Surg Oral Exam: 7. Neck Mass
Terms in this set (53)
45-year-old woman in clinic who presents with a new neck mass either that they've noticed themselves. First step?
"I would first take vitals and assess the patient's general appearance and vital signs. I would determine if there is any need for immediate resuscitation, which is unlikely in this situation given that I am seeing her in clinic."
What is the differential for neck mass?
Neoplasm, Metabolic/autoimmune/idiopathic, Inflammatory/infectious, congenital, trauma
What are the types of neoplasm in the neck?
o Benign (lipomas, hemangiomas, neuromas, fibromas)
o Malignant (thyroid, salivary, lymphoma, sarcoma, metastatic)
o Papillary thyroid carcinoma
o Follicular thyroid carcinoma
o Medullary thyroid carcinoma
o Hurthle cell thyroid carcinoma
o Anaplastic/undifferentiated thyroid carcinoma
o Parathyroid adenoma/carcinoma
o Metastatic tumors (SCC, GI tumors, lung)
What are the types of metabolic, autoimmune and idiopathic causes of neck mass?
o Toxic multinodular goiter
o Subacute or chronic thyroiditis
o Gout (rare)
o Inflammatory pseudotumor (rare)
o Kimura's disease (uncommon chronic inflammatory condition)
o Castleman's disease (benign lympho-proliferative disorder)
What are the inflammatory and infectious causes of neck mass?
o Cervical adenitis (most common - response to regional inflammation/infection)
o Bacterial or viral lymph node (LN) infection (of the LN itself) - Catch scratch, TB
o Acute or chronic sialadenitis (salivary stones or duct stenosis)
What are the congenital causes of neck mass?
o Lateral neck: branchial anomalies (cysts, sinuses, fistulae)
o Midline neck: thyroglossal duct cyst
What are the traumatic causes of neck mass?
o Pseudoaneurysm or AV fistula (rare)
What is the pertinent HPI for a patient with neck mass?
"I would then take a complete history from the patient. I want to characterize the patient's complaint, ask about associated symptoms, and elicit risk factors from the patient's history."
• Characterize the mass: Location (midline vs. lateral), Size (small and localized vs. more diffuse), Fixed vs. mobile with palpation or swallowing, General description: painful, pulsatile
• Associated symptoms: Dysphagia, Ear pain, Cranial nerve asymmetries (IX, X, XI), Hoarseness, Dyspnea
• Malignancy questions: Weight loss, Fevers, chills, night sweats, Enlarged lymph nodes (especially Virchow's node on the left side), History of radiation to neck
• Thyroid questions: Weight gain or loss, Cold or heat intolerance, Exophthalmos, Dry hair/skin, Palpitations (could also signify pheochromocytoma)
• Parathyroid questions (generally not as useful if mass is palpable): GERD, Pancreatitis, Constipation, Changes in personality/mood/mental status, Bone pain
• Infectious: Fevers, chills, night sweats, Sore throat, Sick contacts
What are the pertinent PMH and PSH for a patient with neck mass?
• Severe acne (with history of radiation treatment)
• MEN syndromes
o IA ("PPP") - parathyroid, pituitary, pancreatic
o IIA ("PPM") - parathyroid, pheochromocytoma, medullary thyroid
o IIB ("PMM") - pheochromocytoma, marfanoid habitus, medullary thyroid
• Autoimmune diseases eg. DM1, RA, lupus
• Previous history of neck mass or thyroid concerns
• Kidney stones
• Radiation treatment (x-rays of the neck don't count)
• Head/neck surgeries
What are the pertinent Meds/allergies/SH/FH/ROS for a patient with neck mass?
Medications/ allergies: Identify any potentially relevant medications/ allergies
SH: Identify relevant risk factors. Smoking especially, EtOH, Occupation is important for exposures
FH: Autoimmune diseases (especially thyroid concerns), MEN syndromes, Cancers (specifically thyroid or other head/neck cancer)
Review of Systems: "I would complete a 14-point review of systems focusing on the head and neck and endocrine systems."
What are the pertinent physical exam findings for a patient with neck mass?
