A breast cyst is a fluid-filled sac within the breast. They are often described as round or oval lumps with distinct edges. In texture, a breast cyst usually feels like a soft grape or a water-filled balloon, but can also feel firm.

Breast cysts can be painful and may be worrisome but are generally benign. They are most common in pre-menopausal women in their 30s or 40s. They usually disappear after menopause, but may persist or reappear when using hormone therapy. They are also common in adolescents. Breast cysts can be part of fibrocystic disease. The pain and swelling is usually worse in the second half of the menstrual cycle or during pregnancy.

The halo sign, described as a complete or partial radiolucent ring surrounding the periphery of a breast mass, has long been considered a mammographic sign indicating a benign process. The phenomenon is most frequently seen with cysts and fibroadenomas.

Intraductal papilloma is the most common cause of blood-stained nipple discharge in young females.

An intraductal papilloma is a benign breast condition that develops in one or more of the milk ducts in the
breast. It is usually close to the nipple, but can
sometimes be found elsewhere in the breast. It most commonly occurs in women between ages 35–55 and generally does not increase the risk of developing breast cancer. There are no known risk factors for intraductal papilloma.

Signs and symptoms include:
1. Small lump or a discharge of
clear or blood-stained fluid from the nipple
2. Discomfort or pain around the area (usually not painful)

Diagnosis can be made by:
1. Breast examination
2. Mammogram
3. Ultrasound scan
4. Core biopsy
5. Fine needle aspiration

Women under the age of 40 are more likely to have an
ultrasound scan than a mammogram. The breast tissue in such patients can be dense which can
make the X-ray image in a mammogram less clear.
However, some women under 40 may still have
a mammogram.

Intraductal papillomas are often removed using
surgery. The surgical options include:
1. Excision biopsy
2. Vacuum assisted excision biopsy

If nipple discharge continues, then further surgical options are explored:
1. Microdochectomy (removal of the affected duct or ducts)
2. Total duct excision (removal of all the major ducts)

A thyroglossal duct cyst (TGDC) is the most common mass found in the midline of the neck. The mass is usually located at or below the level of the hyoid bone, although a TGDC can be located anywhere from the foramen cecum to the level of the thyroid gland.
Most patients with a TGDC present with asymptomatic masses in the midline of the neck.
Recurrent inflammation associated with infection of a TGDC is not uncommon. When an infection is present, the cyst often enlarges and an abscess may form. Spontaneous rupture with secondary sinus tract formation can also occur.

The surgical treatment of choice for thyroglossal cysts is the Sistrunk operation, in which an en block resection of the sinus tract and above (including the midportion of the hyoid bone) is performed. Recurrence is approximately 3-5% and is increased by incomplete excision and a history of recurrent infections.

Answer: Fibroadenoma

A fibroadenoma is a painless, unilateral, benign (non-cancerous) breast tumour that is a solid, not fluid-filled, lump. It occurs most commonly in women between the age of 14 to 35 years but can be found at any age. Fibroadenomas shrink after menopause, and therefore, are less common in post-menopausal women. Fibroadenomas are often referred to as a breast mouse due to their high mobility. Fibroadenomas are a marble-like mass comprising both epithelial and stromal tissues located under the skin of the breast. These firm, rubbery masses with regular borders are often variable in size.

Fibroadenoma tends to occur in early age. It is most commonly found in adolescents and less commonly found in postmenopausal women. The incidence of fibroadenoma decreases with increasing age and generally found before 30 years of age in females in the general population. It is estimated that 10% of the world’s female population suffers from fibroadenoma once in a lifetime.

Tetany: A condition that is due usually to low blood calcium (hypocalcaemia) and is characterized by spasms of the hands and feet, cramps, spasm of the voice box (larynx), and overactive neurological reflexes. Tetany is generally considered to result from very low calcium levels in the blood. However, tetany can also result from reduction in the ionized fraction of plasma calcium without marked hypocalcaemia, as is the case in severe alkalosis (when the blood is highly alkaline).

