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Neck mass

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Approach of Neck mass for medical student with quiz

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Neck mass

  1. 1. THE NECK MASS General Sx Topic Reviewed and present by Mr. Patinya Yutchawit, Miss Kaewalin Thongsawangjang, Miss Withunda Akaapimand, Miss Rattanaporn Sirirattanakul, Miss Tritraporn Sawantranon, Mr. Yotdanai Namuangchan, Mr.
  2. 2. THYROID Introduction and anatomy
  3. 3. Follicles -> Lobule Principal cells (ie, follicular) formation of the colloid (iodothyroglobulin), Parafollicular cells :calcitonin
  4. 4. Superior thyroid artery Inferior thyroid artery Thyroidima artery
  5. 5. Superior thyroid artery Inferior thyroid artery Thyroidima artery
  6. 6. Superior thyroid vein Middle thyroid vein Inferior thyroid veins
  7. 7. Nerve Parasympathetic fibers vagus nerves Sympathetic fibers : superior, middle, and inferior ganglia of the sympathetic trunk.
  8. 8. APPROACH TO NECK MASS Start
  9. 9. access • Origin • Cause
  10. 10. Hx • ความชุกชุมของโรค • อายุ • เพศ • ระยะเวลา • ความเจ็บปวด • อาการทั่วไป : ไข้ อ่อนเพลีย เสียงแหบ กลืนลาบาก ไอเลือดปน น้ามูก ปนเลือด หูอื้อข้างเดียว เลือดกาเดาไหลบ่อย แน่นจมูก แผลที่ศีร ะ คอ ช่องปาก ลิ้น
  11. 11. PE • Local examination • Regional examination • General examination
  12. 12. Local examination • Location • Size > 1.5 cm , <1.5cm. 2ข้าง • Shape • Surface • Consistency • Tenderness • Fluctuation • Tranlumination • Attachment • Skin • Punctum • Pulsation • Miscellaneaeous: move follow tongue prtusion,swallowing
  13. 13. Location Mid line Ant. Triangle Post. Triangle Congenital -thyroglossal duct cyst -dermoid cyst -laryngocele Inflammation -adenditis Tumor -thyroid -lymphoma Other -sternocleidomastoid hematoma/fibroma Congenital -brachial cleft cyst -thymic cyst -sialadenopathy (parotid,submandibular) Inflammation -adenitis(viral,bact., glanulomatous) -sialadenitis Tumor -metastasic -upper jugular -submandibular -middle jugular -lymphoma -vascular(carotid tumor, hemangioma) Other - False aneurysm Congenital -lymphangioma Inflammation -adenitis(viral,bact., glanulomatous) Tumor -lymphoma -metastatic -supraclavicular Other Neuroma
  14. 14. investigation • Blood – CBC, ESR, LFT, Ca, heteropliie Ab, HIV Ab, EBV Ab • Imaging – X-ray, U/S, CT, MRI (submucosal),radionuclide scan – sialography • Cytology – FNA • Tissue – biopsy
  15. 15. THYROGLOSSAL DUCT CYST
  16. 16. THYROGLOSSAL DUCT CYST Neck mass that develops from cells and tissues remaining after the formation of the thyroid gland during embryonic development
  17. 17. Pathogenesis • The primitive thyroid descended from its origin at the base of the tongue to its permanent location, low in the neck. Failure of subsequent closure and obliteration of this tract predisposes to thyroglossal cyst formation.
  18. 18. Types of thyroglossal duct cysts –Infrahyoid type : 65 % –Suprahyoid type : 20 % –Juxtahyoid cysts : 15 % –Intralingual location –Suprasternal variety –Intralaryngeal
  19. 19. Clinical presentation • A small,soft,round mass in the midline of neck • Mass rise with swallowing or protrusion of the tongue •It is most commonly diagnosed in preschool- aged children or during mid-adolescence
  20. 20. CLINICAL PRESENTATION Infected cysts may manifest as tender masses with Dysphagia Draining sinus Fever Enlarging neck mass
  21. 21. Diagnosis • Clinical : upward when tongue is extended and swallowing • Contain thyroid tissue – TFT – Thyroid scan –Ultrasound
  22. 22. a midline infrahyoid unilocular mass with a homogeneously hypoechoic internal echotexture, typical of a TDC.
