Anterior Neck MassCase 1

Navarro – Ng3-C

• 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

36 Years OldFemale

PampangaAnterior Neck Mass

Clinical Impression• TOXIC MULTINODULAR GOITER

PHYSICAL EXAMINATION:

PR: 90 bpm

RR: 20cpm

Temp: 37C

No exophthalmos

Neck:

12x10cm

Mutilobulated firm mass (Left)

Moves with deglutition

Differential diagnosis

Anterior neck massbenign 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 overlyingtissues, and suspicious regional lymphadenopathy.

Female sexMale 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 fatiguePalpitationsWeight loss

hypothyroidism, and 5% present with hyperthyroidism

hypothyroidism andhypoparathyroidism

asymptomatic

PE 12X10 cm massNo exopthalmosMultilobulated firm massMass moves with deglutition

minimally or moderately enlarged firm gland Painlessdiffusely 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 fatiguePalpitationsWeight loss

hyperthyroidism subclinical hyperthyroidism or mild thyrotoxicosis; large neck mass – airway obstruction, dysphagia

hyperthyroidism

PE 12X10 cm massNo exopthalmosMultilobulated firm massMass moves with deglutination

Diffusely enlarged thyroid gland Exophthalmos; Dermopathy

Multilobular, asymmetrically 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 levelElevated Free T3 or T4 levelsRAI uptake is increased (showing multiple nodules with increased uptake and suppression of the remaining gland)

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

• 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• Methimazole

• Propylthiouracil (PTU)

• 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 ExcisionReserved for young individuals1 or more large nodules or with

obstructive symptomsDominant nonfunctioning or suspicious

nodules Pregnant Pharmacologic therapy has failed

Complications

Injury to the recurrent and superior laryngeal nerve

HypothyroidismHypoparathyroidism Vocal Cord Paralysis