Hypocalcaemic tetany (HT) is the consequence of severely lowered calcium levels (<2.0 mmol/l), usually in patients with chronic hypocalcaemia. The causal disease for hypocalcaemic tetany is frequently a lack of parathyroid hormone (PTH), (e. g. as a complication of thyroid surgery) or, rarely, resistance to PTH. HT due to severe and painful clinical symptoms requires rapid i. v. calcium replacement by central venous catheter on an intensive care unit.

Indications for a simple mastectomy with a concomitant axillary procedure, which may be either a sentinel node biopsy or an axillary clearance, are as follows:

– Locally advanced breast cancer
– Multifocal breast cancer
– Large tumour relative to the size of the breast, excision of which may compromise final cosmesis
– Extensive ductal carcinoma in situ (DCIS)

Multifocality and multicentricity (MFMC) are frequently used descriptors to assess the extent of disease in patients presenting breast cancer. The presence of two or more foci of cancer within the same breast quadrant is defined as multifocal, while the presence of two or more foci of cancer in different quadrants of the same breast is defined as multicentric. A simple mastectomy involves removing the breast along with an ellipse of skin that encompasses the nipple-areola complex. Unlike a radical mastectomy, it does not involve removal of the underlying muscles and uninvolved lymph nodes.

Patient unsuitability for breast-conserving approaches as a result of contraindications for radiation therapy – Such contraindications include a previous history of chest wall irradiation, either after previous breast-conserving therapy or in mantle field radiation therapy for lymphoma; severe skin disorders, such as scleroderma and psoriasis; and severe pulmonary dysfunction

Patient preference for mastectomy – A patient who is a suitable candidate for breast conservation may opt for a mastectomy instead.

A cholesteatoma consists of squamous epithelium that is trapped within the skull base and that can erode and destroy important structures within the temporal bone. They often become infected and can result in chronically draining ears. Treatment almost always consists of surgical removal. The majority (98%) of people with cholesteatoma have ear discharge or conductive hearing loss or both in the affected ear.

Other more common conditions (e.g. otitis externa) may also present with these symptoms, but cholesteatoma is much more serious and should not be overlooked. If a patient presents to a doctor with ear discharge and hearing loss, the doctor should consider cholesteatoma until the disease is definitely excluded.

Other less common symptoms (all less than 15%) of cholesteatoma may include pain, balance disruption, tinnitus, earache, headaches and bleeding from the ear. There can also be facial nerve weakness. Balance symptoms in the presence of a cholesteatoma raise the possibility that the cholesteatoma is eroding the balance organs in the inner ear.

Follicular thyroid cancer accounts for 15% of thyroid cancer and occurs more commonly in women over 50 years of age. Thyroglobulin (Tg) can be used as a tumour marker for well-differentiated follicular thyroid cancer. Follicular cells are the thyroid cells responsible for the production and secretion of thyroid hormones.

It is impossible to distinguish between follicular adenoma and carcinoma on cytological grounds. If fine needle aspiration cytology (FNAC) suggests follicular neoplasm, thyroid lobectomy should be performed to establish the histopathological diagnosis. Features for the diagnosis of follicular carcinoma are capsular invasion and vascular invasion by tumour cells. Capsular invasion should be carefully evaluated and discriminated from the capsular rupture due to FNA penetration resulting in WHAFFT (worrisome histologic alterations following FNA of thyroid).

– Follicular carcinoma tends to metastasize to lung and bone via the bloodstream.
– Papillary thyroid carcinoma commonly metastasizes to cervical lymph nodes.
– HMGA2 has been proposed as a marker to identify malignant tumours.

The preauricular sinus is a benign congenital malformation of the preauricular soft tissues. Mostly it is noted during routine ear, nose and throat examination, though can present as an infected and discharging sinus. Preauricular sinus is more often unilateral, only occasionally are bilateral forms inherited. The right side is more often involved and females more than males. Most sinuses are clinically silent, eventual, however not rare, appearance of symptoms is related to an infectious process. Erythema, swelling, pain and discharge are familiar signs and symptoms of infection. The most common pathogens causing infection are Staphylococcal species and, less frequently Proteus, Streptococcus and Peptococcus species.