"I would then move on to perform a complete head to toe physical exam focusing on the head and neck and lymphatic systems. I would begin my exam by reassessing the patient's vital signs."
• Head and neck: Location, Character of mass, Presence of any additional masses that may not have been noticed by the patient
• Presence of enlarged lymph nodes elsewhere: mobile vs. fixed, tender vs. non-tender (focus on supraclavicular, cervical, and axillary)
In a pediatric patient this is a midline neck mass.
Thyroglossal duct cyst
In a pediatric patient this is a lateral neck mass.
Branchial cleft cyst/ laryngocele
In an adult this is a left-sided supraclavicular mass (virchow's node).
metastasis from another cancer, specifically abdominal, often gastric cancer
In an adult this is a midline neck mass.
In an Asian adult this is an isolated posterior triangle lymph node mass.
What are the pertinent labs for neck mass?
• CBC: looking at WBC
• Thyroid studies: TSH, free T3, free T4, Microsomal/anti-TPO antibodies: shows up in Hashimoto's, Grave's, and some thyroid carcinoma (in decreasing order of likelihood), Antithyroglobulin: also shows up in Hashimoto's, Grave's, and idiopathic hypothyroidism
• anti-TSH receptor antibodies for Grave's
• Calcitonin/CEA: if considering medullary thyroid carcinoma/MEN syndrome
• Monospot/EBV titer/rapid strep test if considering reactive lymphadenopathy
• Consider serologic testing for catch scratch (Bartonella henselae), and TB
What is the first diagnostic step for diagnosing neck mass?
H&P and TSH
What diagnostic steps necessary for neck mass?
• Ultrasound: almost always the initial next step
• CT for suspicion of deep masses after US
• Radionuclide thyroid scan isn't utilized as much as it used to be but can still be useful if someone is hyperthyroid to differentiate between Grave's, toxic multinodular goiter, and subacute thyroiditis
Biopsy - Fine needle aspiration (FNA)
A patient with neck mass has low TSH, what is the next step?
- hyperfunctioning --> treat hyperthyroidism
- not functioning --> diagnostic US
A patient with neck mass has normal or high TSH, what is the next step?
- High TSH and nodule - do FNA
- High TSH and no nodule - treat for hypothyroidism
- Normal TSH and no nodule - FNA not indicated
If a patient with neck mass has normal or high TSH and nodule found on US, what is next step?
What is the bethesda system for reporting thyroid mass?
• Non-diagnostic - cyst fluid - Repeat US FNA (1-4% malignant)
• Atypia of undetermined significance - Repeat US FNA (5-15% malignant)
• Benign - consistent with benign follicular or thyroiditis - follow and treat for hyperfunction (0-3% malignant)
• Indeterminate - Huerthle cell (35% malignant) --> surgical lobectomy; Follicular neoplasm --> Radionuclide - surgical lobectomy if non-hyperfunctioning
• Suspicious for PTC, Medullary, mets, lymphoma - preop US--> near-total thyroidectomy (60-75% malignant)
• Malignant PTC Medullary, mets, anaplastic, squamous, non-hodgkins lymphoma, - Preop US --> near-total thyroidectomy
What are the risks of excisional biopsy?
Do not lead with this because if node is a malignant metastasis, excisional biopsy can seed the neck with cancer cells! Do it if FNA gives non-diagnostic results often with follicular neoplasm.
Middle-aged woman with a thyroid mass along with possible symptoms from invasion (dysphagia, hoarseness). Dx and Tx?
Papillary thyroid carcinoma
• Dx: FNA (Orphan Annie eye nuclei and psammoma bodies)
• Tx: If <1cm in diameter, can do lobectomy and isthmusectomy with intraoperative frozen sections with progression to total thyroidectomy if positive. If >1cm in diameter, total thyroidectomy
• Long-term considerations: Metastasizes generally to surrounding lymph nodes.
What is Papillary thyroid carcinoma?
Malignancy of follicular cells. Risk factors in radiation exposure, females get it in 40s-50s, first degree relative FH.
Woman over 50 years old presenting with thyroid mass. Dx and Tx?
