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NO LIST OF DIAGNOSIS PATHO/RISK FACTORS/ CAUSES CLINICAL PRESENTATION/ COMPLICATIONS INVESTIGATION MANAGEMENT
BREAST
1 Fibroadenoma ‐ Arises from terminal duct lobular units, Well‐circumscribed, discrete, mobile breast lump of Ultrasound ± Core biopsy Majority of cases need no Tx as they shrink and
considered aberration of normal breast rubbery consistency U/S findings: well circumscribed, round to ovoid, macro‐ disappear over time
development and involution Mildly symptomatic such as pain and tenderness lobulated mass, generally uniform hypoechogenicity Excision for patients with symptomatic fibroadenoma,
‐ Not neoplastic Usually solitary, some may be multiple Histology: prominent fibrous tissue compressing >2cm
‐ Occurs d/t hyperplasia of a single lobule May enlarged during pregnancy, involute/ calcify epithelial cells, collagen arranged in swirls, consists of If < 2cm, can be managed conservatively
‐ Risk factors; young female, hormonal during menopause stromal overgrowth Cryoablation – cryoprobe to freeze and destroy cellular
flux during pregnancy and puberty, Rapid growth in adolescence structure of fibroadenoma
obesity, OCP use Mammography (for >35 y/o); well circumscribed
PE; anywhere on breast, spherical/ovoid, usually 2‐3 discrete oval hypodense or isodense breast glandular
cm, smooth surface with well‐defined margins, firm tissue, coarse popcorn calcification
rubbery, very mobile (breast mouse)
2 Phyllodes Tumour ‐ Fibroepithelial tumor commonly affect Well circumscribed, firm, protruding masses, grey‐ Histology; large mass of connective tissue and cyst with WLE with 1 cm‐margin for malignant tumor and clear
(Cystosarcoma women 35‐55 y/o white in colour with haemorrhagic, necrotic, and “leaf‐like” lobulations. Increased stromal cellularity, margins for benign or borderline lesions
phyllodes) ‐ Predisposing factor; Li‐Fraumeni cystic within clefts lined by epithelium, stromal overgrowth with Mastectomy only for large lesions, 5‐10 cm
syndrome, trauma, pregnancy, increase Unilateral breast mass, enlarging painless mass irregular margins
oestrogen activity U/S; hypoechoic, partially circumscribed mass with
‐ Develop outside lobules and ducts into PE; unilateral, firm in consistency, size range 1‐45 cm, frequent posterior enhancement
stroma bloody discharged if infarcted, axillary Mammography; round lobulated mass, partially
lymphadenopathy circumscribed margins
MRI – evaluate for chest wall invasion in malignant
phyllodes tumour
3 Palpable breast ‐ Localised fluid‐filled cavity within breast Painless/ painful lump, often appear suddenly Breast ultrasound; Large symptomatic or complex should be aspirated with
cysts parenchyma ‐ Simple cyst (round, well‐circumscribed, anechoic fluid sent for cytology
‐ Distended and involuted lobules PE; spherical, variable size, smooth surface, may be lesion, posterior acoustic enhancement)
‐ Most common in perimenopausal fluctuant, large cysts may appear blue/ green through ‐ Complicated cyst (hypoechoic, intracystic debris, thin
women the skin, never tether of fix to skin or muscle, mobile wall, with/without posterior acoustic enhancement)
‐ Derived from terminal duct lobular unit (not as mobile as fibroadenoma) ‐ Complex cyst (heterogenous echogenicity, thick
walls, thick septum, intracystic mass, discrete solid
component attached to wall/septum
4 Breast cancer ‐ Risk factor; age, genetic, Painless hard breast lump, commonly at upper outer First undergo triple assessment for evaluation IBC ‐ Tx; Multimodal therapy – radio‐chemo‐hormonal
mammographic density, FHx, HRT, OCP, quadrant, serous or bloody nipple discharge, skin Biochemical Ix; FBC, RP, LFT, calcium panel therapy ± surgery
early menarche, late menopause, involvement as disease advance, palpable lump in Imaging; CT TAP, bone scan, MRI whole spine, CT/MRI
