This document provides an overview of neck masses and thyroid disorders. It begins with the anatomy of the thyroid gland and approaches to examining neck masses. Specific conditions covered include thyroglossal duct cyst, solitary thyroid nodule, Graves' disease, thyroid cancer including papillary, follicular, anaplastic and medullary carcinomas. Diagnostic tests and treatments for these conditions such as medication, radioactive iodine therapy, surgery and its complications are summarized.
Surgical management of benign multinodular goitreCHRIS ALUMONA
According to the WHO about 200 million people are living with goitres worldwide. Of the benign cases, endemic goitres make up the bulk in iodine deficiency belts. Goitres may be simple or toxic. The aetiopathogenesis and surgical management of this condition is detailed in a practical sense in this presentation.
This is a clinical case presentation of Nodular Thyroid in a 40 year old woman. Detailed Anatomy, Physiology of Neck region including thyroid with their pahophysiology. Possible investigations and modalities of treatment have also been discussed in this presentation.
Surgical management of benign multinodular goitreCHRIS ALUMONA
According to the WHO about 200 million people are living with goitres worldwide. Of the benign cases, endemic goitres make up the bulk in iodine deficiency belts. Goitres may be simple or toxic. The aetiopathogenesis and surgical management of this condition is detailed in a practical sense in this presentation.
This is a clinical case presentation of Nodular Thyroid in a 40 year old woman. Detailed Anatomy, Physiology of Neck region including thyroid with their pahophysiology. Possible investigations and modalities of treatment have also been discussed in this presentation.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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.
34. THYROGLOSSAL DUCT CYST
Neck mass that
develops from
cells and tissues
remaining after
the formation of
the thyroid gland
during
embryonic
development
35. 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.
40. 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
48. 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.
57. ETIOLOGY
• 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
58. Thyroid hormone effects
• 1.Increase metabolic rate of all cells
• 2.Increase sensitivity of beta-adrenergic
receptors
• 3.Stimulate all cells to grow
60. • 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
61. Physical examination
• 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
62. Physical examination
• 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
67. Medication
• Beta blocker : Propranolol 20-40 mg qid
offer relief of the adrenergic symptoms
of hyperthyroidism such as tremor,
palpitations, heat intolerance, and
nervousness
68. Medication
Antithyroid drugs
• 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%)
69. Radioactive Iodine therapy
• Recommended in
- Older patients with small or moderate-size goiter
- Relapse after medical or surgical therapy
- Antithyroid drugs or surgery are contraindicated
70. Radioactive Iodine therapy
Absolute contraindications
• Woman who are pregnant or breastfeeding
Relative contraindications
• Children and adolescent
• Patient with thyroid nodule
• Patient with ophthalmopathy
71. Surgical treatment
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
72. Prep. For surgery
• 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
73. 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
lobe with isthmus and partial/subtotal removal of
74. • 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
82. 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%
86. HISTOPATHOLOGY
mixed papillary and follicular growth patterns
Orphan Annie eye nuclei (= characteristic pale empty
nuclei)
Papillary finger-like projection
Psammoma body
87.
88. 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%
89. •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
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95. Anaplastic carcinoma
• 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
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97. 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.
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98.
99.
100. • 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
101. MEDULLARY CARCINOMA
Tumors of Parafollicular cells (C cells) derived from
neural crest
Neuroendocrine neoplasms
Secrete Calcitonin (useful in diagnosis and follow up)
102. 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
103. 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
105. 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
108. 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
111. 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.
112. 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.
114. 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?
116. 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)
117. 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.
118. 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.
119. 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.
120. 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.
121. WHAT ARE THE COMMONEST
TYPES OF MALIGNANCY?
Type frequency age Behavior Prog
Papillary 70% 20-40s Slow growing, Good
lymphatic spread 10 yr 80%
to nodes
Follicular 20% 35-50s Bloodstream spread, Good
metastasis to lung 10 yr 60%
and bone
Anaplastic <5% 60-70s Aggressive, local Poor
spread 10 yr 10%
Medullary 5% Familial From parafollicular
C cell, MEN
123. 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.
126. 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
- พนฐานศลยศาสตรและอาการของโรคศลยกรรมสาหรบแพทยเวชปฏบตทวไป
คณะแพทยศาสตร ม.ศรนครนทรวโรฒ
- ตารา ห คอ จมก คณะแพทยศาสตร ม.ขอนแกน
- Uptodate : neck mass
127. HEY GUY! FIN.
DO YOU HAVE SOME
QUESTIONS??
Thank you for
your attention.