Follicular Thyroid Carcinoma
• Dx: FNA performed initially, which comes back for follicular neoplasm or follicular lesion of undetermined significance. At this point, a hemithyroidectomy is performed to distinguish between adenoma and carcinoma (with conversion to total thyroidectomy if it's carcinoma).
• Tx: Amount of resection dependent on intraoperative pathology. If carcinoma, will also have radioactive iodine treatment in follow-up.
• Long-term considerations: Metastasizes generally to the bone and lungs (treat with radioactive iodine). Prognosis depends primarily on metastasis and age of onset with younger patients (under 40) having a generally better prognosis.
What is Follicular thyroid carcinoma?
Malignancy of follicular cells. These cells produce thyroglobulin, which can be used as a treatment and recurrence marker.
What is Hurthle cell thyroid carcinoma?
subset of follicular thyroid carcinoma without any change in management. Proceed with lobectomy.
What is Medullary thyroid carcinoma?
Malignancy of the parafollicular cells (C cells) with calcitonin as a tumor marker (along with CEA)
Patient with a family history of hyperparthyroidism and pheochromocytoma has a neck mass. Dx and Tx?
Medullary Thyroid Carcinoma
• Dx: FNA
• Tx: Total thyroidectomy with central lymph node dissection. If there are positive lymph nodes, modified lateral neck dissection.
• Long-term considerations: Poor prognosis if found as a palpable mass. Great prognosis if found during MEN2 screening. Follow-up for remission with CEA and calcitonin levels.
What is anaplastic thyroid carcinoma?
Malignancy of thyroid that always presents as stage 4 (already metastasized) with giant cells and spindle cells on FNA.
Older patient presents with mass that rapidly increased in size and is having difficulty breathing. Dx and Tx?
Anaplastic neck mass
• Dx: FNA
• Tx: Generally palliative as it is rarely curable. Treatment consists of surgical resection, radiation, and chemotherapy.
Smoker with signs of malignancy (weight loss, night sweats, etc.) presents with neck mass. Dx and Tx?
• Dx: FNA
• Tx: PET, CT, and/or triple endoscopy to look for primary lesion. At that point, treatment could be palliative or modified neck dissection with post-operative radiation therapy
• Long-term considerations: Concern for recurrence
Patient with signs and symptoms of bone pain, kidney stones, moans, groans, and psychiatric overtones. Dx and Tx?
• Dx: Elevated calcium, low phosphate, and elevated PTH
• Tx: Surgical resection of the adenoma. If malignant, additional total thyroidectomy and lymph node dissection
• Long-term considerations: Monitor for recurrence.
Middle-aged woman with possible exophthalmos and diffuse enlargement of thyroid along with symptoms of hyperthyroidism (weight loss, heat intolerance, etc.). Dx and Tx?
• Dx: Labs show high T3/T4 with low TSH; differentiate from other causes of hyperthyroidism with elevated TSH-receptor antibodies
o Operative: total thyroidectomy
- Curative: radioactive iodine (75-80% cure rate) but can't use in pregnant women or women who are trying to become pregnant.
- Non-curative: anti-thyroid medications (methimazole and propylthiouracil)
• Long-term considerations: Proptosis does not go away after either surgery or radio-active iodine.
What is Grave's Disease?
Autoimmune disease with antibodies directed to the TSH receptor on follicular thyroid cells (and also extra-ocular muscles)
Older woman presents with symptoms of hyperthyroidism. Dx and Tx?
Toxic Multinodular Goiter
• Dx: Elevated T3/T4 with depressed TSH; radioactive iodine uptake (thyroid scan) shows multiple hot nodules
o How to distinguish from Grave's: in Grave's, elevated TSH-receptor antibodies and thyroid scan shows diffuse uptake
• Tx: Surgical resection, Radioiodine, or anti-thyroid medications
What is Toxic Multinodular Goiter?
Gain-of-function mutation of TSH receptor in some follicular cells causes cells (and progeny, hence nodules) to become disconnected from control by hypothalamus/pituitary and autonomously produce thyroid hormones
Child or young adult with fever and painful, swollen thyroid with possible dysphagia and overlying erythema. Dx and Tx?
