Approach of Neck mass for medical student with quiz

1. THE NECK MASS General Sx Topic
Reviewed and present by Mr. Patinya Yutchawit, Miss Kaewalin Thongsawangjang, Miss Withunda
Akaapimand,
Miss Rattanaporn Sirirattanakul, Miss Tritraporn Sawantranon, Mr. Yotdanai Namuangchan, Mr.

2. THYROID Introduction and
anatomy

5. Follicles -> Lobule
Principal cells (ie, follicular) formation of the colloid
(iodothyroglobulin),
Parafollicular cells :calcitonin

6. Superior thyroid artery
Inferior thyroid artery
Thyroidima artery

7. Superior thyroid artery
Inferior thyroid artery
Thyroidima artery

8. Superior thyroid vein
Middle thyroid vein
Inferior thyroid veins

9. Nerve
Parasympathetic fibers vagus nerves
Sympathetic fibers : superior, middle, and inferior
ganglia of the sympathetic trunk.

11. APPROACH TO NECK
MASS
Start

15. access
• Origin
• Cause

16. Hx
• ความชุกชุมของโรค
• อายุ
• เพศ
• ระยะเวลา
• ความเจ็บปวด
• อาการทั่วไป : ไข้ อ่อนเพลีย เสียงแหบ กลืนลาบาก ไอเลือดปน น้ามูก
ปนเลือด หูอื้อข้างเดียว เลือดกาเดาไหลบ่อย แน่นจมูก แผลที่ศีร ะ คอ
ช่องปาก ลิ้น

17. PE
• Local examination
• Regional examination
• General examination

18. Local examination
• Location
• Size > 1.5 cm , <1.5cm. 2ข้าง
• Shape
• Surface
• Consistency
• Tenderness
• Fluctuation
• Tranlumination
• Attachment
• Skin
• Punctum
• Pulsation
• Miscellaneaeous: move follow tongue prtusion,swallowing

24. Location
Mid line Ant. Triangle Post. Triangle
Congenital
-thyroglossal duct cyst
-dermoid cyst
-laryngocele
Inflammation
-adenditis
Tumor
-thyroid
-lymphoma
Other
-sternocleidomastoid
hematoma/fibroma
Congenital
-brachial cleft cyst
-thymic cyst
-sialadenopathy
(parotid,submandibular)
Inflammation
-adenitis(viral,bact.,
glanulomatous)
-sialadenitis
Tumor
-metastasic
-upper jugular
-submandibular
-middle jugular
-lymphoma
-vascular(carotid tumor,
hemangioma)
Other
- False aneurysm
Congenital
-lymphangioma
Inflammation
-adenitis(viral,bact.,
glanulomatous)
Tumor
-lymphoma
-metastatic
-supraclavicular
Other
Neuroma

29. investigation
• Blood
– CBC, ESR, LFT, Ca, heteropliie Ab, HIV Ab, EBV Ab
• Imaging
– X-ray, U/S, CT, MRI (submucosal),radionuclide scan
– sialography
• Cytology
– FNA
• Tissue
– biopsy

33. THYROGLOSSAL DUCT
CYST

34. THYROGLOSSAL DUCT CYST
Neck mass that
develops from
cells and tissues
remaining after
the formation of
the thyroid gland
during
embryonic
development

35. Pathogenesis
• The primitive thyroid descended from its
origin at the base of the tongue to its
permanent location, low in the neck. Failure of
subsequent closure and obliteration of this
tract predisposes to thyroglossal cyst
formation.

39. Types of thyroglossal duct cysts
–Infrahyoid type : 65 %
–Suprahyoid type : 20 %
–Juxtahyoid cysts : 15 %
–Intralingual location
–Suprasternal variety
–Intralaryngeal

40. Clinical presentation
• A small,soft,round mass
in the midline of neck
• Mass rise with swallowing or
protrusion of the tongue
•It is most commonly
diagnosed in preschool-
aged children or during
mid-adolescence

42. CLINICAL PRESENTATION
Infected cysts may manifest as
tender masses with
Dysphagia
Draining sinus
Fever
Enlarging neck mass

44. Diagnosis
• Clinical : upward when tongue is extended and
swallowing
• Contain thyroid tissue
– TFT
– Thyroid scan
–Ultrasound

45. a midline infrahyoid unilocular mass
with a homogeneously hypoechoic internal
echotexture, typical of a TDC.

