ENT Flashcards
Describe benign lymph node
soft, rubbery, smooth, mobile and stable in size
Describe inflammatory/infectious lymph node
isolated, asymmetric, soft, boggy, erythematous, painful / tender, warm, <2cm (unless abscess) and have rapid change in size
Describe malignant lymph node
hard, rubbery, fixed, painless (unless nerve is involved), irregular, erythematous, >2cm, steady growth and can involve surrounding nodes
Describe cystic masses
Soft, ballotable masses
firm lateral neck mass that moves from side to side but not up and down suggests…
carotid body tumor or vagal schwannoma
Preferred method of diagnosis for neck masses
fine needle aspiration is preferred diagnostic approach for most neck masses with following exceptions
- suspected lymphoma are biopsied by excisional biopsy of entire lymph nodes, because diagnosis by pathology requires entire sample
- benign lesion based on diagnosis from fine needle aspiration or core biopsy can be extracted by excisional biopsy as treatment
Neck mass differential age 0-15
infectious > congenital > neoplastic (malignant > benign)
Neck mass differential age 16-40
infectious > congenital > neoplastic (benign > malignant)
Neck mass differential age >40
neoplastic (malignant = benign) > infectious > congenital
Thyroid mass/nodule epidemiology
thyroid nodules are very common (~5% of physical exam; ~50% of neck ultrasound)
only minority (~5%) of thyroid nodules are malignant
risk factor for nodule: female, family history of thyroid nodule / goitre
risk factor for cancer: radiation exposure, iodine deficiency & goitre, family history of thyroid cancer, MEN2A and MEN2B genetic syndromes
Thyroid mass differential diagnosis
benign: cyst, abscess, colloid nodule, benign neoplasm (follicular adenoma), thyroiditis, goitre
malignant: papillary carcinoma, follicular carcinoma, medullary carcinoma, anaplastic carcinoma, secondary malignancy (lymphoma, metastases)
Malignant thyroid mass prognosis from best to worst
papillary carcinoma (>90%) > follicular carcinoma (85%) > medullary carcinoma (65%) > anaplastic (<5%)
Nodule >4 cm, does not move with swallowing, calcification, hypoechoic nodule, absence of halo rim, non toxic nodule (normal or high TSH, low RAIU, cold nodule on thyroid scan) are all features of what type of thyroid mass
Malignant
Approach to thyroid nodule
management is same for single or multiple thyroid nodules
1) History and Physical Exam
majority of thyroid nodule are incidental findings on physical exam
history and physical exam for benign vs. malignant features
2) Investigation Workup
in order of priority a > b > c
a) TSH level
indication: all patients with thyroid nodule
if normal or high TSH, then nodule is non functioning “cold”, thus more likely to be malignancy and need to be biopsied
if low TSH, then nodule can be “hot” or “cold”, so thyroid scan and RAIU is required
b) thyroid scan and RAIU
indication: patient with thyroid nodule and low TSH
focal “cold” nodule on thyroid scan increase likelihood of malignancy
c) ultrasound
indication: all palpable thyroid nodules
ultrasound can supplement information on anatomical nodules in terms of risk on malignancy
ultrasound also used as baseline for future comparisons
3) Biopsy
if high suspicion of malignancy based on clinical evaluation then FNA biopsy, usually guided by ultrasound
indications for FNA if patient has any of the following
>1cm nodule with high risk radiographic features or history
any nodule with abnormal cervical lymphadenopathy
>1cm nodule that is solid and iso- or hyper-echoic on ultrasound
>2cm mixed cystic solid nodule with suspicious ultrasound features
>2cm spongiform nodule
FNA is not indicated in any purely cystic nodule
FNA provides definitive diagnosis of the nodule being benign or malignant
FNA can be non diagnostic or inconclusive ~25% of time, which may require a repeat FNA
Management of thyroid nodule
See Tony’s pg 51