nulliparous, weight, alcohol axilla, metastatic symptoms brain, PET scan Local‐regional control (surgery, radiotherapy), systemic
‐ DCIS; proliferation of malignant ductal therapy (chemotherapy, hormonal, targeted therapy)
cells arising from terminal duct‐lobular PE; Skin changes (skin retraction/ dimpling, Peau Mammogram; clustered microcalcification, spiculated
unit with preservation of myoepithelial D’orange skin, ulcerated carcinoma), nipple changes mass, architectural distortion Breast surgery Mx
cell layer (retraction, discharge, redness, scaling U/S; spiculation, microlobulations, angular margin, Breast conserving surgery (wide local excision) mostly
‐ LIN; LCIS and ALH. Arises from terminal internal calcification, central vascularity, hypoechoic T1, T2 cancer
duct‐lobular unit Warning signs of nipple discharge; spontaneous nodule, posterior acoustic shadowing Mastectomy, Breast reconstruction
‐ Other; NST, Classical special type discharge, unilateral, progressive, uniductal, bloody Axial Mx; Sentinel lymph node biopsy (SLNB), axillary
discharged, lump present, age > 40 y/o Staging; AJCC 8th edition (TNM), biomarkers as well as clearance
histological grade play role Hormonal therapy
DCIS – 80% asymptomatic, present as mammographic Selective estrogen receptor modulators (SERMs);
abnormalities on screening. Of these 70% got Tamoxifen (20mg daily)
microcalcification with no palpable breast lesion. Can Aromatase inhibitors; anastrozole, letrozole,
also as present mass, Paget’s disease of nipple or exemestane
nipple discharge Targeted therapy; Herceptin
LIN – often incidental finding (Read Mx by Tumour stage in Teddy)

Inflammatory breast carcinoma (IBC) – rapid sweeling

± skin changes (Peau d’orange lymphoedema, nipple
depression (retraction), erythematous swollen breast
w/o palpable mass.
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5 Paget’s disease ‐ Pathological hallmark; malignant, intra‐
epithelial adenocarcinoma cells (Paget
cells) occurring singly or in small groups
within epidermis of nipple
6 Gynaecomastia ‐ Benign enlargement of male breast
tissue commonly in adolescent and
older age groups
‐ Groups of causes; Drugs, Organ failure,
Physiological, Idiopathic, Nutrition,
hypogonadism, neoplasm, other
7 Breast abscess ‐ Risk factors; lactational women,
untreated mastitis, obesity, smoking,
DM, immunosuppressed, Hx of breast
abscess
‐ Lactational breast abscess; lactose‐rich
milk provides ideal growth environment
for infection. Staph aureus, Strep
species. Cracks in nipple allow bacterial
entry
‐ Non‐lactational breast abscess
8 Ductal ectasia/ ‐ Dilatation and shortening of breast duct
periductal mastitis a/w periductal inflammation
‐ 35‐55 y/o female
‐ Risk factor; smoking
9 Intraductal ‐ Benign intraductal papillary growth
papilloma within a dilated duct
10 Chronic ‐ Rare chronic inflammatory breast
granulomatous condition
mastitis ‐ Granulomatous changes occur around
lobules and ducts of the breast in the
absence of specific infection, trauma, or
evidence of sarcoidosis
Erythema and eczematous change of nipple with
crusting exudates, may develop into erosions and
ulcerations, clinically resembles eczema
Unilateral, destroys the nipple
Sx related to breast inflammation; warmth, pain,
swelling, firmness, erythema, tender lump
Systemic infection; fever, malaise, myalgia
PE; signs of breast inflammation, tender breast mass,
fluctuant mass, tender axillary LN in ipsilateral, breast
infection
Acute Cx; cessation of breastfeeding, bacteraemia,
sepsis
Chronic Cx; scarring, breast deformity, mastectomy,
mammary fistula
Cheesy nipple discharge, may be a/w lump
representing a dilated duct, slit nipple retraction,
painful mass or periareolar abscess, family history
PE; nipple discharge (cheesy), inflamed tissue, slit like