47. Pathology
• Cyst cavity
and thyroid tissue
On rare occasion,
turn to carcinoma

48. Treatment
• Antibiotic if infected
• Surgery : Sistrunk’s Operation
- Removal of the cyst, the tract, and
the central portion of the hyoid bone as
well as a portion of the tongue base up
to the foramen cecum.

51. Solitary
thyroid nodule
Euthyroid Hyperthyroid
FNA biopsy cytology
I-131/Sx
FSH,FT3
Hot
nodule
Cold
nodule
TMG
Thyroid scan
TSH FT3
FNA
Reaspirate
Benign
Solid/Mix
NegativeSuspiciousPositive
Malignant
Hormone
suppressive,F/U
Sx Sx
LobectomySx +/- I-131
Cyst

52. GRAVE’S DISEASE

54. Graves’ Disease
• Graves’s disease , Primary toxic goiter , Basedow’s
disease , Exopthalmicgoiter
• autoimmune disease : antibody against the
thyroid-stimulating hormone (TSH) receptor
(Thyroid stimulating immunoglobulin ,TSI)
stimulates the gland to synthesize and secrete
excess thyroid hormone
• Characterized by hyperthyroidism, diffuse goiter,
opthalmopathy and, sometimes, dermopathy.
• Most common cause of hyperthyroidism

56. Age: 20-50 years
Sex: female : male 7-8:1
60-90% of all causes of
thyrotoxicosis
100-200 cases /100,000
population /year
EPIDEMIOLOGY

57. • 50 % Genetic inheritance
• Other factors, such as smoking, sex
steroids, life stresses, and dietary iodine
intake, bacterial or viral infection are
possible causes of Graves’ disease
ETIOLOGY

58. • 1.Increase metabolic rate of all cells
• 2.Increase sensitivity of beta-adrenergic
receptors
• 3.Stimulate all cells to grow
Thyroid hormone effects

59. Metabolic:
ravenous appetite, weight loss, excessive
sweating, heat intolerance
CVS:
Palpitations, shortness of breath, tiredness,
irregular heart beat
CNS:
irritability, insomnia, depression
CLINICAL

60. • GI:
Change in appetite and weight, Increase
frequency of bowel movement, diarrhea
• RP:
reduction in the quantity of menses,
amenorrhea, decreased fertility,
increased incidence of miscarriages
• MS:
wasting and weakness of small muscle of
hand, shoulder, face

61. • GA: looks thin and wasting of face and hands,
sweating
• CVS: tachycardia at rest, persist during sleep.
AF, collapsing pulses, heart failure
• CNS: fine tremor
• Skin: warm and moist, pretibial myxedema
• MS: muscle wasting, proximal muscle weakness,
hyperactive tendon reflex, digital clubbing
Physical examination

62. • Signs in the neck
Diffused, symmetrically enlarged thyroid gland
Systolic bruit audible over its lateral lobe,palpable
thrill
• Signs in the eyes
Lid retraction and lid lag
Exopthalmos
Ophthalmoplegia: proptosis, limitation of upward and
latral gaze
Chemosis: conjunctival swelling and congestion
Physical examination

65.  Thyroid function test
High T3, T4 ; Low TSH
 Thyroid stimulating antibodies (TSAb)
 123I uptake and scan : Increase
Diagnostic tests

66. •Medication
•Radioactive 131I
•Thyroidectomy
Management

67. • Beta blocker : Propranolol 20-40 mg qid
offer relief of the adrenergic symptoms
of hyperthyroidism such as tremor,
palpitations, heat intolerance, and
nervousness
Medication

68. • Reserve for
- Small, non toxic goiters less than 40 g
- Mildly elevated thyroid hormone levels
- Rapid decrease in gland size with antithyroid
medication
• PTU: 100-300 mg tid
• MMI: 10-30 md tid, then once daily
• Side effects: skin rash, fever, vasculitis,rarely
agranulocytosis, aplastic anemia
• High relapse rate when discontinued drug 1-2 year (40-
80%)
Antithyroid drugs
Medication

69. • Recommended in
- Older patients with small or moderate-size goiter
- Relapse after medical or surgical therapy
- Antithyroid drugs or surgery are contraindicated
Radioactive Iodine therapy

70. • Woman who are pregnant or breastfeeding
Relative contraindications
• Children and adolescent
• Patient with thyroid nodule
• Patient with ophthalmopathy
Absolute contraindications
Radioactive Iodine therapy

