ca
• Melanoma
• Male breast ca
Advise them to undergo prophylactic B/L simple mastectomy
And after completion of family – B/L salpingo oopherectomy
3 B. management of cancer breast

Multimodality treatment
SURGIGAL MANAGEMENT
• Simple mastectomy
• Modified radical mastectomy
• Radical mastectomy
• Sentinel node biopsy
• Breast conservation surgery
• Breast reconstruction
Simple mastectomy (SM)

• Remove entire breast + nipple + areola
• No nodal dissection
Indications:
o Prophylaxis : BRCA 1,2
o Toilet simple mastectomy- in ulcerative ca breast ( as a palliative measure)
o Extended simple mastectomy = SM + level I nodes removed
o Nipple sparing / skin sparing SM – BRCA 1,2 mutation

Modified radical mastectomy
Structures removed are:
• Nipple
• Areola
• Breast tissue (entire)
• Pectoralis fascia
• Axillary dissection procedure ( level I, II, III)
Boundaries:
• Laterally – lattismus dorsi
• Medial- sternum
• Superiorly – subclavius muscle
• Inferiorly – 2cm below the infra mammary fold
Figure: Boundaries of MRM
Structures preserved are: (ABCDM)

Axillary dissection boundaries
• Superiorly – axillary artery and vein
• Inferiorly – angular vein
• Medially- bell’s nerve ( long thoracic nerve)
• Laterally- thoraco dorsal pedicle ( vessels + nerve)
❖ Minimum 10 nodes to be removed to call a complete axillary dissection
❖ Most common nerve injured – intercosto brachial nerve- only cutaneous supply**
o Other nerves
▪ Bell’s nerve- winging of scapula

▪ N. to LD – shoulder movements are affected (eg. Medial rotation, climbing
trees)
▪ Medial and lateral pectoral nerve- supply pectoralis major
Figure: Boundaries of Axillary Dissection.
STEPS OF MRM
❖ Position- supine with arm extended in 90’
❖ Skin incision – elliptical Stewart’s incision
❖ Elevate skin flaps till boundaries mentioned
❖ To deal with Pectoralis minor in axillary dissection:
o Patey’s method-
▪ cut and remove
▪ level I, II, III can be removed

o Auchincloss-
▪ Retract P. minor
▪ Level I, II only can be removed
o Scanlon
▪ Cut and resuture
▪ Level I, II, III can be removed
❖ Place 2 drains – one in axilla and another in bed of surgical site
❖ Closure of skin with subcuticular suture – using monocryl (polyglycaprone)
Complications:
• M/c complication – seroma –
o remove drain on 5th day post op
• Nerve related- intercosto brachial nerve
• Flap necrosis
• Lymphoedema of arm
• Lymphoedema of arm + radiotherapy = lymphangiosarcoma—called as STEWART TREVES
SYNDROME
Radical mastectomy of Halstead
• MRM +
• Removal of
o Pectoralis major
o Pectoralis minor
o Serratus anterior ( part of)
• 3 structures preserved ( ABC)
o Axillary vessels
o Bell’s nerve
o Cephalic vein
Sentinel node biopsy

• Sentinel node- 1st node from Ca breast (Axillary node)
• Axillary dissection is the main cause of morbidity.
• To prevent this – sentinel node biopsy is done
• Therefore test the 1st node and look for deposit in 1st node-

o if positive- dissect axilla
o if negative – don’t dissect axilla
❖ sentinel node of breast – GUILIANO sentinel node biopsy ( axillary node)
❖ sentinel node of penis – CABANA ( superficial inguinal node)
▪ Indications:
• Early breast cancer – stage I, IIa, IIb ( T1,T2)
• No node palpable ( on clinical examination or on USG )
▪ Contraindications:
• T3,T4 lesions ( locally advanced breast cancer)
• Palpable node +
• Previous h/o surgery in breast ( 1st level lymphatic is disturbed – it will have a different
pathway)
• Pregnancy
• Contraindications for radiotherapy
o Collagen vascular disease
o Previous h/o RT
o Pregnancy
▪ Procedure of sentinel node biopsy
o Indian method:
▪ Inject methylene/ isosulphan blue in peritumor area

▪ Open axilla dissection see for blue colour node
▪ Dissect and send for frozen section
o Western method:
▪ Inject radio labelled substance ( Tc 99)
▪ High uptake area is captured with gamma camera
▪ Dissect it
o Best method – combined method**
Frozen section biopsy:
o Positive – axillary dissection completely
o Negative – call the radiotherapist- give RT to axilla and send home

Figure: Sentinel Node Biopsy by Radiolabelled Colloid
BREAST CONSERVATIVE SURGERY