  23. 23. Pathology • Cyst cavity and thyroid tissue On rare occasion, turn to carcinoma
  24. 24. Treatment • Antibiotic if infected • Surgery : Sistrunk’s Operation - Removal of the cyst, the tract, and the central portion of the hyoid bone as well as a portion of the tongue base up to the foramen cecum.
  25. 25. Solitary thyroid nodule Euthyroid Hyperthyroid FNA biopsy cytology I-131/Sx FSH,FT3 Hot nodule Cold nodule TMG Thyroid scan TSH FT3 FNA Reaspirate Benign Solid/Mix NegativeSuspiciousPositive Malignant Hormone suppressive,F/U Sx Sx LobectomySx +/- I-131 Cyst
  26. 26. GRAVE’S DISEASE
  27. 27. Graves’ Disease • Graves’s disease , Primary toxic goiter , Basedow’s disease , Exopthalmicgoiter • autoimmune disease : antibody against the thyroid-stimulating hormone (TSH) receptor (Thyroid stimulating immunoglobulin ,TSI) stimulates the gland to synthesize and secrete excess thyroid hormone • Characterized by hyperthyroidism, diffuse goiter, opthalmopathy and, sometimes, dermopathy. • Most common cause of hyperthyroidism
  28. 28. Age: 20-50 years Sex: female : male 7-8:1 60-90% of all causes of thyrotoxicosis 100-200 cases /100,000 population /year EPIDEMIOLOGY
  29. 29. • 50 % Genetic inheritance • Other factors, such as smoking, sex steroids, life stresses, and dietary iodine intake, bacterial or viral infection are possible causes of Graves’ disease ETIOLOGY
  30. 30. • 1.Increase metabolic rate of all cells • 2.Increase sensitivity of beta-adrenergic receptors • 3.Stimulate all cells to grow Thyroid hormone effects
  31. 31. Metabolic: ravenous appetite, weight loss, excessive sweating, heat intolerance CVS: Palpitations, shortness of breath, tiredness, irregular heart beat CNS: irritability, insomnia, depression CLINICAL
  32. 32. • GI: Change in appetite and weight, Increase frequency of bowel movement, diarrhea • RP: reduction in the quantity of menses, amenorrhea, decreased fertility, increased incidence of miscarriages • MS: wasting and weakness of small muscle of hand, shoulder, face
  33. 33. • GA: looks thin and wasting of face and hands, sweating • CVS: tachycardia at rest, persist during sleep. AF, collapsing pulses, heart failure • CNS: fine tremor • Skin: warm and moist, pretibial myxedema • MS: muscle wasting, proximal muscle weakness, hyperactive tendon reflex, digital clubbing Physical examination
  34. 34. • Signs in the neck Diffused, symmetrically enlarged thyroid gland Systolic bruit audible over its lateral lobe,palpable thrill • Signs in the eyes Lid retraction and lid lag Exopthalmos Ophthalmoplegia: proptosis, limitation of upward and latral gaze Chemosis: conjunctival swelling and congestion Physical examination
  35. 35.  Thyroid function test High T3, T4 ; Low TSH  Thyroid stimulating antibodies (TSAb)  123I uptake and scan : Increase Diagnostic tests
  36. 36. •Medication •Radioactive 131I •Thyroidectomy Management
  37. 37. • Beta blocker : Propranolol 20-40 mg qid offer relief of the adrenergic symptoms of hyperthyroidism such as tremor, palpitations, heat intolerance, and nervousness Medication
  38. 38. • Reserve for - Small, non toxic goiters less than 40 g - Mildly elevated thyroid hormone levels - Rapid decrease in gland size with antithyroid medication • PTU: 100-300 mg tid • MMI: 10-30 md tid, then once daily • Side effects: skin rash, fever, vasculitis,rarely agranulocytosis, aplastic anemia • High relapse rate when discontinued drug 1-2 year (40- 80%) Antithyroid drugs Medication
  39. 39. • Recommended in - Older patients with small or moderate-size goiter - Relapse after medical or surgical therapy - Antithyroid drugs or surgery are contraindicated Radioactive Iodine therapy
  40. 40. • Woman who are pregnant or breastfeeding Relative contraindications • Children and adolescent • Patient with thyroid nodule • Patient with ophthalmopathy Absolute contraindications Radioactive Iodine therapy
  41. 41. Recommend in - RAI is contraindication - Have confirmed cancer or suspicious thyroid nodules - Young - Pregnant or desire to conceive soon after treatment - Severe reaction to antithyroid medication or poor compliance - Large goiters causing compressive symptoms or for cosmetic reason - Reluctant to undergo RAI therapy Surgical treatment
  42. 42. • Euthyroid by continue antithyroid drug until the day of surgery • Lugol’s iodine solution or saturated K iodine 3 drops bid for 7-10 day preoperatively → reduce vascularity of gland and decrease risk of precipitating thyroid storm Prep. For surgery
