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256 CHAPTER 7: The Head and Neck
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nodule, slightly above and in front of the mandibular angle and, less commonly, just anterior to the tragus. It may remain benign for years, growing very slowly. Rarely, it suddenly becomes malignant, with rapid growth
and metastases. The second most common benign neoplasm is the Warthin
tumor (papillary cystadenoma lymphomatosum), commonly occurring in the
parotid tail in older men. It is bilateral more often than other salivary gland
tumors. Malignancy is suggested by pain and tenderness, rapid tumor
growth, facial nerve paralysis, and xation to the skin or underlying tissues. Biopsy is necessary because the several tumor types require different
management.
Salivary calculus—sialolithiasis.
in the salivary ducts. The cause is unknown. The stone is in the submandibular gland or duct in ~85% of patients with salivary calculi. Submandibular
swelling, with or without pain, occurs suddenly while the patient is eating,
and subsiding within 2 hours. The sequence may be invariable for several
years and is pathognomonic. Occasionally, the gland becomes infected or the
duct obstructed. With a parotid duct stone, gland swelling may persist for
several days. In all three glands, calculi are frequently identied by palpation. Approximately 80% of the calculi are calcied, so they can be seen by
radiography without contrast. Intraoral dental radiographs are excellent for
demonstrating the calculi. A noncalcied impalpable stone can be detected
by sialography.
Submaxillary and sublingual gland diseases. These glands are subject to the
same diseases as the parotid, with slight variations. Rarely, mumps involves
the submandibular gland and not the parotid; it is more common to have
the both involved. Ranula involving the sublingual or submaxillary gland is
described on page 231.
Thyroid Syndromes
Hypothyroidism. See Chapter 5, page 97.
Hyperthyroidism. See Chapter 5, page 97.
Thyroid Goiters and Nodules
Goiter. Thyroid enlargement is caused by hyperplasia of thyroid tissue,
inltration with foreign substances (e.g., amyloid), infection, or neoplastic
growth (primary thyroid cancers, lymphoma, or metastatic disease).
often unaware of a problem, patients might complain of a neck mass or fullness. The goiter may be evident as a bilobed fullness in the neck above the
suprasternal notch moving superiorly with swallowing. Tangential light
helps visualization. Determine the size of each lobe and isthmus, its extent
within the neck or retrosternal space, consistency (smooth, a single nodule,
multinodular), xation to surrounding structures, tenderness, and the presence or absence of regional lymph node enlargement, including Delphian
nodes. Determine thyroid function as hypothyroid, euthyroid, or hyperthyroid. Clinical classication of goiters is based upon whether the goiter is focal
or diffuse, nodular or non-nodular, toxic (hyperthyroid) or nontoxic (euthyroid or hypothyroid).
Calcium phosphate stones frequently form
Though
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Diffuse nontoxic goiter. Defects in thyroid hormone synthesis limit effective
hormone production so TSH stimulation leads to diffuse thyroid enlargement. All parts of the gland are smooth, enlarged, and rm. The surface
can be slightly irregular (bosselated), but circumscribed nodules are absent.
Frequently called colloid goiter, or endemic goiter, the terms are not always
applicable, sporadic cases occurring in nongoitrous regions. The gland is
often more than twice normal size.
CLINICAL OCCURRENCE: Physiologic Euthyroid Hyperplasia: Before
menstrual periods, females from puberty to 20 years of age, pregnancy;
Hypothyroid: Iodine deciency, antithyroid drugs, thiocyanates, paraami-
nosalicylic acid, phenylbutazone, lithium, amiodarone, and rarely iodides,
inherited defects of thyroid enzymes, chronic thyroiditis.
Nontoxic multinodular goiter. The nodules are polyclonal proliferations with
less-efcient thyroid hormone production than normal thyroid tissue. This is
usually found in women >30 years of age. The gland may be small or large.
The signicant feature is two or more distinct parenchymal nodules. The nodules may vary in consistency in the same goiter. Thyroid hormone secretion
is low or normal.
