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A CASE PRESENTATION

Anterior Neck Mass

GROUP IIIB
RANA, Bisnu
RECILLA, Elisha
SALOMON, Charisse
SAMONTE, Bea
SANGROULA, Pritam
SHAKYA, Migma
SHERPA, Pasang
SHRESTHA, Aimi
SHRESTHA, Amir

DANGAL, Prakash
DONGOL, Sajani
BINOS, Ran
DONES, Melisa

I. GENERAL DATA

AB
64 years old
Female
CC: anterior neck mass of 6 weeks
duration

II. CHIEF COMPLAINT


Anterior neck mass of 6 weeks
duration

III. HISTORY OF PRESENT


ILLNESS
6 weeks PTA,
3X3 cm hard, non-nodular, non-tender,
movable, mass on his R anterior neck
Consult
antibiotics for 2 weeks

HISTORY OF PRESENT
ILLNESS
3 weeks PTA
Mass approximately 8 X 6 cms
dysphagia to solid foods, soft diet
started
voice change
consult

HISTORY OF PRESENT
ILLNESS
5 days PTA
Patient returns with results
CXR: clear lungs, Atherosclerotic aorta

: noted soft tissue density


overlying the
right
: lateral portion of the lower
cervical spine

HISTORY OF PRESENT
ILLNESS

Ultrasound:
-Large thyroid mass, right
(103.6 X 56.6 X 117.9 mm)
-Enlarged left thyroid lobe
(68.1 X 32.5 X 25.7 mm) with increased
vascularity, which may be due to
neoangiogenesis.
-Bilateral jugular LN and left
supraclavicular LN, most likely
metastasis

HISTORY OF PRESENT
ILLNESS
Patient advised to have FT4 and TSH done
Few hours PTC,
Patient now complains of dyspnea
especially in the recumbent position
Patient also notes further enlargement
of the mass from first consult.
Progression of dysphagia
Results: FT4 = 0.72 mg/dL
TSH = 18.8 IU/ml

IV. PAST MEDICAL


HISTORY
Appendicites: S/P Appendectomy
Hypertension

V. FAMILY HISTORY

(+) CVD,
(+) Asthma
(+) Goiter
(-) History of Cancer

VI. PERSONAL and


SOCIAL HISTORY
Smoker (1.5 packs/day, stopped 15
years)
Occasional Alcohol Intake

VII. PHYSICAL
EXAMINATION
General Survey: Conscious, coherent, NIRD
Vital Signs: BP: 160/90, HR: 78, RR: 24, Temp:
37.0 C
HEENT: Normocephalic, Pink palpebral
conjunctivae, anicteric sclerae, pupils 2-3mm
EBRTL
Neck: (+) 12X10cm firm, solid, non-tender, nonmovable mass at the right anterior aspect
displacing the trachea to the left
: Left thyroid measure about 7X3 cms, solid,
firm,
movable, non-tender
: Multiple lymphadenopathies along the SCM,
bilaterally, and the left supraclavicular area.

PHYSICAL EXAMINATION
Chest/Lungs: Symmetric chest
expansion, no retraction, clear breath
sign
CVS: Adynamic precordium, normal
rate, regular rhythm
Abdomen: Soft, non- tender
Extremities: No gross deformities, full
and equal pulse

VIII. SALIENT FEATURES

64 years old, Female


Increasing anterior neck mass
Change in voice
Dysphagia to solid foods, soft diet started
Smoker (1.5 packs/day, stopped 15 years)
High TSH level (18.8 IU/ml)

SALIENT FEATURES
(+) 12X10cm firm, solid, non-tender,
non-movable mass at the right anterior
aspect displacing the trachea to the
left : Left thyroid measure about 7X3
cms, solid, firm, movable,
nontender, Multiple lymphadenopathies
along the SCM, bilaterally, and the left
supraclavicular area.

SALIENT FEATURE
CXR: clear lungs, Atherosclerotic aorta;
noted soft tissue density overlying the
right; lateral portion of the lower
cervical spine

IX. INITIAL DIAGNOSIS


Thyroid Carcinoma stage IVC

X. DIFFERENTIAL
DIAGNOSIS
Diagnosis
Rule- In
Rule- Out
1. Thyroiditis
2. Goiter

Anterior neck mass


Change in voice
Dysphagia

3. Thyroglossal cyst

Anterior neck mass


Movable

4. Thyroid
Carcinoma

Rapid growth
Hard mass
Smoker

Fast growing neck


mass
Age 64 years old
Hard
Fast growing mass
Movable mass

XI. COURSE IN THE WARD


FNAB was done awaiting result
Referral to ENT for direct
laryngoscope
Fiberoptic laryngoscopy
(+) Bulging of the right pharyngeal wall and
epiglottis
Vocal cords were difficult to visualize,
phonation was necessary

Incision biopsy was done

XII. FINAL DIAGNOSIS

CASE
DISCUSSION

I. Anatomy
Color: brownish-red
Consistency: firm
Location: Ant neck at C5-T1,
overlays 2nd 4th tracheal rings;
posterior to the strap muscles
Ave weight: approx. 20 g
Synthesize, stores, release T3 &
T4 (triiodothyronine & thyroxine,
respectively)