  43. 43. Hemithyroidectomy - Entire isthmus is removed along with 1 lobe. Done in benign diseases of only 1 lobe. Subtotal thyroidectomy- Done in toxic thyroid, primary or secondary, and also for toxic multinodular goiter (MNG). Partial thyroidectomy - Removal of gland in front of trachea after mobilization. Done in nontoxic MNG. Its role is controversial. Near total thyroidectomy- Both lobes are removed except for a small amount of thyroid tissue (on one or both sides) in the vicinity of the recurrent laryngeal nerve entry point and the superior parathyroid gland. Done in papillary thyroid carcinoma. Total thyroidectomy- Entire gland is removed. Done in case of follicular carcinoma of thyroid, medullary carcinoma of thyroid. Hartley Dunhill operatio - Removal of 1 entire lateral
  44. 44. • Total or near total thyroidectomy - Coexistent thyroid cancer - Refuse RAI - Severe ophthalmopathy - Life threatening reaction to antithyroid medication e.g. vasculitis, agranulocytosis, liver failure * High rate of hypothyroidism • Subtotal thyroidectomy (4-7 g remain) - All remaining patients Higher recurrent rate of hyperthyroidism
  45. 45. Bleeding Hypocalcemia Recurrent laryngeal nerve injury Superior laryngeal nerve injury Thyroid crisis COMPLICATION
  46. 46. THYROID CANCER
  47. 47. • Benign follicular adenoma • Malignant : primary – Follicular epithelium-differentiated : papillary ,follicular – Follicular epithelium-undiffentiated : anaplstic – Parafollicular cells : medullary – Lymphoid cells : lymphoma • Malignant : Secondary - Metastasis
  48. 48. Thyroid cancer
  49. 49. THYROID CANCER Follicular epithilial – differentiated  Papillary carcinoma (75 – 80%)  Follicular carcinoma (15 – 20 %) Follicular epithilial – undifferentiated  Anaplastic carcinoma (<5%) Parafollicular cell  Medullary carcinnoma (5%) Lymphoid cell  lymphoma
  50. 50. PAPILLARY CARCINOMA Most common thyroid cancer*** Age 30-50 years old Risk factor = Previous exposure to Ionizing radiation Most common presentation = Asymptomatic thyroid mass/nodule Excellent prognosis = 10 years survival rate >95%
  51. 51. SPREADING Lymphatic spreading (35-43%) Blood vessels invasion (40%) Distant metastasis (3-7%)
  52. 52. SIGNS AND SYMPTOMS Asymptomatic Thyroid mass If advanced CA  Hoarsness  Dysphagia  Cough  Dyspnea
  53. 53. INVESTIGATION Fine Needle Aspiration Ultrasonography  distinguish solid from cystic lesions and identify calcifications Thyroid scan  Cold nodule
  54. 54. HISTOPATHOLOGY mixed papillary and follicular growth patterns Orphan Annie eye nuclei (= characteristic pale empty nuclei) Papillary finger-like projection Psammoma body
  55. 55. FOLLICULAR CARCINOMA 2nd common thyroid cancer High incidence in iodine-depleted countries Common in patient > 50 years Closely resemble to follicular adenoma  capsular or vascular invasion is defined malignat status Hematologic spreading  distant metastasis difficult to control May be involve cervical lymph node 10-year survival rate > 90%
  56. 56. Here comes your footer ▫ Page * •follicular carcinomas demonstrate capsular invasion (B, arrow-heads) that may be minimal, as in this case, or widespread with extension into local structures of the neck. The presence of vascular invasion is another feature of follicular carcinomas. •Hurthle cell tumor-Variant of follicular Neoplasm in which oxyphil cells predominate histology
  57. 57. • recurrent laryngeal nerve palsy 2-7% • permanent hypoparathyroidism 1-3% • hematoma 1-2% • wound infection < 1% • hypertrophy of the scar
  58. 58. • anaplastic carcinomas are aggressive tumors, with a mortality rate approaching 100%. Survival calculated in months • mean age of 65 years. • About half of the patients have a history of multinodular goiter, Spread by lymphatic and by the bloodstream Here comes your footer ▫ Page * Anaplastic carcinoma
  59. 59. ANAPLASTIC CARCINOMA Here comes your footer ▫ Page *
  60. 60. Here comes your footer ▫ Page * highly anaplastic cells, which may take one of several histologic patterns: (1) large, pleomorphic giant cells, including occasional osteoclast-like multinucleate giant cells; (2) spindle cells with a sarcomatous appearance; (3) mixed spindle and giant cells; and (4) small cells resembling those seen in small cell carcinomas arising at other sites.