nipple retraction, eczematous skin, subareolar mass
upon palpation
Gross; intraductal polypoidal mass
Bloody nipple discharge
Pressure over duct at areolar margin produces
copious discharge. Palpable underlying mass
Most common clinical presentation is a firm,
unilateral, and discrete breast mass that is often
associated with an abscess or inflammation of the
overlying skin and fistulae
Mammography
Breast MRI. If +ve, require confirmatory biopsy
Punch biopsy or full‐thickness wedge biopsy of nipple
Microscopically – ductal epithelial hyperplasia, ductal
elongation and branching, proliferation of peri‐ductal
fibroblasts and increase in vascularity in involved tissue
Biochem; RP, LFT, TFT, testosterone, LH/FSH, prolactin,
etc
Imaging; mammography, U/S breast, testicular U/S
U/S; hypoechoic collection, no vascularity within
collection, acoustic enhancement d/t fluid content
Mammography – too painful on breast with abscess,
done after resolve, to exclude possibility of malignancy
Needle aspiration
Mammographic features may include
microcalcifications, lobulated, partially smooth masses,
nipple retraction, retro‐areolar duct dilatation, and
rarely speculated looking mass
US can show mammary duct dilatation, mixed solid and
cystic mass close to the areola, solid mass, and abscess
collection
Mammographically, it may present as a round or oval
mass with a well‐circumscribed or indistinct margin. It
may be associated with microcalcifications.
Under ultrasound, the mass is commonly found near the
nipple.
The tumor will be in a dilated duct and will often show
flow on color or power Doppler
Microscopically, all the patients showed noncaseating
granuloma formation with variable numbers of
Langhans‐type multinucleated giant cells, neutrophil
polymorphs, and lymphocytes around the breast
lobules
Fat necrosis and microabscess formation were also
observed
USG shows that the abscesses communicate through
tiny channels (arrow), and hyperechoic small particles
that flow through these channels
MOZZAR
Tx according to underlying cancer
Simple mastectomy & SLNB
Breast conserving therapy & SLNB & RT (complete
resection of nipple‐areola complex followed by whole
breast RT)
Conservative Mx  Tamoxifen
Surgical excision
Needle aspiration (US guided) + Antibiotic (flucloxacillin
or doxycycline for 7‐10 days)
Continue feeding from affected side
Local cold and analgesia for pain relieve
Surgical incision and drainage
Patients with discharge and discomfort are advised to
treat symptomatically via applying warm compresses
over the central part of the breast, wearing a supportive
bra with breast pads to absorb any nipple discharge, and
maintaining nipple and areola hygiene. These measures
both ameliorate symptoms, as well as reduce the risk of
infection
More aggressive procedures and major mammary duct
excision may be required for smokers or those patients
with recurrent periductal mastitis associated with duct
ectasia and duct fistulation
Treatment of intraductal papilloma involves surgical
excision and complete removal of the tumor. This is due
to the possibility of upgrading to atypical ductal
hyperplasia or DCIS upon excision
Surgical excision, in the form of lumpectomy with
complete removal of the papilloma, is recommended
Treatment choices for GM include corticosteroids,
antibiotics, abscess drainage, wide surgical resection,
and even mastectomy
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ENDOCRINE, HEAD, NECK
11 Thyroglossal cyst ‐ Congenital cyst of epithelial remnants of Smooth, rounded, cystic lump. 75% in midline, 25% Histology: cyst lined by pseudostratified ciliated In infected; directed antibiotics coverage, avoid incision
(midline mass) thyroglossal tract slightly to left or right columnar epithelium and squamous epithelium, with and drainage, wait for 3 months for inflammation to
