case of a child with front neck swelling has been described along with follow up plans and pathological correlation of the disease.

1. Clinicopathological conference
Department of General Surgery ,Pathology , Internal Medicine and
Anaesthesiology
Speaker
Dr Pooja Pandey
Surgery PG Resident -1st Year
Department of general surgery
MIMS,Barabanki
Moderator
Dr A.K.Srivastava
Professor
Department of general surgery
MIMS , Barabanki
Head Of the Department -DR.N.K.Gupta
Department of general surgery
MIMS,Barabanki
Date-22.2.2021

2. Particular of the patient
Name- Baby kajal
Age/Sex -6yrs/F
Father’s name-Mr. Balram
Address- Raniyamau , Barabanki Uttar Pradesh, India
Mobile no-7275152069
Reporting department – Emergency
Date of reporting-25.12.20
Time-12.10pm
C.R.No- 2012250030

3. Chief complaints
 Swelling in front of the neck for 6 months.

4. History of present illness
The patient was apparently well 6 months back .Incidentally her parents
noticed swelling of about pea size in front of the neck .The swelling was
gradually increasing in size and initially localize in front of the neck .
Gradually the swelling grew towards the left side of the neck and then
towards the right side and overall attained a shape of butterfly .

5.  The swelling doesn’t increase in size while having cough ,blowing her nose and
drinking liquids .
 It is not interfering her neck movements .
 No history of trauma or discharge present from the swelling .
 No history of infection in ear ,nose, eye , throat, sinuses ,mouth , gum , teeth.
 No history of swelling underneath the tongue.
History of present illness contd…

6.  It is not associated with pain ,fever
 It is not associated with difficulty in breathing ,difficulty in swallowing.
 It is not associated with alteration in voice
 It is not associated with chest pain, hemoptysis ,bone pain , headache
and seizure .
History of present illness contd….

7.  Appetite of the patient is normal.
 There is no history of tiredness, lethargy ,weight gain , cold
intolerance , constipation , swelling of legs .
 There is no history of weight loss, heat intolerance , palpitation ,
tremor , excessive sweating , muscle weakness , difficulty in
climbing stairs , sadness ,crying , excitability and diarrhea .
 Normal bowel habits reported.
History of present illness contd….

8. Past history
 There is no past history of hypertension ,diabetes mellitus ,
tuberculosis , thyroid disorder .
 No history of radiation till now.
 No any history of surgical intervention.

9. Family history
 There is no family history of thyroid disorder ,Hypertension ,diabetes mellitus
and tuberculosis .
 There is a history of intake of Gota namak ( gotta salt ) in their diet .
 Antenatal period of her mother’s was uneventful and took all antenatal care
given at PHC. No history of birth injury.
Farmer Housewife
9yrs,primary
school(neck swelling
x1months)
6yr,non
school
goer
4yr,non
school
goer

10. Personal history
Mixed diet.
Normal bladder and bowel movement.
Normal sleep pattern.
 Developmental milestones attained at time .
Actively plays with her sibblings and talkative .
Non school goer (father went for admission last year at government school
but due to covid pandemic it got postponed)
There are no sign and symptoms of any precocious puberty .

11. Allergy and medication history
No history of allergy to any drug and food.
No any history of treatment for the neck swelling in the past .
She has not being taking any drugs before visiting our set up.

12. General physical Examination
 Child is active , co-operative and obeying commands of her father.
 Skin condition –dry
 Eyeball –normal
 Eyebrow –normal on both sides
 No lid lag
 Skin creases over forehead –present
 No pallor , icterus, clubbing, cyanosis, oedema, dehydration and
lymphadenopathy (except cervical lymph nodes)
 Tremor- absent

13. General Examination
 Weight-15kg
 Height-1.05mt
 Body mass index-13.6kg/mt2
 Head circumference-47cm
 Temperature-97.6degree F
 Blood Pressure- 118/78mmHg (sitting posture)
 Pulse rate -88/min regular in rate and rhythm and normal in
volume and character.(not sleeping pulse)
 Respiratory rate -16/min
 SpO2-99%at room air.