Indications:
o Early breast cancer
o DCIS
BCS has 4 components:
1. Wide local excision
• Clean negative margin from pathologist on all sides ( 1 mm negative )

2. Axillary status should be identified
• N0- Sentinel node biopsy

• N1 –Axillary dissection
3. Radio therapy to remaining breast
4. Keep patient on follow up
• Since only tumor was removed – it may recur
Contraindications of BCS:
1. If wide local excision not possible like in
• Locally advanced breast cancer (skin fixed, chest wall fixed)
• After 2 times wide local excision – margin is positive – go for MRM

• Multicentric and multifocal cancer ( can’t do WLE)
• Small breast but tumor is big – cosmetic deformity
2. Where RT is contraindicated
• Collagen vascular disease
• Previous h/o RT
• Pregnancy- 1st and 2nd trimester (in 3rd trimester – we can give RT after delivery)
• Huge pendulous breast – we’ll have to expose abdominal contents while giving
radiotherapy to the remaining Breast.
3. Patients who tend to Loss to follow up
• Low Socio-economic patients

• Uneducated patients
• Psychiatry patients
Following are not contraindications:

• Family history
• Central/ subareolar tumor
• Node+
BREAST RECONSTRUCTION SURGERY

• Can be done immediately (if RT is not needed)
Autogenous tissues Implants (Silicon) – kept in sub pectoralis layer

• TRAM flap ( previous decade) Indications:
• LD flap If Patient wants
• Gluteus maximus muscle ▪ Augmentation of breast
• DIEP flap ( latest) ▪ B/L breast reconstruction (
don’t have enough tissue for
graft)
Contraindications:
▪ Silicon allergy
▪ If you are planning radiotherapy
( since it will rupture)
TRAM flap (Transverse Rectus Abdominis Muscle flap)
• Pedicle –
• Free flap –

o Require microvascular anastomoses
• Disadvantage: weakness in abdominal wall
DIEP ( Deep Inferior Epigastric Perforator ) flap
• (Skin + subcutaneous + fat) Free flap – Inferior epigastric artery based ( from pubic
region)
• Require microvascular anastomoses
Figure: Flaps to reconstruct
Adjuvant Therapy
Chemotherapy Hormone Therapy Radiotherapy

To prevent micro mets For ER+ cases To prevent local recurrence (
and distant mets To prevent cancer in opposite since pectoralis major is left
breast behind)

Indicated in Indicated for: Indicated in
• >1cm • ER + premenopausal(ovary • Locally advanced
• Node + produces estrogen) breast cancer
• Anti oestrogen – • Chest wall+
Tamoxifen/ SERM • To axilla if
• ER+ Post-menopausal o <10 nodes are removed
(oestrogen form peripheral o Extracapsular spread
conversion of androgen to o No axillary dissection done
oestrogen)
• Aromatase inhibitor-
Anastrazole, Letrazole
• MC Cause of Lymphedema in Western Countries is due to RT to axilla** which can lead to
Stewart Treves Syndrome** ( Lymphangiosarcoma)
Chemotherapy:
✓ CAF - 6 cycles ( when given as adjuvant)
• Cyclophosphamide
• Adriamycin
• 5 FU
✓ Neoadjuvant _-3 cycles before surgery
✓ If her2 + - Herceptin (trastuzumab)- anti her2 antibody
Hormone therapy
✓ Tamoxifen – 10 mg BD x 5 years ( min) – 15 yrs ( max)
o Antagonist in breast
o Agonist on endometrium
o Mortality decreased by 30%
o Recurrence in opposite breast decresed by 40%
➢ Side effects:
➢ Added advantages
o Decreased osteoporosis ( Agonist in bone)

SERM: Selective Estrogen Receptor Modulators
o Raloxifene
o Tormefene
Other Cancer Breast related Lesions
Paget’s disease:
• Clinical Features: nipple discharge and nipple erosion

• Differential Diagnosis: Eczema
Eczema Paget’s disease

B/L U/L
Associated with skin lesions + -
Responds to steroids -
• Superficial manifestation of underlying breast cancer
• 40-50% patients we can palpate a lump
• If lump is negative- take a nipple scrap biopsy-
o Shows Paget’s cells – pale, vacuolated cells in epithelium

o It comes under Tis
• Treatment – do MRM
Inflammatory breast cancer ( T4d)

O/E :
• Mastitis like appearance
• Paeu de orange+
• Redness+
• Extensive subdermal lymphatic infiltration +
❖ Immediately start on neoadjuvent chemotherapy and do MRM
❖ Bad prognosis
Male breast cancer
Predisposed by
• BRCA 2 mutation
• Klinefelter syndrome