‐ Cystic expansion of remnant Moves with swallowing and tongue protrusion heterotopic thyroid tissue resolve prior to definitive operation
thyroglossal tract – failure of Usually asymptomatic but may be infected Pre‐op TFT Sistrunk operation – en bloc cystectomy
thyroglossal duct to obliterate after Located anywhere from base of tongue to behind CT neck with contrast: well circumscribed lesion with
embryologic descent of thyroid sternum homogenous fluid attenuation surrounded by thin
enhancing rim
U/S thyroid and thyroglossal cyst: well‐defined, thin‐
walled, hypoechoic mass with posterior acoustic
enhancement in midline
12 Dermoid cyst ‐ Congenital; developmental inclusion of Small, non‐tender, mobile, subcutaneous lump Histology; cyst lined by epidermis with evidence of Complete surgical excision of the cyst, preferably in one
(midline mass) epidermis along lines of fusion of skin May be fluctuant, skin‐coloured, or bluish adnexal structures (eg hair follicles, sebaceous glands piece w/o spillage of cyst contents
dermatomes and sweat glands) – cyst teratoma
‐ Acquired; d/t forced inclusion of skin Imaging Ix eg X‐ray, U/S, CT
into subcutaneous tissue following an
injury, usually on fingers
13 Plunging ranula ‐ Pseudocyst a/w sublingual glands and Simple ranula; confined to floor of the mouth Complete resection if possible
(midline mass) submandibular ducts Large ranula can present as a neck mass If not, marsupialisation and suturing of pseudocyst wall
‐ Congenital; secondary to an to the oral mucosa
imperforate salivary duct or ostial
adhesions
‐ Acquired; trauma to sublingual gland
leading to mucus extravasation and
formation of pseudocyst
14 Brachial ‐ Second brachial cleft anomalies Located close to parotid gland, sinus persist as FNAC of cyst yield opalescent fluid with cholesterol Surgical excision of cyst where possible
(pharyngeal) cyst ‐ Affect both sexes equally, usually young external auditory canal (1st brachial cleft anomaly) crystals under microscopy Treatment of infection with antibiotics
and/or fistula adults Anterior to upper/middle third of SCM muscle (2nd Fistulogram if fistula present to delineate course
(anterior triangle ‐ Failure of obliteration of 2nd brachial brachial cleft anomaly)
mass) cleft Smooth, firm swelling, ovoid in shape, its long axis
runs downwards and forwards
May be fluctuant, usually not transiluminable
On left side of neck, may present as suppurative
thyroiditis (3rd/4th brachial cleft anomaly)
15 Chemodectoma ‐ Tumour of paraganglion cells of carotid Solid, non‐painful mass at level of hyoid bone DO NOT PERFORM FNAC Surgical excision with pre‐operative embolization
(Carotid body body, at bifurcation of common carotid Mass is pulsatile but no expansile CT and/or MRI to delineate tumour anatomy Any enlarged ipsilateral lymph nodes are also removed
tumour) (anterior artery Can be moved side to side but not up and down CT; homogenous mass with intense enhancement Radiotherapy for pt unfit for surgery or tumour too large
triangle mass) May be bilateral following IV contrast administration
Angiograph – GOLD STANDARD Ix; hypervascular mass
displacing the bifurcation
16 Pharyngeal pouch/ ‐ False diverticulum develops in elderly, Cystic swelling, low down in anterior triangle, usually Barium swallow, Oesophageal manometry Leave alone if small and asymptomatic
Zenker’s males>females of left Minimally invasive Tx; endoscopic cricothyroid
diverticulum ‐ Herniation of pharyngeal mucosa Halitosis (bad smelling breath), regurgitation of myotomy
(anterior triangle between 2 parts of inferior pharyngeal undigested food with coughing, upper oesophageal Surgical; cricopharyngeal myotomy + diverticulectomy
mass) constrictor dysphagia, hoarseness, weight loss, squelching sound or diverticulopexy
‐ Caused by failure of cricopharyngeus to on deep palpation
