Transcript Anterior Neck Mass 2 Group 2

Anterior Neck Mass 2
Group 2: Nuevo - Olegario
General Data
 65 years old
 Female
Anterior Neck Mass
History of Present Illness
5 yrs
PTC
4 yrs
PTC
 2x2 cm anterior neck mass
 No other accompanying symptoms
 Progressive increase in size of the mass
 She started to feel the presence of a “lump in the throat”
 Consulted → L thyroxine 100 ug/tab 1 tab TID (1 month)
 Easy fatigability, Palpitations, Weight loss
 Consulted → Serum T3 ,T4, and TSH
→ advised to discontinue medication
Consulted at USTH
Physical Examination
 VS: BP=120/80 PR=85/min RR=28/min
 Eyes: Pink palpebral conjunctiva & Anicteric sclerae
 Neck:
 8 X 6 cm firm anterior neck mass
 Well‐defined borders
 Moves with deglutition
 No palpable cervical adenopathies
 Heart/Chest/Abdomen – Unremarkable
1
If you were the physician who initially
saw the patient one year ago, what
would you have done?
2
What do you think were the serum
T3,T4, and TSH levels in the
previous consult?
What do you call this condition?
HYPERTHYROIDISM
T3
T3, T4, TSH levels
during previous
consult:
-
TRH
HYPOTHALAMUS
TSH
T4
PITUITARY
T3
T3 & T4 - 
TSH - 
-
+
THYROID
TISSUE
+
T4
HYPERTHYROIDSIM
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(+) Goiter or Nodule
Nervousness
Palpitations
Hyperactivity
Increased sweating
Heat Hypersensitivity
Fatigue
Increased appetite
Weight Loss
Insomnia
Frequent Bowel Movements (Diarrhea)
Hypomenorrhea
Warm, moist Skin
Tremor
Tachycardia
Elderly patients may present:
• Atypically
• (Apathetic or Masked
Hyperthyroidism)
• Most do not have
exopthalmos & tremor
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Atrial fibrillation
Syncope
Altered sensorium
Heart faliure
Weakness
3
What is your diagnosis?
Other considerations?
Salient Features
SUBJECTIVE
 65 y/o, F
 Anterior neck mass
 Progressive increase in
size (1 year)
 Felt a “lump in the throat”
 L-Thyroxine 100 ug/tab 1
tab TID
 Easy fatigability,
Palpitations, Weight loss
(Hyperthyroidism)
OBJECTIVE
 BP=120/80, PR=85/min,
RR=28/min
 Eyes:
 Pink palpebral conjunctiva &
Anicteric sclerae
 Neck:
 8 X 6 cm
 Firm anterior neck mass
 Well‐defined borders
 Moves with deglutition
 No palpable cervical
adenopathies
 Abdomen – Unremarkable
Impression
CRITERIA
SIMPLE NONTOXIC GOITER
AGE & GENDER
Puberty; Pregnancy; Menopause
SIGNS & SYMPTOMS
Asymptomatic
Enlarged, Non-tender, Soft, Symmetric, Smooth
RISK FACTORS
TSH. T3.T4
Auto-Antibodies
Iodine uptake
Others
Intrinsic Thyroid Hormone Production Defect
Low Iodine Intake
Ingestion of Goitrogens
(Broccoli, Cauliflower, Cabbage)
Drugs that inhibit thyroid hormone production
Normal / Slight ↑ TSH, Slight ↓ T4
(-)
Normal or High
L-Thyroxine
Contraindicated in older patients
because goiters rarely shrink and
are autonomous
GIVEN IN EXCESS
DRUG – INDUCED
HYPERTHYROIDISM
DRUG INDUCED
 Adult Initially 50-100 mcg daily, adjusted every 4-6 wk by 50
mcg until normal metabolism is maintained.
 May require doses of 100-200 mcg daily.
 Patient >50 yr Max: 50 mcg/day initially.
 OTHER DRUGS: Amiodarone, Lithium, Interferon a,
Interleukin-2 and Iodine
Differential Diagnosis
CRITERIA
GRAVES DISEASE
(Toxic Diffuse Goiter)
PLUMMER’S DISEASE
(Toxic Solitary or Multinodular
Goiter)
Female (5:1)
Peak: 40 – 60 y/o
>50 y/o (multinodular)
Young (solitary)
SIGNS &
SYMPTOMS
Diffuse Goiter & Symmetric
Exopthalmos
(at onset or as late as 20 yrs)
Dermopathy
(pretibial myxedema)
Mild hyperthyroidism
Absent Extra-thyroidal
manifestation
RISK FACTORS
Strong familial predisposition
Long standing history of Goiter
TSH. T3.T4
Auto-Antibodies
Iodine uptake
Others
↓ TSH, ↑ T3 & T4
+ Autoantibodies
Diffuse
↓ TSH, ↑ T3 & T4 (mild)
- Autoantibodies
Single or Multiple foci
AGE & GENDER
Differential Diagnosis
SUBACUTE THYROIDITIS
SILENT LYMPHOCYTIC
THYROIDITIS
PITUITARY TUMOR
Female
(Postpartum or Spontanoues)
30- 50 y/o
Neck pain with radiation
(jaws & ears)
Asymmetric
Firm& Tender
Hyper to Hypo
Resolves within months
Antecedent Viral URI
↓ TSH, ↑ T3 & T4
+ Autoantibodies
No uptake
↑ ESR
Absence of thyroid tenderness
Hyper to Hypo to Eu
Resolves within months
Headache
Visual Manifestations
(bitemporal
hemianopsia)
Endocrinopathies
Family history of autoimmune
thyroid disease
↓ TSH, ↑ T3 & T4
+ Autoantibodies
No uptake
↓ ESR
↑ TSH, T3 & T4
↑ a subunit of TSH
↑ Uptake
4
How would you manage this patient
now?
Treatment
 Most euthyroid patients with small, diffuse goiters
do not require treatment
 If large goiters – use of exogenous thyroid
hormone to decrease size and stabilize gland
growth
 Endemic goiter – iodine administration
When to consider surgery?
 Continuous growth despite T4 suppression
 (+) obstructive symptoms
 (+) substernal extension
 Suspected to be malignant or proven malignant by
FNA biopsy
 Cosmetically unacceptable
**if there is a need for lifelong T4 therapy – treatment
of choice is total lobectomy on dominant nodule and
subtotal resection of the contralateral side
Prognosis
 The prognosis for a patient with hyperthyroidism is
good with appropriate treatment.
 Postoperative recurrences: 2 - 16%
 Risk of hypothyroidism is directly related to the
extent of surgery and occurs in about ½ of patients
 Myxedema coma can result in death.
 Uncommon complications: vocal cord paralysis and
hypoparathyroidism.
Thank You!