Diffuse toxic goiter—Graves disease. See Chapter 5, page 98. The thyroid is
smooth, diffusely enlarged and a bruit may be heard. The ophthalmopathy occurs
independently of goiter and thyroid function.
Toxic multinodular goiter.
produces elevated hormone levels. This often arises from a long-standing
nontoxic multinodular gland. The onset is usually gradual with signs of
hyperthyroidism, e.g., atrial fibrillation, weight loss, diarrhea. The gland
is bilaterally enlarged with multiple nodules apparent by palpation or
ultrasound.
Retrosternal goiter. When a goiter’s lower border cannot be palpated in
the neck, especially when the neck is short, consider retrosternal extension.
Rarely, the goiter is entirely retrosternal, rising into the neck only with
increased intrathoracic pressure, e.g., a Valsalva. This is a plunging goiter.
Increased retromanubrial dullness is uncommon. A goiter in the superior
thoracic aperture may compress other structures, causing cough, dilated
upper thoracic veins and rarely facial edema from pressure on the internal
jugular vein (Fig. 7-74), dyspnea from airway compression during sleep,
dyspnea when the head is tilted to the side or the arms are held up beside the head, and/or hoarseness from pressure on the recurrent laryngeal
nerve. Tracheal compression is inferred by dyspnea or the Kocher sign in
which pressure on the lateral lobe produces stridor. The trachea may be
displaced laterally (Fig. 7-59).
the arms up beside the head for a few minutes. Venous suffusion, facial
cyanosis, and dyspnea imply thoracic inlet obstruction.
jugular vein is rarely compromised, so the facial cyanosis and neck edema
associated with superior vena caval obstruction are absent. For unknown
reasons, retrosternal goiter is associated with a high incidence of hyperthyroidism.
Autonomous function of one or more nodules
Pemberton Sign: Have the patient sit holding
DDX: The internal
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FIG. 7-74 Venous Engorgement: compression of the external jugular vein by a retrosternal goiter produces engorge-
ment of the superficial branches in the skin of the neck and clavicular regions.
Solitary thyroid nodule. A solitary nodule is a benign or malignant neoplasm,
cyst, or a dominant nodule in a multinodular gland. Many nodules solitary by pal-
pation are found to be part of a multinodular process by ultrasound. Fine-needle
aspiration of solitary nodules is the diagnostic procedure of choice. Thyroid irradiation in childhood increases the risk for carcinoma. Finding an isolated nodule
in an atrophic thyroid gland suggests a Plummer nodule or toxic adenoma.
Toxic adenoma. Thyroid-stimulating hormone receptors are constitutively
activated resulting in thyroid hormone overproduction. The symptoms and
signs of hyperthyroidism accompany a single nodule in an otherwise atrophic gland.
Epithelial carcinoma.
follicular, and anaplastic.
ter radiation exposure, presenting in most cases as a painless nodule. Anaplastic cancer spreads widely and rapidly, whereas papillary and follicular
cancers spread regionally before widely metastasizing.
Medullary carcinoma.
is sporadic, inherited alone, or inherited as a multiple endocrine neoplasia
(MEN) syndrome 2A or 2B. Screen all patients with a family history of MEN-
2A or MEN-2B, and those with a family history of medullary carcinoma.
Thyroiditis.
especially in women after beginning childbearing. The thyroid is damaged
by antibody- or cellular-cytotoxicity, or via induction of apoptosis. Disrupted
follicles release preformed thyroid hormones directly into the circulation resulting in clinical hyperthyroidism and suppressing TSH and iodine
uptake.
Graves disease, though not usually thought of as thyroiditis, is an immunemediated disease often leading to thyroid failure. In addition to autoimmunity, viral and bacterial infections occur.
TSH and low iodine uptake distinguish thyroiditis from Graves disease, toxic
adenomas, and toxic multinodular goiter. Thyroid hormone ingestion might
be identied by history but may be surreptitious. Graves disease produces a
diffuse, smooth goiter.
Thyroid gland inammation, usually autoimmune, is common,
Several distinct syndromes are identied by their clinical pictures.