71. Recommend in
- RAI is contraindication
- Have confirmed cancer or suspicious thyroid nodules
- Young
- Pregnant or desire to conceive soon after treatment
- Severe reaction to antithyroid medication or poor
compliance
- Large goiters causing compressive symptoms or for
cosmetic reason
- Reluctant to undergo RAI therapy
Surgical treatment

72. • Euthyroid by continue antithyroid drug until
the day of surgery
• Lugol’s iodine solution or saturated K iodine 3
drops bid for 7-10 day preoperatively →
reduce vascularity of gland and decrease risk
of precipitating thyroid storm
Prep. For surgery

73. Hemithyroidectomy - Entire isthmus is removed along
with 1 lobe. Done in benign diseases of only 1 lobe.
Subtotal thyroidectomy- Done in toxic thyroid, primary
or secondary, and also for toxic multinodular goiter
(MNG).
Partial thyroidectomy - Removal of gland in front of
trachea after mobilization. Done in nontoxic MNG. Its
role is controversial.
Near total thyroidectomy- Both lobes are removed
except for a small amount of thyroid tissue (on one or
both sides) in the vicinity of the recurrent laryngeal
nerve entry point and the superior parathyroid gland.
Done in papillary thyroid carcinoma.
Total thyroidectomy- Entire gland is removed. Done in
case of follicular carcinoma of thyroid, medullary
carcinoma of thyroid.
Hartley Dunhill operatio - Removal of 1 entire lateral

74. • Total or near total thyroidectomy
- Coexistent thyroid cancer
- Refuse RAI
- Severe ophthalmopathy
- Life threatening reaction to antithyroid
medication e.g. vasculitis, agranulocytosis, liver
failure
* High rate of hypothyroidism
• Subtotal thyroidectomy (4-7 g remain)
- All remaining patients
Higher recurrent rate of hyperthyroidism

75. Bleeding
Hypocalcemia
Recurrent laryngeal nerve injury
Superior laryngeal nerve injury
Thyroid crisis
COMPLICATION

78. THYROID CANCER

79. • Benign follicular adenoma
• Malignant : primary
– Follicular epithelium-differentiated : papillary
,follicular
– Follicular epithelium-undiffentiated : anaplstic
– Parafollicular cells : medullary
– Lymphoid cells : lymphoma
• Malignant : Secondary
- Metastasis

80. Thyroid cancer

81. THYROID CANCER
Follicular epithilial – differentiated
 Papillary carcinoma (75 – 80%)
 Follicular carcinoma (15 – 20 %)
Follicular epithilial – undifferentiated
 Anaplastic carcinoma (<5%)
Parafollicular cell
 Medullary carcinnoma (5%)
Lymphoid cell
 lymphoma

82. PAPILLARY CARCINOMA
Most common thyroid cancer***
Age 30-50 years old
Risk factor = Previous exposure to Ionizing radiation
Most common presentation = Asymptomatic thyroid
mass/nodule
Excellent prognosis = 10 years survival rate >95%

83. SPREADING
Lymphatic spreading (35-43%)
Blood vessels invasion (40%)
Distant metastasis (3-7%)

84. SIGNS AND SYMPTOMS
Asymptomatic Thyroid mass
If advanced CA
 Hoarsness
 Dysphagia
 Cough
 Dyspnea

85. INVESTIGATION
Fine Needle Aspiration
Ultrasonography
 distinguish solid from cystic lesions and identify calcifications
Thyroid scan
 Cold nodule

86. HISTOPATHOLOGY
mixed papillary and follicular growth patterns
Orphan Annie eye nuclei (= characteristic pale empty
nuclei)
Papillary finger-like projection
Psammoma body

88. FOLLICULAR
CARCINOMA
2nd common thyroid cancer
High incidence in iodine-depleted
countries
Common in patient > 50 years
Closely resemble to follicular
adenoma  capsular or vascular
invasion is defined malignat
status
Hematologic spreading  distant
metastasis difficult to control
May be involve cervical lymph
node
10-year survival rate > 90%

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•follicular carcinomas demonstrate capsular invasion (B, arrow-heads) that may be
minimal, as in this case, or widespread with extension into local structures of the
neck. The presence of vascular invasion is another feature of follicular carcinomas.
•Hurthle cell tumor-Variant of follicular
Neoplasm in which oxyphil cells predominate
histology

93. • recurrent laryngeal nerve palsy 2-7%
• permanent hypoparathyroidism 1-3%
• hematoma 1-2%
• wound infection < 1%
• hypertrophy of the scar