14. Systemic Examination
Central Nervous System- conscious , oriented
no neurological deficit
Respiratory System – Bilateral air entry present
Bronchovesicular breathing sound .
No added sound
Cardio Vascular System- S1,S2 heard
No murmur
Abdominal examination- Soft ,non tender ,no distension
no organomegaly
Bowel sound present .

15.  Examination of scalp , face , oral cavity , back of
the neck and spine done which is normal

16. Local Examination
 On inspection – swelling is seen in front and sides
of the neck in the thyroid region.
 Butterfly shape
 Extending 5cm below the chin and1cm above the
suprasternal notch .
 Swelling moves on deglutition but do not moves
with protrusion of tongue .
 Skin over the swelling is normal , no visible
pulsation is noticed.
 Back of the neck is normal ,no skin pigmentation.

17. On palpation
 No local rise in temperature over the swelling .
 Swelling is firm in consistency on left side and softer on
right side .
 Swelling is extending upto the upper border of the
thyroid cartilage above and below upto the suprasternal
notch . Isthmus is 2x1cm in the midline ,left side of
swelling is 4x2cm extending till the left medial border of
the sternocleidomastoid ,right side swelling is 2x1cm
extending till the right medial border of
sternocleidomastoid.
 Surface of the swelling is nodular on left side and on
right side it is smooth .
 The margins are rounded both sides.
 Skin over the swelling is free .
 Trachea is in the mid line

18. On palpation continued
 Lymph node of left cervical level II,III and IV and right cervical level II is
present.
 Lymph node of both side is round in shape , smallest one is 1cm and
largest one is 1.5cm ,soft in consistency , multiple in number (Level II-
[2Left and Right -3],Level III-1,Level IV-2) ,non tender and non matted.

19. Right
Left

20. Non tender.
 Carotid pulsation of both side was palpable .
Kocher’s test – negative
No venous prominence , visible pulsation over the swelling .
On palpation continued

21. On Percussion
Superior mediastinum is resonant
On Auscultation
No audible bruit

22. Provisional Diagnosis
 Multinodular goiter.

23. Investigations done
 Complete Blood count
 Thyroid profile –T3,T4 and TSH
 S.Calcium
 Ultrasound of neck
 Chest Xray PA view

24. Complete blood count
 Haemoglobin- 13.7gm/dl
 Total leucocyte count- 7500cells/mm3
 Platelet count- 2.48lakh/mm3
 Differential count –N39 L48 E10 M3 B0

25. Thyroid profile and S.Calcium
 Triiodothyronine total (T3)- 0.37ng/ml (Ref-1.05-2.07)
 Thyroxine total (T4)- 1.10microgm/dl (Ref- 6.1-12.6)
 Thyroid stimulating hormone (TSH) - >150micro IU/ml
(Ref- 0.37-5.90)
 S.Calcium- 11.38 mg/dl (Ref -8.2-16.5)

26. Ultrasound of the neck
Left lobe of thyroid –hyperechoic nodule (TIRADS3)-well defined
smooth outline,size-38x37mm,predominantly solid with cystic
component ,no micro/macrocalcification/any echogenic foci seen.
Isthmus 14mm and right lobe 27mm are bulky with few ill defined
isoechoic nodular lesions.
Multiple subcentimetric left sided neck lymph nodes noted.
Impression – Feature of multinodular goiter, showing largest nodule
in left lobe (TIRAD3)
Multiple subcentimetric left sided neck lymph nodes are noted.

27. Treatment given
T. Thyroxine 25 microgram 1 tab one daily in an empty stomach
Syrup multivitamin 5ml twice daily

28. After 1 month of thyroxine(25microgram) there is
reduction in size of the swelling ,TSH 5microIU/ml and
baby found to be active than seen in an emergency

29. Fine needle aspiration biopsy done
Follicular neoplasm Bethesda category IV

30. On Second visit after FNAC

31. Discussion

32.  Thyroid diseases are common worldwide.
 In India too, there is a significant burden of thyroid diseases.
 According to a projection from various studies on thyroid disease, it has been estimated
that about 42 million people in India suffer from thyroid diseases.
 Thyroid diseases are different from other diseases in terms of their ease of diagnosis,
accessibility of medical treatment, and the relative visibility that even a small swelling of
the thyroid offers to the treating physician.
 Early diagnosis and treatment remain the cornerstone of management.
Introduction
Ambika Gopalakrishnan Unnikrishnan, Usha V. Menon
Indian J Endocrinol Metab. 2011 Jul; 15(Suppl2): S78–S81. doi: 10.4103/2230-8210.83329

