Transcript Anterior Neck Mass Case 1 Navarro – Ng 3-C

Anterior Neck Mass
Case 1
Navarro – Ng
3-C
36 Years Old
Female
Pampanga
Anterior Neck Mass
•
HISTORY OF PRESENT ILLNESS:
–
7 Years Ago
•
–
–
She noted an enlarging left
anterior neck mass
1 Year Ago
•
Easy fatigability
•
Palpitations
•
Weight loss
•
Consulted a physician and
was prescribed medications
that relieved her symptoms.
However, the mass continued
to increase in size prompting
her admission
PHYSICAL EXAMINATION:
PR: 90 bpm
RR: 20cpm
Temp: 37C
No exophthalmos
Neck:
12x10cm
Mutilobulated firm mass (Left)
Moves with deglutition
Clinical Impression
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TOXIC MULTINODULAR GOITER
Differential diagnosis
Anterior neck mass
benign pathology
malignant pathology
Family history of Hashimoto’s
thyroiditis;
Past or family history of thyroid
carcinoma
Symptoms of hypo-or hyperthyroidism
H/O external neck radiation during
childhood or adolescence
Pain or tenderness associated with the
nodule
Recent change in voice (hoarseness or
dysphonia),
difficulty in swallowing (dysphagia)
Surface of nodule being soft, smooth,
and mobile
firm consistency of nodule
Multinodular goitre without a dominant
nodule
irregular shape, its fixation to underlying
or overlying
tissues, and suspicious regional
lymphadenopathy.
Female sex
Male sex; Young patients (< 20 years age)
or old (> 70 years age)
Patient
Hashimoto’s
thyroiditis
Riedel's
Thyroiditis
Nontoxic goiter
Sex
Female
Female > male
Female>male
Female>male
Age
36
30- 50
30-60
Symptoms
Easy fatigue
Palpitations
Weight loss
hypothyroidism, and
5% present with
hyperthyroidism
hypothyroidism
and
hypoparathyroidi
sm
asymptomatic
PE
12X10 cm mass
No
exopthalmos
Multilobulated
firm mass
Mass moves
with deglutition
minimally or
moderately enlarged
firm gland
Painless
diffusely enlarged,
firm gland, which is
also lobulated
painless, hard,
"woody" thyroid
gland
anterior neck
mass,
Soft, diffusely
enlarged gland
(simple goiter)
or nodules of
various size and
consistency in
case of a
multinodular
goiter.
Hyperthyroidism
Patient
Grave's Disease
Toxic
Multinodular
Goiter
Thyroid
Adenoma
Sex
Female
Female
preponderance
(5:1)
F=M
Female
Age
36
peak incidence
between the ages
of 40 to 60 years
older patients
>50 years old
Symptoms
Easy fatigue
Palpitations
Weight loss
hyperthyroidism
subclinical
hyperthyroidi
sm or mild
thyrotoxicosis;
large neck
mass – airway
obstruction,
dysphagia
hyperthyroidism
PE
12X10 cm mass
No exopthalmos
Multilobulated
firm mass
Mass moves with
deglutination
Diffusely enlarged
thyroid gland
Exophthalmos;
Dermopathy
Multilobular,
asymmetricall
y enlarged
gland
solitary thyroid
nodule without
palpable thyroid
tissue on the
contralateral side
Toxic Multinodular
Goiter
“Plummer’s Syndrome”
Long-standing simple goiter
Recurrent episodes of hyperplasia &
Involution –> irregular enlargement
of thyroid
Variations among follicular cells in
response to external stimulus
Mutations in proteins of TSH-signaling
pathway
Diagnostic Studies
Suppressed TSH level
Elevated Free T3 or T4 levels
RAI
uptake is increased (showing
multiple nodules with increased uptake
and suppression of the remaining gland)
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Diagnostic Studies

FNA
biopsy
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
Diagnostic Studies
CT scan is helpful to
evaluate the extent of
retrosternal
extension and airway
compression

What do you think were the
medications given to this patient
to control her symptoms of easy
fatiguability, palpitations?
Explain their mechanism of
action.
Beta Blockers
•
Drugs: Propranolol, Metoprolol, Atenolol
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MOA:
–
–
bind to beta-adrenoceptors and thereby block the
binding of norepinephrine and epinephrine to
these receptors.
Ameliorate many disturbing signs and symptoms
of hyperthyroidism secondary to increased
circulating catecholamines by blocking beta
receptors
Thioamides
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Methimazole
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Propylthiouracil (PTU)
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MOA:
–
–
inhibit synthesis by acting against
iodide organification and coupling of
iodotyrosines
Blocks peripheral conversion of T4
to T3 (PTU)
How would you manage this
patient?
Management:
Surgical Excision
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Reserved for young individuals
1 or more large nodules or with
obstructive symptoms
Dominant nonfunctioning or suspicious
nodules
Pregnant
Pharmacologic therapy has failed
Complications

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Injury to the recurrent and superior
laryngeal nerve
Hypothyroidism
Hypoparathyroidism
Vocal Cord Paralysis