relax
Cx; chest infection (d/t chronic aspiration),
diverticular neoplasm, squamous cell carcinoma
17 Cystic hygroma ‐ Congenital cystic lymphatic 50‐65% present at birth, may present later Radiological Ix; CXR, CT to delineate extent of cyst Non‐surgical Tx; aspiration and injection of sclerosant
(posterior triangle malformation Lobulated swelling, soft, fluctuant, compressible Partial/ complete surgical excision
mass) Transiluminable
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18 Cervical rib ‐ Causes thoracic outlet syndrome Hard mass in posterior triangle at root of neck Dx by chest X‐rays
(posterior triangle Arterial; pallor, gangrene or necrosis of tips of fingers
mass) Venous; oedema, cyanosis
Neurological; radicular Sx (pain, paraesthesia),
wasting of small muscles of hand
19 Neuroma/ ‐ Slow growing tumour arising from Fusiform, mobile in plane perpendicular to axis of
Schwannoma peripheral neural structures of the neck nerve
(posterior triangle May be Tinnel’s positive (tap on mass for any
mass) paraesthesia occurring in distribution of nerve)
20 Sialolithiasis ‐ Stones of salivary gland that may be Complete obstruction; acute pain, gland swelling, at Non‐contrast CT scan General measure; hydration, soft diet, good oral
impacted within gland or duct meal times, rapid onset withing minutes of starting to Plain X‐rays – pick up radio‐opaque stones hygiene, massage of gland, application of moist hot
‐ 80% submandibular, 10% parotid, 7% eat, resolves about an hour after meal Sialogram – rarely done towel, analgesia, antibiotics
sublingual Partial obstruction; occasional symptomatic episodes Surgical removal. If cannot, partial gland resection
interspersed by asymptomatic periods of days to Other; lithotripsy, wire basket removal, sialoendoscopy
weeks, chronically enlarged mass in submandibular
region
Some may be palpable along duct or at duct opening

Cx; sialadenitis, abscess formation

21 Pleomorphic ‐ Benign tumour, 85% occur in parotid Slow growing, painless swelling occurring in lower Histology; very heterogenous, has epithelial cells Surgical excision
adenoma gland pole of parotid surrounded by loose stroma with islands of Blair incision
Irregular and lobulated surface, texture of cartilage chondromyxoid and interspersed island of Parotid; superficial parotidectomy. If deep/ large, total
Does not invade or metastasise myoepithelial cells. Tumour appears to be parotidectomy with preservation of facial nerve
encapsulated, multiple sites of capsular penetration Submandibular; total gland excision together with
adjacent connective tissue, sparing lingual and
Dx by clinical, FNAC ± MRI hypoglossal nerves
22 Warthin’s tumour ‐ 2nd most common tumour in salivary Slowly enlarging, soft to firm cystic fluctuant swelling Histology; benign neoplasm, cystic spaces lined by two‐ Can be left alone if only Warthin’s tumour cells since no
gland in parotid tail tiered epithelium, surrounded by dense lymphoid malignant potential
‐ Only in parotid gland Invariably benign with no risk of malignant change stroma with germinal centres Superficial parotidectomy if causing trouble to patient
Dx by clinical, FNAC ± MRI
23 Thyroid cancers ‐ Classified into follicular cell derived FNAC Anaplastic thyroid cancer – palliative therapy, external
(PTC, FC, HCC, AC) and non‐follicular cell TFT, tumour markers, U/S thyroid/neck, non‐contrast CT beam radiotherapy, tracheostomy
derived (MTC, TL) neck Lymphoma – chemoradiotherapy
Medullary thyroid cancer – surgical resection
24 Thyroiditis Chronic lymphocytic thyroiditis/ Asymptomatic, ~20% hypothyroidism, ~5% Histology; lymphocytic infiltration, follicular destruction Levothyroxine
Hashimoto’s disease thyrotoxicosis of gland If enlarging/ compressive Sx/ suspected malignancy 