33. Clinical embryology
Langman’s medical embryology 12th edition chapter 17 pg -272-275

34. Clinical embryology contd…
Langman’s medical embryology 12th edition chapter 17 pg -272-275

35. Clinical embryology contd…
Langman’s medical embryology 12th edition chapter 17 pg -272-275

36. Clinical correlates contd…
Langman’s medical embryology 12th edition chapter 17 pg -272-275

37.  The normal thyroid gland weighs 20–25
g.
 The functioning unit is the lobule
supplied by a single arteriole and
consists of 24–40 follicles lined with
cuboidal epithelium.
 The follicle contains colloid in which
thyroglobulin is stored
Surgical anatomy
Bailey &Love 27th edition chapter 50 pg no 801

38. Anatomy of thyroid gland
The arterial supply is
rich, and extensive
anastomoses occur
between the main
thyroid arteries and
branches of the
tracheal
and oesophageal
arteries

39. Bailey &Love 27th edition chapter 50 pg no 802
 There is an extensive lymphatic network
within and around the gland.
 Although some lymph channels pass
directly to the deep cervical nodes, the
subcapsular plexus drains principally to
the central compartment juxtathyroid –
‘Delphian’ and paratracheal nodes and
nodes on the superior and inferior thyroid
veins (level VI),and from there to the deep
cervical (levels II, III, IV and V) and mediastinal
groups of nodes (level VII)

40.  The relationship between the recurrent laryngeal nerve (RLN) and the thyroid is of
supreme importance to the operating surgeon.
 A branch of the vagus, the nerve recurs round the arch of the aorta on the left and
the subclavian artery on the right.
 The clinical significance of this is that on the left the nerve has more distance in
which to reach the tracheoesophageal groove and therefore runs in a medial
plane.
 On the right, there is less distance and the nerve runs more obliquely to reach the
tracheoesophageal groove.
Schwartz’s principle of surgery 11th edition pg no 1654-1687

41. Along their course in the neck, the
RLNs may branch, and pass anterior,
posterior, or interdigitate with branches of the
inferior thyroid artery (Fig. 38-3). The
right RLN may be nonrecurrent in 0.5% to 1% of
individuals
and often is associated with a vascular
anomaly. Nonrecurrent
left RLNs are rare but have been reported in
patients with situs
inversus and a right-sided aortic arch
The RLNs terminate
by entering the larynx posterior to the
cricothyroid muscle
Schwartz’s principle of surgery 11th edition pg no 1654-1687

42.  Approximately mately 2% of nerves on the right are non-recurrent and will enter the
larynx from above.
 The nerve runs posterior to the thyroid and enters the larynx at the cricothyroid joint.
This entry point is at berry’s ligament a condensation of pretracheal fascia that binds
the thyroid to the trachea. This is the point at which the nerve is at most risk of injury
during surgery. In terms of surgical anatomy, the nerve can be located in the
tracheosophageal groove where it forms one side of Beahrs’ triangle (the other two
sides are the carotid artery and the inferior thyroid artery) or at the cricothyroid joint.
 The nerve will normally be found as the thyroid lobe is mobilised laterally, lying under
the most posterolateral portion of the gland called the tubercle of Zuckerkandl.
Schwartz’s principle of surgery 11th edition pg no 1654-1687

43. Synthesis ,storage and secretion of thyroid hormone
K.D.Tripathi pharmacology pg no 246

44. Regulation of thyroid function
K.D.Tripathi pharmacology pg no 248

45. THYROID ENLARGEMENT
 The normal thyroid gland is impalpable. The term goitre (from the Latin guttur
= the throat) is used to describe generalized enlargement of the thyroid
gland.
 A discrete swelling (nodule) in one lobe with no palpable abnormality
elsewhere is termed an isolated (or solitary) swelling.
 Discrete swellings with evidence of abnormality elsewhere in the gland are
termed dominant.
Med Clin North Am.2012March ;96(2):329-349.doi:10.1016/j.mcna.2012.02.002

