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Z Year3 Clinical Presentations > Midline Neck Lump > Flashcards

Midline Neck Lump Flashcards

1
Q

What are the thyroid causes of a midline neck lump?

A
  1. Phsyiological goitre
  2. Multinodular goitre
  3. Graves disease
  4. Hashimotos thryoiditis
  5. Thyroglossal cyst
  6. Thyroid cyst
  7. Solitary adenoma
  8. Carcinoma
  9. Subacute thryoiditis
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2
Q

What are the non-thyroid causes of a midline neck lump?

A
  1. Lipoma
  2. Dermoid cyst
  3. Epidermal cyts
  4. Abscess
  5. Lymphoma
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3
Q

What questions should a GP ask about a midline neck lump?

A
  1. How long has lump been there
  2. Has lump changed size
  3. Is lump painful
  4. Other lumps
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4
Q

What would a sudden onset of a midline neck lump suggest?

A
  1. acute haemorrhage into a thyroid cyst
  2. fast growing thyroid carcinoma
  3. subacute thyroiditis
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5
Q

What would a gradual onset of a midline neck lump suggest?

A

thyroglossal cysts (can show up after infection)

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6
Q

What would be an increasing size midline neck lump suggest?

A
  • haemorrhage

- infection of an existing lump

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7
Q

What would a slow growing midline neck lump suggest?

A

thyroid neoplasms (not anaplastic carcinoma)

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8
Q

What would a painful midline neck lump suggest?

A
  • subacute thyroiditis
  • infected thryroglossal cysts
  • acute haemorrhagic cysts
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9
Q

What would a discomfort when swallowing midline neck lump suggest?

A

hashimotos

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10
Q

What would other lumps as well as a midline neck lump suggest?

A

cervical lymphadenopathy, malignant until proven otherwise

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11
Q

What assoicated symptoms should the GP ask about with a midline neck lump?

A
  1. Hypothyroidism, hyperthyroidism?
  2. Any symptoms suggestive of compression or invasion?
  3. Any symptoms of infection (malaise, fever, rigor)?
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12
Q

What would hypothyroidism symptoms be?

A
  1. Apathetic/ blunting or thought/ fatigue
  2. Weight gain
  3. Constipation
  4. Cold intolerance
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13
Q

What would hyperthyroidism symptoms be?

A
  1. Irritable/nervous/ restless
  2. Increased appetite and weight loss
  3. Diarhhoea
  4. Heat intolerance
  5. Palpitations
  6. Oligomenorrhoea
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14
Q

What can cause compression or invasion?

A
  • if goitre so large can exert pressure on surrounding tissues and cause symptoms e.g. stridor, dyspnoea, dysphagia and or discomfort during swallowing
  • Changes in voice due to malignant tumour invading recurrent laryngeal nerve or hypothyroidism can cause oedema of vocal cords
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15
Q

Why is asking about autoimmune disease in PMHx important with midline neck lump?

A

Graves and Hashimotos thyroiditis is more common if already autonimmune disease

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16
Q

Why is asking about known risk of thyroid malignancy in PMHx important with midline neck lump?

A

previous radiation to neck risk factor for subsequent development of papillary thyroid carcinoma

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17
Q

Why is asking about autoimmune disease in FHx important with midline neck lump?

A

family predisposition

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18
Q

Why is asking about hereditary forms of thyroid carcinoma in FHx important with midline neck lump?

A

25% of medullary thyroid carcinoma (MTC) familial or part of MEN-2

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19
Q

What questions do you ask about lump and location in a midline neck lump?

A
  1. Location
  2. Relationship to other structures
  3. Character of lump
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19
Q

What questions do you ask about lump and location in a midline neck lump?

A
  1. Location
  2. Relationship to other structures
  3. Character of lump
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20
Q

What would a superficial midline neck lump suggest?

A
  1. lipoma
  2. epidermal cyst
  3. . dermoid cyst
  4. abcess
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21
Q

What would a deep midline neck lump suggest?

A

thyroid gland

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22
Q

What would a moves on swallowing midline neck lump suggest?

A

thyroid gland (attached to pretrachea fascia)

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23
Q

What would a moves with tongue protusion midline neck lump suggest?

A

Thyroglossal cyst (attached to hyoid bone)

24
Q

What would a moves tethered to neighbouring muscles or skin midline neck lump suggest?

A

malignancy or Riedel’s thyroiditis

25
Q

What does a diffuse, smoother elargement midline neck lump suggest?

A

Physiological goitre, Graves’, Hasimotos or de Quevarin’s thyroidisits (may also be tender)

26
Q

What does a solitary solid nodule midline neck lump suggest?

A

malignancy more likely

27
Q

What does a solitary cystic nodule midline neck lump suggest?

