Anterior Neck Mass

1. Anterior Neck Mass SabalvaroDyan, SalacCarmina, Salazar Janelle , Salazar Riccel, Salcedo Von, Saldana Emmanuel, Sales Stephanie, Salonga Cryscel

2. 65 year old female with anterior neck mass

3. History of Present Illness

4. Physical Examination

5. 65 y/o Female • 2 X 2 cm anterior neck mass • Progressive increase in size – “lump in throat • Prescribed L thyroxine 100 ug/tab 1 tab TID • took for one month until she noted easy fatigability, palpitations, and weight loss • Discontinued medication as advised by physician Physical Examination • VS: BP=120/80 PR=85/min RR=28/min • Pink palpebral conjunctive, anictericsclerae • Neck: 8 X 6 cm firm anterior neck mass with well‐defined borders and moves with deglutition; no palpable cervical adenopathies • Heart/Chest/Abdomen – unremarkable Salient Features

6. 1. If you were the physician who initially saw the patient one year ago, what would you have done?

7. 2. What do you think were the serum T3 ,T4, and TSH levels in the previous consult? What do you call this condition?

8. Low circulating levels of T4 and T3 • Primary Thyroid Failure • Raised TSH levels • Secondary Hypothyroidism • Low TSH levels that do not increase following TRH stimulation

9. HYPOTHYROIDISM • Deficiency in the circulating levels of thyroid hormone leads to hypothyroidism, and, in neonates, to cretinism, which is characterized by neurologic impairment and mental retardation. • Hypothyroidism may also be associated with deafness (Pendred's syndrome)4 and Turner's syndrome.

11. In adults, symptoms in general are nonspecific: • Tiredness, weight gain, cold intolerance, constipation, and menorrhagia • Patients with severe hypothyroidism or myxedema • Facial and periorbital puffiness • Characteristic facial features as a consequence of the deposition of glycosaminoglycans in the subcutaneous tissues • The skin becomes rough and dry and often develops a yellowish hue from reduced conversion of carotene to vitamin A. • Hair becomes dry and brittle, and severe hair loss may occur • Loss of the outer two-thirds of the eyebrows.

12. An enlarged tongue may impair speech, which is already slowed, in keeping with the impairment of mental processes. • Myxedema madness • Untreated dementia • Nonspecific abdominal pain accompanied by distention and constipation. • Libido and fertility are impaired in both sexes. • Cardiovascular changes in hypothyroidism include: • Bradycardia, cardiomegaly, pericardial effusion, reduced cardiac output, and pulmonary effusions • Cardiac failure is uncommon • When hypothyroidism occurs as a result of pituitary failure, features of hypopituitarism such as pale, waxy skin, loss of body hair, and atrophic genitalia may be present

13. LABORATORY FINDINGS • Hypothyroidism is characterized by low circulating levels of T4 and T3. • Raised TSH levels are found in primary thyroid failure, whereas secondary hypothyroidism is characterized by low TSH levels that do not increase following TRH stimulation. • Thyroid autoantibodies are present and are highest in patients with autoimmune disease (Hashimoto's thyroiditis, Graves' disease), although they are also elevated in patients with nodular goiter and thyroid neoplasms. • Other findings include anemia, hypercholesterolemia, and decreased voltage with flattening or inversion of T waves on electrocardiogram. Comatose patients with myxedema also have hyponatremia and CO2 retention.

14. TREATMENT • THYROXINE • Treatment of choice • 50 to 200 mcg per day, depending upon patient's size and condition. • Starting doses of 100 mcg of thyroxine daily are well tolerated • Elderly patients and those with coexisting heart disease and profound hypothyroidism should be started on a considerably lower dose such as 25 to 50 mcg daily because of associated hypercholesterolemia and atherosclerosis. • The dose can be slowly increased over weeks to months to attain a euthyroid state.

15. A baseline ECG should always be obtained in patients with severe hypothyroidism prior to treatment. • Patients are instructed to take tablets in the morning, usually without other medications, or at mealtime to assure good absorption. • Thyroxine dosage is titrated against clinical response and TSH levels, which should return to normal. • Patients who present with myxedema coma, in contrast to the patients with mild to moderate hypothyroidism, require an initial emergency treatment with large doses of intravenous thyroxine (300 to 400 g), and careful monitoring in an ICU setting.

16. 3. What is your diagnosis? Other considerations? Explain.