46. Classification of thyroid swelling
Bailey &Love 27th edition chapter 50 pg no 801

47.  Any enlargement of the thyroid gland is referred to as a goiter.
 Goiters may be diffuse, uninodular, or multinodular. Most nontoxic goiters are
thought to result from TSH stimulation secondary to inadequate thyroid
hormone synthesis.
 Elevated TSH levels induce diffuse thyroid hyperplasia, followed by focal
hyperplasia, resulting in nodules that may or may not concentrate iodine,
colloid nodules, or microfollicular nodules.
 The TSH-dependent nodules progress to become autonomous. Familial goiters
resulting from inherited deficiencies in enzymes necessary for thyroid hormone
synthesis may be complete or partial.
Multinodular goiter
Schwartz’s principle of surgery 11th edition pg no 1654-1687

48. Multinodular goiter etiology
Schwartz’s principle of surgery 11th edition pg no 1654-1687

49.  The term endemic goiter refers to the occurrence of a goiter in a significant
proportion of individuals in a particular geographic region. In the past, dietary
iodine deficiency was the most common cause of endemic goiter.
 This condition has largely disappeared in North America due to routine use of
iodized salt and iodination of fertilizers, animal feeds, and preservatives.
 However, in areas of iodine deficiency, such as Central Asia, South America,
and Indonesia, up to 90% of the population have goiters.
 Other dietary goitrogens that may participate in endemic goiter formation include
kelp, cassava, and cabbage.
 In many sporadic goiters, no obvious cause can be identified.
Schwartz’s principle of surgery 11th edition pg no 1654-1687

50.  Patients also describe having to clear their throats frequently (catarrh). Dysphonia from
RLN injury is rare, except when malignancy is present.
 Obstruction of venous return at the thoracic inlet from a substernal goiter results in a
positive Pemberton’s sign—facial flushing and dilatation of cervical veins upon raising
the arms above the head .
 Sudden enlargement of nodules or cysts due to hemorrhage may cause acute
pain.
 Physical examination may reveal a soft, diffusely enlarged gland (simple goiter)
or nodules of various size and consistency in case of a multinodular goiter.
 Deviation or compression of the trachea may be apparent.
Schwartz’s principle of surgery 11th edition pg no 1654-1687

51.  Diagnostic Tests
 Patients usually are euthyroid with normal TSH and low-normal or normal free T4
levels. If some nodules
 develop autonomy, patients have suppressed TSH levels or become
hyperthyroid.
 RAI uptake often shows patchy uptake with areas of hot and cold nodules.
 FNAB is recommended in patients who have a dominant nodule or one that is painful or
enlarging, as carcinomas have been reported in 5% to 10% of multinodular goiters.
 CT scans are helpful to evaluate the extent of retrosternal extension and airway
compression.
Schwartz’s principle of surgery 11th edition pg no 1654-1687

52. Schwartz’s principle of surgery 11th edition pg no 1654-1687

53.  Treatment Most euthyroid patients with small, diffuse goiters do not require
treatment.
 Some physicians give patients with large goiters exogenous thyroid hormone to
reduce the TSH stimulation of gland growth; this treatment may result in
decrease and/or stabilization of goiter size and is most effective for small diffuse
goiters.
 Endemic goiters are treated by iodine administration.
Schwartz’s principle of surgery 11th edition pg no 1654-1687

54. Surgical resection is reserved for goiters that
(a)continue to increase despite T4 suppression,
(b) cause obstructive symptoms,
(c) have substernal extension (considered a relative indication by
some groups),
(d) have malignancy suspected or proven by FNAB, and
(e) are cosmetically unacceptable.
Near-total or total thyroidectomy is the treatment of choice, and
patients require lifelong T4 therapy.
Schwartz’s principle of surgery 11th edition pg no 1654-1687

