Midline Neck Lumps Flashcards
What are thyroid differentials for a midline neck lump
Physiological goitre (puberty, pregnancy_ Multinodular goitre Graves disease Hashimoto's thyroiditis Thyroglossal cyst Thyroid cyst Solitary adenoma Carcinoma Subacute thyroiditis (de Quervain's, Riedel's)
What are non-thyroid differentials for a midline neck lump
Lipoma Dermoid cyst Epidermal cyst Abscess Lymphoma
What questions should be asked about the lump
How long has it been there
Has the lump changed in size
Is the lump painful
Are there any other lumps
What can the length of duration of a lump tell you
Sudden appearance - acute haemorrhage into a thyroid cyst, or fast-growing thyroid carcinoma/subacute thyroiditis
What can the changes in size of a lump tell you
Rapid increase - haemorrhage or infection
Slow growing - thyroid neoplasm (except anaplastic)
What information can you get from whether the lump is painful or not
Most are not painful
Subacute thyroiditis, infected thyroglossal cysts or acute haemorrhagic cysts are often painful
Hashimotos - discomfort, no pain
What other symptoms should be asked about when regarding a midline lump
Any symptoms of hypo/hyperthyroiditis
Any symptoms suggestive of compression or invasion
Symptoms of infection
What are the symptoms of compression
Stridor
Dyspnoea
Dysphagia or discomfort in swallowing
What are the symptoms of invasion
Changes in the quality of voice due to Recurrent laryngeal nerve and/or vocal cords invasion (may also be seen in hypothyroidism due to oedema of the vocal cords)
What aspects of the past medical history should be enquired about for midline neck lumps
Any autoimmune disorders e.g. T1DM, PA, vitiligo, Addison’s
Known risk factors for thyroid malignancy e.g. previous radiation for papillary thyroid carcinoma
What aspects of the family history should be enquired about for the midline neck lump
Autoimmune diseases
Hereditary forms of thyroid carcinoma (medullary thyroid carcinoma)
What can the location of a midline lump tell you
Superficial - lipoma, epidermal cyst, dermoid cyst or abscess
Deep - thyroid
What does the midline lump’s relationship to other structures tell you
Moves on swallowing - thyroid gland
Moves on tongue protrusion - thyroglossal cyst
Tethered to neighbouring muscles - malignancy, Reidel’s
What does the character of the midline lump tell you
Diffuse, smooth enlargement - physiological goitre, Graves’, Hashimoto’s, de Quervain’s thyroiditis
Solitary, solid - malignancy
Solitary, cystic - Thyroglossal, epidermal, dermoid, thyroid cysts
Multiple nodules - multinodular goitre (focal hyperplasia)
What other features should be examined other than the midline lump itself
Any cervical lymphadenopathy - thyroid malignancy
Extent of thyroid swelling
Any signs of hyper, hypothyroidism
What is Pemberton’s sign
elevate the arms above the head which results in facial venous congestion and plethora due to thoracic inlet obstruction by a retrosternal mass
What would serum calcitonin be investigated for a thyroid disease
only there is family history of thyroid cancer.
MTC is a tumour of the calcitonin-secreting parafollicular C-cells, thus calcitonin can be used as a serum marker
What investigations should be done for thyroid nodules
Fine needle aspiration (+ USS guidance if needed)
What may present as an upper midline lump that grown sub-acutely, is not painful but mildly tender. It moves on swallowing and sticking out the tongue. It is not attached to muscles and has well-defined boundaries + smooth. Cystic and non-pulsailte.
Thyroglossal Cyst (attached to the hyoid bone)
What nay cause a change in thyroglossal cyst size or sudden appearance
Thyroglossal cysts occur due to abnormal descent of the thyroid gland to the thyroid cartilage. Sudden increases may represent infection secondary to another infection.
Diffuse midline swelling in the lower 1/3. Non-tender and moves when swallowing. Smooth and no palpable nodules. Has symptoms of hyperthyroidism + lid lag and exophthalmos
Graves disease
What is the pathophysiology of Graves and Hashimotos
Graves - Anti-TSH that causes hyperthyroid
Hashimoto - Antithyroid Abs that causes hypothyroid
What are the histological types of thyroid neoplasia
Papillary Follicular Medullary Lymphoma Anaplastic Metastases
How does tachycardia in hyperthyroidism differ from that of anxiety
Hyperthyroid - associated with AF and arrhythmias, persists when the patient is sleeping