• Testicular feminization syndrome
NOTE: Gynaecomastia is not a predisposing factor
Figure: Male Breast Cancer
Management:
• TNM staging is same like females
• Indepth infiltration is more common
• No lobular cancer seen in males – only ductal cancer
• Investigations are same
• Biopsy by trucut biopsy

• Treatment is also same – MRM
• After MRM – study for ER
o If ER + ( mostly) – give them tamoxifen
NOTE:
• Gold standard investigation to look for mets – PET- CT ( for all LABC)
• Replaced by old investigations like bone scan and x ray flat bones.
Chapter 3C- Miscellaneous Diseases
Nipple discharges:
❖ Bloody-
o Young – duct papilloma

o Old age – CA breast
❖ Greenish yellow – duct ectasia
❖ Milky discharge

o Physiologic
o Pathologic – drugs
Surface discharge form breast – Eczema and Paget’s disease
Eczema Paget’s disease

B/L U/L
Associated with skin lesion + -
Responds to steroids -
Duct papilloma Duct ectasia( no pain)

Papilloma inside duct Duct is abnormally dilated
Young female Middle aged female
Bloody discharge Greenish yellow discharge
Periductal mastitis (Zuska disease)**
Pain +
Predisposed by smoking females
Ductography
Filling defect Dilated ducts
Treatment Hadfield’s operation
• Tennis racket shaped incision ( on skin) - conical excision of all ducts with apex at nipple
and microdochectomy - Radical approach
- No lactation possible hereafter from this breast
- Done only for incurable periductal mastitis

ANDI ( ABERRATION IN NORMAL DEVELOPMENT AND INVOLUTION OF BREAST)
Non proliferative lesions Proliferative lesions

Not premalignant No risk of malignancy Risk of malignancy
Duct ectasia Sclerosis Atypical ductal hyperplasia
Fibro adenosis Radial scar Atypical lobular hyperplasia
Cyst disease Fibroadenoma Atypical epithelial hyperplasia
Apocrine changes Duct papilloma
Fibroadenosis
• Young females
• Clinical features:
o Lumpiness in breast
o Painful cyclical mastalgia ( preovulation)
o Fullness of breast ( pre menstrual)
• Treatment : reassurance and analgesics
o oil of evening prime rose
o danazol
o tamoxifen
Fibroadenoma
• Most common benign lesion of female
• Most common <30 yrs
• 2nd MC tumor next to ca breast

• c/f: breast mouse ( Indian rubbery firm consistency mass)
• no pain
• Giant fibroadenoma = >5cm in size
• Types : pericanalicular and intracanalicular
Pericanalicular Intracanalicular
Hard fibroadenoma
m/c type
Painless
Young females (<30 yrs)
Breast mouse
Slow growing

Treatment:
Enucleation
Or excision
• Management:
o Cosmetic incision
▪ Subareolar incision
▪ Gaillard Thomas submammary incision
o Non cosmetic – radial incision
• Mammography shows – Pop corn calcification
Figure: Popcorn Calcification
Mondor’s disease
• Superficial vein thrombophlebitis
• MC vein – lateral thoracic vein
o Thoracodorsal vein
o Superior epigastric vein
❖ C/F : painful, tender, cord like ( DDX : lymphatic permeation by tumor)

❖ Management: rest shoulder , arm restriction with analgesics
❖ If pain persists – excision

Figure: Mondor’s Disease
Phyllodes tumor:
• Arising from the intervening tissue of breast / supporting tissue
• Reason:
o Leaf like appearance on cutting
o USG – cystic spaces( hence also called as cystosarcoma phyllodes)- misnomer
• C/F : painless , massive size
o Benign, borderline, malignant
• No lymph node enlargement
• No lymphadenectomy required
• Treatment : wide local excision / simple mastectomy
Figure: Phyllodes Tumor

Gynecomastia – enlargement of male breast
SIMON’S GRADING
I. MILD
II. MODERATE
a. No skin redundancy
b. Skin redundancy
III. Marked with skin redundancy and ptosis of breast tissue
Causes:
I. Physiological – puberty
II. Pathological:
a. Estrogen excess
• Tumors in testis
• Endocrine disorders
• Cirrhotic liver
• Klinefelter’s syndrome
• Testicular feminization syndrome
b. Androgen deficient
• Hypogonadism
• ACTH deficiency
• B/L orchidectomy
c. Testis failure
• Orchitis
• Trauma
• Undescended testis
• Radiotherapy
d. Drugs: (DISCKO FM)
• Digitalis and Di ethyl stilbesterol
• Isoniazid
• Spironolactone and steroids
• Cimetidine
• Ketoconazole
• Oestrogen
• Flutamide and frusemide
• metronidazole

Figure: Gynecomastia
Management:
• Testosterone
• Danazol
• Treat the cause

Surgical :
• Liposuction
• Resection by sub mammary/ subareolar incision-
o Webster operation**
• Not precancerous except secondary to klinefelter syndrome.
Mastitis in lactating women:
• Most common – Staphylococcus aureus ( from baby’s saliva)
• Lead to breast abscess
o Latest treatment – USG guided aspiration of abscess**
o Can do repeated aspiration
• Avoid feeding from infected breast
• But express milk by pump
• Treatment : Cloxacillin with tight support for breast.