A

thyroglossal, epidermal, dermoid or thyroid cyst

28
Q

What would a multiple nodule midline neck lump suggest?

A

multinodular goitre (focal hyperplasia) more likely

29
Q

What other things should a GP examine in a midline neck lump suggestion?

A
  1. Cervical lymphadenopathy
  2. Extent of thyroid swelling
  3. Any signs of hyper or hypothyroidism
30
Q

Why do you look for cervical lymphaednopathy in midline neck lump?

A
  • raise suspicion or thryoid malignancy

- reflects infective cause of neck swelling

31
Q

How do you look for the extent of neck swelling?

A
  • Examine with neck extended

- Percuss for retrosternal extension of lump or to try and elecit Pemberton’s sign

32
Q

What are the hand signs of hyperthyroidism?

A
  1. Fine tremor
  2. Tachycardia/atrial fibrillation
  3. sweating
  4. palmar erythema
  5. thyroid acropachy (clubbing)
  6. Onycholysis
33
Q

What are the eye signs of hyperthyroidism?

A
  1. Lid lag
  2. Lid retraction
  3. Exophthalmos
  4. Chemosis
  5. Opthalmoplegia
34
Q

What are other key signs of hyperthyroidism?

A
  1. Thyroid bruit
  2. Wasting/proximal myopathy
  3. Pretibial myxoedema (in Graves specifically)
35
Q

What are the hand signs of hypothyroidism?

A

bradycardia

36
Q

What are the eye signs of hypothyroidism?

A

loss of outer third of eyebrows

37
Q

What are the other key signs of hypothyroidism?

A
  1. Slow, deep voice
  2. Dry, coarse skin
  3. Oedematous-looking face
  4. Slow reflexes
38
Q

What investigations are essential in midline neck lump?

A
  1. TSH

2. Serum calcitron

39
Q

What does an elevated TSH mean?

A

hypothyroidism

40
Q

What does a suppresed TSH mean?

A

hyperthyroidism

41
Q

What is the next step if TSH is low?

A

request free tri-iodothyronine (t3) and free thyroxine (T4)

42
Q

What is the next step if TSH is high?

A

request thyroid peroxidase antibodies (Hasimoto’s)

43
Q

When do you measure serum calcitron?

A

if significant FHx or thyroid cancer or MEN-2

44
Q

Who do you refer to if evidence of altered thyroid function?

A

first endocrinology as thyroid cancer rare

45
Q

Who do you refer to if euthyroid patients with thyroid nodules?

A

endocrine surgeon

46
Q

When is the referral urgent?

A

if other symptoms e.g. growing quickly, lymphadenopathy change in voice

47
Q

What are the thyroid noduel investigations?

A
  1. FNA
  2. US to guide needle + estimate size and if solid, cystic or mixed (solid or mixed likely malignant)
  3. Radionuclide scanning
48
Q

What would a hot radionuclide scanning mean?

49
Q

What would a cold radionuclide scanning mean?

A

5-20% malignant

50
Q

When do you do a CT or MRI for thyroid nodule investigations?

A

only if retrosternal extension of a goitre, invasive tumours or heamoptysis

51
Q

What are the possible outcomes for FNA of a thyroid nodule?

A
  1. Insufficient aspirate to make a diagnosis (Thy1)
  2. Benign (e.g. thyroiditis) (Thy2)
  3. Follicular lesion/suspected follicular neoplasm (Thy3)
  4. Suspicious of malignancy (Thy4)
  5. Diagnostic of malignancy (Thy5)
52
Q

Why is FNA not that useful?

A

not distinguish between benign follicular adenoma and a malignant follicular carcinoma

53
Q

What is the management stages for follicular adenoma/carcinoma?

A
  1. Surgery
  2. T3 replacement
  3. I31I ablation
  4. T4 suppression
  5. Follow up
54
Q

What surgery can be offered?

A
  1. Low risk follicular carcinoma may be treated by thyroid lobesctomy
  2. High risk offered total or near-total thyroidectomy
55
Q

Why is T3 replacement annoying?

A

TSH levels need to be high at same time of radio-iodine (so T3 must be stopped 2 weeks prior to it and if T4 6 weeks prior)

56
Q

Why is 131I ablation useful?

A

radioiondine taken up by thyroid cells which then destroyed by radiation

57
Q

Why do you do T4 suppression?

A

dose sufficecent to supress TSH secretion completely - as 1. TSH would stimulate any remaining potentially malignanat thyroid tissue to grow
2. If TG levels rise above 0 in presence of T4 suppression suggest return of malignant thyroid cells

58
Q

How often is follow up?

A

annual clinical examination with measurement of serum TSH and TG

Z Year3 Clinical Presentations (37 decks)

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