  61. 61. • Advanced or metastatic disease – no effective therapy for advanced or metastatic anaplastic thyroid cancer – median survival from diagnosis ranges from three to seven months – Death is usually attributable to upper airway obstruction – Radiation therapy does not prolong survival, most have local recurrences – Chemotherapy response duration is generally short, and long-term survival (as well as local control in the neck) probably unaffected
  62. 62. MEDULLARY CARCINOMA Tumors of Parafollicular cells (C cells) derived from neural crest Neuroendocrine neoplasms Secrete Calcitonin (useful in diagnosis and follow up)
  63. 63. INCIDENCE 80% of cases are sporadical tumors Age 50-60 years old Lymphatic metastasis 50-60% May occur in combination known as MEN 2A or 2B
  64. 64. SIGNS AND SYMPTOMS a lump at the base of the neck, which may interfere with or become more prominent during swallowing. If locally advanced disease : hoarseness, dysphagia, and respiratory difficulty. Various paraneoplastic syndromes, including Cushing or carcinoid syndrome (uncommon) +/- Diarrhea Distant metastases : weight loss, lethargy, and bone pain
  65. 65. INVESTIGATION Serum Calcitonin level  The higher the greater of likelihood to be MTC  Basal level >100 pg/mL
  66. 66. PATHOLOGY Medullary carcinoma of thyroid. These tumors typically show a solid pattern of growth and do not have connective tissue capsules Medullary carcinoma of the thyroid. These tumors typically contain amyloid stroma
  67. 67. STAGING
  68. 68. TREATMENT Total Thyroidectomy Prophylactic/Therapeutic resection of central and bilateral cervical lymph nodes
  69. 69. POSTOPERATIVE MANAGEMENT Thyroxine therapy maintain euthyroidism adjuvant therapy with radioiodine SURGERY FOR RESIDUAL DISEASE Serum calcitonin and CEA should be measured 6 months after surgery detect the presence of recurrence
  70. 70. WRAP-UP! Approach to neck mass
  71. 71. THE HALF-BAKED CONCEPT IS OKAY, AS LONG AS IT’S IN THE OVEN. Let’s continue baking!
  72. 72. CASE : A PAINLESS LUMP IN THE NECK History A 40-year-old woman has been referred to the surgical outpatients with a painless lump in the neck. She had noticed the lump 2 weeks previously when looking in the mirror. She had not noticed any other lumps and does not complain of any other symptoms. She has not gained or lost any weight recently and her bowel habit has remained normal.
  73. 73. CASE : A PAINLESS LUMP IN THE NECK Examination Examination reveals a solitary 2x2 cm swelling to the left of the midline just above the manubrium. The swelling is firm, smooth and fixed. The swelling moves on swallowing, but does not move on protrusion of the tongue. There are no associated palpable lymph glands. General examination reveals no further abnormalities.
  74. 74. INVESTIGATION Hemoglobin 12.0 g/dL Mean cell volume 77 fL White cell count 10.4x109/L Platelets 250x109/L Sodium 137 mmol/L Potassium 3.7 mmol/L Urea 5 mmol/L (2.5–6.7 mmmol/L) Creatinine 71 μmol/L (44–80 μmol/L) Thyroid-stimulating hormone (TSH) 0.62mu/L (0.5–5.7 mu/L) Free tri-iodothyronine (T3) 3.4 pmol/L (2.5– 5.3 pmol/L)
  75. 75. QUESTIONS 1. What is the differential diagnosis for a lump in the anterior triangle of the neck? 2. Where is this lump likely to be originating from? 3. What steps would you take in the assessment of this lump? 4. Which factors may suggest malignancy? 5. What are the commonest types of malignancy?