95. • anaplastic carcinomas are aggressive tumors, with a mortality rate
approaching 100%. Survival calculated in months
• mean age of 65 years.
• About half of the patients have a history of multinodular goiter, Spread by
lymphatic and by the bloodstream
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Anaplastic carcinoma

96. ANAPLASTIC CARCINOMA
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highly anaplastic cells, which may take one of several histologic patterns: (1) large,
pleomorphic giant cells, including occasional osteoclast-like multinucleate giant
cells; (2) spindle cells with a sarcomatous appearance; (3) mixed spindle and giant
cells; and (4) small cells resembling those seen in small cell carcinomas arising at
other sites.

100. • Advanced or metastatic disease
– no effective therapy for advanced or metastatic anaplastic
thyroid cancer
– median survival from diagnosis ranges from three to seven
months
– Death is usually attributable to upper airway obstruction
– Radiation therapy does not prolong survival, most have
local recurrences
– Chemotherapy response duration is generally short, and
long-term survival (as well as local control in the neck)
probably unaffected

101. MEDULLARY CARCINOMA
Tumors of Parafollicular cells (C cells) derived from
neural crest
Neuroendocrine neoplasms
Secrete Calcitonin (useful in diagnosis and follow up)

102. INCIDENCE
80% of cases are sporadical tumors
Age 50-60 years old
Lymphatic metastasis 50-60%
May occur in combination known as MEN 2A or 2B

103. SIGNS AND SYMPTOMS
a lump at the base of the neck, which may interfere with
or become more prominent during swallowing.
If locally advanced disease : hoarseness, dysphagia, and
respiratory difficulty.
Various paraneoplastic syndromes, including Cushing or
carcinoid syndrome (uncommon)
+/- Diarrhea
Distant metastases : weight loss, lethargy, and bone pain

104. INVESTIGATION
Serum Calcitonin level
 The higher the greater of likelihood to be MTC
 Basal level >100 pg/mL

105. PATHOLOGY
Medullary carcinoma of
thyroid. These tumors
typically show a solid
pattern of growth and do
not have connective tissue
capsules
Medullary carcinoma of
the thyroid. These tumors
typically contain amyloid
stroma

106. STAGING

107. TREATMENT
Total Thyroidectomy
Prophylactic/Therapeutic resection of central and
bilateral cervical lymph nodes

108. POSTOPERATIVE
MANAGEMENT
Thyroxine therapy maintain euthyroidism
adjuvant therapy with radioiodine
SURGERY FOR RESIDUAL DISEASE
Serum calcitonin and CEA should be measured 6 months
after surgery detect the presence of recurrence

109. WRAP-UP! Approach to neck
mass

110. THE HALF-BAKED
CONCEPT
IS OKAY, AS LONG AS
IT’S IN THE OVEN.
Let’s continue baking!

111. CASE : A PAINLESS LUMP
IN THE NECK
History
A 40-year-old woman has been referred to the
surgical outpatients with a painless lump in the
neck. She had noticed the lump 2 weeks
previously when looking in the mirror.
She had not noticed any other lumps and does
not complain of any other symptoms. She has
not gained or lost any weight recently and her
bowel habit has remained normal.

112. CASE : A PAINLESS LUMP
IN THE NECK
Examination
Examination reveals a solitary 2x2 cm swelling
to the left of the midline just above the
manubrium. The swelling is firm, smooth and
fixed. The swelling moves on swallowing, but
does not move on protrusion of the tongue.
There are no associated palpable lymph glands.
General examination reveals no further
abnormalities.

113. INVESTIGATION
Hemoglobin 12.0 g/dL
Mean cell volume 77 fL
White cell count 10.4x109/L
Platelets 250x109/L
Sodium 137 mmol/L Potassium 3.7 mmol/L
Urea 5 mmol/L (2.5–6.7
mmmol/L)
Creatinine 71 μmol/L (44–80
μmol/L)
Thyroid-stimulating hormone (TSH) 0.62mu/L
(0.5–5.7 mu/L)
Free tri-iodothyronine (T3) 3.4 pmol/L (2.5–
5.3 pmol/L)

114. QUESTIONS
1. What is the differential diagnosis for a lump in
the anterior triangle of the neck?
2. Where is this lump likely to be originating from?
3. What steps would you take in the assessment of
this lump?
4. Which factors may suggest malignancy?
5. What are the commonest types of malignancy?