Courses of treatment typically include the following:
– Draining the pus occasionally as it can build up a strong odour
– Antibiotics when infection occurs.
– Surgical excision is indicated with recurrent fistula infections, preferably after significant healing of the infection.
In case of a persistent infection, infection drainage is performed during the excision operation. The operation is generally performed by an appropriately trained specialist surgeon e.g. a otolaryngologist or a specialist General Surgeon.
The fistula can be excised as a cosmetic operation even though no infection appeared. The procedure is considered an elective operation in the absence of any associated complications.

Axillary dissection is a surgical procedure that incises the axilla to identify, examine, or remove lymph nodes. Axillary dissection has been the standard technique used in the staging and treatment of the axilla in breast cancer.
Axillary dissection should be reserved for patients with proven axillary disease preoperatively or with a positive sentinel node biopsy.

Axillary dissection is only therapeutic in patients who are node positive.

Wide local excision (Lumpectomy) is defined as complete surgical resection of a primary tumour with a goal of achieving widely negative margins (ideally a 1-cm margin around the lesion). It is applicable in most patients with stage I and stage II invasive carcinomas. This patient has a tumour size of 2cm which is small hence wide local excision should be done.

Acute otitis media (AOM) is a painful type of ear infection. It occurs when the area behind the eardrum, the middle ear, becomes inflamed and infected.

The following behaviours in children often mean they have AOM:
– fits of fussiness and intense crying (in infants)
– clutching the ear while wincing in pain (in toddlers)
– complaining about a pain in the ear (in older children).

Perforation of the tympanic membrane is not unusual as the process advances, most frequently in posterior or inferior quadrants. Before or instead of a single perforation, an opaque serum like exudate is sometimes seen oozing through the entire tympanic membrane.

With perforation and in the absence of a coexistent viral infection, the patient generally experiences rapid relief of pain and fever. The discharge initially is purulent, though it may be thin and watery or bloody; pulsation of the otorrhea is common. Otorrhea from acute perforation normally lasts 1-2 days before spontaneous healing occurs. Otorrhea may persist if the perforation is accompanied by mucosal swelling or polypoid changes, which can act as a ball valve.

Due to this patient having a relapse after using carbimazole following orbital radiotherapy for severe proptosis., total thyroidectomy is the treatment of choice.
Thyroidectomy is the definitive surgical management for Graves thyrotoxicosis and usually requires a short course of pre-treatment with thionamides or inorganic iodine to achieve euthyroid state; this reduces operative complications and thyroid vascularity. Although subtotal thyroidectomy was once practiced, most surgeons now recommend complete thyroidectomy to minimize chances of relapse.

Radioactive iodine (I-131) is widely used to treat the thyrotoxicosis of Graves’ disease, but, despite its demonstrable efficacy and safety, there have long been concerns about its possible adverse effect on thyroid eye disease. A study showed that after radioiodine treatment 15% of patients developed new or worsened ophthalmopathy, whereas this occurred in only 3% of patients treated with methimazole and in none treated with radioiodine plus prednisone. In the radioiodine group 24% of those with pre-existing ophthalmopathy suffered an exacerbation, whereas only 8% of patients without eye disease at baseline developed it.

A fibroadenoma is a painless, unilateral, benign (non-cancerous) breast tumour that is a solid, not fluid-filled, lump. It occurs most commonly in women between the age of 14 to 35 years but can be found at any age. Fibroadenomas shrink after menopause, and therefore, are less common in post-menopausal women. Fibroadenomas are often referred to as a breast mouse due to their high mobility. Fibroadenomas are a marble-like mass comprising both epithelial and stromal tissues located under the skin of the breast. These firm, rubbery masses with regular borders are often variable in size.

Duct ectasia, also known as mammary duct ectasia, is a benign (non-cancerous) breast condition that occurs when a milk duct in the breast widens and its walls thicken. This can cause the duct to become blocked and lead to fluid build-up. It’s more common in women who are getting close to menopause. But it can happen after menopause, too.