55. Schwartz’s principle of surgery 11th edition pg no 1654-1687

56. Schwartz’s principle of surgery 11th edition pg no 1654-1687

57. Follicular carcinoma of thyroid
 Follicular carcinomas account for 10% of thyroid cancers and occur more
commonly in iodine deficient areas.
 Women have a higher incidence of follicular cancer, with a female-to-male ratio
of3:1, and a mean age at presentation of 50 years old.
Schwartz’s principle of surgery 11th edition pg no 1654-1687

58.  Usually present as solitary thyroid nodules, occasionally with a history of rapid size
increase, and long-standing goiter.
 Pain is uncommon, unless hemorrhage into the nodule has occurred.
 Unlike papillary cancers, cervical lymphadenopathy is uncommon at initial presentation
(about 5%), although distant metastases may be present.
 In <1% of cases, follicular cancers may be hyperfunctioning, leading patients to present
with signs and symptoms of thyrotoxicosis.
Clinical presentation of follicular
carcinoma of thyroid
Schwartz’s principle of surgery 11th edition pg no 1654-1687

59. Hurthle Cell Carcinoma
 Hurthle cell carcinomas account for approximately 3% of all thyroid
malignancies and, under the World Health Organization classification,
are considered to be a subtype of follicular thyroid cancer.
 Hurthle cell cancers also are characterized by vascular or capsular
invasion and, therefore, cannot be diagnosed by FNAB.
Variant of follicular carcinoma
Schwartz’s principle of surgery 11th edition pg no 1654-1687

60. Hurthle cell tumors differ from follicular carcinomas in that they are more
often multifocal and bilateral (about 30%), usually do not take
up RAI (about 5%), are more likely to metastasize to local nodes
(25%) and distant sites, and are associated with a higher mortality
rate (about 20% at 10 years).
How it is different from follicular carcinoma?
Schwartz’s principle of surgery 11th edition pg no 1654-1687

61.  FNAB is unable to distinguish benign follicular lesions from follicular
carcinomas.
 Therefore, preoperative clinical diagnosis of cancer is difficult unless distant
metastases are present.
 Large follicular tumors (>4 cm) in older men are more likely to be malignant
Investigation of Follicular carcinoma of thyroid
Schwartz’s principle of surgery 11th edition pg no 1654-1687

62. A commonly used panel of seven genes used to “rule in” malignancy detects
mutations in
BRAF, Ras, RET/PTC, and PAX/PPARg and has been associated
with a sensitivity of 57% to 75%, specificity of 97% to 100%,
7 gene panel for Follicular carcinoma of
thyroid
Schwartz’s principle of surgery 11th edition pg no 1654-1687

63. Schwartz’s principle of surgery 11th edition pg no 1654-1687

64. Schwartz’s principle of surgery 11th edition pg no 1654-1687

65.  Patients diagnosed by FNAB as having a follicular lesion should undergo
thyroid lobectomy because at least 70% to 80% of these patients will
have benign adenomas.
 Total thyroidectomy is recommended by some surgeons in older patients
with follicular lesions >4 cm because of the higher risk of cancer in this
setting (50%) and certainly should be performed in patients with atypia on
FNA, a family history of thyroid cancer, or a history of radiation exposure.
 Intraoperative frozen-section examination usually is not helpful, but it should
be performed when there is evidence of capsular or vascular invasion or
when adjacent lymphadenopathy is present.
Treatment of follicular carcinoma of thyroid
Schwartz’s principle of surgery 11th edition pg no 1654-1687

66.  Prophylactic nodal dissection is not needed because nodal involvement is
infrequent, but in the unusual patient with nodal metastases, therapeutic neck
dissection is recommended.
 Prophylactic central neck dissection may be considered in patients with large
tumors.
Treatment of follicular carcinoma of thyroid
Schwartz’s principle of surgery 11th edition pg no 1654-1687

67.  The cumulative mortality from follicular thyroid cancer is approximately 15% at 10
years and 30% at 20 years.
 Poor long-term prognosis is predicted by age over 50 years old at presentation,
tumor size >4 cm, higher tumor grade, marked vascular invasion, extrathyroidal
invasion, and distant metastases at the time of diagnosis
Prognosis of Follicular carcinoma of thyroid
Schwartz’s principle of surgery 11th edition pg no 1654-1687

68. Thank you