BLOOD SUPPLY
SUPERIOR THYROID
ARTERY
(SCA)
INFERIOR THYROID
ARTERY
(ITA)
THYROIDEA IMA ARTERY

VENOUS SUPPLY
SUPERIOR THYROID
VEIN
MIDDLE THYROID
VEIN
INFERIOR THYROID
VEIN

NERVE SUPPLY
RECURRENT LARYNGEAL
NERVE
Left and Right RLN
Innervate all intrinsic muscles
except cricothyroid muscle
(external laryngeal nerve)
Injury to one RLN- Paralysis of
the ipsilateral vocal cord
( paramedian- normal, week
voice , abducted- hoarse
voice and ineffective cough)
Bilateral RLN injury- airway
obstruction, loss of voice

NERVE SUPPLY
Superior laryngeal nerves

inability to tense the ipsilateral vocal cord


difficulty

"hitting high notes


projecting the voice
voice fatigue during
prolonged speech

LYMPHATIC
Upper group: into prelaryngeal
and upper deep cervical
(jugulodigastric) lymph nodes.
Lower group: into pretracheal
and lower deep cervical lymph
nodes& nodes along the
recurrent laryngeal nerves.
Those from lower part of
isthmus drain into retrosternal
or brachiocephalic nodes in the
superior mediastinum.

HISTOLOGY
The follicular cells are
cuboidal epithelial cells
forming the wall of spherical
thyroid follicles. They secrete
two hormones: thyroxine and
triiodothyronine.
The parafollicular cells or Ccells lie between the
basement membrane and
the follicular cells. They
secrete a hormone called
thyrocalcitonin (or
calcitonin).

II. PHYSIOLOGY

SYNTHESIS, STORAGE &


SECRETION

1. Thyroglobulin production by follicular cell and


released into colloid by exocytosis
2. Iodine uptake by follicular cell from the blood
and transferred to colloid
3. Attachments of iodine to tyrosine on
thyroglobulin in colloid
4. Coupling processes between the iodinated
tyrosine molecules to form T4 and T3
5. Secretion (upon stimulation) of T4 and T3 occurs
by endocytosis a piece of colloid, uncouplingof T4
and T3 and diffusion out of the follicular cell into
the blood

SYNTHESIS, STORAGE &


SECRETION

III. DIAGNOSTIC TESTS


1. Thyroid Function Test

TSH, FT4, FT3

2. Ultrasound
3. FNAB
4. Thyroid scan

THYROID FUNCTION TEST


Serum TSH
Most sensitive and specific test
Reflect ability of the anterior pituitary to
detect free T4 levels
Free T4 and Free T3 Assay
Measure the biologically active thyroid
hormones which cause the clinical
manifestation

THYROID FUNCTION TEST

ULTRASOUND
Main advantage: determine consistency of
mass
Simply cyst = thyroid cyst (purely fluid)
Complex cyst = goiter
Solid nodule = tumor

Noninvasive, no radiation exposure

THYROID IMAGING
Radionuclide Imaging
Both iodine -123 and Iodine -131 are
used to image the thyroid gland
The images provide not only about the
size and shape of the gland, but also the
distribution of functional activity

THYROID IMAGING
Iodine - 123
Emits low dose radiation
Has a half-life of 12-14 hours
Used to image lingual thyroids or goiter

Iodine 131
Use leads to a higher dose radiation exposure
Half life of 8 10 days
Use to screen and treat patients with
differentiated thyroid cancers for metastatic
disease

FINE-NEEDLE ASPIRATION
BIOPSY (FNAB)
Most important test in thyroid masses
specially if one nodule predominates, or
painful or has recently enlarged. To rule out CA
With or without ultrasound guidance
23 or 25-gauge needle
Immersed 70% alcohol solution
Air dried
Stained
Papanicolaous stain
Wrights stain

IV. TYPES
INCIDENCE
PAPILLARY

80% in
iodinesufficient
areas
Children and
individuals
exposed to
external
radiation
2:1 femaleto-male
ratio
Mean age:
30 to 40
years

FOLLICULAR

ANAPLASTIC

10% of
<5% of
thyroid
thyroid
cancers
cancers
Occur more Women are
commonly
more
in iodinecommonly
deficient
affected
areas
7th and 8th
decade of
3:1 femaleto-male
life
ratio
Mean age :
50 years old

MEDULLARY

5% of
thyroid
cancers
Unilateral
(80%)
Derived from
the
parafollicular
cells
Occurs in the
setting of
MEN
syndrome 2A
or 2B

CLINICAL MANIFESTATIONS
PAPILLARY

FOLLICULAR

Most
patients are
euthyroid
Slow-growing
painless
mass in the
neck
(+)
Dysphagia,
dyspnea,
and
dysphonia
Lymph node
metastases
are common
Distant
metastases
are
uncommon
at initial

Present as
solitary thyroid
nodules
History of rapid
size increase,
and longstanding goiter
Painless
cervical
lymphadenopa
thy is
uncommon
Distant
metastases
may be
present
<1% of cases,
follicular
cancers may
be

ANAPLASTIC

MEDULLARY

Long Initial
standing
manifestation
neck mass
s are those of
a
Rapidly
enlarges and
paraneoplasti
may be
c syndrome
painful
Dysphonia,
dysphagia,
and dyspnea
are common
Lymph nodes
usually are
palpable at
presentation
metastatic
spread also
may be
present

V. MANAGEMENT