17. Diagnosis • Hyperthyroidism secondary to over dosage to L thyroxine

18. Other Considerations

19. Differential Diagnoses • Nodular Non-toxic Goiter • Graves’ Disease • Toxic Multinodular Goiter • Toxic Adenoma • Solitary Thyroid Nodule

20. Nodular Non-toxic Goiter

21. Enlargement of the thyroid gland • No toxicity; no cancer • The following factors increase your chance of developing nontoxic goiter: • Sex: female (nontoxic goiter is more common in women than men) • Age: over 40 years Reference: http://www.mbmc.org/healthgate/GetHGContent.aspx

22. SYMPTOMS • Nontoxic goiters usually do not have noticeable symptoms. • Swelling on the neck • Breathing difficulties, coughing, or wheezing with large goiter • Difficulty swallowing with large goiter • Feeling of pressure on the neck • Hoarseness

23. MANAGEMENT • A goiter only needs to be treated if it is causing symptoms. • Treatments for an enlarged thyroid include: • Radioactive iodine to shrink the gland, particularly if the thyroid is producing too much thyroid hormone • Surgery (thyroidectomy) to remove all or part of the gland • Small doses of Lugol's iodine or potassium iodine solution if the goiter is due to iodine deficiency • Treatment with thyroid hormone supplements if the goiter is due to underactive thyroid Reference: http://www.nlm.nih.gov/medlineplus/ency/article/001178.htm

24. INDICATIONS FOR SURGERY • Huge goiter which is cosmetically unacceptable • Compression symptoms • Suspicion of malignancy

25. GRAVES’ DISEASE • Atype of hyperthyroidism, is caused by a generalized overactivity of the entire thyroid gland. • An autoimmune disease; thyroid-stimulating antibodies directed at TSH receptors on follicular cells. • It is named for Robert Graves, an Irish physician, who was the first to describe this form of hyperthyroidism about 150 years ago.

26. ETIOLOGY • The trigger for auto-antibody production is not known. • Genetic predisposition – HLA DR3 • Since Graves' disease is an autoimmune disease which appears suddenly, often quite late in life, it is thought that a viral or infection may trigger antibodies which cross-react with the human TSH receptor (a phenomenon known as antigenic mimicry, also seen in some cases of Type I diabetes). • Yersiniaenterocolitica Reference: http://en.wikipedia.org/wiki/Graves%27_disease

27. CLINICAL FEATURES • Triad: • Goiter including the pyramidal lobe • Thyrotoxicosis • Exophthalmos • Symptoms: • Heat intolerance • Thirst • Sweating • Weight loss despite adequate caloric intake • Amenorrhea • Tachycardia or atrial fibrillation • Congestive heart failure

28. PE: • Weight loss • Flushing • Warm and moist skin • Inappropriate sweating • Tachycardia • Widening of pulse pressure • Fine tremor • Muscle wasting • Hyperactive tendon reflexes • Pretibialmyexedema • Gynecomastia • Audible bruit over the gland • Laboratory Findings: • Decreased TSH • Increased circulating T3/T4 levels • Increased circulating thyroid autoantibodies • Thyroid stimulating immunoglobulins (TSI) • Tyhroid stimulating antibodies (TSAb) • Radioactive iodine scan shows diffuse uptake through the gland of 45-90 percent.

29. MANAGEMENT • Medical: • Propylthiouracil (PTU) • Methimazole (Tapazole) • Carbimazole • Beta-blockers (Propanolol)

30. Relapse rate in 12-18 months • Risk for fetal goiter, hypothyroidism • No morbidity related after surgery • Treatment of choice for small goiters and pregnant patients (PTU) • Euthyroid state is achieved in 4-6 weeks

31. Radioactive Iodine • Ease of treatment • Highly effective especially in diffuse goiters • No morbidity related to surgery • Treatment of choice for failed surgical management • The effect is seen in 1.5-4 months • Standard dose = 10 mCl = 8500 cGy

32. Surgery • Complete and permanent control of toxicity • Rapid control of symptoms • Removal of mass • Treatment of choice for huge goiters • Needs pre-operative preparation • Overall morbidity of 1-2%

33. Toxic MultinodularGoiter • Usually occur in individuals older than 50 years of age who often have a prior history of a nontoxic multinodulargoiter • Over several years, enough thyroid nodules become autonomous to cause hyperthyroidism. • Similar to Graves’ disease, but symptoms and signs of hyperthyroidism are less severe and extrathyroidal manifestations are absent. • May present with atrial fibrillation or palpitations, tachycardia, nervousness, tremor or weight loss. • Low TSH, normal or minimally increased T4, elevated T3, T3>T4.

34. Toxic MultinodularGoiter • Thyroid scan – heterogenous uptake with multiple regions of increased and decreased uptake. • 24hr uptake of radioiodine may not be increased. • Management • Antithyroid drugs + beta blockers – normalize thyroid function and address the clinical features of thyrotoxicosis, but often stimulates the growth of the goiter; spontaneous remission does not occur. • Radioiodine – treat areas of autonomy, decrease the mass of the goiter • A trial of radioiodine should be considered before subjecting patients to surgery.

35. Toxic MultinodularGoiter • Surgery • Definitive treatment of underlying thyrotoxicosis and goiter. • Subtotal thyroidectomy is the standard procedure. • Patients should be rendered euthyroid using antithyroid drugs before operation.

36. Toxic Adenoma • A solitary, autonomously functioning thyroid nodule • Typically occurs in younger patients • (+) thyroid nodule with symptoms of hyperthyroidism • Size is at least 3cm before hyperthyroidism occurs. • Absent clinical features suggestive of Graves’ disease or other causes of thyrotoxicosis

37. Toxic Adenoma • Thyroid scan – definitive diagnostic test • Focal uptake in the hyperfunctioning nodules • Diminished uptake in the remained of the gland • Suppression of the activity of the normal thyroid

38. Toxic Adenoma • Radioiodine ablation – treatment of choice • 131I is concentrated in the hyperfunctioning nodule with minimal uptake and damage to normal thyroid tissue. • Relatively large doses – correct thyrotoxicosis in about 75% of patients within 3 months. • Hypothyroidism occurs in <10% of patients over the next 5 years.

