Benign

Presented by:
Jobelline Mae C. Fernandez
 OBJECTIVES:
To present a history and physical exam of a 30 year
old patient with anterior neck mass
To present the differential diagnoses of the case
To discuss the anatomy and physiology relevant to
the case
To discuss the current guidelines on thyroid nodule
Date of Admission: Aug. 17, 2017
Time of interview: 8:00am
 GENERAL DATA
Name: E. M. Address: Sta. Barbara,

Age: 30 y/o Zamboanga City

Gender: Female Civil Status: Single

Religion: Islam
CHIEF COMPLAINT:
Anterior Neck Mass
 PRESENT MEDICAL
Pertinent history HISTORY
Pertinent negatives Actions taken
2 years PTA:

Mass on the left (-) trauma to neck No consult was

anterior neck (-) Dysphagia done
Painless (-) Weight loss/gain No meds taken
Firm (-) Hoarseness
Approximately 2x1 (-) Palpitations
cm in diameter (-) Heat Intolerance
Moves with (-) Cold Intolerance
deglutition
 PRESENTPertinent
MEDICAL
Pertinent history negatives HISTORY
Actions taken

1 year PTA:
(-) Dysphagia No consult was done
Mass noted to be (-) Weight loss/gain No meds taken
gradually (-) Hoarseness
enlarging now (-) Palpitations
measuring 3x2 cm (-) Heat Intolerance
Painless (-) Cold Intolerance
Firm
Moves with
deglutition
 PRESENTPertinent
MEDICAL
Pertinent history negatives HISTORY
Actions taken
1 month PTA: (-) Diaphoresis No meds taken
(-) Dysphagia Consult was done
Mass noted to be (-) Weight loss/gain
gradually enlarging (-) Hoarseness UTZ
approximately 4x3 (-) Palpitations FNAB
Painless (-) Heat Intolerance
Moves with (-) Cold Intolerance
deglutition
 PAST MEDICAL HISTORY

No known medical illness

No maintenance medication
No previous surgery
No known allergies to foods and drugs
No previous exposure to radiation
 FAMILY HISTORY
No Hypertension, Diabetes Mellitus,
Bronchial Asthma, Cancer, Autoimmune
disease
Parents- Deceased with unrecalled cause
3 children- Alive and well
 PERSONAL & SOCIAL HISTORY
Non-alcoholic beverage drinker
Non smoker
Diet Fish and Vegetables
No allergies to any food or medications
 REVIEW OF SYSTEMS
General (-) weight loss, (-) easy fatigability
Skin (-) jaundice, (-) lesions (-) rashes
HEENT Head (-) headache, (-) dizziness
Eyes (-) eye discharges, (-) itchiness
Ears (-) hearing abnormalities, (-) ear pain, (-)
discharges
Nose (-) discharges
Throat (-) dysphagia
Respiratory (-) cough, (-) DOB
Cardiologic (-) chest pain
GI (-) pain, (-) changes in bowel movements
Genito- (-) discharges, (-) pain, (-) dribbling
urinary
MSK (-) limited mobility, (-) edema
Neurologic (-) seizures
 PHYSICAL EXAMINATION
Vital Signs
BP: 110/70 mmHg Temp: 36.4c PR: 114 bpm RR: 22
cpm

General Appearance: Awake, calm, NIRD

Skin: No changes in skin color, warm and moist
 Head: Normocephalic, with equal distribution of hair
Eyes: AS, PPC
Ears: No aural discharge
Nose: Mucosa pink, septum midline. no discharges
noted
Mouth: Oral mucosa pink, dentition poor, tongue
midline; tonsils not inflamed; pharynx without exudates
Neck: Neck supple. Trachea midline. no CLAD
(+) 4 x 3 cm left anterior neck mass, firm, well
circumscribed border and moves with deglutition,
does not move with tongue protrusion, (-) bruit
 Lymph Nodes: (-) lymphadenopathy
Thorax and Lungs. Thorax symmetric with
good excursion. Lungs resonant. Breath
sounds vesicular with no adventitious lung
sounds
Cardiovascular: AP, NRRR, no murmurs
Breasts: No lesions
 Abdomen: Flat; BS active-6 clicks/min. No
tenderness or masses. (-) organomegaly, (-)
costovertebral angle tenderness (CVAT).
Genitalia: not examined
Extremities: Warm and without edema.
Calves supple, non-tender
Neurologic:
Mental Status: Coherent and cooperative,
oriented to 3 spheres
Motor: Good muscle bulk and tone. Strength
5/5 throughout.
 SALIENT FEATURES
(Clinical)