115. TAKE YOUR FRIEND’S
ANSWER SHEET, TAKE A
LOOK AND GIVE THEM
GRADE.
Talk about it.

116. WHAT IS THE DIFFERENTIAL
DIAGNOSIS FOR A LUMP IN THE
ANTERIOR TRIANGLE OF THE
NECK?
Multiple: lymph nodes
Solitary: does it move
with
swallowing?
• yes:
- thyroid origin
- thyroglossal cyst
(moves with protrusion
of the tongue)
• no:
- salivary gland
- dermoid cyst
- carotid body
tumur
- lymph node
- branchial cyst
- cold abscess (TB)

117. WHERE IS THIS LUMP LIKELY
TO BE ORIGINATING FROM?
… to the left of the midline just above the manubrium
… The swelling moves on swallowing, but does not move
on protrusion of the tongue.
“Thyroid origin”
The majority of patients are clinically euthyroid and have
normal thyroid function. The presence of abnormal
thyroid function suggests a benign diagnosis.

118. WHAT STEPS WOULD YOU
TAKE IN THE ASSESSMENT OF
THIS LUMP?
Less than 20 per cent of thyroid nodules are malignant,
with the majority being cystic or benign. Many solitary
thyroid nodules are dominant nodules in a multinodular
goitre,which carry a 5 per cent risk of malignancy.
Ultrasound is used to distinguish between solid and
cystic nodules as well as differentiating a solitary nodule
from a dominant nodule in a multinodular goitre.
Fine-needle aspiration has a high sensitivity and
specificity for distinguishing benign from malignant
lumps in the thyroid. The main limitation of fine-needle
aspiration is in the differentiation of benign follicular
adenoma from malignant follicular cancer. If a follicular
neoplasm is diagnosed on fine-needle aspiration, the
lesion will need to be fully excised to exclude
malignancy.

119. WHAT STEPS WOULD YOU
TAKE IN THE ASSESSMENT OF
THIS LUMP?
Radio-isotope scanning provides a functional
assessment of the thyroid nodule, which can be
classified as cold or hot.
Most solitary thyroid nodules are cold, with a risk of
cancer at around 20 per cent.

120. WHICH FACTORS MAY
SUGGEST MALIGNANCY?
• age younger than 20 years or older than 70 years
• male sex
• recent origin and rapid growth or increase in size
• firm, hard, or immobile nodule
• presence of cervical lymphadenopathy
• associated symptoms of dysphagia or dysphonia
• history of neck irradiation
• prior history of thyroid carcinoma or a positive family
history.

121. WHAT ARE THE COMMONEST
TYPES OF MALIGNANCY?
Type frequency age Behavior Prog
Papillary 70% 20-40s Slow growing,
lymphatic spread
to nodes
Good
10 yr 80%
Follicular 20% 35-50s Bloodstream spread,
metastasis to lung
and bone
Good
10 yr 60%
Anaplastic <5% 60-70s Aggressive, local
spread
Poor
10 yr 10%
Medullary 5% Familial From parafollicular
C cell, MEN

122. TAKE’EM HOME! A brief review.

123. POINTS
>20% of adult neck masses are malignant
70% of pediatric neck masses are infectious in nature
Know your anatomy then develop a differential diagnosis
Close observation
Generally, one course of a broad spectrum antibiotic is
acceptable then ….. It is never wrong to refer to a specialist
for evaluation and probable biopsy
Imaging is important but tissue is everything
If you don’t get an answer with a FNA, repeat it up to three
times. Consider ultrasound guided or CT guided FNA.
Never violate a neck if you’ve no idea about it.

124. POINTS
Avoid excisional biopsies
Use CT but consider MRI for
salivary gland problems
Role of nonionizing
ultrasound
Like a stethoscope

126. REFERENCE
- An introduction to the symptoms and sing of surgical
disease:
Norman L.Browse
- Bailey and Love's Short Practice of Surgery - 25th
Edition
- 100 cases in surgery
- พื้นฐานศัลยศาสตร์และอาการของโรคศัลยกรรมสาหรับแพทย์เวชปฏิบัติทั่วไป
คณะแพทยศาสตร์ ม.ศรีนครินทรวิโรฒ
- ตารา หู คอ จมูก คณะแพทยศาสตร์ ม.ขอนแก่น
- Uptodate : neck mass

127. HEY GUY! FIN.
DO YOU HAVE SOME
QUESTIONS??
Thank you for
your attention.