39. Toxic Adenoma • Surgical resection • Limited to enucleation of the adenoma • Lobectomy • Preservation of thyroid function • Low risk of hypoparathyroidism • Low risk of damage to the recurrent laryngeal nerve

40. Toxic Adenoma • Medical therapy using antithyroid drugs and beta blockers – normalize thyroid function but is not an optimal long term treatment • Ethanol injection under ultrasound guidance • Repeated injections – often >5 sessions • Reduce nodule size

41. Solitary Thyroid Nodule • Present in approximately 4 percent of the population • Pain is unusual. When present, it should raise suspicion for intrathyroidal hemorrhage in a benign nodule, thyroiditis, or malignancy. • History of hoarseness - may be secondary to malignant involvement of the recurrent laryngeal nerves • Risk factors for malignancy – exposure to ionizing radiation and family history of thyroid and other malignancies associated with thyroid cancer.

42. Solitary Thyroid Nodule • Mass moves with swallowing. • Hard, gritty of fixed nodules are more likely to be malignant. • Most are euthyroid. • If a patient with a nodule is found to be hyperthyroid, the risk of malignancy is approximately 1 percent. • FNAB – most important diagnostic test • Benign – 65% (includes cysts and colloid nodules) • Suspicious – 20% • Malignant – 5% • Nondiagnostic – 10%

43. Solitary Thyroid Nodule • Ultrasound • For detecting nonpalpable thyroid nodules • For differentiating solid from cystic nodules • For diagnosing suspicious nodules with microcalcifications • For identifying adjacent lymphadenopathy • CT and MRI – unnecessary in except for large, fixed, or substernal lesions. • 123I or 99mTc – rarely necessary, unless evaluating patients for “hot” or autonomous thyroid nodules

44. Solitary Thyroid Nodule • Malignant tumors – generally treated by total or near-total thyroidectomy • Simple thyroid cysts - resolve with aspiration in approximately 75 percent of cases • Unilateral thyroid lobectomy - if the cyst persists after three attempts at aspiration • Lobectomy • For cysts >4 cm in diameter • For complex cysts with solid and cystic components

45. Solitary Thyroid Nodule • Colloid nodule – should be observed with serial ultrasound and Tg measurements • Repeat FNAB if nodule enlarges • L-thyroxine – in doses sufficient to maintain a serum TSH level between 0.1 and 1.0 μU/mL. • 50% decrease in size • Thyroidectomy – if a nodule enlarges on TSH suppression, causes compressive symptoms, or for cosmetic reasons • Exceptions: Patient who has had previous irradiation of the thyroid gland or who has a family history of thyroid cancer. • In these patients total or near-total thyroidectomy is recommended. • High incidence of thyroid cancer (≥ 40%) • Decreased reliability of FNA biopsy

46. 4. How would you manage this patient now?

47. Goal: restoration of clinical and biochemical euthyroid state by omitting or reducing the dosage of medications and other measures as needed depending on clinical status. • ECG • Blood test: TSH, T3, T4 levels, monitored regularly • SYMPTOMATIC TREATMENT: • To control tachycardia, hypertension and atrial fibrillation: 20 - 40 mg doses of propranolo Q 6hours; d • If beta blockers are contraindicated: Diazepam and/or chlorpromazine

48. RADIOACTIVE IODINE • ingestion of a radioactive iodine tablet (6-12 wks) which is then taken up by thyroid cells. These overactive cells are destroyed so that the thyroid can shrink in size and produce hormone at normal levels. • In patients with underlying heart disease and in elderly patients, it is desirable to treat with antithyroid drugs (methimazole) until the patient is euthyroid. The medication is then stopped for 5-7days before the appropriate dosage of 131I. • Although it is a safe treatment, most people become hypothyroid after radioactive iodine therapy and therefore require lifelong thyroid hormone replacement therapy.

49. THYROIDECTOMY • Now uncommonly performed; the surgeon removes most or all of the gland • Candidates for surgery: include pregnant hyperthyroid patients intolerant of anti-thyroid drugs, patients desiring definitive therapy without the use of radioactive iodine, children, and patients with very large or multinodular goiters. • Patients are treated with antithyroid drugs until euthyroid (about 6wks). In addition, 10-14 days prior to surgery, they receive saturated solution of potassium iodide 5 drops BID, to diminish vascularity of the gland and simplify surgery • However, in cases of total removal of the thyroid gland, patient must take thyroid replacement pills for the rest of his or her life

50. NON-PHARMACOLOGICAL • High calorie diet in order to replace all the energy burned by the body in hyperthyroid state • Drink plenty of water and juices to replace all the fluid losses. Avoid or limit caffeinated drinks for such could produce anxiety.