  76. 76. TAKE YOUR FRIEND’S ANSWER SHEET, TAKE A LOOK AND GIVE THEM GRADE. Talk about it.
  77. 77. WHAT IS THE DIFFERENTIAL DIAGNOSIS FOR A LUMP IN THE ANTERIOR TRIANGLE OF THE NECK? Multiple: lymph nodes Solitary: does it move with swallowing? • yes: - thyroid origin - thyroglossal cyst (moves with protrusion of the tongue) • no: - salivary gland - dermoid cyst - carotid body tumur - lymph node - branchial cyst - cold abscess (TB)
  78. 78. WHERE IS THIS LUMP LIKELY TO BE ORIGINATING FROM? … to the left of the midline just above the manubrium … The swelling moves on swallowing, but does not move on protrusion of the tongue. “Thyroid origin” The majority of patients are clinically euthyroid and have normal thyroid function. The presence of abnormal thyroid function suggests a benign diagnosis.
  79. 79. WHAT STEPS WOULD YOU TAKE IN THE ASSESSMENT OF THIS LUMP? Less than 20 per cent of thyroid nodules are malignant, with the majority being cystic or benign. Many solitary thyroid nodules are dominant nodules in a multinodular goitre,which carry a 5 per cent risk of malignancy. Ultrasound is used to distinguish between solid and cystic nodules as well as differentiating a solitary nodule from a dominant nodule in a multinodular goitre. Fine-needle aspiration has a high sensitivity and specificity for distinguishing benign from malignant lumps in the thyroid. The main limitation of fine-needle aspiration is in the differentiation of benign follicular adenoma from malignant follicular cancer. If a follicular neoplasm is diagnosed on fine-needle aspiration, the lesion will need to be fully excised to exclude malignancy.
  80. 80. WHAT STEPS WOULD YOU TAKE IN THE ASSESSMENT OF THIS LUMP? Radio-isotope scanning provides a functional assessment of the thyroid nodule, which can be classified as cold or hot. Most solitary thyroid nodules are cold, with a risk of cancer at around 20 per cent.
  81. 81. WHICH FACTORS MAY SUGGEST MALIGNANCY? • age younger than 20 years or older than 70 years • male sex • recent origin and rapid growth or increase in size • firm, hard, or immobile nodule • presence of cervical lymphadenopathy • associated symptoms of dysphagia or dysphonia • history of neck irradiation • prior history of thyroid carcinoma or a positive family history.
  82. 82. WHAT ARE THE COMMONEST TYPES OF MALIGNANCY? Type frequency age Behavior Prog Papillary 70% 20-40s Slow growing, lymphatic spread to nodes Good 10 yr 80% Follicular 20% 35-50s Bloodstream spread, metastasis to lung and bone Good 10 yr 60% Anaplastic <5% 60-70s Aggressive, local spread Poor 10 yr 10% Medullary 5% Familial From parafollicular C cell, MEN
  83. 83. TAKE’EM HOME! A brief review.
  84. 84. POINTS >20% of adult neck masses are malignant 70% of pediatric neck masses are infectious in nature Know your anatomy then develop a differential diagnosis Close observation Generally, one course of a broad spectrum antibiotic is acceptable then ….. It is never wrong to refer to a specialist for evaluation and probable biopsy Imaging is important but tissue is everything If you don’t get an answer with a FNA, repeat it up to three times. Consider ultrasound guided or CT guided FNA. Never violate a neck if you’ve no idea about it.
  85. 85. POINTS Avoid excisional biopsies Use CT but consider MRI for salivary gland problems Role of nonionizing ultrasound Like a stethoscope
  86. 86. REFERENCE - An introduction to the symptoms and sing of surgical disease: Norman L.Browse - Bailey and Love's Short Practice of Surgery - 25th Edition - 100 cases in surgery - พื้นฐานศัลยศาสตร์และอาการของโรคศัลยกรรมสาหรับแพทย์เวชปฏิบัติทั่วไป คณะแพทยศาสตร์ ม.ศรีนครินทรวิโรฒ - ตารา หู คอ จมูก คณะแพทยศาสตร์ ม.ขอนแก่น - Uptodate : neck mass
  87. 87. HEY GUY! FIN. DO YOU HAVE SOME QUESTIONS?? Thank you for your attention.

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