Ch. 11 Neck Mass that Moves with Swallowing

Question 1

What is Thyroglobulin?

Answer 1

A glycoprotein housed within thyroid follicles that is a storage form/precursor of T4 and T3.

Serum thyroglobulin levels correlated positively with the amount of thyroid tissue, thyroid injury/inflammation, and the TSH level.

Question 2

What cancers are associated with psammoma bodies?

Answer 2

• Papillary carcinoma of the thyroid
• Serous cystadenocarcinoma of the ovary
• Meningioma
• Mesothelioma

Question 3

What is the first test in a work-up for thyroid mass

Answer 3

TSH = most sensitive measure of thyroid dysfunction and the only test indicated in screening or in the absence of symptoms of hyper- or hypothyroidism

Question 4

What are the appropriate imaging studies for a thyroid nodule?

Answer 4

Beside neck U/S –> can detect nodules and lymphadenopathy, characterize masses as solid or cystic, and guide FNA

Hypoechoic nodules and those with irregular margins/microcalcifications –> more likely to be malignant

Question 5

What is the next step for an FNA result of suspected follicular neoplasm?

Answer 5

Remove one lobe of the thyroid.

Open biopsies of a thyroid nodule require removal of the entire lobe (meaning the R or L lobe of the thyroid gland, called a thyroid lobectomy). A simple biopsy is not done due to: (a) the thyroid gland being extremely vascular so trying to remove part of the lobe would be very bloody, (b) tumor cells may be spilled in the process, and (c) removing a lobe of the thyroid does not adversely affect thyroid function.

Question 6

What mgmt strategy should be employed to reduce the risk of developing thyroid storm in the OR?

Answer 6

Drops of Lugol iodine solution daily beginning 10 days pre-op

PTU or methimazole can also be used preop but are C/I in pregnant women

If thyroid storm occurs, treatment is beta-blockade

Question 7

A 48-year-old female undergoes evaluation for hoarseness. Her work-up reveals a 4.2cm right thyroid nodule. Subsequent US guided FNA reveals a Bethesda Category VI nodule, consistent with papillary carcinoma. What is the next most appropriate step in her management?

a. Right thyroid lobectomy and isthmusectomy
b. Nuclear medicine thyroid scan
c. Laryngoscopy
d. Total thyroidectomy
e. MRI of the neck

Answer 7

c. Laryngoscopy

Discussion: In patients with thyroid cancer who present with signs of invasion into adjacent structures, laryngoscopy should be performed to evaluate the function of the vocal cords pre-operatively. A nuclear medicine thyroid scan would not change management at this point in her evaluation, nor would MRI. A total thyroidectomy would be the definitive procedure of choice after laryngoscopy to evaluate her vocal cords. Although lobectomy and isthmusectomy is an appropriate definitive procedure for some thyroid cancers, this patient’s age and size of tumor make it an inferior operation in this setting.

Question 8

A 50-year old female undergoes a total thyroidectomy for papillary thyroid carcinoma. Tumor size is 3cm and there were no involved lymph nodes. Post-operatively she undergoes radioactive iodine remnant ablation. Which of the following is appropriate long-term follow-up care for thyroid cancer surveillance?

a. Annual I131 scan
b. Annual thyroglobulin measurement
c. Annual CT scan of the neck
d. Annual TSH measurement
e. Annual CT scan of the chest

Answer 8

b. Annual thyroglobulin measurement

Discussion: Thyroglobulin is only produced by thyroid cells and is an excellent clinical indicator of recurrence. In the setting of TSH suppression, a climbing thyroglobulin level should prompt further investigation of a possible recurrence. TSH levels should be monitored more frequently than annually to maintain TSH suppression. CT scans of the neck or chest are not indicated for routine surveillance. I131 scanning can be useful for further evaluation if a recurrence is suspected.

Question 9

Which of the following thyroid nodule characteristics is concerning for malignancy?

a. Presence of microcalcifications
b. Decreased vascularity
c. Complex with cystic and solid features
d. Isoechoic to surrounding thyroid tissue
e. Distinct borders

Answer 9

a. Presence of microcalcifications

Discussion: Malignant thyroid nodules typically are hypoechoic to surrounding thyroid tissue. They usually have increased vascularity on Doppler ultrasound. They are usually solid in nature and can have indistinct borders. The presence of microcalcifications should make the examiner more suspicious of an underlying malignancy.

Question 10

Mgmt of Cystic Hygroma

Answer 10

Often extend into mediastinum, and therefore CT scan BEFORE attempted surgical removal = mandatory

Question 11

Head and Neck: how to treat the following conditions:

1. Ludwig Angina
2. Facial nerve injuries
3. Cavernous sinus thrombosis
4. Dizziness
5. Meniere disease

Answer 11

1. Ludwig Angina
   
   1. Abscess of floor of mouth (often the result of a bad tooth infection)
   2. Mgmt: I & D / Intubation and trache
2. Facial nerve injuries
   
   1. Paralysis and swelling that resolves on own
3. Cavernous sinus thrombosis
   
   1. Development of diplopia (from paralysis of extrinsic eye muscles), along with facial pain and high fever, in a pt suffering from frontal or ethmoid sinusitis
   2. Mgmt: RARE BUT SERIOUS EMERGENCY (30% mortality) that requires hospitalization
   3. Dx: MRI
   4. Tx: aggressive IV abx for 3-4 weeks + PCN + cephalosporin
4. Dizziness:
   
   1. If inner ear is the culprit, pt describes room as spinning
   2. Tx: Meclizine, prometazine, diazepam
5. Meniere disease
   
   1. Vertigo, tinnitus, hearing loss
   2. Tx: Diuretics