Fat necrosis is a benign condition and does not increase the risk of developing breast cancer. It can occur anywhere in the breast and can affect women of any age. Men can also get fat necrosis, but this is very rare.

Breast cysts are a benign condition. They’re one of the most common causes of a breast lump, and can develop in either one or both breasts. It’s thought they develop naturally as the breast changes with age due to normal changes in hormone levels. It’s common to have more than one cyst. Breast cysts can feel soft or hard and can be any size, ranging from a few millimetres to several centimetres. They’re usually oval or round in shape and can develop quickly.

Atypical hyperplasia is a precancerous condition that affects cells in the breast. Atypical hyperplasia describes an accumulation of abnormal cells in the breast.

Duct ectasia is the cause of nipple discharge, with different percentages recorded in different articles (>10%, >30% and >50%). Duct ectasia differs from cystic disease since it is an inflammatory process, usually affecting the ducts below the nipple. It develops gradually, either through the ductal system or the breast lobes. The acute inflammation may be caused by epithelial rupture and diffusion of the contents into the fibrous duct-wall and the underlying structures. These contents consist of neutral fat and lipid crystals that are typical of duct ectasia. The chronic granulation-type reaction may develop foreign body-like giant cells and a multiform inflammatory cell population. Since the whole process in duct ectasia is long in duration, plasma cells are sometimes dominant in the inflammatory infiltrations. Other findings in duct ectasia include the following:
-Serous or green-white nipple discharge in 20% of cases;
-Nipple inversion that leads to fibrosis and development of ring or tubular calcification (this finding is typical in the mammogram and especially when the disease is in its advanced stages);
-Apocrine metaplasia with or without epithelial hyperplasia. The epithelial layer consists of widened atrophic cells.
The condition may be managed symptomatically and/or with antibiotics, but in persistent or recurrent cases it is managed with surgical excision of the ducts below the nipple. A focused excision is preferred to a complete subareolar excision since the later technique is associated with higher rates of seroma formation, nipple numbness and nipple inversion. The Hadfield’s procedure (major duct excision) is an option.

A breast abscess is a localised collection of pus in the breast tissue. It is usually caused by a bacterial infection. Breast infections, including mastitis and breast abscesses, are most often seen in women aged 15 to 45 years. Mastitis can occur as a result of breastfeeding and if left untreated it can progress to an abscess. The bacteria most commonly associated with this is staphylococcus aureus.

Answer: Acute Epstein Barr virus infection

The Epstein–Barr virus is one of eight known human herpesvirus types in the herpes family, and is one of the most common viruses in humans. Infection with Epstein-Barr virus (EBV) is common and usually occurs in childhood or early adulthood.
EBV is the cause of infectious mononucleosis, an illness associated with symptoms and signs like:
fever,
fatigue,
swollen tonsils,
headache, and
sweats,
sore throat,
swollen lymph nodes in the neck, and
sometimes an enlarged spleen.
Although EBV can cause mononucleosis, not everyone infected with the virus will get mononucleosis. White blood cells called B cells are the primary targets of EBV infection.

Aspiration is the treatment of choice in thyroid cysts, but the recurrence rates are high (60%–90% of patients), particularly with repeated aspirations and large-volume cysts.
Percutaneous ethanol injection (PEI) has been studied in several large randomized controlled studies, with reported success in 82–85% of the cases after an average of 2 sessions, with a volume reduction of more than 85% from baseline size.
PEI may also be considered for hyperfunctioning nodules, particularly if a large fluid component is present. It has a success rate ranging from 64% to 95%, with a mean volume reduction of 66%, but recurrences are more common and the number of sessions required to achieve good response is higher (about 4 sessions per patient). PEI is a safe procedure, with the most common reported adverse effects being local pain, dysphonia, flushing, dizziness, and, rarely, recurrent laryngeal nerve damage.
Surgery, Lobectomy is also a reasonable therapy for cystic lesions, as an alternative to the previously mentioned procedures.

