Grand Round - Neck Lumps

8/18/2019 Grand Round - Neck Lumps

1/25

Neck LumpsNODULES AND NEOPLASMS BY NITY


2/25

Presenting Complaint

! "ear ol# $emale re%erre# to En#ocrinolog" clinic %or e&aluation ono#ule(

Patient reports t'is mi#line neck lump )as %oun# inci#entall" )'ile getting rea#" %or )ork one morning(

S'e )ent to 'er *P+ )'o re%erre# 'er to t'e En#ocrinolog" Clinic at


3/25

Di-erentials.

T'"roi#Non/t'"roi#

P'"siological goitre Lipoma

Multino#ular goitreDermoi# c"st

*ra&es0 #iseaseEpi#ermal c"st

,as'imoto0s t'"roi#itis

A1scess

T'"roglossal c"stL"mp'oma

T'"roi# c"st

Carcinoma

Su1acute t'"roi#itis 2#e 3uer&ain0s+ 4ie#el0s5


4/25

,istor" Intro#uction 6 Consent

C'eck Name an# Age

Occupation

Presenting Complaint

,istor" o% Presenting Complaint

C'eck ICE

Constitutional S"mptoms 7 Une8 9eig't loss+ Une8 C'ange in appetite+ $e&er+ Energ" le&els

Past Me#ical ,istor" 7 Dia1etes+ ,ig' BP+ C'olesterol+ Stroke+ ,eart Attack

Drug ,istor" 7 Allergies+ 4egular Drugs+ OTC Me#s.

$amil" ,istor"

Social ,istor"

ICE

Summarise


5/25

Lump Speci:c ,istor"

;( ,o) long 'as t'e lump 1een t'ere.( ,as t'e lump got 1igger or smaller.


6/25

Important Points / Patient,istor"

;( An" autoimmune #isor#ers.( >no)n risk %actors %or t'"roi# malignanc"


7/25

Important Points / Patient,istor"

Patient reports 'er &oice seems to 'a&e 1ecome slig'tl" more 'usS'e recalls onl" occasional #iscom%ort )it' sensation t'at somet'inpus'ing in( Denies s'ortness o% 1reat'(

Denies %amil" 'istor" o% t'"roi# cancer

Denies personal 'istor" o% ra#iation t'erap" or t'"roi# or an" ot'ercancer


8/25

E8amination


9/25

Lump Speci:c E8amination

;( Location Super:cial@Deep( 4elations'ip to ot'er structures


10/25

E8amination 9'at components o% t'e p'"sical e8am are critical %or t'is patient.

?$ull ,ea# an# neck e8am to look %or an" lumps or 1umps

?Palpate %or l"mp'a#enopat'"

?Palpate t'"roi# %or no#ularit"+ :rmness or 'ar# masses

?Pem1erton0s sign


11/25


12/25

E8amination On p'"sical e8am+ "ou palpate a grossl" enlarge# t'"roi# glan# )it#ominant no#ule on t'e rig't t'"roi# lo1e


13/25

3uestion A%ter t'oroug' 'istor" an# p'"sical+ )'at )oul# "ou or#er :rst %or tpatient.

?A( T'"roi# %unction tests 2TS,+ T=5

?B( CT neck

?C( M4I neck

?D( 4a#ioacti&e Io#ine uptake scan

?E( All o% t'e a1o&e


14/25

3uestion A%ter t'oroug' 'istor" an# p'"sical+ )'at )oul# "ou or#er :rst %or tpatient.

?A( T'"roi# %unction tests 2TS,+ T=5

?B( CT neck

?C( M4I neck

?D( 4a#ioacti&e Io#ine uptake scan

?E( All o% t'e a1o&e


15/25

9'at Ne8t.


16/25

3uestion Patient is sent %or la1s as )ell as $NA( Patient returns to clinic t'e %)eek )it' $NA report rea#ing cannot rule out %ollicular neoplasmsurger" in#icate#.

Yes

No


17/25

3uestion Patient is sent %or la1s as )ell as $NA( Patient returns to clinic t'e %)eek )it' $NA report rea#ing %ollicular cells+ cannot rule out %ollicneoplasm( Is surger" in#icate# %or "our patient at t'is time.

? Yes

?No


18/25

In#ications %or T'"roi#ectom/,"pert'"roi#ism 2*ra&e0s5 not responsi&e to me#ical t'erap"

/Malignanc" 2con:rme# or 'ig' suspicion 1ase# on 'istor" an#@or $N

/*oitre )it' compressi&e s"mptoms

/Large t'"roi# no#ule 2Fcm5 t'at is una1le to 1e a#eGuatel" samp2sampling error #ue to large area o% no#ule an# risk o% com1inationan# malignant cells5


19/25

T'"roi# No#ules Benign

? Benign t'"roi# c"sts 2#egenerate# no#ules5

? Colloi# no#ules

? Multino#ular goiter

Malignant? Papillar" carcinoma

? $ollicular carcinoma

? ,urt'le cell tumor

? Me#ullar" T'"roi# Carcinoma

? Anaplastic Carcinoma

? L"mp'oma o% t'"roi#


20/25

Imaging / Ultrasoun#

/ CT Neck %or surgical planning


21/25

Treatment Me#ical Management?In&ol&e en#ocrinolog" earl" to assist in management? T'"roi# 'ormone replacement %or '"pot'"roi#ism

? T'"roi# suppression %or '"pert'"roi#ism

?I/;


22/25

Treatment / Post/surgical t'erap"?I/;


23/25

Algorit'm@O&er&ie)

FNA

Benign

Malignant or

suspicious

indeterminate

surgeryTissue

pathology

Thyroid nodule/mass

$ollo)clinicall"

R e p e a t F N A


24/25

/Intraoperati&e/ Blee#ing

/ Damage to arteries@&eins o% neck

/Postoperati&e presentation/ InHur" to recurrent lar"ngeal ner&e

/ Unilateral7 'oarseness

/ Bilateral7 respirator" #istress

/ Blee#ing

/ E8pan#ing 'ematoma causes compression+ s'ortness o% 1reat'/ ,"pocalcemia

/ 4emo&al or inHur" to parat'"roi# glan#s or t'eir 1loo# suppl"

/ Scar

Complications o% t'"roi#ecto

If patient develops expanding

neck hematoma

postoperatively treatment

involves immediate opening of

sutures to evacuate clot and

return to !R to explore and

stop "leed


25/25

Take 'ome Points / Al)a"s o1tain t'"roi# %unction tests as part o% intial )opatient )it' t'"roi# pat'olog"

/ Per%orm %ull ,ea# Neck e8am

/ T'"roi# no#ules s'oul# un#ergo $NA %or c"topat'olog"

Grand Round - Neck Lumps

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