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)
- Solitary
- Functioning – Cool off with PTU, Betablockers, Iodine then surgery (131I not to be used in young women)
- 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