Figure: Mastitis going for Abscess

Chapter 4- Hernia
4a- Anatomy of Hernia

Inguinal canal/ House of Bassini
• Extending from deep ring to superficial ring
• 4cm
Deep ring Superficial ring Saphenous opening

• •
Femoral canal
• 1.75 cm in length
• Extends form femoral ring to saphenous opening
• Medial most compartment of femoral sheath
• Boundaries:
o Anteriorly-
o posteriorly-
o Medially –
o Laterally –
o Content:
• Femoral hernia does not go inferiorly: due to HOLDEN’S LINE
o HOLDEN’S LINE: attachment of deep membranous layer of superficial fascia of
abdomen with fascia lata of thigh
o Therefore femoral hernia is retort shaped.
Hesselbach’s triangle
• Boundaries:
o Laterally- Inferior epigastric artery
o Medially- Rectus abdominis
o Inferiorly- Inguinal canal

• Hernia here is direct hernia
• Indirect hernia goes from deep to superficial ring.
Indirect Hernia Direct Hernia

Young age Old age
Congenital / acquired Mostly acquired (except ogilvie)
Due to preformed sac. MC in Males
MC in Males Predisposed by
▪ Collagen vascular disorder
▪ Smoking
▪ Increased intraabdominal pressure
Eg. Constipation, difficulty in micturition,
BPH, chronic cough- COPD
Course:
Deep ring to superficial ring
Pyriform shaped
• Sac is lateral to inferior epigastric artery
• Sac is anteriolateral to cord structure

Treatment:
• Herniotomy +
• Herniorrhaphy/hernioplasty
Complications: Less chance of obstruction

High chances of obstruction (due to wide neck of sac)
In females:
• Indirect hernia is most common hernia in females.
• Direct hernia never occurs
• Femoral hernia is more common in females compared to males.
Males:
• Indirect hernia is most common hernia.
Contents of cord:
1. Vas deferns/ Round ligament of uterus
2. 3 Arteries:
3. Veins: corresponding veins forms pampiniform plexus

4. Nerves
• Genital branch of genitofemoral nerve
• Ilioinguinal nerve
• Iliohypogastric nerve
Anatomy of hernia sac:
• Has Mouth, Neck, Body, Fundus
• Neck less hernia- Direct hernia
o Therefore never goes for strangulation

Classification based on extent of sac:
1. Vaginal or complete hernia: sac extends till base of scrotum

2. Incomplete/ Funicular hernia: sac extends till root of scrotum
3. Bubonocele : Hernia is confined to inguinal canal.
Contents of sac:
Enterocoele Omentocoele
Contains bowel
Reducibility:
Initially: difficult
(due to narrow neck)
Later: easily reducible with gurgling sound
Elastic in consistency
Clinical examination:
• Cough impulse:
▪ Sign of reducible hernia
▪ Absent in irreducible / obstructed hernia/ in dense adhesions
Tests done:
1. Three finger test( ZIEMANN’S TEST)
• Ask patient to cough. Impulse felt in
o Index finger- indirect hernia ( deep ring)

o Middle finger – direct hernia ( superficial ring)
o Ring finger – Femoral hernia ( saphenous opening)
2. Deep ring occlusion test ( DRO test)
▪ Occlude deep ring with thumb
▪ Ask patient to cough
▪ Swelling appears- direct hernia
▪ Swelling doesn’t appear – indirect hernia
False positive test:
o Deep ring is wide
o Pantaloon hernia
3. Finger invagination test:
• Done only in males
• Not possible in females due to absence of lax skin

• Invaginate little finger from scrotum towards superficial ring
• Ask patient to cough
• Impulse felt at tip – indirect hernia
• Impulse felt at pulp – direct hernia
o Other advantages of invagination test:
▪ Detect posterior wall weakness
▪ Superficial ring laxity is noted
Malgaigne’s Bulges
• B/L pyriform shaped swelling in inguinal region in old patient when asked to lift head
• Present due to muscle weakness
• Treatment of choice : Hernioplasty
Classification of hernia:
NYHUS:
TYPE 1 TYPE 2 TYPE 3 TYPE 4