Acute Suppurative Thyroiditis
• Dx: ultrasound and FNA with culture (other labs can contribute to infectious picture such as elevated WBC; thyroid function tests are typically normal)
o Operative: Drainage with failure of antibiotic treatment or if ultrasound shows the presence of an abscess; removal of fistula after the infection has subsided
o Non-operative: antibiotics regardless
What is acute suppurative thyroiditis?
Infection of thyroid with possible presence of fistula
Man or woman of any age presenting with painful, swollen thyroid and could be either hyperthyroid, hypothyroid, or euthyroid with a subacute time course. Dx and Tx?
• Dx: history consistent with change in thyroid symptoms. In addition, radionuclide uptake scan shows low uptake throughout the course of the illness, which distinguishes hyperthyroid phase from Grave's disease.
o Non-operative: NSAIDs, can treat hyperthyroid symptoms with B-blocker like propranolol, steroids if serious
What is Dequervain's Thyroiditis?
Possibly viral in origin and can be seen after URI. Initially, patients are hyperthyroid as cells lining colloid space allow colloid to leak into circulation. This causes negative feedback and resultant low levels of TSH. Once the released colloid is used up, hypothyroid state exists in setting of low TSH. Eventually, the system adjusts and patient ends up euthyroid.
Middle-aged woman with painless, enlarged thyroid and symptoms of hypothyroidism (weight gain, cold intolerance, fatigue, etc.) Dx and Tx?
• Dx: elevated anti-TPO antibodies (most commonly) in the setting of low T3/T4 and high TSH.
o Operative: generally just for resection of cysts or nodules that develop, which are more likely in Hashimoto's
o Non-operative: T4 replacement with levothyroxine (T4 replacement safer than T3 replacement)
• Long-term considerations: increased risk for papillary thyroid carcinoma and thyroid lymphoma
What is Hashimoto's thyroiditis?
Autoimmune disease with antibodies directed against thyroid peroxidase, thyroglobulin, or TSH receptors
Patient with Fever, chills, sick contacts, palpable lymph nodes on exam.
Lymphadenopathy secondary to infection
• Dx: Monospot/EBV titer, strep swab, CBC
• Tx: depending on etiology, treat with antibiotics, wait, or limit contact sports (EBV for spleen rupture)
Patient with recent strep throat infection who presents with fever, chills, sore throat, trismus (hard to open mouth), drooling, and neck mass with uvular deviation and tonsillar petechiae. Dx and Tx?
• Dx: Rapid strep test with reflex culture along with physical exam
• Tx: The abscess must be drained. Depending on the size, start with direct drainage with a needle and syringe. If there still appears to be more pus or if the abscess is large to begin with, use a scalpel to make a hockey-stick incision to drain the pus.
• Long-term considerations: Follow-up to ensure resolution and be on the lookout for retropharyngeal abscess formation
What is a peritonsillar abscess?
Generally occurs after/during tonsillar infection. The peritonsillar area is formed of loose tissue, which is susceptible to abscess formation.
Difference between radical and modified radical neck dissection?
Preservation of SCM, jugular vein, and accessory nerve in modified radical.
How do you treat a thyroid storm?
IV hydration, cooling, PTU, acetaminophen, propranolol, and dexamethasone.
What are the Delphian lymph nodes?
Lymph nodes that the thyroid was believed drained into first and would act as sentinel or oracle (Oracle of Delphi predicting the future) nodes that would allow surgeons to tell if the malignancy had metastasized yet.
What are the notable side effects of PTU/methimazole?
Agranulocytosis and hepatotoxicity (among other milder effects).
What is the follow-up following total thyroidectomy for follicular or papillary carcinoma?
After a total thyroidectomy, the patient is placed on Cytomel (lithyronine; synthetic T3) instead of Synthroid (levothyroxine). After six weeks, Cytomel is stopped and a radionuclide scan is performed to look for remaining thyroid tissue (Cytomel is chosen because it has a much shorter half-life and so the patient will by hypothyroid for shorter and will have a more robust TSH response). If negative, patient is then put on Synthroid with thyroglobulin measured at one year (marker for papillary thyroid). If positive, radioactive iodine ablation with repeat radionuclide scans at 1, 3, and 5 years and then every 5 years.