Malignant thyroid cancers are classied as papillary,
Thyroid cancer is more common in women and af-
Neoplasia of thyroid C-cells producing calcitonin
DDX: The elevated T4 and T3, low
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Subacute thyroiditis—De Quervain thyroiditis, viral thyroiditis. Acute
painful thyroid inammation is caused by viral infection or postinfectious
inammation. Anterior neck pain is the presenting symptom, often aggra-
vated by swallowing. The pain frequently refers to the ear, so the complaint
can be earache. The gland is unusually rm and rather small, and it frequently contains one or more, often tender, nodules. The patient is euthyroid or
hyperthyroid in the acute phase.
Hashimoto thyroiditis.
functioning tissue and brosis. This is the most common cause of acquired
hypothyroidism and is more common in women, the prevalence increasing with age. The symptoms are related to hypothyroidism; neck symptoms are rare. Most patients become hypothyroid with time. The gland
is uniformly rm and nontender, may be diffusely enlarged, but is often
normal or small. A rare encephalitis, Hashimoto encephalitis, is unrelated
to thyroid function and responds to corticosteroids.
immune diseases more common in patients with Hashimoto thyroiditis
include type-1 diabetes, Addison disease, vitiligo, rheumatoid arthritis,
and systemic lupus.
Postpartum thyroiditis. Following delivery, the thyroid becomes inamed
in association with thyroperoxidase antibodies. Symptoms begin 2–6 months
postpartum. Hyperthyroidism is most common, often followed by a period
of hypothyroidism. It is more common in patients with thyroid autoimmunity before pregnancy. Self-limited, requiring only symptomatic therapy,
it frequently recurs with subsequent pregnancies.
may be present, the thyroid is nontender and may not appear a likely source
of the problems. Mild symptoms of both hyper- and hypothyroidism are
often misattributed to postpartum psychosocial stresses including inadequate
sleep, mood changes, and family stress.
Reidel thyroiditis. The thyroid gland is densely brotic with brosis extend-
ing into the surrounding tissues. It is related to other IgG-4-related brosing
conditions.
trachea, neck veins, or recurrent laryngeal nerves. Women in midlife are most
often affected. Thyroid function is usually preserved. The gland is hard and
xed.
Patients present with compressive symptoms of the esophagus,
Chronic lymphocytic inltration leads to loss of
DDX: Other auto-
DDX: Although a goiter
Acute suppurative thyroiditis. Infection of the thyroid gland by bacteria or
fungi often extends from branchial cleft remnants. There is acute pain and
fever. The gland is slightly enlarged, asymmetric, and uctuance may be
noted.
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CLINICAL VIGNETTES AND QUESTIONS
CASE 7-1
A 25-year-old woman presents with pain in her left eye associated with
decreased vision. She describes a blacked out spot in the middle of her
visual eld. These symptoms have progressed over the last 24 hours.
The eye pain worsens with eye movement. She has never had symptoms
like this previously and denies any signicant past medical history.
QUESTIONS:
1. What is the differential diagnosis for this patient’s presentation?
2. What is the most likely diagnosis?
3. What ndings might you expect on physical examination?
CASE 7-2
A 26-year-old woman presents for evaluation of headache and double
vision. She has had a sinus infection for 10 days. This morning she woke
up with a sharp headache behind the eye and double vision. Her husband noted some swelling around the right eye this morning. Her temperature is 38.7ºC.
QUESTIONS:
1. What is your differential diagnosis for this patient’s presentation?
2. What is the most likely diagnosis?
3. What cranial nerve decit would be most likely in this patient and
why?
4. What are predisposing risk factors for this condition?
A 26-year-old ethnic Lebanese man complains of painful oral ulcers. He
has had four episodes in the preceding 11 months. He has also had painful genital ulcers that have healed but left scars. When the genital ulcers
occurred he was evaluated for STDs; that evaluation was unrevealing.