INDIRECT HERNIA INDIRECT HERNIA POSTERIOR WALL RECURRENT HERNIA
DEFECT
DEEP RING NORMAL DEEP RING IS Dilated

GILBERT CLASSIFICATION: 7 TYPES
1. Indirect + small defect
2. Indirect + medium defect
3. Indirect + large defect
4. Entire floor defect ( posterior wall ) – direct
5. Diverticular type- Direct
6. Pantaloon
7. Femoral
European Hernia Society Classification:

• Primary / Recurrent
• Lateral / Medial / Femoral
• Defect : 1 finger = 1.5 cm
o Eg. PL2 hernia = primary lateral 2 finger ( 3 cm defect)
MCQ points:
o Lumbar hernia – only natural weakness seen in the body
o Surgical scar : max 70% of initial strength ( irrespective of duration of healing)
o Weight lifting doesn’t cause hernia
o Obesity is inversely related to hernia ( Inguinal Hernias)
o Collagen vascular disorder, elderly, pregnancy increases incidence of hernia.
Management of Hernias:
TRUSS – hernia belt ( Not advised nowadays)
o Used only in reducible small hernia
o Disadvantage: dense adhesions will form – make surgery difficult

Figure: TRUSS
• Congenital hernia:
o Herniotomy
o Identify sac – preperitoneal pad of fat
o Dissect the sac and remove
o Ligate at neck
• Adults:
o Herniotomy + herniorrhaphy / hernioplasty
Herniorrhaphy
• No mesh- only suture is used
• Done only in emergency nowadays– due to increased chances of mesh infection

Types:
• Original Bassini – approximate conjoint tendon with inguinal ligament ( intermittent
sutures)
• Modified Bassini – Continuous sutures to approximate conjoint tendon with inguinal
ligament.
• Maloney’s Darning procedure: ( best – results equal to mesh repair)
o Dense continuous sutures between conjoint tendon and inguinal ligament. Sutures
themselves looks like a mesh.
• Shouldice repair- Double breasting of fascia transversalis
• Mc Vay’s repair- approximate Conjoint tendon with iliopecteal ligament of cooper. (
femoral hernia is also cured)

Hernioplasty
Gold standard- Lichtenstein tension free mesh repair
• Treatment of choice for direct hernia
(as in direct hernia – posterior wall is already weak- if we put sutures it becomes further
weak)
Also remember:
Lytle repair- narrow the deep ring with prolene sutures (in case of wide deep ring)
Tanner’s slide:
• It’s a incision made on anterior rectus sheath to relieve tension ( when bassini was
used – patient used to bend to that side due to tight sutures)
Femoral hernia surgeries:

• 20% patients have abnormal obturator artery medial to lacunar ligament
• Most common presentation – obstruction at lacunar ligament
Therefore 1st step- releive obstruction
• Dissect lacunar ligament (don’t injure abnormal obturator artery)
• Then place a mesh between inguinal and cooper’s ligament
Skin incisions and Names in femoral hernia:
Midline incision- Henry’s procedure
• Midline extraperitoneal femoral hernioplasty
• Treatment of choice for femoral hernia

Other named Surgeries in Hernia:
GPRVS- Giant Prosthesis Reinforcement Visceral Surgery( STOPPAS repair)
• Huge mesh kept preperitoneally after reducing the hernia
• No sutures required
• Intraabdominal pressure will seal it.

Gilbert plug mesh
• Plug a mesh into the defect
Meshes in Hernia Repair

1. Mesh types
• NET (can be woven or knitted)
✓ Adherence is easy ( tissue enters mesh- adherence due to friction)
✓ Fixation may or may not be done
• Sheet
✓ Adherence is not there
✓ Fixation is must to prevent mesh migration
2. Materials used for mesh
I. Polypropylene mesh
✓ White colour

✓ Fix with 2.0 prolene / tackers
✓ Hydrophobic (Hence Prevents Bacterial ingrowth**)
✓ Prevents bacterial growth due to hydrophobic nature
II. Polyester mesh
✓ Hydrophilic
✓ Increases bacterial growth but also increased anti inflammatory cells
reaching there.- so it can be used and nothing to worry.
III. PTFE (Poly Tetra Fluoro Ethylene)
✓ Flat sheet
✓ No tissue ingrowth
✓ Used as non adhesive barrier between layers
3. Weight of mesh
Light weight= 40 g/m2 Heavy weight mesh = 80g/m2
o Goes for contracture

o Other features are opposite to light
weight
4. Biological mesh
• They have a scaffold to encourage neovascular ingrowth and collagen deposition.
• Expensive
• Derived from
✓ Human / animal dermis
✓ Bovine pericardium
✓ Porcine submucosa
• Contraindicated in infection (mesh will be dissolved)
• Prevents attachment of bowel to mesh
• Used in burst abdomen
5. Absorbable mesh
• Used for temporary closure of abdomen in burst abdomen
• No role in hernia repair

