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