Discrete masses graded P3 or R3/M3 or U3 and above should be triple assessed using core biopsy rather than FNAC unless core biopsy is not feasible.
When cytology or biopsy has been reported as C1 or B1 it will require a further biopsy to delineate the pathology in most instances.
The exceptions are when the lesion is suspected to be a lipoma or hamartoma following imaging and discussion. Following triple assessment, if there is non-concordance by more than one grade then further biopsy and or investigations should be undertaken.
In this case, Excisional biopsy is the next required biopsy to delineate the pathology.

A meta-analysis found that there was a twofold increase in the risk of endometrial cancer following extended versus standard adjuvant tamoxifen therapy in patients with breast cancer.
The systematic review of four randomized controlled trials showed that the absolute risk of endometrial cancer in patients receiving adjuvant tamoxifen for 10 years was 3.2% compared with 1.5% in patients receiving 5-year standard therapy (cumulative risk ratio [RR] 2.29, 1.60 to 3.28, P<0.001).
The breast cancer treatment tamoxifen (sometimes called by its brand name, Nolvadex) increases the risk of developing endometrial cancer, but not nearly enough to outweigh its benefits against breast cancer in most women. This risk occurs because of the way tamoxifen works: Even as it acts against the growth-promoting effects of the female hormone oestrogen in breast tissue, it acts like an oestrogen in other tissues, such as the bones and the uterus. This can be good news for the bones because oestrogen helps preserve bone density, but it may slightly increase the risk of cancer in the uterus. According to the American Cancer Society, the risk of developing endometrial cancer from tamoxifen is about 1 in 500 — a small risk, but higher than that for women in the general population. Tamoxifen also slightly increases the risk of uterine sarcoma, a cancer that begins in the muscle of the uterine wall.

Tamoxifen belongs to a class of medications known as selective oestrogen response modifiers (SERMs). Another SERM called Fareston (chemical name: toremifene) has been found to increase the risk of endometrial hyperplasia, or the overgrowth of cells lining the uterus. Hyperplasia itself is not cancer but can sometimes develop into cancer. Evista (chemical name: raloxifene), another SERM used to lower the risk of breast cancer in high-risk women, does not have oestrogen-like effects on the uterus and does not increase endometrial cancer risk.

Carbimazole was not found to cause gynaecomastia.

Drugs frequently causing gynecomastia:
Antiandrogens – Bicalutamide, flutamide, finasteride, dutasteride
Antihypertensive – Spironolactone
Antiretroviral – Protease inhibitors (saquinavir, indinavir, nelfinavir, ritonavir, lopinavir), reverse transcriptase inhibitors (stavudine, zidovudine, lamivudine)
Environmental exposure – Phenothrin (antiparasitic)
Exogenous hormones – Oestrogens, prednisone (male teenagers)
Gastrointestinal drugs – H2 histamine receptor blockers (cimetidine)

Mnemonic for causes of gynaecomastia: METOCLOPRAMIDE

M etoclopramide
E ctopic oestrogen
T rauma skull/tumour breast, testes
O rchitis
C imetidine, Cushings
L iver cirrhosis
O besity
P araplegia
R A
A cromegaly
M ethyldopa
I soniazid
D igoxin
E thionamide

Sentinel lymph node biopsy has become the gold standard for axillary staging for patients with clinically and radiologically node negative axilla. The recommended technique is the dual technique of blue dye/radioisotope and this is associated with high sentinel node identification rates (> 95 %). However, in centres where radioisotope is not available, blue dye guided four node sampling appears to be a reasonable alternative. Sentinel node biopsy was shown to be an accurate technique for axillary node staging in the ALMANAC Trial with less associated morbidity and strong health economic arguments for its use.

The tumour in this patient is small so a wide local excision should be done.
Lumpectomy or breast wide local excision is a surgical removal of a discrete portion or lump of breast tissue, usually in the treatment of a malignant tumour or breast cancer. It is considered a viable breast conservation therapy, as the amount of tissue removed is limited compared to a full-breast mastectomy, and thus may have physical and emotional advantages over more disfiguring treatment. Sometimes a lumpectomy may be used to either confirm or rule out that cancer has actually been detected. A lumpectomy is usually recommended to patients whose cancer has been detected early and who do not have enlarged tumours.