QUESTIONS:
1. What is the differential diagnosis for this patient?
2. What is the most likely diagnosis?
3. What other ndings are needed to conrm this diagnosis?
4. What is pathergy?
CASE 7-3
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CASE 7-4
An 8-year-old boy is brought to the emergency department by his parents due to fever, sore throat, and difculty breathing. He seems to
be more comfortable sitting slightly forward. He has not ingested or
inhaled any foreign material. He has not received routine vaccinations
due to religious objection by his parents. On examination he is in mild
glottis appears cherry red.
QUESTIONS:
1. What is the differential diagnosis for this patient’s presentation?
2. What is the most likely diagnosis?
3. What would be the likely pathogen?
4. What are the common causes of stridor in adults?
CASE 7-5
A 15-year-old girl presents with right sided neck pain. She has been ill
for 6 days. She was diagnosed 4 days ago with strep pharyngitis and
started amoxicillin. Two days ago she started to have fevers, rigors, and
increasing right-sided neck pain. It is painful when she swallows. She
has a cough and pleuritic pain with deep breaths. She appears ill, her
temperature is 38.3ºC, and her oropharynx has mild posterior erythema
without exudates. Her neck has tender lymphadenopathy, fullness on
the right side, and pain with exion, extension, and rotation.
QUESTIONS:
1. What is your differential diagnosis?
2. What is the most likely diagnosis and why?
3. Which bacteria is likely to be isolated from this patient’s blood cultures?
A 52-year-old man presents with dizziness associated with nausea and
vomiting. Over the last 24 hours he has had a sense that the room is
spinning. He is most comfortable lying in bed looking at the ceiling
light xture. He is able to walk though it increases his sense of spinning.
His medical history is notable for hypertension and hypothyroidism. A
recent TSH was normal. He denies tinnitus or hearing loss.
QUESTIONS:
1. What information from the history helps differentiate central ver-
sus peripheral vertigo?
2. What physical examination ndings help differentiate central ver-
sus peripheral vertigo?
3. Based on the history what is the most likely diagnosis?
CASE 7-6
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CASE 7-7
A 72-year-old woman presents to the emergency room with sudden
onset of left eye pain and decreased vision. She and her husband were at
a movie. She developed the pain as the lights went down. She describes
blurred vision with halos around lights. She has pain around her eye
and a diffuse headache. She is nauseated but has not vomited. Her phys-
tion, and a ciliary ush. The pupil is not reactive and the funduscopic
examination is obscured by a cloudy cornea.
QUESTIONS:
1. What is the most likely diagnosis?
2. What precipitated this condition and why?
3. What factors predispose or cause this condition?
4. What medications can precipitate this condition?
CHAPTER 8
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The Chest: Chest Wall, Pulmonary, and
Cardiovascular Systems; The Breasts
SECTION 1
Chest Wall, Pulmonary, and
Cardiovascular Systems
MAJOR SYSTEMS AND PHYSIOLOGY
The Thoracic Wall: The skeletal and muscular shell of the thorax encloses the
heart and lungs, powers breathing, and is the mechanical platform for arm
and neck motion. It is bounded anteriorly by the sternum and ribs, laterally
and posteriorly by ribs, and supported posteriorly by the spine. The inferior
boundary is the diaphragm and rib margins. Superiorly, it is bounded by the
clavicles and soft tissues of the neck. The thoracic wall includes the bodies of
12 thoracic vertebrae, 12 pairs of ribs, and the sternum.
Bones. The thorax resembles a truncated cone, each pair of ribs having a
greater diameter than that above, making the rib cage much smaller at the
top than at the base. The ribs are separated by intercostal spaces numbered
from the rib above. The rst rib slopes slightly downward from back to front.
Each succeeding rib has a greater slope, the intercostal spaces widening from
top to bottom.
Sternum. The sternum (Fig. 8-1) consists of the manubrium, body, (gladiolus),
and xiphoid cartilage. There is a brocartilage (rarely synovial) joint between
the manubrium and body; mobility at this joint is slight. While it is cartilaginous at birth, the xiphoid begins calcifying in childhood and this continues throughout life. The xiphoid is commonly monod, lance shaped and
caudally oriented. Variations are very common and include bid and trid
divisions, xiphoidal foramina as well as ventral and dorsal projections. When
angulated forward, the xiphoid can be mistaken for an abdominal mass.