‐ Most common cause of hypothyroidism Biochemical; high TSH, low T4, high TPO antibody total thyroidectomy
‐ Autoimmune PE‐ firm, irregular non‐tender goitre, painless
Subacute lymphocytic thyroiditis (silent Triphasic course of self‐limiting thyrotoxicosis (2‐4m), Biochemical; high TPO antibody, high anti‐Tg antibody, Sx alleviation by beta‐blocker therapy
or post‐partum) hypothyroidism (~6m) before returning to euthyroid ESR normal If hypothyroid  levothyroxine
‐ If post‐partum, development of thyroid state
dysfunction within 12 months after PE – goitre, painless
pregnancy in a previously euthyroid
female
Subacute granulomatous thyroiditis (de Painful thyroid gland Biochemical; high ESR, normal WBC, evolving TFT, Sx alleviation; NSAIDs for pain, beta‐blockers for
Quervain’s) URTI preceding, low grade fever, pain worse with normal anti‐TPO antibodies thyrotoxicosis, levothyroxine during hypothyroidism
‐ Most common cause of painful thyroid swallowing, turning of head, radiate to lower jaw, ear,
occiput
Triphasic course – thyrotoxicosis (4‐6w),
hypothyroidism (6m), euthyroid
Acute suppurative thyroiditis Acute neck swelling, pain, high fever Biochemical; high ESR, high WBC, normal TFT Tx of infection; broad‐spectrum Abx then culture‐
‐ Bacterial infection PE – neck swelling, airway distress, compressive Radiological; CT neck directed x 14 days
abscess
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Source control; surgical incision (unstable),
percutaneous drainage (stable), partial/ total
thyroidectomy (failure of Tx)
Invasive fibrous thyroiditis (Reidel’s) Compressive sx, neck pain, association with systemic Biochemical; hypothyroidism If have compressive sx – surgery for debulking
‐ Idiopathic disorder fibrosis Radiological; U/S neck – diffuse hypoechoic, hypo‐ Medical Tx with steroids, if refractory, trail of tamoxifen
‐ Progressive fibrosis and inflammation of PE – hard fixed mass, with extension to adjacent vascular appearance of extensive fibrosis + carotid or mycophenolate mofetil + prednisolone
thyroid gland and adjacent cervical structures, can cause dyspnoea, hoarseness, artery encasement
structures dysphagia, restricted neck movements
Drug‐induced thyroiditis Amiodarone type 1 – thioamides + potassium
‐ Aetiology; amiodarone, lithium, IFN‐ perchlorate
alpha, IL‐2 Amiodarone type 2 – steroids
25 Thyroid storm ‐ Risk factor; thyroid surgery, radioiodine, Severe tachycardia, fever, confusion, vomiting, Acute Mx
withdrawal of drugs, acute illness ie mania, coma IV fluids + cooling measure + electrolyte replacement +
DKA, untreated & undertreated PE – goitre, ophthalmopathy, lid lag, hand tremor, nutritional support + glucose
hyperthyroidism warm moist skin Beta blocker to control Sx – propranolol
Thioamide – PTU
Lugol’s solution to block release of thyroid hormone
IV hydrocortisone to reduce T4‐T3 conversion
Definitive Tx – radioiodine therapy or surgery
26 Primary hyperPTH ‐ Elevated or inappropriately normal PTH Classic pentad of symptoms; Kidney stones, Painful Biochemical; high total serum Ca, high PTH, low Surgery indication; symptomatic, asymptomatic with
in presence of hypercalcemia bones, Abdominal groans (PUD, acute pancreatitis, phosphate, high ALP, 24 hour urinary calcium and serum Ca >1.0 mg/dL
‐ Risk factors; females, older age, cholelithiasis, constipation), Psychic moans creatinine, mild hyperchloremic metabolic acidosis
exposure to low‐dose therapeutic (depression, cognitive dysfunction, psychosis), Localization study; sestamibi0technetium 99m scan Single adenoma – focused parathyroidectomy with
radiation, familial predisposition Fatigue overtones+muscle weakness with single photon emission CT (SPECT) + ultrasound intraoperative PTH monitoring
‐ Aetiology; parathyroid adenoma, 4‐ neck Multiple adenoma – surgical resection (bilateral neck