HISTORY
2 years hx of anterior neck
mass
Gradually enlarging
Painless, firm
No dysphagia, DOB,
hoarseness, weight loss
No exposure to radiation
No FH of thyroid cancer
PHYSICAL EXAM
(+) 4 x 3 cm left anterior
neck mass
Characteristics: well
circumscribed border,
moves with deglutition,
non-fluctuant, (-) bruit
 DIFFERENTIAL DIAGNOSES FOR ANTERIOR NECK MASS
Differentials Rule-in Rule-out

CONGENITAL
Thyroglossal Anterior neck mass 90% of cases are presented in
Duct Cyst Moves with swallowing children before age of 10
Does not move with tongue
protrusion
INFLAMMATORY
Hashimotos Anterior neck mass Characteristic: Non-lobulated
Thyroiditis Most common cause of (-) cold intolerance
inflammatory thyroid (-) weight gain
nodule (-) hoarseness
Common in women
Age 30-50 y.o
 DIFFERENTIAL DIAGNOSES FOR ANTERIOR NECK MASS
Differentials Rule-in Rule-out

CONGENITAL
Thyroglossal Anterior neck mass 90% of cases are presented in
Duct Cyst Moves with swallowing children before age of 10
Does not move with tongue
protrusion
INFLAMMATORY
Hashimotos Anterior neck mass Characteristic: Non-lobulated
Thyroiditis Most common cause of (-) cold intolerance
inflammatory thyroid (-) weight gain
nodule (-) hoarseness
Common in women
Age 30-50 y.o
 WHAT ARE THE COMMON CAUSES OF ANTERIOR NECK MASS?
Differentials Rule-in Rule-out

CONGENITAL
Thyroglossal Anterior neck mass 90% of cases are presented in
Duct Cyst Moves with swallowing children before age of 10
Does not move with tongue
protrusion
INFLAMMATORY
Hashimotos Anterior neck mass Characteristic: Non-lobulated
Thyroiditis Most common cause of (-) cold intolerance
inflammatory thyroid (-) weight gain
nodule (-) hoarseness
Common in women
Age 30-50 y.o
DDXx RULE-IN RULE OUT
AUTOIMMUNE
Graves Disease (+) Anterior Neck (-) heat intolerance
Mass (-) weight loss
(-) palpitations
(-) No known autoimmune/no FH autoimmune disease
(-) tremors
(-) bruit
NEOPLASTIC
Thyroid Cancer Anterior neck mass Well-circumscribed, gradually
Moves with deglutition enlarging
Characteristic: painless, firm, (-) lymphadenopathy
solitary No family history of Thyroid Ca
No exposure to radiation
No compressive symptoms
(hoarseness, DOB, dysphagia)
CANNOT TOTALLY RULE OUT
Benign Thyroid Gradually enlarging
Adenoma Well circumscribed
No family history of Thyroid Ca
No exposure to radiation
No compressive symptoms
(hoarseness, DOB, dysphagia
DDX RULE-IN RULE OUT
AUTOIMMUNE
Graves Disease (+) Anterior Neck Mass (-) heat intolerance
(-) weight loss
(-) palpitations
(-) diaphoresis
(-) tremors
(-) bruit
NEOPLASTIC
Thyroid Cancer Anterior neck mass Well-circumscribed, gradually
Moves with deglutition enlarging
Characteristic: painless, firm, (-) lymphadenopathy
solitary No family history of Thyroid Ca
No exposure to radiation
No compressive symptoms
(hoarseness, DOB, dysphagia)
CANNOT TOTALLY RULE OUT
Benign Thyroid Gradually enlarging
Adenoma Well circumscribed
No family history of Thyroid Ca
No exposure to radiation
No compressive symptoms
(hoarseness, DOB, dysphagia
Arriving at an impression
HISTORY
2 years hx of anterior neck mass
Gradually enlarging
Painless, firm
No dysphagia, DOB, hoarseness,
weight loss
No exposure to radiation PRE-IMAGING
No FH of thyroid cancer DIAGNOSIS:
Anterior Neck Mass
PHYSICAL EXAM Probably Benign
(+) 4 x 3 cm left anterior neck
mass
Characteristics: well
circumscribed border, moves
with deglutition
HISTORY
2 years hx of anterior neck mass
Gradually enlarging
Painless, firm
No dysphagia, DOB, hoarseness, weight loss
No exposure to radiation
No FH of thyroid cancer