• Made up of polyglycolic acid = also called as “VICRYL MESH”
6. Dual mesh/ Tissue separation mesh
• One side by prolene ( towards skin)
• Other side by vicryl/ collagen/ PTFE / cellulose ( visceral side)
• Prevents bowel adhesion
Mesh placement techniques:
1. Onlay mesh – between skin and anterior rectus sheath
2. Inlay mesh- between the muscle layers

✓ Sublay intraparietal – between rectus abdominis and posterior rectus sheath
✓ Sublay extraperitoneal – between oblique mucles and fascia transversalis
3. Intraperitoneal- along the posterior surface of peritoneum ( Inside the Peritoneal cavity)
✓ Use only dual mesh
• IPOM- Intraperitoneal Onlay mesh using DUAL mesh is done by Laparoscopic surgeons
commonly in practice
NOTE:
• In open surgeries – we can use inlay/ onlay/ intraperitoneal mesh
• In laparoscopy- use only intra peritoneal / sublay extraperitoneal mesh.
• Overlap of mesh- 2 – 5 cm on all sides (beyond the defect)

Complications of hernia
1. Irreducible hernia
• Hernia is not going back inside (adhesion)
• Not emergency – but plan for surgery
• Can become obstructed hernia
2. Obstructed hernia
• Bowel is viable
• Emergency
3. Strangulated hernia
• Bowel is not viable
Management of obstructed hernia:
▪ Take a inguinoscrotal incision
▪ Open the fundus and let the toxic fluid drain out
▪ Cut the constriction point
▪ Look for viability of bowel-
o Mesenteric artery pulsation
o Peristalsis
▪ If no pulsation and peristalsis + bowel looks bluish
o Keep a warm pad on bowel + 100% O2
o If pulsation appear- reduce the content
o And do hernioraphy
Complications of hernia surgery:

4b Types of hernia
1. Sliding inguinal hernia
• Sac + intraperitoneal structures + some retroperitoneal structures ( eg..caecum,
descending colon)
• Most common on left side
• Most common content sigmoid colon

• If on right side- content is caecum (MC)
Management:
• Dissect sac and ligate
• Posterior dissection is not advised – to prevent injury to retroperitoneal organs.
2. Maydl’s/ W shaped hernia
• Most distal part is B- present inside the abdomen (more prone for ischaemia)
• If we see A and C being viable and push bowel inside
▪ Delayed bowel leak from B can occur

▪ Retrograde strangulation
Figure: Maydl’s hernia
3. Scrotal abdomen
▪ Huge indirect hernia
▪ May be associated with sliding hernia
4. Richter’s hernia
▪ Seen in femoral and obturator hernia

▪ One circumference of bowel is obstructed
▪ Fluid is secreted in response- hence presents as diarrhea
5. Internal Hernia
▪ Stammer’s Hernia : hernia through defect in transverse mesocolon
▪ Peterson hernia: hernia behind Roux limb
Gaps in ligaments causing hernia

▪ Ogilvie:
▪ Laguier’s hernia:
▪ Beclard hernia:
▪ Narath Hernia:
▪ Berger’s Hernia :
Sportsman Hernia:
o No swelling
o No cough impulse
o Seen in rugby/ football players
o Young men
o C/F-
▪ Pain at inguinal region extending to scrotum and upper thigh
▪ ( DD- rupture of adductor tendon, Gilmores groin( inflammatory pain) )
o Investigation of choice- MRI
o Treatment- Laparoscopic repair.
Ventral Hernia
Hernia on the ventral surface of the body
• Umbilical and paraumbilical
• Epigastric
• Incisional
• Parastomal
• Spigelian hernia
• Traumatic
• Lumbar (Dorsolateral hernia)- Though coming under Ventral hernia it is seen on the Dorsum
side.