gland hyperplasia, multiple adenomas, Other; bone mineral density test, ECG exploration)
parathyroid cancer Parathyroid hyperplasia – total parathyroidectomy and
auto‐transplantation
PTH cancer – en‐bloc excision +/‐ lymph nodes
27 Familial ‐ Common cause of PTH‐dependent Lifelong hypercalcemia High Ca, normal PTH, low 24hr urine Ca, low urine Ca:Cr No Tx needed as pt mostly asymptomatic
hypocalciuric hyperCa clearance ratio
hyperCa ‐ Autosomal dominant condition
28 Parathyroid cancer ‐ Palpable neck mass, dysphagia, choking, hoarseness Serum Ca >3 mmol/L En =‐bloc excision +/‐ lymph nodes
or vocal cord paralysis, dyspnoea, severe bone loss, High PTH (5x normal), high ALP
pathological fractures
29 Secondary ‐ D/t physiological/ appropriate secrete Asymmetrical enlargement and nodular hyperplasia Blood tests; ALP, Ca panel, PTH, TFT, PO4, Vit D Low‐phosphate diet
hyperPTH of PTH by normal PTH gland of PTH gland +/‐ Imaging; ultrasound thyroid Surgical indication; bone pain, calciphylaxis, fracture,
pruritus
Total parathyroidectomy with autotransplantation or
subtotal parathyroidectomy
30 Tertiary hyperPTH ‐ Long‐term secondary hyperPTH where Surgical indication; symptomatic (bone pain, fractures,
parathyroid gland develops etc), calciphylaxis
autonomous hypersecretion Subtotal or total parathyroidectomy with
‐ Aetiology; chronic renal failure, autotransplantation and upper thymectomy
hyperPTH in pt who had renal transplant
31 Adrenal ‐ Asymptomatic adrenal mass ≥ 1cm Evaluate functional status; plasma renin activity, plasma Surgical resection
incidentaloma detected on imaging aldosterone concentration, aldosterone/renin ratio, Conservative Mx if <4cm
serum ACTH, 24hr urine cortisol, LDDST, 24 hr urine
catecholamine
32 Hyperaldosteronism ‐ Primary – adrenal hyperplasia, Hypertension Screening; plasma renin activity (PRA), plasma Unilateral – adrenalectomy
adenoma (Conn’s syndrome), Hypokalaemia aldosterone concentration Bilateral hyperplasia – MRA eg spironolactone
carcinoma Severe muscle weakness, paralysis, paraesthesia, Confirmatory test; salt suppression test, imaging (CT
‐ Secondary – extra‐renal disorders, polyuria, polydipsia, metabolic alkalosis, mild adrenal)
cirrhosis, nephrotic syndrome hyperNa
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33 Hypercortisolism – ‐ Aetiology; iatrogenic, Cushing’s disease, Non‐specific; glucose intolerance, DM, HTN, obesity,
Cushing syndrome adrenal tumour, ectopic ACTH oligomenorrhoea, osteoporosis
More specific; central obesity, extremity wasting,
dorsocervical fat pads, rounded facies
Most specific; spontaneous bruising, proximal
myopathy, wide striae, hypokalaemia
Others; depression, insomnia, psychosis, impaired
cognition, facial plethora, acne, hirsutism,
hyperpigmentation, fungal skin infection,
nephrolithiasis, polyuria
34 Pheochromocytoma ‐ Catecholamine‐secreting tumour arises 5Ps; pressure (HTN), palpitation (tachycardia,
from chromaffin cells (adrenal medulla) tremor), pain (headache, chest pain), perspiration,
and/or sympathetic ganglia pallor
Screening tests; 24hr urinary free cortisol, LDDST, late
night (11pm) salivary cortisol
Localization test; serum basal ACTH level
Diagnostic tests; 24 hr urinary fractionated
metanephrines and catecholamines & vanillylmandelic
acid (VMA), plasma free metanephrines, plasma free
catecholamines
Localization test; CT/ MRI adrenal or MIBG scintigraphy
or PET
MOZZAR
Cushing disease – trans‐sphenoidal resection of ACTH
producing pituitary tumour
Ectopic ACTH – resection of primary lesion
Ketoconazole as medical Mx of Cushing syndrome
Primary adrenal hyperplasia – bilateral adrenalectomy
Cortisol secreting adrenocortical tumour – unilateral
adrenalectomy
Alpha blockade (phenoxybenzamine)
Beta blocker after complete alpha‐adrenergic blockade,
1 week prior to surgery
Ca channel blockers
IV hydration
Adrenalectomy