Ribs. Each rib is a attened arch. All sternal rib ends continue as costal car-
tilages. The rst to seventh ribs are usually termed true ribs or vertebrosternal
because their costal cartilages join directly to the sternum. The costal cartilage
of the rst rib connects to the manubrium at a brous joint. The other six true
ribs attach to the sternum by synovial joints. The second rib attaches to both
the manubrium and body with two synovial joints. The eighth to twelfth ribs
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FIG. 8-1 The Bony Thorax. The left clavicle is removed exposing the underlying first rib. The xiphoid and rib cartilages
are stippled. Not e the surface landmarks: the supraster nal notch, the angle of Louis, and the infrasternal notch. The two lower
rib margins form the intercostal angle.
are false ribs without anterior attachment to the sternum. The eighth, ninth,
and tenth ribs are vertebrochondral, each costal cartilage usually joining the
cartilage of the rib above. The 11th and 12th ribs are vertebral or oating ribs
without anterior attachment. Important variations include supranumerary
ribs such as the more common variation cervical rib articulated to the C7 vertebral body as well as the rare variant of lumbar ribs.
Thoracic wall muscles. The ribs are pulled together by contraction of the
internal and external intercostal muscles attaching to adjacent rib margins and
spanning the intercostal spaces. With the rst rib xed by scaleni contraction, contracting the intercostals, levatores costarum, and serratus posterior
superior rotates the ribs upward. Fixing the last rib by quadratus lumborum
contraction while contracting the subcostals and transversus thoracis rotates
the ribs downward.
The Respiratory System: The thoracic respiratory system is composed of the
trachea entering superiorly, the lungs with their branching airways, arterial,
venous and lymphatic vascular channels, and the pleura lining both the lung
(visceral pleura) and chest wall and mediastinum (parietal pleura).
Respiratory excursions of the thorax. At the end of passive expiration,
thoracic volume is at its normal minimum or functional residual capacity.
Inspiration increases thoracic dimensions anteroposteriorly, transversely,
and vertically, expanding lung volume. Volume varies as the third power of
changes in linear dimension, so relatively small changes in thoracic cavity
height, width, and depth produce large volume changes. Normal passive expi-
ration results from elastic recoil of the lungs and chest wall. Forced expiration
Major Systems and Physiology 265
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A. B.
Axis
Spine
Axis
Sternum
D.
FIG. 8-2 Models Illustrating Thoracic Respiratory Movements. A. At rest, the handle of a cylindric paint can
hangs obliquely, so its center and the side of the pail are equidistant from the central axis of the cylinder. When the handle
is raised to the horizontal, the center of the handle diverges from the side increasing the distance from the central axis. B. In
this model, two parallel rigid hoops pierce two vertical sticks. Elevation of the front stick (represent ing the sternum) increases
the distance between it and the other stick (representing the spine). The differences in the points of the arrows show this
change in the anteroposterior diameter. C. The semicircular ribs hang from the sternum and the spine, like the hoops in B
and the bucket handle in A. Elevation of the sternum and the lateral bows of the ribs during inspiration increases both the
transverse (as in A) and the anteroposterior (as in B) diameters of the thorax. D. Inspiratory volume is further augmented
by depression of the diaphragm.
occurs with contraction of abdominal and chest wall muscles resulting in
greatly accelerated airow.
Increasing the anterior–posterior diameter of the thorax. The chest is like a
cylindrical pail with its wire handle bowed in a semicircle of slightly greater
diameter than the cylinder (Fig. 8-2A). When the handle hangs obliquely, the
distance from its center to the cylindric axis is the radius of the pail. Raising
the handle toward the horizontal moves it away from the side of the pail. In
Figure 8-2B, a straight piece of wood represents the thoracic spine, a vertical
stick is the sternum at end expiration (dotted), and the dotted hoop is a pair
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