Though Inguinal and Femoral are seen ventrally – they are not put under this classification** ( So
you can get in exam as EXCEPT)
1. Umbilical hernia
In children:
▪ Congenital ( umbilical ring fail to close)
▪ Defect is not so tight
▪ No strangulation
▪ Wait for 2 years
▪ Ideal age for surgery : simple anatomical repair

✓ 2 years ( NEET- FROM B&L)
✓ 5 YEARS ( AIIMS – From sabiston)
Mayo’s repair: “Pant on vest repair” – overlapping of rectus sheath . Not performed now.
In Adults:
• Abdominal pathology-
✓ Obesity
✓ Cirrhosis and ascites
✓ Pregnancy
• Strangulation is common in adults
• <2cm – wait and watch

• >2cm – surgery
✓ Anatomical repair
✓ Laparoscopic repair
✓ Mayo’s repair
2. Epigastric hernia of Linea alba/ Ghost hernia/ Sacless hernia/ Fatty hernia of linea alba
• Defect is transverse
• Preperitoneal pad of fat comes out first
• Undergoes strangulation – hence presents with pain
• Pain mimics peptic ulcer disease
• Young males (25-40 years)
• Cough impulse may or may not be present (based on strangulation)
• Ghost/ Sacless hernia – only preperitoneal fat pad comes ( no peritoneum)

• Management-
o Open entire linea alba while operating – look for minor defects
o Recurrent due multiple defects missed during previous surgery
o Adult- close with non absorbable surtures
o Child – absorbable suture
3. Incisional hernia
• 10-50% incidence
• Port site hernia (laparoscopy)- 1-5%
• Broad necked – less risk of strangulation

• We can operate electively
• Factors causing incisional hernia.
Surgery related Surgeon factors Patient factors

Wound infection Poor technique
mc- midline> paramedian Used absorbable sutures (
instead of prolene)
Mc – emergency Surgery> Excessive tension
elective surgery
Jenkins rule – length of suture
material to be used =4x length
of incision
Management
▪ Linea alba closure – poly prolylene/ poly-diaxonone (Longest absorbable suture)
o Continuous sutures used
o Intermittent sutures used ( Give less gap < 1cm between Sutures)
Burst abdomen happen on 6th day post op.
Treatment:
• Mesh repair
o Onlay technique ( by open method)
o Laparoscopic -IPOM ( intra peritoneal Onlay Mesh)- Dual mesh is used.

(Errata in Video : Sublay is kept above the peritoneum below the rectus
muscle*)
o e-TEP ( extended – Total Extraperitoneal Repair)
o Abdominoplasty ( remove excess fat)
4. Spigelian hernia
• Occur in spigelian fascia(connecting xiphi sternum to supra pubic)
• Inter parietal hernia- between muscles
• Occur at any age
• Most common site- infra umbilical

• Seen mostly above arcuate line** > than below Arcuate line
• C/F-
o Young age- pain + and Lump may or may not be palpable
o Old age – Pain seen with Cough impulse+ and defect palpated.
• IOC : CT abdomen/ USG
• High incidence of strangulation
• Repair:
o IPOM
o Open method- close the defect
Note: hernia with decreased incidence of strangulation:

• Umbilical hernia
• Incisional hernia
5. Lumbar hernia:
Superior lumbar triangle boundaries Inferior lumbar triangle( Petit’s triangle)

boundaries:
( Grynfelt Hernia- Rare) ( Petit’s Hernia – Most common)
• Superiolateral : External oblique (
defect)
• Inferiolateral: iliac crest
• Medially : Lattisimus dorsi
Treatment: DOWDPONKA OPERATION

Figure: Lumbar Hernias
6. Parastomal hernia
• Most commonly seen after end colostomy ( 50 % cases)
• To prevent this we keep a mesh
• SUGAR BAKER PROCEDURE (MESH- BOWEL – MESH)
7. OBTURATOR HERNIA
• Occurs through obturator foramen
• Mc in elderly females
• C/F-
o swelling in scarpa’s triangle of thigh
o Presents as strangulation
o Flexion ,abduction and external rotation of hip – makes swelling visible.
• Howship Romberg sign: Referred pain to knee ( due to obturator nerve compression)
• Hannington kiff sign: absent obturator reflex
• Treatment: Posterior approach and keep a mesh

4c. LAPAROSCOPIC ANATOMY OF HERNIA
• Triangle of Doom :
o Apex-
o Medial-
o Laterally
o Base –
▪ Content :
✓ External iliac artery and vein

▪ When we damage the vessels here person may die ( hence doom)
• Triangle of Pain:
o Laterally-
o Medially-
o Base-
o Contents:
✓ Lateral cutaneous nerve of thigh
✓ Anterior cutaneous nerve of thigh
✓ Femoral branch of genitofemoral nerve
✓ Femoral nerve
o Importance of this triangle:
✓ If trackers are put below iliopubic tract – it causes severe pain
✓ Most common – lateral cutaneous nerve of thigh – meralgia
paraesthetica