Pre-existing chronic autoimmune (Hashimoto’s) thyroiditis is the only known risk factor for primary thyroid lymphoma and is present in approximately one-half of patients. Among patients with Hashimoto’s thyroiditis, the risk of thyroid lymphoma is at least 60 times higher than in patients without thyroiditis.

The treatment approach primarily depends on the histopathologic classification and the disease stage and involves a combination of surgical management, radiation therapy, and systemic therapy. Surgical management is either breast-conserving therapy (BCT) or mastectomy. Systemic therapy has significantly improved in recent years with the development of hormone therapy (tamoxifen) and targeted therapy (trastuzumab). The most important prognostic factors are lymph node status, tumour size, patient’s age, and tumour receptor status (hormone receptors and HER2).

Branchial cleft cysts are congenital anomalies that usually arise from second cleft/pouch, with remnants of the third and fourth pouch are rare. Children are typically born with these congenital lesions; however, they may not be evident for weeks, months, or possibly years. The lesions present as fistulae, cyst, sinus tracts, or cartilaginous remnants due to incomplete obliteration during embryogenesis.

They are often asymptomatic, but can often become tender, enlarged, or inflamed with possible abscess formation during episodes of upper respiratory tract infections.
The patient can present with purulent drainage of the sinus to skin or pharynx from spontaneous rupture of branchial cleft cyst abscess. The most concerning symptoms include dysphagia, dyspnoea, and stridor due to cyst compression of the upper airway.

The physical examination will differ depending on the location of the branchial cleft cyst:
– A primary branchial cleft cyst is typically smooth, non-tender, fluctuant mass found between the external auditory canal and submandibular area. It is usually with the parotid gland and facial nerve. Two types of lesions exist. Type 1 is rare and characterized as duplication of the membranous external auditory canal. Type 2 lesions contain both ectoderm and mesoderm elements including cartilage. The patient usually presents with soft tissue mass or draining sinus located on the angle of the mandible or otorrhea, making an otologic exam critical in these cases.
– A secondary branchial cleft cyst is located between the lower anterior border of the sternocleidomastoid and the tonsillar fossa of the pharynx. It can be in proximity to the glossopharyngeal and hypoglossal nerve as well as carotid vessels. Compared to the primary branchial cleft cysts, secondary cysts are tender if secondarily inflamed or infected. If it is associated with a sinus tract, a mucoid or purulent discharge may be present on the skin or into the pharynx.

The treatment of a branchial cleft cyst is typically elective excision due to the risk of infection or present infection, further enlargement, or malignancy.

– Carotid Body Tumour: Painless oropharyngeal or upper anterior triangle of the neck; pulsatile, compressible with a bruit or thrill, mobile from medial to lateral direction.
– Bartonella henselae infection is Isolated, mobile, fluctuant, tender, warm, erythematous, > 2 cm near the site of inoculation.
– Thyroglossal duct cyst: In the Midline, adjacent to the hyoid bone; rises with deglutition.

Hashimoto thyroiditis is part of the spectrum of autoimmune thyroid diseases (AITDs) and is characterized by the destruction of thyroid cells by various cell- and antibody-mediated immune processes.
The thyroid gland may become firm, large, and lobulated in Hashimoto’s thyroiditis, but changes in the thyroid can also be nonpalpable. Enlargement of the thyroid is due to lymphocytic infiltration and fibrosis, rather than tissue hypertrophy.

