Head and Neck Disease

Differential diagnosis

  • Thyroid (benign, malignant)
  • Thyroglossal duct cyst
  • Brachial cleft cyst
  • Lymph nodes (reactive, lymphoma)
  • Parotid (infectious, obstructive, malignant)
  • Lipoma
  • Sebaceous cyst

History
OLDSCARS and mass changes

  • Compression: dysphagia, SOB, hoarseness, stridor
  •  B symptoms (wt loss, fevers/chills, night sweats)
  • Risk Factors: Family History, Radiation History (Belarus, Kazakstan), smoking, personal Hx (breast, lung, kidney, melanoma), recent infections, thyroiditis (Hashimoto’s is a RF for lymphoma)
  • Hyperthyroid (heat intolerance, wt loss, eye changes, diarrhea, sweaty, tremor)
  • Hypothyroid (fatigue, wt gain, constipation, slowed mentation, coarse/brittle hair)
  • PMHx and PSHx, Rx (PTU, synthroid, Li, beta-blockers), Allergies

Physical Exam

  • Vitals
  • Inspection: Hands (onycholysis, tremor), Eye findings, Thyroid (at rest and with swallowing), Neck (stick out tongue), Systemic findings of thyroid disease (pre-tibial myxedema), Groin/other masses
  • Palpation:  thyroid (size, mobility, tender, consistency, singular/confluence), LN (occipital, post auricular, pre auricular, submandibular, submental, ant and post cervical chains, supra and infraclavicular), Delphian nodes felt at the hyoid can indicate carcinoma or subacute thyroiditis
  • Substernal goitre – percuss manubrium, look for dilated vasculature, tracheal deviation, Pemberton’s
  • Auscultation – thyroid bruits (heard in thyrotoxicosis; R/O cardiac origin)

Thyroid masses

  • Benign
    • Functioning – Cool off with PTU, Betablockers, Iodine then surgery (131I not to be used in young women)
      • Toxic adenoma
      • Grave’s
      • Acute thyroiditis
      • Toxic goiter
    • Non-functioning
      • Solitary
        • Colloid
        • Adenoma
      • Multiple
        • Multinodual goiter (4 cm)
  • Malignant
    • Papillary – 80%, non-aggressive, psammoma bodies, lung/bone mets, palpable LN (lymphatic spread), post-op 131I
    • Follicular – 10%, female>male, spread by blood, lung/bone/liver mets
    • Medullary – 5%, amyloid, calcitonin secreting, FHx, stimulate with pentagastin (MEN IIb, MEN IIa)
    • Anaplastic –1-2%, women, rapid growth, painful, cervical LA and lung mets, local recurrence

Approach

  • Red flags
    • > 2 cm
    • > 40 y.o.
    • Male
    •  Solitary/dominant
    • Spread (lung, nodes)

What to do next?
Fine Needle Aspiration — (25gauge needle x 4, 10 strokes/needle with 1 pass through skin, on slides and into liquid media RPMI – complications include bleeding, infection, RLN injury, airway injury, esophageal injury, seeding cancer 0.02%); Ultrasound (size and nodal involvement), TSH

Risks of surgery

  • Recurrent laryngeal nerve damage
  • Airway compression
  • Abnormal PTH

Lynphoma (Ddx – cat scratch disease or Bartonella, phenytoin and drug reaction, lymphoma, reactive LN)

  • Staging: CXR, CT abdo/pelvis, BM biopsy, LP (high risk morphology)
  • Hodgkin’s – Reed Sternberg cells on smear, bimodal distribution (20’s, >50’s)
    • Painless mass (neck)
    • B symptoms (Night sweats, fever, weight loss)
    • Generalized pruritis
    • Pain in involved LN following EtOH

Ann Arbour Staging
Stage I – one LN region
Stage II – two LN areas on one side of diaphragm
Stage III – LN on both sides of the diaphragm
Stage IV – Disseminated with bone marrow or liver involvement
A. No B symptoms
B. B symptoms

Treatment: Chemo (ABVD for Hodgkin’s, R-CHOP for Non-Hodgkin’s), and Radiotherapy
Thyroglossal duct cyst

  • Embryology: thyroid buds off foregut diverticulum at base of tongue – foramen cecum (3 wk embryonic age), moves anteriorly and caudad, descent connected to development of hyoid bone
  • Residual tissue in midline neck –at or below hyoid bone, moving with tongue protrusion
  • Usual age: 2-4 years old
  • Do a nuclear scan to determine if it is the pt’s only thyroid tissue
  • Treatment: Sistrunk operation – resect cyst in continuity with central portion of hyoid and tract connecting to base of pharynx., and ligate foramen cecum

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