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Evaluation of the Neck Mass. University of Florida Department of Surgery. Differential Diagnosis. Congenital Lateral neck Branchial cyst, sinus, fistula near SCM Slow, soft, painless Tx : Excision Medial neck Thyroglossal duct cyst

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evaluation of the neck mass

Evaluation of the Neck Mass

University of Florida

Department of Surgery

differential diagnosis
Differential Diagnosis
  • Congenital
    • Lateral neck
      • Branchial cyst, sinus, fistula near SCM
        • Slow, soft, painless
        • Tx: Excision
    • Medial neck
      • Thyroglossal duct cyst
        • thyroid gland usually travels from the base of the tongue to the neck.
        • Moves when swallowing
        • Workup: TFT, thyroid scan
        • Tx: Excision + removal of central hyoidbone (Sistrunk procedure)
    • Ectopic thymus, parathyroid, thyroid
    • Congenital torticollis – soft tissue swelling
      • birth trauma, intrauterine positioning
differential diagnosis1
Differential Diagnosis
  • Infectious
    • Abscess – staph / strep / polymicrobial
      • Tx: abx +/- drainage
    • TB – single large node, usu. painless, cervical
      • Workup: PPD, rule out HIV
      • Tx: Anti-TB meds
    • Cat scratch fever – Bartonellahenselae
      • Single enlarged node
      • Weeks to months after exposure
      • Self limited
    • Mono – get EBV titer
      • p/w cervical adenopathy
hyperthyroid hypothyroid
Hyperthyroid / hypothyroid
  • Goiter – enlargement of thyroid gland
    • Iodine deficiency, Grave’s disease, Toxic Multinodular Goiter, acute/subacute/chronic thyroiditis
tumors
Tumors
  • Benign
    • Tx: surgical excision
    • Examples:
      • Lipoma
      • Hemangioma
      • Neuroma
      • Fibroma
      • Carotid body tumor
tumors1
Tumors
  • Malignant
    • Primary
      • Thyroid cancer
      • Salivary gland cancer (near ear or angle of mandible)
      • Lymphoma (lateral neck, rubbery and mobile)
      • Sarcoma
    • Secondary
      • metastates
neck mass history
Neck Mass - History
  • Age – rule of 80%
  • Rate of growth: Days / Months / Years
    • Days – think infectious
    • Months – think cancer
    • Years – think congenital
  • Fever / cough / sore throat
  • Recent travel, bites, animal exposure
  • Weight loss / night sweats
  • Fatigue / cold intolerance, wt gain
  • Nervousness, sweating, heat intolerance, palpitations
  • Smoking / alcohol use / hx radiation
  • Trauma
  • Family history
physical exam

Location of neck mass

Lateral neck, central neck, supraclavicular, cervical

Size

Soft / Hard

Mobile / fixed

Painful / Painless

Lymphadenopathy

Complete examination of oropharynx – direct, fiberoptic

Physical Exam
location of metastases
Location of metastases
  • Supraclavicular – check for chest malignancy
    • Virchow’s node – left supraclavicular area
thyroid masses
Thyroid masses
  • Benign thyroid nodule – palpable
    • Follicular adenoma
    • Colloid nodule
    • Benign cyst
    • Solitary toxic adenoma (dec TSH, inc T3 & T4)
      • Tx: radioactive iodine or unilateral lobectomy
thyroid cancer
Thyroid cancer
  • Thyroid cancer
    • Papillary – young, prior radiation, good prognosis
      • Good 131 I uptake
      • Lobectomy and isthectomy
      • Total Thyroidectomy if diffuse/bilateral disease
    • Follicular adenoma – cannot dx w/FNA
      • Good 131 I uptake
      • Mets to bone
      • Males 3:1
      • Lobectomy and isthectomy
      • Total Thyroidectomy if large/diffuse
thyroid cancer cont
Thyroid cancer cont.
  • Thyroid cancer
    • Medullary Carcinoma
      • Associated with MEN II
      • Secretes calcitonin
      • Poor 131 I uptake
      • Poor prognosis
      • Tx: total thyroidectomy and median lymph node dissection.
        • modified neck dissection if lateral cervical nodes are positive.
    • Hurthle cell – cannot dx with FNA
      • Adenoma - Lobectomy and Isthmectomy
      • Carcinoma - Total Thyroidectomy and modified radical neck dissection if lat nodes are positive.
thyroid cancer cont1
Thyroid cancer cont
  • Thyroid cancer
    • Anaplastic
      • Poor 131I uptake
      • Giant cells / spindle cells on histology
      • Bad prognosis
      • Total thyroidectomy if resectable (usu. Not)
parathyroid
Parathyroid
  • Primary hyperparathyroidism
    • Adenoma (85%)
      • MEN I, MEN IIa
      • High PTH, high Ca
      • Tx: excision, confirm with intraoperative PTH
    • Hyperplasia
      • MEN I, MEN IIa
      • Tx: remove all but one parathyroid, intraoperative PTH
    • Carcinoma
      • Palpable mass
      • High PTH, high Ca
      • Tx: resection of gland, ipsilateral thyroid lobectomy, and ipsilateral lymph node resection.
general workup approach
General Workup Approach
  • Rule out infectious
    • EBV, heterophil titer (mono), HIV, PPD
    • Abx trial
  • Check thyroid / parathyroid
    • TSH/T3/T4, PTH/Ca, calcitonin
  • Fine needle aspiration
  • Imaging
    • Ultrasound: cystic vs. solid
    • Radionucleotide thyroid scan
      • Cold – 25% malignant
      • Hot – 5% malignant
    • CXR, CT (look for primary), MRI (upper neck, skull base)
fine needle aspiration
Fine Needle Aspiration
  • Fine needle – 25 gauge
  • Multiple aspirations
  • Used with US
  • 5% false negative rate
  • Cannot distinguish benign/malignant follicular thyroid tumors or Hurthle cell tumors
  • Good for cystic vs inflammatory, papillary, medullary, anaplastic cancers