Laboratory studies and potential results for patients with suspected Hashimoto thyroiditis include the following:
– Serum thyroid-stimulating hormone (TSH) levels: Sensitive test of thyroid function; levels are invariably raised in hypothyroidism due to Hashimoto thyroiditis and in primary hypothyroidism from any cause
– Free T4 levels: Needed to correctly interpret the TSH in some clinical settings; low total T4 or free T4 level in the presence of an elevated TSH level further confirms diagnosis of primary hypothyroidism
– T3 levels: Low T3 level and high reverse T3 level may aid in the diagnosis of nonthyroidal illness

Thyroid autoantibodies: Presence of typically anti-TPO (anti-thyroid peroxidase) and anti-Tg (anti-thyroglobulin) antibodies delineates the cause of hypothyroidism as Hashimoto thyroiditis or its variant; however, 10-15% of patients with Hashimoto thyroiditis may be antibody negative.
While their role in the initial destruction of the follicles is unclear, antibodies against thyroid peroxidase (TPO) (also called TPOAb) or thyroglobulin are relevant, as they serve as markers for detecting the disease and its severity. They are hypothesized to be the secondary products of the T cell mediated destruction of the gland.

Answer: Kiesselbach’s plexus

Epistaxis is defined as acute haemorrhage from the nostril, nasal cavity, or nasopharynx. The source of 90% of anterior nosebleeds within the Kiesselbach’s plexus (also known as Little’s area) on the anterior nasal septum.

Kiesselbach’s plexus (Kiesselbach’s area or Little’s area) is a vascular region of the anteroinferior nasal septum that comprises four arterial anastomoses:
1)anterior ethmoidal artery – a branch of the ophthalmic artery
2)sphenopalatine artery

Multiple endocrine neoplasia type 2 (MEN2) is a hereditary condition associated with 3 primary types of tumours: medullary thyroid cancer, parathyroid tumours, and pheochromocytoma. MEN2 is classified into subtypes based on clinical features. Virtually all patients with classical MEN2A develop medullary thyroid carcinoma (MTC), which is often the first manifestation of the disease and usually occurs early in life. Pheochromocytomas (PHEOs) tend to be diagnosed several years later or simultaneously with the MTC.

All of the listed options are true regarding radioiodine therapy, except for the first option. Treatment with radioiodine does not increase the risk of parathyroid carcinoma.

Recurrence of Graves’ disease is treated similar to normal Graves’ disease. However, some patients may need definitive treatment with radioiodine or thyroidectomy. These patients are usually hypothyroid post treatment and are treated with L-thyroxine until their TSH values are within normal parameters.

Fine-needle aspiration (FNA) cytology of axillary lymph nodes is a simple, minimally invasive technique that can be used to improve preoperative determination of the status of the axillary lymph nodes in patients with breast cancer, thereby serving as a tool with which to triage patients for sentinel versus full lymph node dissection procedures. FNA of axillary lymph nodes is a sensitive and very specific method with which to detect metastasis in breast cancer patients. Because of its excellent positive predictive value, full axillary lymph node dissection can be planned safely instead of a sentinel lymph node dissection when a preoperative positive FNA result is rendered.

Patients with a Quinsy or peritonsillar abscess (PTA) typically present with a history of acute pharyngitis accompanied by tonsillitis and worsening unilateral pharyngeal discomfort. Patients also may experience malaise, fatigue, and headaches. They often present with a fever and asymmetric throat fullness. Associated halitosis, odynophagia, dysphagia, and a hot potato–sounding voice occurs.
The presentation may range from acute tonsillitis with unilateral pharyngeal asymmetry to dehydration and sepsis. Most patients have severe pain. Examination of the oral cavity reveals marked erythema, asymmetry of the soft palate, tonsillar exudation, and contralateral displacement of the uvula.
Indications for considering the diagnosis of a PTA include the following:
Unilateral swelling of the peritonsillar area
Unilateral swelling of the soft palate, with anterior displacement of the ipsilateral tonsil
Nonresolution of acute tonsillitis, with persistent unilateral tonsillar enlargement
A PTA ordinarily is unilateral and located at the superior pole of the affected tonsil, in the supratonsillar fossa. At the level of the supratonsillar fold, the mucosa may appear pale and even show a small pimple. Palpation of the soft palate often reveals an area of fluctuance. Flexible nasopharyngoscopy and laryngoscopy are recommended in patients experiencing airway distress. The laryngoscopy is key to ruling out epiglottitis and supraglottitis, as well as vocal cord pathology.