Figure:
Triangle of Pain and Doom
Laparoscopic hernia repair techniques:
TEP( TOTAL EXTRA PERITONEAL REPAIR) TAPP ( TRANSABDOMINAL PRE PERITONEAL

REPAIR)
ADVANTAGES: ADVANTAGES:
o Peritoneum not opened o Easy to do
o No paralytic ileus o Short learning curve
DISADVANTAGES: DISADVANTAGES:
o Long learning curve o Paralytic ileus
o Bowel injury
Extra Edge:
o Space of Retzius – Retropubic space ( SPACE BETWEEN THE BLADDER AND PUBIC
SYMPHYSIS)
o Space of Bogros – Retro inguinal space ( SPACE BEHIND THE INGUINAL CANAL ANTERIOR
TO PERITONEUM)
o We use these two spaces to do laparoscopic surgeries.

CORONA MORTIS/ CIRCLE OF DEATH:
• Formed by
o External iliac artery

o Internal iliac artery
o Obturator artery
o Abnormal obturator artery
o Inferior epigastric artery.
Abnormal obturator artery ( present in 20% patients) is required to complete corona mortis
Injury to it may lead to death .

Myopectineal orifice of Fruchad
o Medially – rectus abdnominis
o Laterally- iliopsoas
o Superiorly- conjoint tendon
o Inferiorly – pecten pubis
Application : all types of hernia can be prevented by keeping a mesh here.
NOTE:
o Treatment of choice for mesh infection in laparoscopic repair – laparoscopic removal of mesh.


Section B - Work Book

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Section : B: Head and Neck, Thyroid and Breast

Acknowledgement for this section - B

RRM’S SURGERY SIXER APP BASED WORKBOOK 1

Chapter 1a. Oral cavity

Ulcers in oral cavity

Painful Ulcers Painless Ulcers

Figure: Gummatous Ulcer

Syphilis oral lesions:

Primary Secondary Tertiary

RRM’S SURGERY SIXER APP BASED WORKBOOK 2

Conditions associated with malignant transformation:

High risk Medium risk (3S) Low risk ( equivocal risk)

• White patch/ plaque

• m/c premalignant lesion

• management- stop smoking and laser

• 17 times malignant potential

3. Chronic hyperplastic candidiasis

• Treat with oral antifungal drugs

4. Oral submucous fibrosis

• Betel nut produces – arecoline

• Causes submucous fibrosis

5. Sideropenic dysphagia (plummer Vinson or Paterson Kelly syndrome)

RRM’S SURGERY SIXER APP BASED WORKBOOK 3

• Koilonychias + iron deficiency anemia

• D/t iron deficiency – they have epithelial atrophy – which is premalignant

• Iron supplement – heals epithelial atrophy

• Smoking – m/c – 1.5-2% risk

• Dietary- deficiency in antioxidant ( Vit A,C,E)

• Environmental – UV light and sunlight ( for Ca lip)

• Infections- HIV 1,2, HPV 16,18 and Syphilis

Oral cancers- M/C is SCC

RRM’S SURGERY SIXER APP BASED WORKBOOK 4

B/L lymph node enlargement is seen in CA

TNM staging – AJCC 8th edition

a. Involvement of skin of face, inferior alveolar nerve, floor of mouth

b. Pterygoid plates, carotid sheath, masticator space, internal carotid artery

• N1 - <3cm ( single Node)

III- T3NO; any T N1 ( node starts in III)

RRM’S SURGERY SIXER APP BASED WORKBOOK 5

2. Extra nodal extension is N3b

3. Extrinsic muscle invasion is removed from T4

• Oral ulcer – to be evaluated if following are seen:

✓ > 3 weeks swelling in oral cavity/ neck

❖ Gadolinium – suppression techniques and variation in image sequence

• M/C distant mets : Lungs – CT thorax before surgery

• CT facial Bones – to look for bony invasion

• m/c painless ulcer

o Pain – if infiltrating nerve

• Trismus- infiltration of pterygoid plates

• Bony invasion( mandible) – bony pain

• T1- <2cm – 1cm margin excision and approximate cut edge

• T2 – 2-4cm – hemiglossectomy + reconstruction

RRM’S SURGERY SIXER APP BASED WORKBOOK 6

1. RFFF ( Radial Forearm Free Flap)

• Based on radial artery

2. PMMC flap ( Pectoralis Major Myocutaneous flap)

3. Delto pectoral flap ( DP flap)

• Can be used in females

• Based on internal mammary artery

RRM’S SURGERY SIXER APP BASED WORKBOOK 7

o Infiltrating mandible – segmental mandibulectomy and reconstruct with radius bone.

• 90 % are lower lip

o Lower lip cancer – B/L lymph nodes+