PHYSICAL EXAM Diagnosis:

(+) 4 x 3 cm left anterior neck mass Colloid
Characteristics: well circumscribed border, Adenomatous
moves with deglutition Goiter (CAN)

PARACLINICALS
Normal TSH
TIRADS 3 on ultrasound
BETHESDA IV on FNA
 DIFFERENTIAL DIAGNOSES AND
DISTINGUISHING CHARACTERISTICS
CLINICAL
IMAGING
PATHOLOGY
 MANAGEMENT
Lobectomy Left with Isthmusectomy
Specimen
 CASE
DISCUSSION
 ANATOMY
TRIANGLES OF THE NECK
 ANATOMY
THYROID GLAND
brown in color and firm in
consistency and is located
posterior
to the strap muscles
Weight: 20 g, varies with body
weight and iodine intake
Thyroid lobe: located adjacent
to the thyroid cartilage,
connected in the midline by an
isthmus that is located just
inferior to the cricoid cartilage.
 ANATOMY

CLINICAL ANATOMY
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CLINICAL ANATOMY
ANATOMY
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 ANATOMY

Malignant lymph nodes are much more likely to occur in levels III, IV, and VI than in
level II
-ATA Guidelines
 HISTOLOGY
Divided into lobules
that contain 20 to 40
follicles
Follicles: spherical, 30
m in diameter, lined by
cuboidal epithelial cells
Central store of colloid
secreted from the
epithelial cells under
the influence of TSH.
Parafollicular cells->
contain and secrete
calcitonin. Located in
interfollicular stroma
 PHYSIOLOGY

I. IODINE METABOLISM
Iodine iodide bloodstream extracellular
spaces Active transport (ATP)dependent into
thyroid follicular cells
 PHYSIOLOGY
II. THYROID HORMONE SYNTHESIS,SECRETION & TRANSPORT
SYNTHESIS
A. Iodine trapping
B. Oxidation of I and
Iodination of
Tyrosine on Tg
C. Coupling
2 DIT = T4
1 DIT + 1 MIT = T3
D. Hydrolysis of Tg to
release fT3 and fT4
E. Deiodination to yield
Iodide to be reused in
the thyrocyte
 PHYSIOLOGY
II. THYROID HORMONE SYNTHESIS,SECRETION & TRANSPORT
TRANSPORT
bound to globulin,
albumin,
prealbumin
fT3 T4- active

SECRETION
Hypothalamus: TRH
A Pituitary Gland:
TSH
Thyroid gland: T3,
T4
 What is the appropriate laboratory and
imaging evaluation for patients with
clinically or incidentally discovered thyroid
nodules?
Investigations
A serum TSH level
If the serum TSH is subnormal, a radionuclide thyroid
scan should be obtained
If the serum TSH is normal or elevated, a
radionuclide scan should not be performed as the
initial imaging evaluation
Ultrasound of neck
Thyroidal uptake on F18-flurodeoxyglucose positron
emission tomography (18FDG-PET) scan
FNAC
Thyroid Image
Reporting and
Data System
Algorithm for evaluation and management of
patients with thyroid nodules
Most common significant complication postoperatively
Permanent RLN injury
Permanent hypoparathyroidism

Other complications:
Infection
Bleeding
Thank You